PULMONARY TUBERCULOSIS

Definition:

Tuberculosis, one of the oldest diseases known to Tuberculosis, one of the oldest diseases
known to affect humans, is caused by bacteria belonging to affect humans, is caused by bacteria
belonging to the Mycobacterium tuberculosis complex. The the Mycobacterium tuberculosis complex.
The disease usually affects the lungs, although in up disease usually affects the lungs, although in up to
one-third of cases other organs are involved. If to one-third of cases other organs are involved. If
properly treated, tuberculosis caused by drug- properly treated, tuberculosis caused by drug-
susceptible strains is curable in virtually all cases. susceptible strains is curable in virtually all cases. If
untreated, the disease may be fatal within 5 If untreated, the disease may be fatal within 5 years in
more than half of cases. Transmission years in more than half of cases. Transmission usually takes place
through the airborne spread usually takes place through the airborne spread of droplet nuclei produced
by patients with of droplet nuclei produced by patients with infectious pulmonary tuberculosis.

Other name:

Koch’s Disease

 In 1882, the microbiologist Robert Koch discovered the tubercle bacillus, at a time when one of
every seven deaths in Europe was caused by TB

Causative Agent:

Mycobacterium tuberculosis

 Mycobacteria belong to the family Mycobacteriaceae and the order Actinomycetales. Of the
pathogenic species belonging to the M. tuberculosis complex, the most frequent and important
agent of human disease is M. tuberculosis. The complex includes M. bovis (the bovine tubercle
bacillus, once an important cause of tuberculosis transmitted by unpasteurized milk and
currently the cause of a small percentage of cases in developing countries), M. africanum
(isolated from cases in West, Central, and East Africa), M. microti (the “vole” bacillus, a less
virulent and rarely encountered organism), and M. canettii (a very rare isolate in African cases).

 M. tuberculosis is a rod-shaped, non-spore-forming, thin aerobic bacterium measuring 0.5 µm

by 3 µm. Mycobacteria, including M. tuberculosis, are often neutral on Gram's staining.
However, once stained, the bacilli cannot be decolorized by acid alcohol, a characteristic
justifying their classification as acid-fast bacilli (AFB; ). Acid fastness is due mainly to the
organisms' high content of mycolic acids, long-chain cross-linked fatty acids, and other cell-wall
lipids.
Incubation Period:

Symptoms may occur as early as several weeks after infection, or it may occur after many years.
An infected person has the greatest risk of developing TB within the first two years after infection.

Period of Communicability:

As long as viable bacilli is being discharged in the sputum.

Clinical Signs & Symptoms:

Pulmonary Symptoms: General Symptoms:

-Dyspnea - Fatigue

-Non-productive or productive cough - anorexia

-Hemoptysis (blood tinge sputum) - Weight loss

-Chest pain that may be pleuritic or dull - low grade fever with chills and

-Chest tightness sweats (often at night)

-Crackles may be present on auscultation

Laboratory findings & Diagnostic Exam

 Tuberculin test
 Usually known as the Mantoux tuberculin skin test.
 Is a method for screening for exposure to TB infection.
 A person who has infected with TB will have developed a
hypersensitivity to the TB bacteria even they did not develop the
disease.
 Is performed by injecting a small amount of fluid (tuberculin) into skin
in the lower part of the arm.
 The skin area is inspected 48-72 hours later for a bump.
 The reaction is read by measuring the diameter of induration across the
fore arm in millimeter (mm).
 A positive response usually shown by a hard, raised bump at the
injection site – likely to have TB infection.
 Skin test are not 100% accurate and they did not always indicate the
presence of active disease.

 Chest X-ray
  A chest radiograph is used to detect chest abnormalities.
 Lesion may appear anywhere in the lungs and may differ in size, shape, density and
cavitation.
 Abnormalities may suggest TB, but cannot be used to definitively diagnose TB.
 Chest radiograph may be used to rule out the possibility of pulmonary TB in a person
who has had a positive reaction to Mantoux test and no symptoms of disease.
 Microbiological Examination
 The acid fast smear plays an important role in the early diagnosis of mycobacterial
infections.
 Microscopy is the oldest, easiest, most rapid and inexpensive procedure that can be
performed in the laboratory to detect the present of acid-fast-bacilli (AFB).
 Detection of significant number of AFB (using Ziehl-Neelsen stain) in sputum @ tissue
sample is considered a positive diagnose, although disease may confirmed by laboratory
culture of the bacterium (difficult & slow-takes at least 4 weeks).
 If bacteria that cause TB infection grow in the culture (OGAWA & LJ media), other test
may be done to determine which antibiotic will be most effective in treating the
infection – sensitivity testing.
 A positive culture for M. tuberculosis confirms the diagnosis of TB disease.

Type of Patients

1. New – patient who has never had treatment for tuberculosis or who was taken anti TB drugs for
less than one month.
2. Relapse – a patient previously treated who has been declared cured or treatment completed
and is diagnosed bacteriologically smear positive.
3. Failure – a patient who while on treatment is sputum smear positive at five months or later
during the course of treatment.
4. Transfer IN – a patient who has been transferred from another facility with proper referral or
transfer slip.
5. Return after Default – a patient who returns with positive smear following interruption of
treatment for two months or more.

