Diagnostic Evaluation for Heart Diseases

A variety of invasive and noninvasive tests may be used in the diagnosis of heart disease. 1. Electrocardiography: Measures electrical potential generated from the heart muscle. Patient Preparation y Explain to the patient the need to lie still, relax, and breathe normally during the procedure. y Note current cardiac drug therapy on the test request form as well as any other pertinent clinical information, such as chest pain or pacemaker. y Explain that the test is painless and takes 5 to 10 minutes. Implementation y Place the patient in a supine or semi-Fowler s position. y Expose the chest, ankles, and wrists. y Place electrodes on the inner aspect of the wrists, on the medical aspect of the lower legs, and on the chest. y After all electrodes are in place, connect the lead wires. y Press the START button and input any required information. y Make sure that all leads are represented in the tracing. If not, determine which electrode has come loose, reattach it, and restart the tracing. y All recording and other nearby electrical equipment should be properly grounded. y Make sure that the electrodes are firmly attached Nursing Interventions Disconnect the equipment, remove the electrodes, and remove the gel with a moist cloth towel. If the patient is having recurrent chest pain or if serial ECG s are ordered, leave the electrode patches in place Interpretations Normal Results P wave that doesn t exceed 2.5 mm (0.25 mV) in height or last longer than 0.12 second. PR interval (includes the P wave plus the PR segment) persisting for 0.12 to 0.2 second forheart rates above 60 beats/min. QT interval that varies with the heart rate and lasts 0.4 to 0.52 second for heart ratesabove 60 beats/min. Voltage of the R wave leads V1 through V6 that doesn t exceed 27 mm. Total QRS complex lasting 0.06 to 0.1 second. Abnormal Results Myocardial infarction (MI), right or left ventricular hypertrophy, arrhythmias, right or left bundle-branch block, ischemia, conduction defects or pericarditis, and electrolyte abnormalities. Abnormal wave forms during angina episodes or during exercise. Precautions

y y

y y y y y

  

The recording equipment and other nearby electrical equipment should be properly grounded to prevent electrical interference. Double-check color codes and lead markings to be sure connectors march. Make sure that the electrodes are firmly attached, and reattached them if loose skin contact is suspended. Don t use cables that are broken, frayed, or bare. Interfering Factors Improper lead placement. Complications Skin sensitivity to the electrodes.

2. Echocardiography: Short pulses of ultrasounds transmitted through heart bounce off heart structure reflex test on a screen. It allows the practitioner to visualize heart size and shape, myocardial wall thickness and motion, and cardiac valve structure and function. It also helps evaluate overall left ventricular function and detect some MI complications. Plus, it can evaluate prosthetic valve function and help detect mitral valve prolapse; mitral, tricuspid, or pulmonic valve insufficiency; cardiac tamponade; pericardial diseases; cardiac tumors; subvalvular stenosis; ventricular aneurysm; cardiomyopathies; and congenital abnormalities Nursing considerations Reassure the patient that this 15 to 30 minute test doesn t cause pain or pose any risk Mention that he may undergo other tests, such as ECg and phonocardiography, simultaneously. Tell him that two recordings will be made, one with him on his back, and one with him on his left side Tell him he must sit still while recording takes place because movement may distort results Permit the patient to resume activities as ordered

3. Ultrasonography: Similar to echocardiography is synchronized with the E.C.G. to provide a three dimensional recording of heart structure. 4. Roentgenography; y Fluoscopy: Provides direct observation of heart size, position, contour and relationships. y Radiography: Provides permanent record of heart size, configuration. y Angiocardiography: Opaque media injected into circulatory system outlines blood flow through heart and vessels, performed in conjunction with cardiac catheterization. Nursing considerations Assess vital signs before the examination to provide a baseline and to help to detect changes in the client s condition during or after procedure. Remove any metal items such as religious medal or clothing that contains metal such as hooks and eyes on a bra. Metal produces a dense image that may be confused with tissue abnormality. Request a lead apron or collar to shields a fetus or vulnerable body parts during x-ray If the radiographic study involves administration of a contrast medium, ask the client about allergies, especially to seafood or iodine, or previous adverse reactions during a

diagnostic examination. A reaction can range from mild nausea and vomiting to shock and death Know the location of emergency equipment and drugs in case there is an unexpected allergic reaction to contrast medium To avoid interference with subsequent visual imaging, schedule procedures requiring iodine before those that use barium To promote urinary excretion, encourage the client to drink large amount of fluid after an examination involving iodine to promote its excretion Check on bowel elimination and stool characteristics for at least 2 days after administration of oral barium contrast medium. Barium retention can lead to constipation and bowel obstruction. Report absence of bowel elimination beyond 2 days. Administration of a prescribed laxative is often necessary. 5. Cardiac Catheterization: Opaque catheter introduced into heart chambers via large peripheral Vessels is observed by fluoroscopy or image intensification, pressure managements and blood samples provide additional sources of information. Purpose  To evaluate valvular insufficiency or stenosis, septal defects, congenital anomalies, myocardial function, myocardial blood supply, and cardiac wall motion.  To aid in diagnosing left ventricular enlargement, aortic root enlargement, ventricular aneurysms, and intracardiac shunts. Procedure Patient Preparation y Explain the procedure to the patient. y Tell him to restrict fluids for at least 6 hours before the test. y Inform him that the test takes 1 to 2 hours. y Tell him that he may receive a mild sedative but will remain conscious during the procedure. y Have the patient to void just before the procedure. y Check the patient history for hypersensitivity to shellfish, iodine, or contrast media used in other diagnostic tests. Discontinue any anticoagulant therapy as ordered. Implementation y The patient is placed supine on padded table and his heart rate and rhythm, respiratory status, and blood pressure are monitored throughout the procedure. y An I.V. line is started, if not already in place, and a local anesthetic is injected at the insertion site. y A small incision is made into the artery or vein, depending on whether the test is for the left or right. y The catheter is passed through the sheath into the vessel and guided using fluoroscopy. y In the right-sided catheterization, the catheter is inserted into the antecubital or femoral vein and advanced through the vena cava into the right side of the heart and into the pulmonary artery. y If left-sided heart catheterization, the catheter is inserted into the brachial or femoral artery and advanced retrograde through the aorta into the coronary artery ostium and left ventricle. y When the catheter is in place, contrast medium is injected to make visible the cardiac vessels and structures.

Nitroglycerin is given to eliminate catheter-induced spasm or watch its effect on the coronary arteries. y After the catheter is removed, direct pressure is applied to the incision site until bleeding stops, and a sterile dressing is applied. Nursing Interventions y Monitor the patient s heart rate and rhythm, respiratory and pulse rates, and blood pressure frequently. y Monitor the patient s vital signs every 15 minutes for 2 hours after the procedure, every 30 minutes for the next 2 hours, and then every hour for 2 hours. y If no hematoma or other problems arise, begin monitoring every 4 hours. If vital signs are unstable, check every 5 minutes and notify the practitioner. y Observe the insertion site for a hematoma or blood loss. Additional compression may be necessary to control bleeding. y Check the patient s color, skin temperature, and peripheral pulse below the puncture site. y Enforce bed rest for 8 hours. If the femoral route was used for catheter insertion, keep the patient s leg extended for 6 to 8 hours. y If medications were withheld before the test, check with the practiotner about resuming their administration. y Administer prescribed analgesics. y Make sure a posttest ECG is scheduled to check for possible myocardial damage. Interpretation Normal Results  No abnormalities of heart valves, chamber size, pressures, configuration, wall motion, or thickness, and blood flow.  Coronary arteries have a smooth and regular outline.

