VOL: 98, ISSUE: 40, PAGE NO: 48
Julie Glyn-Jones, BSc, RGN, is team manager, community TB team, Lambeth PCT, LondonWhen Tom Smith first started to feel unwell with general tiredness and an increasing cough he ignored his symptoms and carried on as normal. He smoked heavily and had a high alcohol intake, and therefore these symptoms were not unusual. He spent most days drinking alcohol in the local park and socialising with his friends. Indeed, it was his friends who mentioned that he might have tuberculosis (TB) and should seek help.
When Tom Smith first started to feel unwell with general tiredness and an increasing cough he ignored his symptoms and carried on as normal. He smoked heavily and had a high alcohol intake, and therefore these symptoms were not unusual. He spent most days drinking alcohol in the local park and socialising with his friends. Indeed, it was his friends who mentioned that he might have tuberculosis (TB) and should seek help.
Mr Smith's drinking circle were knowledgeable about TB through access to a rolling education and TB screening service offered at the local day centre. A visit to the screening service confirmed his friends' suspicions and Mr Smith was diagnosed with infectious pulmonary TB. Approximately 70% of TB cases are in the lungs, but it can affect any part of the body (Department of Health 1996). Most clients with TB are managed as outpatients. However, due to Mr Smith's poor state of general health he was admitted to hospital to start treatment.
As a specialist TB nurse I first met Mr Smith as an inpatient. He was unhappy that he could not leave the single room he had been given. All the staff needed to wear masks, and this served to increase his sense of isolation. For an individual like Mr Smith, who was used to spending his days outside on a park bench, the confined space in hospital was almost unbearable. He was angry and initially refused to take his prescribed medication. As he was threatening to leave hospital, I planned for his discharge immediately, reasoning that he would not remain an inpatient for long.
The TB chest physician reviewed him, and the correct treatment was prescribed. I visited his home address to assess the living conditions he would return to on discharge from hospital.
To overcome some of the barriers an individual like Mr Smith can pose to completing treatment it is essential that the service is flexible and acceptable to him. Our community TB team has an integrated nursing team which works across three acute and one community trust and last year cared for over 300 people with TB. Specialist nurses see clients on the ward, in clinic and at home.
From our conversations I gleaned that Mr Smith would need very close supervision to take his medication at home. With his history of high alcohol intake I was concerned that he might forget the medication, and living on his own meant that there was no one to remind him. After discussions with the chest physician we agreed that he should be on a directly observed therapy (DOT) programme throughout his treatment.
Encouraging and supporting clients to take medication every day for six months is a regular challenge for TB specialist nurses. In the beginning up to 12 tablets need to be taken, but this number usually reduces after the first two months. If patients do not follow their treatment correctly the causative organism can become resistant to the medications, which then makes the treatment regime much more complicated and requires specialist monitoring. As clients begin to feel well after one to two months it can be difficult to ensure that treatment is taken for the whole six months. Luckily side-effects from the medication are usually not severe.
Creating a good rapport with the client and building a trusting relationship is the basis for ensuring treatment is taken correctly.
Questioning Mr Smith about his family revealed that he had a teenage daughter who visited frequently. I contacted her and asked her to attend for screening at the next clinic. Mr Smith felt protective towards his daughter and did not wish to put her at further risk. Discussing his family and the risks he posed to them if he did not follow the treatment enabled us to establish common ground. We both wanted what was best for his family. After contacting his daughter she visited him and further added weight to the fact that he should stay in hospital and comply with treatment.
However, Mr Smith discharged himself from hospital after becoming aggressive with staff. I visited him at home soon afterwards to be greeted with a flat refusal to continue with treatment. He was adamant he would not take medication and did not believe that he had TB. I visited him a second time that week with no change. It was impossible to reason with him and I left without success. After speaking with the chest physician and consultant in communicable disease we discussed admitting Mr Smith against his wishes to ensure that he posed no further risk to the public.
I tried one last time and was directed to the park where Mr Smith was socialising with his friends. He was in a good mood this time and introduced me to his circle of friends. He had told them he was better and needed no continuing treatment. I explained the risks Mr Smith posed when his friends became aware of his decision and they were shocked and angry that he was putting himself and them at risk.
After a lengthy discussion Mr Smith agreed to start treatment again. He was still infectious for the first two weeks and was advised to stay at home and not mix with others, especially children.
A colleague or I administered DOT three times a week, usually on a park bench. Some days it could be difficult to find Mr Smith, but the local network usually pointed me in the right direction. Despite initial resistance Mr Smith seemed to like seeing us and became unhappy when the regular nurses could not visit. Chatting to him and his group of friends made the visits last up to 40-50 minutes, and it was impossible to dispense with this social interaction before the tablets were taken.
Many clients do respond positively to someone who demonstrates a genuine interest in them as a person and not just in their disease. With a lot of patience and persuasion Mr Smith attended the chest clinic a few times for routine blood tests and chest X-rays, but on the whole his care was managed from the park bench.
Identifying all the individuals Mr Smith had been in contact with proved difficult. He was unhelpful at times, and many of them had no fixed address. Offering appointments in the local chest clinic was fruitless, as they did not attend. We arranged to bring forward the regular screening in the day centre to capture any individuals infected. This was publicised locally and through word of mouth.
Liaising closely with the homeless team and day centre staff meant that we invited individuals at risk to attend personally. Due to advanced age and an impaired immune system from drinking and sleeping rough this group would be particularly at risk from contracting any infectious disease. It seemed that Mr Smith had not been infectious for very long before treatment, as no other cases were detected.
The most effective way to conquer TB is to ensure there are no delays in starting treatment and that individuals are cured of the disease. The challenge it to ensure that patients take the whole course of prescribed medication and the role of the nurse is to break down the barriers that prevent some individuals achieving this.
See Respiratory news on page 59.