Others

-a patient who is starting treatment again after interrupting treatment for more than two months
and has remained smear negative

-sputum negative patients initially who became smear positive

-chronic case refers to a patient who is sputum positive at the end of a re-treatment period

Multi Drug Resistant Tuberculosis (MDRTB) – a patient who does not respond to short course
therapy. Needs sputum culture and sensitivity to antibiotic test to determine which drugs will still be
effective.
Medical Management

The two aims of tuberculosis treatment are

1) interrupt tuberculosis transmission by rendering patients noninfectious

2) to prevent morbidity and mortality by curing patients with tuberculosis disease.

 Chemotherapeutic agents for 6-12 months

 To ensure eradication and prevent relapse

 Multidrug treatment: to prevent development of resistant strains

 Considered non-infectious after 2-3 weeks of therapy

TB DOTS

.
Nursing Management

1. Promoting Airway clearance fluid intake postural drainage

2. Advocating adherence to treatment regimen inform client about the drugs, schedule, side effects prevention of transmission
covering the mouth and nose during coughing and sneezing proper disposal of tissues hand hygiene

3. Promoting activity and adequate nutrition

• progressive activity

• small frequent meals and liquid nutritional supplements

4. Monitoring and Managing Potential Complications

a. Malnutrition: collaborate with the dietician, physician, patient and family

 provide high calorie nutritional supplement

b. Side effects of medication

 assess for side effects

 take medicines before meals or 1 hour after meals

c. Multidrug resistance

 monitor vital signs and observe for changes in clinical status

d. Spread of TB infection

 monitor vital signs and observe for spikes of fever and change in renal and cognitive function

Nursing Diagnosis: Airway Clearance, ineffective May be related to Thick, viscous, or bloody secretions Fatigue, poor cough
effort Tracheal/pharyngeal edema Possibly evidenced by Abnormal respiratory rate, rhythm, depth Abnormal breath
soundsrhonchi, wheezes), stridor Dyspnea

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Respiratory Status: Airway Patency (NOC) Maintain patent airway. Expectorate secretions without assistance. Demonstrate
behaviors to improve/maintain airway clearance. Participate in treatment regimen, within the level of ability/situation. Identify
potential complications and initiate appropriate actions.

ACTIONS/INTERVENTIONS Airway Management (NIC) RATIONALE Independent

 Assess respiratory function, e.g., breath sounds, rate, rhythm, and depth, and use of accessory muscles.
Diminished breath sounds may reflect atelectasis. Rhonchi, wheezes indicate accumulation of secretions/inability to
clear airways that may lead to use of accessory muscles and increased work of breathing.
 Expectorationmay be difficult when secretions are very thick as a result of infection and/or inadequate hydration.
Blood-tinged or frankly bloody sputum results from tissue breakdown (cavitation) in the lungs or from bronchial
ulceration and may require further evaluation/ intervention. Positioning helps maximize lung expansion and
 decreases respiratory effort. Maximal ventilation may open atelectatic areas and promote movement of secretions
into larger airways for expectoration.
 Prevents obstruction/aspiration.
 Suctioning may be necessary if patient is unable to expectorate secretions. High fluid intake helps thin secretions,
making them easier to expectorate.

Note ability to expectorate mucus/cough effectively; document character, amount of sputum, presence of hemoptysis. Place
patient in semi- or high-Fowler’s position. Assist patient with coughing and deep-breathing exercises. Clear secretions from
mouth and trachea; suction as necessary. Maintain fluid intake of at least 2500 mL/day unless contraindicated. Collaborative

Humidify inspired air/oxygen. Prevents drying of mucous membranes; helps thin

secretions.

Nursing Diagnosis: Nutrition: imbalanced, less than body requirements May be related to Fatigue Frequent cough/sputum
production; dyspnea Anorexia Insufficient financial resources Possibly evidenced by Weight 10%–20% below ideal for frame and
height Reported lack of interest in food, altered taste sensation Poor muscle tone

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Nutritional Status (NOC) Demonstrate progressive weight gain toward goal with normalization of laboratory values and be free
of signs of malnutrition. Initiate behaviors/lifestyle changes to regain and/or to maintain appropriate weight.