Abnormal Results Coronary artery narrowing greater than 70% suggests significant coronary artery disease.  Narrowing of the left main coronary artery and occlusion or narrowing high in the left anterior descending artery suggests the need for revascularization surgery.  Impaired wall motion suggests myocardial incompetence.  A pressure gradient indicates valvular heart disease.  Retrograde flow of the contrast medium across a valve during systole indicates valvular incompetence. Precautions  Coagulopathy, impaired renal function, and debilitation usually contraindicate catheterization of both sides of the heart. Unless a temporary pacemaker is inserted to counteract induced ventricular asystole, left bundle-branch block contraindicates catheterization of the right side of the heart.  If the patient has valvular heart disease, prophylactic antimicrobial therapy may be indicated to guard against subacute bacterial endocarditis.


Complications  Ineffective endocarditis in a patient with vulvular heart disease.

Myocardial infarction, arrhythmias, cardiac tamponade, pulmonary edema, hematoma, blood loss, adverse reaction to contrast media, and vasovagal response.

6. Digital Subtraction Angiography (D.S.A): Combines angiography with computer processing to produce high-resolution images of cardiovascular structures. The images are converted to digital signals with a number assigned to each color density from white to black. These images undergo a subtraction process that eliminates interference and extraneous structures, such as bone and soft tissue. DSA helps evaluate coronary arterial flow, myocardial perfusion, and left ventricular function and wall movement. It may also enable the practitioner to visualize carotid and peripheral vessels. Performed on outpatient basis, DSA provides a clear view or arterial structures. Because the contrast medium is injected into a vein, DSA eliminates the risks associates with arterial puncture. And because the dilute, low-dose contrast medium doesn t depress cardiac and kidney function, the test is safer for patients with heart failure, diabetes, and renal impairment Nursing considerations Care for a patient undergoing DSA as you would care for patient undergoing cardiac catheterization Antiplatelet agents Diuretics Inotropic agents thrombolytics

Cardiovascular drugs
Therapeutic Drug Categories Drug to treat angina Beta blockers, calcium channel blockers, nitrates Drugs to treat blood clot disorders Anticoagulants Drugs to treat heart failure Ace inhibitors, combination drugs, diuretics, digitalis drugs Drugs to treat heart rhythm disorders (arrhythmias) Antiarrhythmic drugs, anticoagulants (for atrial fibrillation), beta blockers, calcium channel blockers, digitalis drugs Drugs to treat high blood pressure(hypertension) ACE inhibitors, alpha blockers, alpha and beta blockers, beta blockers, calcium channel blockers, centrally acting drugs, combination drugs, diuretics, peripheral adrenergic antagonists, vasodilators Drugs to treat high cholesterol Cholesterol-lowering agents Post-heart attack drugs Anticoagulants, thrombolytic, and anti-platelets; beta blockers Post heaty-valve replacement drugs Anticoagulants

Purpose Used in Hypertension Used in Angina Pectoris and MI Used in Shock Used in Arrhythmias Used in CHF Antihypertensive drugs The Drugs employed to control hypertension can be classified as: Diuretics Beta-blockers Alpha adrenergic blockers Calcium channel blockers Angiotensin-converting enzyme inhibitors Angiotensin II receptor blockers Peripheral vasodilators Common Drugs in HPN IN Evaluating the effectiveness of these drugs is simply to monitor the BP if it becomes NORMAL 1. The Beta-Blockers (B1) These agents are antagonist of the beta- receptors of the sympathetic nervous system. They reduce cardiac output by diminishing the sympathetic nervous system response and sympathetic tone. Vascular resistance and heart rate decrease causing reduced blood pressure. Beta-blockers can either block the beta- receptor, beta 2 receptor or BOTH. The selective beta-blockers (B1) are specific to one type of receptor only. The following are the common beta-blockersNon-selective (B1 and B2) Propranolol Carteolol Nadolol Penbutolol Pindolol Timolol Selective and Specific (B1) Acebutolol Atenolol Betaxolol Bisoprolol Metoprolol Pharmacodynamics: the mechanism of action of the beta-blockers These agents block the betaadrenergic receptors in the body, thereby decreasing the heart rate and in turn, the blood pressure. The non-selective agents block both Beta1 and 2 receptors causing bronchial constriction. The onset of action is 30 minutes and the duration may range from 6-12 hours. Clinical Indications of the beta-blockers Hypertension Angina pectoris Myocardial infarction Contraindications and precautions these agents are not given to patients with: Heart blocks Bradycardia Congestive heart failure Chronic obstructive pulmonary disease

Diabetes Side effects and adverse effects CVS- Bradycardia, Hypotension, rebound hypertension when abruptly stopped RespiBronchoconstriction, bronchospasms Others- insomnia, depression, nightmares, constipation Impaired ability of the liver to convert glycogen to glucose causing HYPOGLYCEMIA! Implementation Monitor patient s vital signs. Take the heart rate before giving the drug Instruct the patient to take the drug as prescribed. Warn not to abruptly stop the medication Suggest to avoid over-the-counter medications Give health teaching as to name of drug, dosages and side effects. Remind client NOT to change position abruptly as to avoid orthostatic Hypotension Alert diabetic clients of the possible hypoglycemic effect Inform that this can cause sexual dysfunction Advise client to utilize other means to control blood pressure such as diet modification, exercise, lifestyle changes, etc Advise to eat high fiber foods to counter- act constipation 2. The Angiotensin Converting Enzyme Inhibitors These are commonly called ACE inhibitors because the agents BLOCK the conversion of AI to AII in the LUNGS. These agents alter one of the mechanisms of blood pressure control- the RAAS or reninangiotensin-aldosterone system. Angiotensin II is a very powerful vasoconstrictor and stimulus for the release of aldosterone. The Angiotensin Converting Enzyme Inhibitors Pril Benazepril Captopril- prototype Enalapril Enalaprilat Fosinopril Lisinopril Moexipril Quinapril Ramipril Trandorapril Pharmacodynamics: The mechanism of action of the ACE inhibitors These agents prevent the conversion of angiotensin I to angiotensin II by inhibiting the enzyme in the lungs- the angiotensin converting enzyme. The action leads to decreased AII and decreased aldosterone level leading to a decrease in blood pressure. The Prils Pharmacodynamics: The mechanism of action of the ACE inhibitors The effect of lowering the blood pressure is attributed to the decrease in cardiac workload and decrease peripheral resistance and blood volume. Clinical indications of the ACE inhibitors Hypertension, either alone or in combination with other agents. Congestive heart failure, left ventricular dysfunction Diabetes Contraindications and Precautions in the Use of ACE inhibitors Presence of allergy is a clear contraindication. The ACE inhibitors are NOT given to patients with renal dysfunction because these drugs may cause further decrease in renal blood flow. If given to pregnant women, the drugs cross the placenta and produce renal abnormalities in the fetus. Pharmacodynamics: the adverse effects CVS- reflex tachycardia, chest pain, angina, cardiac

arrhythmias CNS- dizziness, drowsiness, and lightheadedness GIT- GI irritation, nausea, vomiting, peptic ulcer, constipation and liver damage Renal- renal insufficiency, proteinuria Others- rash, photosensitivity, dermatitis and alopecia, sodium excretion and potassium retention, fatal pancytopenia. COUGH- this cough is really unrelenting and bothersome. Implementation The nurse should encourage the patient to implement lifestyle changes such as weight reduction, smoking cessation, decreased intake of alcohol, dietary restriction of salt/fats and increased exercise. Give the drug on an empty stomach, either 1 hour before or 2 hours after meals to ensure proper drug absorption Monitor the patient who is at risk of developing fluid volume alteration Provide comfort measures like safety Precaution, environmental control, skin care, oral care and symptomatic relief of cough. Provide patient teaching including the name of drug, dosage, measure to handle adverse effects and the warning signs to report. Stress the importance of NOT abruptly stopping the medication if symptoms are improving. Caution the patient to change position slowly and to avoid hazardous or delicate tasks and driving if drowsiness is a problem 3. The Angiotensin II Receptor Blockers These are SELECTIVE agents that specifically bind to the angiotensin II receptors in the blood vessels and adrenal cortex to prevent the release of aldosterone and to prevent vasoconstriction. Prototype: Losartan Candesartan Irbesartan Losartan Telmisartan Valsartan Pharmacodynamics- The mechanism of action of the A-R-B These agents work by attaching to the Angiotensin II receptors in the vascular smooth muscles and in the adrenal gland. The action results in VASODILATION because AII action (constriction) is inhibited and BLOCKAGE of aldosterone release Clinical Use of the A-R-B Hypertension, either alone or in combination. These agents are also used if the patient cannot tolerate the unrelenting cough associated with ACE inhibitors. Contraindications and precautions associated with the A-R-B These agents are contraindicated in the presence of allergy. It is NOT GIVEN to pregnant mothers because of the associated FETAL DEATH and severe fetal abnormalities. Lactating women should also avoid these drugs because they can affect the neonate. Pharmacodynamics: the adverse effects CNS- headache, dizziness, weakness, syncope and orthostatic Hypotension GIT- Diarrhea, abdominal pain, nausea, dry mouth and tooth pain Respiratory- mild cough Skin- rash, dry skin and alopecia. Implementation Encourage the patient to implement lifestyle changes, including weight loss, smoking cessation, decrease in alcohol and salt in the diet, and increased exercise, to increase the effectiveness of antihypertensive therapy. Administer without regard to meals; give with food to decrease GI distress if needed. Alert the surgeon and mark the patient's chart prominently if the patient is to undergo surgery to alert

medical personnel that the blockage of compensatory angiotensin II could result in hypotension following surgery that needs to be reversed with volume expansion. Ensure that the patient is not pregnant before beginning therapy and suggest the use of barrier contraceptives while on this drug to avert potential fetal death or abnormalities that have been associated the these drugs. Find an alternative method of feeding the baby if patient is nursing to prevent the potentially danger- block of the renin- angiotensin system in the neonate. Monitor the patient carefully in any situation that might lead to a drop in fluid volume (e. g., excessive eating, and vomiting diarrhea, dehydration) to detect treat excessive hypotension that may occur. Provide comfort measures to help the patient tolerate drug effects (e.g., small, frequent meals; access to bathroom facilities; safety precautions if CNS effects occur environmental control; appropriate skin care needed; analgesics as needed). 4. Calcium channel blockers These agents prevent the movement of calcium into the cardiac and smooth muscle cells when the cells are stimulated. This blocking of calcium will interfere with the muscle cell's ability to contract, leading to a loss of smooth muscle tone, vasodilation, and a decrease in peripheral resistance. These effects will decrease blood pressure, cardiac workload, and myocardial oxygen consumption. Calcium channel blockers are very effective in the treatment of angina because they decrease the cardiac workload. Pharmacodynamics: Mechanism of action Calcium channel blockers inhibit the movement of calcium ions across the membranes of myocardial and arterial muscle cells, altering the action potential and blocking muscle cell contraction. This effect will depress myocardial contractility, slow cardiac impulse formation in the conductive tissues, and relax and dilate arteries, causing a fall in blood pressure and a decrease in venous return.

The calcium channel blockers that are used in the treatment of hypertension include the following: The -dipine and others Diltiazem (Cardizem, Tiamate) Verapamil Amlodipine (Norvasc) Felodipine (Plendil) Isredipine (DynaCirc) Nicardipine(Cardene) Nifedipine (CALCIBLOC, Procardia XL)prototype! Nisoldipine (Sular) CONTRAINDICATION and PRECAUTIONS These drugs are contraindicated in the presence of allergy to any of these drugs With heart block or sick sinus syndrome because these could be exacerbated by the conductionslowing effects of these drugs With renal and hepatic dysfunction, which could alter the metabolism and excretion of these drugs; and with pregnancy and lactation because of the potential for adverse effects on the fetus and neonate. EFFECTS The adverse effects associated with these drugs are related to their effects on cardiac output and on smooth muscle. CNS effects include dizziness, lightheadedness, headache, and fatigue. GI problems can include nausea and hepatic injury related to direct toxic effects hepatic cells. Cardiovascular effects include hypotension, bradycardia, peripheral edema, and heart block. Skin flushing and rash may also occur The main use of calcium channel blockers is the treatment of angina Also in hypertension Also in

vascular spasm= Raynauds IMPLEMENTATION Monitor blood pressure carefully while patient is on therapy because of increased hypotensive episodes If possible, obtain serial ECG tracing Provide comfort measures to help patient tolerate drug effects- includes serving small frequent feedings and safety precaution due to hypotension and dizziness Provide health teaching as to drug name, dosage, administration, side effects and warning manifestations to report 5. The Vasodilators Vasodilators produce relaxation of the vascular smooth muscle, decreasing peripheral resistance and reducing blood pressure. They cause the reflex tachycardia that occurs when blood pressure drops The vasodilators are used to treat severe hypertension Diazoxide (Hyperstat) Hydralazine (Apresoline) Minoxidil (Loniten) Sodium Nitroprusside (Nitropress) Tolazoline (Priscoline) Pharmacodynamics: mechanism of action of the vasodilators The vasodilators act directly on vascular smooth muscle to cause muscle relaxation, leading to vasodilation and drop in blood pressure. They are indicated for the treatment of severe hypertension that has not responded to other therapy. Contraindications and Precautions The vasodilators are contraindicated in the presence of known allergy to the drug; with pregnancy and lactation because of the potential for adverse effects on the fetus and neonate; and with any condition that could be exacerbated by a sudden fall in blood pressure, such as cerebral insufficiency. The adverse effects of the vasodilators CNS- dizziness, anxiety, headache CVS- reflex tachycardia, CHF, chest pain, edema; skin rash, lesions (abnormal hair growth with minoxidil), hypotension GI upset, nausea, and vomiting Cyanide toxicity (dyspnea, headache, vomiting, dizziness, ataxia, loss of consciousness, imperceptible pulse, absent reflexes, dilated pupils, pink color, distant heart sounds, shallow breathing) may occur with nitroprusside, which is metabolized to cyanide and which also suppresses iodine uptake and can cause hypothyroidism. IMPLEMENTATION Encourage the patient to implement lifestyle changes, including weight loss, smoking cessation, decrease in alcohol and salt in the diet, and increased exercise, to increase the effectiveness of antihypertensive therapy. Monitor blood pressure closely during administration to evaluate for effectiveness and to ensure quick response if blood pressure falls rapidly or too much. Monitor blood glucose and serum electrolytes to avoid potentially serious adverse effects. Monitor the patient carefully in any situation that might lead to a drop in fluid volume (e.g., excessive sweating, vomiting, diarrhea, dehydration) to detect and treat excessive hypotension that may occur. Provide comfort measures to help the patient tolerate drug effects (e.g., small, frequent meals, access to bathroom facilities safety precaution if CNS effects occur, environmental control, appropriate skin care as needed, analgesic as needed).