ACTIONS/INTERVENTIONS Nutrition Management (NIC) RATIONALE Independent

 Document patient’s nutritional status on admission, noting skin turgor, current weight and degree of weight loss,
integrity of oral mucosa, ability/inability to swallow, presence of bowel tones, history of nausea/vomiting or diarrhea.
Ascertain patient’s usual dietary pattern, likes/dislikes. Useful in defining degree/extent of problem and appropriate
choice of interventions. Helpful in identifying specific needs/strengths.
 Consideration of individual preferences may improve dietary intake. Useful in measuring effectiveness of nutritional
and fluid support. May affect dietary choices and identify areas for problem solving to enhance intake/utilization of
nutrients.
 Monitor I&O and weight periodically. Investigate anorexia and nausea/vomiting, and note possible correlation to
medications. Monitor frequency, volume, consistency of stools.
 Encourage and provide for frequent rest periods. Helps conserve energy, especially when metabolic requirements are
increased by fever. Reduces bad taste left from sputum or medications used for respiratory treatments that can
stimulate the vomiting center. Maximizes nutrient intake without undue fatigue/energy expenditure from eating large
meals, and reduces gastric irritation. Creates a more normal social environment during mealtime, and helps meet
personal, cultural preferences.
 Provide oral care before and after respiratory treatments.
 Encourage small, frequent meals with foods high in protein and carbohydrates.
 Encourage SO to bring foods from home and to share meals with patient unless.

Nursing Diagnosis: Knowledge, deficient [Learning Need] regarding condition, treatment, prevention, self-care, and discharge
needs May be related to Lack of exposure to/misinterpretation of information Cognitive limitations Inaccurate/incomplete
information presented Possibly evidenced by Request for information Expressed misconceptions about health status Lack of or
inaccurate follow-through of instructions/behaviors Expressing or exhibiting feelings of being overwhelmed

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Knowledge: Illness Care (NOC) Verbalize understanding of disease process/prognosis and prevention. Initiate
behaviors/lifestyle changes to improve general well-being and reduce risk of reactivation of TB. Identify symptoms requiring
evaluation/intervention. Describe a plan for receiving adequate follow-up care. Verbalize understanding of therapeutic
regimen and rationale for actions.

ACTIONS/INTERVENTIONS Teaching: Disease Process (NIC) RATIONALE

Independent

 Review how TB is transmitted (e.g., primarily by inhalation of airborne organisms, but may also spread through stools
or urine if infection is present in these systems) and hazards of reactivation. Knowledge may reduce risk of
transmission/reactivation. C
 omplications associated with reactivation include cavitation, abscess formation, destructive emphysema,
spontaneous pneumothorax, diffuse interstitial fibrosis, serous effusion, empyema, bronchiectasis, hemoptysis, GI
ulceration, bronchopleural fistula, tuberculous laryngitis, and miliary spread.
 DOT by community nurses is often the most effective way to ensure patient adherence to therapy. Monitoring can
include pill counts and urine dipstick testing for presence of antitubercular drug. Patients with MDR-TB may be
monitored with monthly sputum specimens for AFB smear and culture. Note: In some states, there are legal means
for involuntary confinement for care if efforts to ensure patient adherence are ineffective.
 Refer to public health agency.

POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age, physical

condition/presence of complications, personal resources, and life responsibilities)
 Therapeutic Regimen: ineffective management—complexity of therapeutic regimen, economic difficulties, family
patterns of health care, perceived seriousness/benefits. Infection, risk for (secondary)—decrease in ciliary action,
stasis of body fluids, suppressed inflammatory response, tissue destruction, chronic disease, malnutrition, increased
environmental exposure.
 Fatigue—increased energy requirements to perform ADLs, discomfort. Therapeutic Regimen: Families, ineffective
management—complexity of therapeutic regimen, decisional conflicts, economic difficulties, family conflict.

Complications and sequelae of Tuberculosis from the Diseases Database include:

 Intraspinal abscess / granuloma

 Hepatomegaly
 Pneumothorax
 Cranial nerve disorder
 Poncet's disease
 Septic arthropathy
 Erythema induratum
 Lung cavity
 Asherman's syndrome
 Adrenal cortex insufficiency
 Mediastinitis
 VDRL positive
 Pathological fracture
 Leucoerythroblastic anaemia
 Tracheal stenosis
 Urethral stricture
 Pyrexia of unknown origin
 Dacryoadenitis
 SIADH
 Cervical lymphadenopathy
 Eales disease
 Lung abscess
 Pericardial effusion
 Monocytosis
 Cough
 Pericarditis
 Intracranial abscess / granuloma
 Amenorrhoea
 Brain failure
 Kyphosis
 Intracranial calcification
 Bronchiectasis
 Haemoptysis
 Female infertility
 Vasculitis
 Epididymo-orchitis
 Renal failure
 Cachexia
 Vesicovaginal fistula
 Hypercalcaemia
 Short stature
 Thrombotic thrombocytopenic purpura
 CSF lymphocytosis
 Hilar lymphadenopathy
 Eosinophilia
 Chronic constrictive pericarditis
 Osteomyelitis
 Carpal tunnel syndrome
 Red cell production reduced
 Dactylitis
 Groin mass
 Goitre
 AA amyloidosis
 Pleuritis
 Breathlessness
 Liver granuloma
 Pyelonephritis, acute
 Froin's syndrome
 Coin lesion (chest x-ray)
 Angiotensin converting enzyme levels raised (plasma or serum)
 Urinary tract infection
 Pleural effusion
 Abnormal sputum
 Erythema nodosum
 Digital clubbing
 Acid fast bacillus
 Upper zone lung fibrosis
 ESR raised
 Lupoid rash
 Lymphocytosis
 Aseptic meningitis
 Uveitis