Provide thorough patient teaching Offer support and encouragement to deal with the diagnosis drug regimen. 6. Drugs for the Treatment of Congestive Heart Failure Vasodilators- Nitrates that act to directly relax vascular muscle tone and cause decrease in blood pressure with pooling of blood in the veins. The preload and afterload will be decreased ACE inhibitors- are agents that block the conversion of angiotensin I to angiotensin II. The result is blockage of the vasoconstriction and decreased blood volume. The afterload will be decreased. Diuretics are employed to decrease the blood volume, which decreases the venous return and the blood pressure. The results are decreased preload and decreased afterload. Beta stimulators will stimulate the beta receptors in the sympathetic nervous system, increasing the myocardial contraction- called positive inotropic effect. Cardiotonic drugs- these agents affect the INTRACELLULAR calcium levels in the heart muscles leading to increased contractility . The result is increased cardiac output, increased renal blood flow, increased perfusion and increased urine formation. The cardiotonic drugs are: the cardiac glycosides and the phosphodiesterase inhibitors. 7. The cardiac glycosides These are agents extracted from the foxglove plant. They are available in oral and parenteral preparations. The following are the cardiac glycosides: Digoxin (Lanoxin) Digitoxin (Crystodigin) Ouabain Pharmacodynamics: the Mechanism of action They increase the level of CALCIUM inside the cell by inhibiting the Sodium- Potassium pump. More calcium will accumulate inside the cell during cellular depolarization. Positive inotropic Effect- the myocardium will contract forcefully Increased cardiac output Increased blood flow to the body organs like the kidney and liver Negative chronotropic effect- the heart rate is slowed due to decreased rate of cellular repolarization Bradycardia Decreased conduction velocity through the AV node Clinical Use of the cardiac glycosides Treatment of congestive heart failure Treatment of dysrhythmias like atrial flutter, atrial fibrillation and paroxysmal atrial tachycardia Contraindications and Precautions Contraindicated in the presence of allergy to any cardiac glycoside. They are NOT given to patients with ventricular dysrhythmias, heart block or sick sinus syndrome, aortic stenosis, acute MI, electrolyte imbalances (HYPOKALEMIA, HYPOMAGNESEMIA and HYPERCALCEMIA) and renal failure (may cause accumulation of drug) Pharmacodynamics: the Adverse Effects of the Cardiac glycosides CNS- Headache, weakness , seizures and drowsiness CVS- arrhythmias If digitalis toxicity is developing- the nurse must assess the following adverse effects: Anorexia, nausea and vomiting, visual changes- YELLOW halo around an object, and palpitations or very slow heart rate

Drug-Drug Interactions If taken with Verapamil, Amniodarone, quinidine, quinine, erythromycin and tetracyclines- can increase the risk of INCREASED effects of digitalis. If taken with potassium-losing diuretics like furosemide- can INCREASE the risk of toxicity and arrhythmias. Potassium replacement must be given. If given with cholestyramine, charcoal and colestipol- can cause impaired absorption of digitalis Implementation Administer the initial rapid digitalization and loading dose as ordered intravenously Monitor the APICAL pulse rate for ONE full minute before administering the drug. Withhold the drug if Less than 60 in adults Less than 90 in infants More than 110 in adults Retake pulse in one hour, if pulses remain abnormal, refer! Check the spelling of the drug- DIGOXIN is different from DIGITOXIN! Check the dosage preparation and the level of digitalis in the blood. (Therapeutic level is 0.5 to 2.0 nanograms/mL) Administer intravenous drug VERY slow IV over 5 minutes to avoid arrhythmias. Do NOT administer intramuscularly because it can cause severe pain Administer the drug without food if possible to avoid delayed absorption. Weight patient daily to determine fluid retention Maintain emergency equipment and drugs= Potassium salts, Lidocaine for arrhythmias, phenytoin for seizures, atropine for bradycardia. Provide comfort measures- small, frequent meals, adequate lighting, comfortable position, rest periods and safety precautions Provide health teaching- drug name, action, dosage and side effects. Advise the patient to report any of the following: Visual changes, rapid weight gain, unusually low heart rate, persistent nausea, vomiting and anorexia Monitor serum potassium level Evaluation Evaluate effectiveness of the drug: Increased urine output Normal heart rate in arrhythmia 8. The Antianginal drugs In the treatment of angina, three agents are commonly employed- Organic nitrates Beta-blockers and Calcium-channel blockers. The benefits of the drugs lie in their different mode of action. The nitrates can cause vasodilatation of the veins and to some extent, coronary artery Beta-blockers will decrease the heart rate Calcium-channel blockers will decrease force of contraction leading to a decreased myocardial workload and demand. They can also produce vasodilation Anti anginal drugs are effective if the chest pain is relieved 9. The Organic nitrates These agents are simple nitric and nitrous acid esters of alcohols. Being alcohol, they differ in their volatility. The following are the nitrates commonly used: Nitroglycerin- A moderately volatile nitrate Isosorbide Dinitrate (Isordil) or mononitrate Amyl nitrate- an extremely volatile nitrate The Organic nitrates Nitroglycerin This agent is supplied in oral, spray, transdermal and ointment preparations. Pharmacodynamics: the mechanism of action Nitroglycerin relaxes the smooth muscles in the vascular system by its conversion to nitric oxide, a chemical mediator in the body that relaxes smooth muscles.

Administered nitrates Increased nitrates in the blood increased formation of nitric oxide increased cGMP formation increased dephosphorylation of myosin Vascular smooth muscle relaxation vasodilatation Pharmacokinetics- absorption to excretion It can be given orally, parenterally and topically. The onset of action of nitroglycerin is more than 1 hour. Because significant first-pass hepatic effect, Nitroglycerin is given SUBLINGUALY. Pharmacodynamics: Side effects and adverse effects HEADACHE is the most common effect of nitroglycerin. CVS- postural Hypotension, facial flushing, tachycardia TOLERANCE- the tolerance to the actions of nitrates develop rapidly. This can be managed by providing a day of abstinence. Monitor vital signs, especially watchful for hypotensive episodes Advise patient to remain supine or sit on a chair when taking the nitroglycerin for the first time. Emphasize that he should change his position slowly or rise from bed slowly to avoid orthostatic Hypotension Offer sips of water before giving sublingual nitroglycerin because dryness may inhibit drug absorption Apply nitroglycerin ointment to the designated mark on paper. The nurse should remove any excess ointment on the skin from the previous dose. She should NEVER USE her bare fingers because the drug can be absorbed, utilize gloves or tongue blades instead. Apply nitroglycerin patch to an area with few hairs. Never touch the medication portion. The patch and the ointment should NOT be applied near the area for defibrillation because explosion and skin burns may result Emphasize that tolerance to the nitroglycerin can occur. If the medication cannot relieve the pain, report to the hospital immediately. Provide client health teaching- the sublingual nitroglycerin tablet is USED if chest pain occurs The dose may be repeated if pain is unrelieved within 5 minutes. Repeat the medication administration if the pain has not yet subsided. DO NOT give more than 3 tablets!!! If chest pain persists for more than 15 minutes, hospital consult should be done immediately. Instruct the client to avoid alcohol while taking nitroglycerin to avoid potentiating the hypotensive effect of the medication If beta blockers and calcium-channel blockers are given, instruct the patients to consult the physician before discontinuing the medication Other components of health teaching for home self-administration: If taking Sublingual Nitroglycerin, the patient should be instructed to place the tablet under the tongue for quick absorption. A burning sensation/biting/stinging sensation may indicate that the tablet is FRESH! Store the tablet in a dark container, keep it away from heat and direct sunlight to avoid lessening the potency Other components of health teaching for home self-administration: HEADACHES are common in the initial period of nitroglycerin therapy. Advise patient to take PARACETAMOL for relief The nitroglycerin patch is applied once a day, usually in the morning. The sites should be rotated, in the chest, arms and thighs avoiding hairy areas. Other components of health teaching for home self-administration: Position supine with elevated legs to manage Hypotension. Nitroglycerin tablet can be taken prophylactically in situations where chest pain is anticipated- Sex, exercise, etc.. If patient is taking beta blockers, instruct how to obtain heart rate in a minute 10. Drugs for Shock Dopamine

This is a sympathomimetic drug often used to treat Hypotension in shock states that are not caused by Hypovolemia. This drug is an immediate precursor of nor-epinephrine, occurs naturally in the CNS basal ganglia where it functions as a neurotransmitter. Pharmacodynamics: It can activate the alpha and beta adrenergic receptor depending upon the concentration. It stimulates receptors to cause cardiac stimulation and renal vasodilation. The dose range is 1-20 micrograms/kg/min Pharmacokinetics: Dopamine is administered IV, excreted in the urine. At low dose (1-2 micrograms), dopamine DILATES the renal and mesenteric blood vessels producing an increase output (dopaminergic effect) At moderate dose of 2-10 micrograms, dopamine enhance cardiac output by increasing heart rate (beta 1-adrenergic effect) and elevates blood pressure through peripheral vasoconstriction (alpha adrenergic effect) At higher doses of more than 10 micrograms- vasoconstriction of all vessels will predominate that can lead to diminished tissue perfusion Dopamine is indicated to treat Hypotension, to increase heart rate and to increase urine output (given less than 5 mg/kg/min) The nurse typically prepares the dopamine drip- dopamine (at a concentration of 400-800 mg) is mixed in 250 mL D5W and administered as drip via an infusion pump for precise dosage administration. Sodium bicarbonate will inactivate the dopamine Pharmacodynamics: side effects- Tachycardia hypertension ectopic beats, angina dysrhythmias, myocardial ischemia, nausea and vomiting. Nursing consideration Check the IV site hourly for signs of drug infiltration of dopamine, which can cause severe tissue necrosis. Phentolamine should be infiltrated in multiple areas to reduce tissue damage. Drug is effective if Urine output is increased and BP is increased 11. Anti-Arrhythmias Arrhythmias (sometimes called Dysrhythmias) are conduction dysfunctions caused by abnormalities in impulse generation or impaired transmission of the impulses. They are simply deviations from the normal rate or pattern of the heartbeat. Anti-Arrhythmias Four things may happen during arrhythmias: The heart will beat too FAST (tachycardia, either the atrium or the ventricle) The heart will beat too slow (bradycardia) The heart will respond to other impulses generated by the cardiac cells (other than the SA node) The heat will respond to impulses traveling along extra pathways Anti-Arrhythmias Anti-arrhythmic agents are given to modify impulse generation and conduction. The desired action of these antidysrhythmics is to restore the cardiac rhythm to normal. They affect the action potential of the cardiac cells, altering their automaticity, conductivity, or BOTH Because the anti-arrhythmic drugs affect the conduction system, they also can produce ARRHYTHMIAS! They are also Pro-Arrhythmics! The classes of anti-arrhythmic agents: Class 1 agents - are fast SODIUM channel blockers that affects the depolarization phase. Class 2 agents- are BETA blockers that affect the depolarization. Class 3 agents- are POTASSIUM channel blockers that diminish the outward potassium current during repolarization of cardiac cells. Class 4 agents- are calcium channel blockers that decrease the calcium influx into the specialized cardiac muscle cells causing slowed

conduction Class 1 agents - Class 1 A- Quinidine, Procainamide, Disopyramide, Moricizine Class 1 BLidocaine, Mexiletine, Tocainide Class 1 C- Encainide, Flecainide, propafenone Class 2 agents- are BETA blockers that affect the depolarization. They decrease the conduction velocity, automaticity and recovery time. Examples are: Propranolol, Metoprolol, pindolol, acebutol and esmolol Class 3 agents- are POTASSIUM channel blockers that diminish the outward potassium current during repolarization of cardiac cells. They increase the refractory period and prolong the action potential. Examples are: sotalol, bretylium, amniodarone Class 4 agents- are calcium channel blockers that decrease the calcium influx into the specialized cardiac muscle cells causing slowed conduction. They increase the refractory period of the AV node, which decreases the ventricular response. The examples of calcium channel blockers are diltiazem and verapamil Miscellaneous- digoxin and adenosine General Nursing Process for Anti-arrhythmics Assessment Patient History- the nurse obtains health and drug histories. She should elicit symptoms of shortness of breath, heart palpitations, coughing, chest pain, previous angina or dysrhythmias, and the current medications. Physical Examination- the nurse performs assessment and baseline monitoring Laboratory examsthe nurse obtains ECG results and cardiac markers- CK-MB, AST and LDH) Nursing Diagnoses Alteration on perfusion: decreased cardiac output Alteration in thought processes and sensoryperceptual alteration Anxiety related to irregular heartbeat Risk for activity intolerance Risk for injury related to CNS effects Knowledge deficit regarding drug therapy Planning The client will no longer experience abnormal cardiac rhythm The client will comply with the drug regimen Monitor Vital signs especially BP and HR. Patient can develop Hypotension Administer the parenteral drugs slow IV for a period of 2-3 minutes Monitor ECG for abnormal patterns and report findings. Instruct to report palpitations and abnormal cardiac rate Maintain life support equipment on stand by to treat severe adverse reactions that might occur Establish safety precautions- side rails, lighting, and noise control. Provide client teaching. Instruct the client to take the prescribed drug as ordered. Emphasize the client to avoid alcohol, caffeine and tobacco. Alcohol can intensify the hypotensive effects, caffeine increases the cathecolamine levels and tobacco can promote vasoconstriction. Instruct the client to report side effects including dizziness, faintness, and nausea and vomiting. Evaluation Evaluate the effectiveness of the prescribed anti-dysrhythmic by comparing heart rates with baseline heart rate. Assess the client s response to the drug.

Monitor for adverse effect- sedation, Hypotension, cardiac arrhythmias, respiratory depression, CNS effect. Evaluate the effectiveness of the teaching plan. Monitor the effectiveness of comfort measures and compliance to regimen. 12. Anticoagulants These drugs are sometimes referred to as blood thinners, but this term is not truly accurate. They inhibit the ability of the blood to clot preventing clots from forming in blood vessels and from getting bigger. Under a number of different circumstances, it becomes necessary to stop clotting. Anticoagulants, antiplatelet agents, and thrombolytics each have specific indications and uses. Any patient who has had a heart valve replaced with a mechanical valve (see Chapter 13) requires lifelong oral anticoagulants in order to prevent clots from forming on the valve. Patients who develop atrial fibrillation (see Chapter 16) may require anticoagulants; clot formation in the left atrium is a potential hazard of this rhythmic disturbance. Oral anticoagulants are prescribed for patients who develop thrombophlebitis, an inflammation of the veins in the legs or pelvis. (See Chapter 17.) One of the dangers of this condition is the development of blood clots that may travel to the lungs and cause pulmonary emboli. Lastly, some patients who have a serious heart attack involving the front surface of the heart are prescribed an anticoagulant to prevent clots from forming on the inner lining of the scar. Heparin is an anticoagulant that is administered intravenously when rapid anticoagulation is necessary. All patients undergoing open-heart surgery are treated with heparin while their blood is being oxygenated by the heart-lung machine. At the end of the operation, medication is given to reverse the effects of heparin. (See Chapter 11.) When a person first develops thrombophlebitis, heparin is often used because its action is almost immediate. It also is used in people who have had a heart attack and have been treated with thrombolytic therapy. Keeping the affected artery open often requires vigorous anticoagulation. Aspirin is not an anticoagulant but has a profound effect on a component of the blood called platelets blood cells that stick together and cause clots to form. Platelets are important in blood clotting and are in large part responsible for allowing us to stop bleeding when we cut ourselves. Platelets are also in part

responsible for the formation of a clot in a coronary artery-a phenomenon that initiates many heart attacks. Because of aspirin s ability to inhibit the clotting action of platelets, it is designated as an antiplatelet and is frequently prescribed in patients who have recovered from a heart attack, in order to prevent clots from forming in the veins used for coronary bypass surgery. The most recent and exciting class of drugs that are useful for people with heart attacks are the thrombolytic drugs. These agents are given intravenously as soon as possible with the goal of dissolving the METHODS OF TREATMENT offending clot within a coronary artery. A patient having a heart attack can be helped considerably if the clot can be dissolved before it causes permanent, debilitating damage. The three most commonly used thrombolytics are t-PA, streptokinase, and APSAC. They are generally used only in hospitals or in emergency situations. EXAMPLES OF ANTICOAGULANTS, ANTIPLATELETS, AND THROMBOLYTICS Generic name (trade names): acetylsalicylic acid or aspirin (Alka-Seltzer, Anacin, Ascriptin, Bayer, Bufferin, Easprin, Ecotrin, St. Josephs, Zorprin) Description: It is a nonnarcotic analgesic and antiplatelet used since 1899. Effects: Helps prevent blood clots. Also treats pain, fever, arthritis, colds, menstrual cramps, headaches, and joint and muscular aches. Possible side eflects: Indigestion is the most common side effect. Dosage: to inhibit clotting, 81 mg to 325 mg per day Notes: l Aspirin can cause Reye s syndrome, a rare brain and liver disorder that usually occurs in children. Aspirin may increase the effect of other anticoagulant drugs. Generic name (trade name): dipyridamole (Persantine) Description: It is an antiplatelet and antianginal drug first introduced in the late 1970s. Effects: Helps keep blood clots from forming in people

who have just had a heart attack, heart surgery, a stroke, or a heart valve replacement (usually given with aspirin or warfarin). Possible side effects: Adverse effects are rare, but may include nausea, headache, flushing, dizziness or faintness, or rash. Note: l Dipyridamole may increase the effect of other anticoagulants. Generic name (trade names): warfarin (Coumadin, Panwarfin) Description: Warfarin is the prototype oral anticoagulant. It and some drugs related to it have been used for nearly 50 years. Effects; Prevents blood clots, especially in the leg and pelvic veins where blood flow is at its slowest. Also used in people with atria] fibrillation or after a heart valve replacement. Possible side effects: Excessive bleeding is the most common adverse effect. Nausea or vomiting, loss of appetite, abdominal pain or diarrhea, rash or bruising, and hair loss are also possib!e. Note: l Interacts with a variety of drugs. Check with your physician and pharmacist. Diphtheria in children 1 746 ViewsDiphtheria is a serious bacterial infection, usually affecting the mucous membranes of nose and throat. Diphtheria typically causes a bad sore throat, fever, swollen glands and weakness. But the hallmark sign is a thick, gray covering in the back of throat that can make breathing difficult. Diphtheria can also infect your skin.

Diphtheria Why do you get diphtheria? The disease is mainly transmitted by: y Droplets from the nose or throat being passed from person to person, egg by coughing or sneezing. y Contaminated personal items, such as tissues or drinking glasses that have been used by an infected person (occasionally) y Contaminated household items, such as towels or toys (rarely). What are the symptoms of the disease? The incubation period, which is the time that elapses between a person being infected and the disease developing, is usually two to five days. Signs and symptoms of diphtheria may include: y A sore throat and hoarseness y Painful swallowing y Swollen glands (enlarged lymph nodes) in your neck y A thick, gray membrane covering your throat and tonsils y Difficulty breathing or rapid breathing y Nasal discharge y Fever and chills y Malaise. Risk factors: y Children younger than 5 years old and adults older than 60 are particularly at risk of contracting diphtheria, as are: y Children and adults who don't have up-to-date immunizations y People living in crowded or unsanitary conditions y Undernourished people y People who have a compromised immune system Skin (cutaneous) diphtheria: A second type of diphtheria can affect the skin. A wound infected with bacteria is typically red, painful and swollen. A wound infected with diphtheria-causing bacteria also may have patches of a sticky, gray material. Diagnosis: Throat swab and culture. Complications: y Breathing problems: Diphtheria-causing bacteria may produce a poison (toxin). This toxin damages tissue in the immediate area of infection the nose and throat, for example. This localized infection produces a tough, gray-colored membrane which is composed of dead cells, bacteria and other substances on the inside of your nose and throat. This tough membrane, or covering, is dangerous because it can obstruct breathing. y Heart damage: The diphtheria toxin may spread through your bloodstream and damage other tissues in your body, such as your heart muscle. One complication of diphtheria is inflammation of the heart muscle (myocarditis). Signs and symptoms of myocarditis include fever, vague chest pain, joint pain and an abnormally fast heart rate. y Kidney damage: The diphtheria toxin may damage the kidneys, affecting their ability to filter wastes from the blood. y Nerve damage: The toxin can also cause nerve damage, targeting certain nerves such as those to the throat, making swallowing difficult. Nerves to the arms and legs may also become inflamed,

causing muscle weakness. In severe cases, nerves that help control the muscles used in breathing may be damaged, leading to paralysis of these muscles and trouble breathing. Treatment: y Diphtheria anti toxin: The antitoxin neutralizes the diphtheria toxin already circulating in your body. The antitoxin is injected into a vein (intravenously) or into a muscle (intramuscular injection). y Antibiotics: Diphtheria is also treated with antibiotics, such as penicillin or erythromycin. Antibiotics help kill bacteria in the body, clearing up infections. Patients with allergies to penicillin G or erythromycin can use rifampacin or clindamycin. Prevention: Diphtheria vaccine is given in combination with pertussis and tetanus as DPT vaccine at 6, 10, 14 weeks. Pertussis In Children What is pertussis? y Pertussis is an infection of the nose, throat, and lungs. It is also called whooping cough. With pertussis, air passages narrow and get plugged with thick sputum (spit). This may cause your child to have coughing spells. Anyone can have pertussis, but it is most serious in babies and young children. A baby may get pertussis before he is old enough to get the shots to prevent the infection. y Pertussis is not common because most children get shots (immunizations) to prevent the disease. The DTaP vaccine protects your child against diphtheria (D), pertussis (aP), and tetanus (T). This vaccine is usually given in a series of 5 shots before a child is 6 years old. Teenagers and young adults lose DPT protection as they age. They should receive a booster shot with the Tdap vaccine to help protect them. What causes pertussis? Pertussis is caused by a germ called a bacteria. It is easily spread in the air from someone with pertussis who coughs or sneezes. It may take 3 to 21 days to get pertussis after coming in contact with the bacteria. This time is called the incubation period. What are the signs and symptoms of pertussis? Pertussis begins like a cold. After a coughing spell, it may seem like your child cannot get his next breath. When the coughing ends and your child takes a breath, he may make a "whooping" noise. When coughing, his face or fingertips may turn red, blue, or white because he is not getting enough oxygen. This part of the disease may last 14 days or longer. After 2 to 4 more weeks, your child will begin to feel better. The cough may last 1 to 3 months. Your child may also have the following signs and symptoms: y A cough that may worsen after 7 to 14 days y Higher than normal body temperature y Mouth drooling y No interest in eating or drinking y Vomiting (throwing up) because of the coughing y Red or watery eyes y Sneezing and a stuffy nose y Tiredness How is pertussis treated? y Antibiotic medicine: Antibiotic medicine may be used to treat pertussis after coughing begins. y Drink extra liquids: Encourage your child to drink small amounts of fluids every hour when awake. This will help prevent him from becoming dehydrated. Dehydration is caused by not drinking enough liquid, or by losing too much body water. Body water can be lost with diarrhea, vomiting, or high fevers. Signs of dehydration include dry skin and mouth, and dark urine or less

urine than usual. Good liquids for most people to drink are water, some fruit juices, and decaffeinated sports drinks. Limit the amount of caffeine that your child drinks. Caffeine may be found in coffee, tea, and in some soda pops, sports drinks, and foods. Read the food and drink labels to learn if they contain caffeine. y Fever: Your child can take acetaminophen or ibuprofen for fever. Do not give your child other over-the-counter (OTC) medicines without first talking to your child's caregiver. Some of these medicines also contain acetaminophen. Taking too much acetaminophen can hurt your child's liver. Do not give your child aspirin. It may cause a serious disease called Reye syndrome. Read medicine labels to see if your child's medicine has aspirin. Aspirin may also be called salicylate or acetylsalicylate. y Food: Older children should eat a variety of healthy foods, including fruits, vegetables, breads, dairy products, meat, and fish. Eating healthy foods may help your child feel better and have more energy. It may also help him get better faster. If your child is not hungry or tires easily, try feeding him smaller amounts more often. y Hospital: Babies and young children are more likely to have serious breathing problems with pertussis. They may need to go into the hospital for tests and treatment. y Humidifier: Run a cool mist humidifier to increase air moisture in your child's room. Follow the humidifier instructions carefully for running and cleaning it. Keep the humidifier out of your child's reach. Using the humidifier will help loosen the mucus in your child's throat and make it easier to breathe. It may also soothe your child's cough. y Nose: Use a bulb syringe to gently clean your baby's nose. Wash the bulb syringe after each use. Clean out your baby's nose before breast or bottle feeding so he can breathe easier while feeding. You may need to feed your baby smaller amounts more often if he gets tired during feedings. Clean your baby's nose before putting him down to sleep. y Rest: Your child should rest as much as possible. Try to keep your child calm. His breathing and coughing may become worse if he is crying and afraid. How can I keep my child from spreading pertussis to others? y Your child should stay away from others if he has signs and symptoms of pertussis. He should also stay away from others if he has had contact with someone with pertussis. Call your child's school or day care to tell them that your child has pertussis. Your child should not return to school or day care until your caregiver has said it is OK. y Ask your child's caregiver if family members or others need to receive antibiotic medicine or a booster shot. This may prevent them getting pertussis. How can pertussis be prevented? Pertussis can be prevented by getting the DTaP or Tdap vaccine. y DTaP vaccine: This vaccine is given to help prevent diphtheria, tetanus, and pertussis (whooping cough). Children usually get 5 doses of the vaccine. These should be given at ages 2, 4 and 6 months, between 15 and 18 months, and between 4 and 6 years. y Tdap vaccine: This vaccine is a booster shot used to help prevent diphtheria, tetanus, and pertussis (whooping cough) in older children and adults. This booster vaccine is given only once to adolescents (11 years of age or older) who have been vaccinated for it before. It is also given only once to adults who have been vaccinated for it before or who do not know if they have had it before.
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What are the risks of having pertussis? Pertussis is very easily spread to others. If your child has not had the DPaT shots, he may get pertussis. Pertussis may cause other serious health problems, more often in children less than 1 year old. Your child could get pneumonia or an ear infection. Rarely, it may affect your child's brain. This could cause

your child to have seizures (convulsions) which may lead to brain damage. Such complications can be very serious. Follow your caregiver's instructions. Call your caregiver if you are worried or have questions about the medicine or your child's care. Tuberculosis What Is It? Tuberculosis is a bacterial infection that kills more than 2 million people a year. Most of these deaths occur in developing countries. The bacterium that usually causes tuberculosis in humans is Mycobacterium tuberculosis. About one-third of the world's population is infected with tuberculosis. However, most do not show signs of the disease. In these people, the bacteria are inactive (latent) and cannot be transmitted to others. If the body's immune system weakens, tuberculosis can become active and cause disease. Worldwide, tuberculosis is second only to the human immunodeficiency virus (HIV) in causes of death by infectious disease among adults. Many developing countries are suffering dual epidemics of tuberculosis and HIV. The interaction between these two diseases has been labeled "Toxic synergy" because each epidemic impacts people in the same impoverished regions of the world, and because each worsens the other. People with HIV have weakened immune systems, so they are more likely to acquire a new case of tuberculosis, or to develop reactivation of latent disease. Those with tuberculosis are more likely to die if they are co-infected with HIV. Tuberculosis typically affects the lungs. But in up to one-third of infected people, particularly those with HIV/AIDS, the illness also involves other areas of the body. Common sites of infection include the lymph nodes, the membranes that cover the brain (meninges), the joints, the kidneys and the membrane covering the digestive organs (peritoneum). Tuberculosis bacteria are spread from person to person through the air. The bacteria are in droplets of secretions that come out of your mouth or nose when you cough or sneeze. One-time exposure to someone with tuberculosis is not likely to cause infection. Repeated or prolonged exposure is usually necessary. Touching someone with tuberculosis or sharing his or her utensils will not lead to infection, because the bacteria infect the lungs only when they are inhaled into the lungs. When infection occurs, a bacteria-filled droplet is inhaled into the deepest portion of the lung, where the bacteria reproduce (replicate) and spread through the body. At this point, the immune system usually can keep the bacteria from replicating any more, but usually cannot destroy them completely. The disease usually remains in this inactive or dormant state for life. People with inactive tuberculosis do not have any symptoms, and there is no way to tell they have been infected except for a special skin test. Active tuberculosis occurs in several different forms: y Primary pulmonary tuberculosis In about 5% of people, the immune system can't stop the initial tuberculosis infection. These people develop active tuberculosis within one year of exposure to the bacteria. This type of active tuberculosis is most common in infants and children, especially in developing countries with high rates of malnutrition and poor medical care. People with HIV and other diseases that suppress the immune system are also at risk. y Postprimary (reactivation) pulmonary tuberculosis About 95% of people infected with tuberculosis can inactivate the disease at first. Most of them never develop active disease. In those that do, the bacteria eventually overcome the immune system and begin to replicate and spread, usually in the lungs. The bacteria may destroy large areas of the lungs, forming cavities filled with bacteria and dead cells. y Extra-pulmonary tuberculosis Tuberculosis also can become active in other parts of the body, whether or not the lungs are involved. Common sites of infection include the bones, kidneys, lymph nodes and central nervous system.

Disseminated or miliary tuberculosis Tuberculosis can spread through the entire body by way of the bloodstream. Symptoms Most people infected with tuberculosis have inactive disease that does not cause any symptoms. In these people, a skin test for tuberculosis (called a PPD skin test, for "protein purified derivative") will show positive results within three months of getting the infection. Once a PPD is positive, it usually will remain positive throughout life. Among people with active tuberculosis, symptoms vary according to the type of disease: y Primary pulmonary tuberculosis Some people, especially young children, with this type of tuberculosis have no symptoms other than fever and fatigue. Other symptoms can include: o Cough o Chest pain o Night sweats o Poor appetite o Problems gaining weight y Postprimary (reactivation) tuberculosis Symptoms include: o Fever o Night sweats o Weight loss o Poor appetite o Weakness o Chest pain o A general sick feeling
y

There usually is also a cough, which eventually produces discolored mucus. As the illness progresses, people may cough up blood (sometimes in large amounts), become short of breath and ultimately develop severe breathing problems. y Extra-pulmonary tuberculosis Symptoms depend on where the tuberculosis has spread. For example, if tuberculosis affects the lymph nodes (about 25% of cases), it can cause swollen glands, usually at the sides and base of the neck. In tuberculosis of the bones and joints (about 8% of cases), the spine, hips and knees are the most likely sites of infection. Joints will become painful and swollen. Genitourinary tuberculosis (about 15% of cases) can cause pain in the side (between the ribs and hip), frequent urination, pain or discomfort during urination, and blood in the urine. y Disseminated or miliary tuberculosis Symptoms include: o Fever o Night sweats o Weight loss o Weakness o Lung problems (cough, shortness of breath, chest pain) Although the bacteria are spread throughout the body, there may not be any other symptoms. But if there are, they can occur nearly anywhere. Some of the more common symptoms are: y Headaches y Visual difficulties y Swollen lymph nodes y Painful joints y Scrotal masses

Skin rashes Abdominal pain Diagnosis Your doctor will ask you about symptoms such as cough, fever, weight loss, night sweats, swollen glands and breathing problems. He or she also will ask whether you have ever been exposed to anyone with tuberculosis, and if you have ever traveled to developing countries where tuberculosis is common. Your doctor will examine you. He or she will ask if you have ever had a tuberculosis skin test and what the results showed. If your doctor suspects that you have active pulmonary tuberculosis, he or she will have you get a chest X-ray. Your doctor will have you cough up samples of mucus (sputum), which will be stained with special chemicals and then examined for the presence of bacteria. The sputum also will be cultured, which means it is tested to see if tuberculosis bacteria grow. It may take up to several weeks to get the culture test result, because the bacteria grow slowly. People with extra-pulmonary tuberculosis may have a normal chest X-ray and negative stains and cultures of their sputum. In these cases, other techniques are used to help make the diagnosis including: y A blood test called QuantiFERON-Tb Gold y Culture of other bodily fluids (such as urine or fluid from the space around the lung) y Biopsy of tissue to look for characteristic changes consistent with TB y Samples examined for evidence of tuberculosis using PCR (polymerase chain reaction) Expected Duration Once someone's healthy immune system has controlled a primary tuberculosis infection, the bacteria usually will remain inactive for life. A PPD skin test may be positive in these people, indicating a history of tuberculosis infection, but the lifetime chance of developing active TB disease is only about 10%, unless your immune system is weakened by a disease such as HIV/AIDS or medications that suppress the immune system. If you develop active tuberculosis disease, it takes up to two weeks of treatment before you can no longer spread tuberculosis to other people. However, it takes at least six months to complete successful treatment. In some cases, patients are infected with strains of tuberculosis that are resistant to the most commonly used and effective antibiotics. These resistant strains can take up to 24 months to treat. Prevention In developing countries with high rates of tuberculosis, a vaccine against the disease often is given at birth. The vaccine is not used routinely in the United States and most European countries because the risk of transmission in these countries is low, and because the vaccine is not very effective. People with a positive skin test for TB (PPD) who have never received medication to prevent TB from becoming active should consider taking isoniazid (INH) for up to 9 months. Also people with HIV infection who live in parts of the world that have high rates of TB are encouraged to take isoniazid, even if they have a negative PPD. Treatment Doctors usually treat tuberculosis with a combination of four drugs, such as isoniazid (INH), rifampin (Rifadin, Rimactane), pyrazinamide (pms-Pyrazinamide, Tebrazid) and ethambutol (Myambutol). This combination is considered first line treatment. The therapy usually lasts 6 months or longer. It is very important that you take these medications as prescribed to prevent the bacteria from becoming resistant to the drugs. It is also important that all of your close contacts are screened for tuberculosis, so they can be treated if they are infected. Tuberculosis strains that are resistant to isoniazid and rifampin (the two most effective tuberculosis antibiotics) are called multidrug resistant (MDR-TB). To cure MDR-TB, patients must take combinations of "second-line" tuberculosis medications: ethionamide (Trecator-SC), moxifloxacin (Avelox), levofloxacin (Levaquin), cycloserine (Seromycin), kanamycin (Kantrex) and others. These medications are
y y

more likely to cause side effects than first-line drugs are. Also they are not as effective so they must be taken for up to two years. Extensively drug-resistant (XDR-TB) strains have been identified in many countries throughout the world. These strains are resistant to isoniazid, rifampin, the aminoglycoside drug family (such as kanamycin), and the quinolone drug family (such as levofloxacin and moxifloxacin). XDR-TB is very difficult to treat, and sometimes, surgery is necessary to remove the diseased portion of the lung. When To Call a Professional Call your doctor if you develop cough, fever, weight loss, swollen glands, night sweats or other symptoms of tuberculosis. You also should call your doctor if you have been exposed to someone with active tuberculosis. Ask your doctor about your need for routine PPD testing if you often travel to developing countries or work in an environment where tuberculosis risk is high, such as a medical facility or institution. Prognosis Tuberculosis that is not resistant to medication is almost always cured if the person complies with the treatment regimens and antibiotics are started before major parts of the lung are destroyed. People who are infected with drug-resistant tuberculosis strains may have less chance of being cured, depending on which drugs they are resistant to and how much lung damage they have before effective treatment is started. Without proper treatment, more than half of people with active tuberculosis will die within five years.