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BAB II

TINJAUAN PUSTAKA

2.1 Pulmonary Tuberculosis

2.1.1 Definition

Tuberculosis is a disease caused by Mycobacterium tuberculosis complex

infection and is an important public health problem in Indonesia. Stem-shaped

M.tuberculosis, measuring 5μ in length and 3μ in width, did not form spores and

included aerobic bacteria. Mycobacteria is referred to as Acid Basil Basil (BTA)

because the color produced by staining with Gram, can not be removed with acid.

The structure of the cell wall mycobacteria, there is fat associated with

arabinogalaktan and peptidoglycan beneath it. This structure decreases the

permeability of the cell wall thus reducing the effectiveness of antibiotics.

Lipoarabinomannan Another molecule in the cell wall mycobacteria play a role in

the interaction between the host and the pathogen makes M. tuberculosis can

survive in macrophages (Wijaya, 2012).

2.1.2 Etiology

The process of M. tuberculosis infection is usually inhaled, so pulmonary

TB is the most frequent clinical manifestation compared to other organs.

Transmission of this disease is mostly through inhalation of bacilli containing

droplet nuclei, especially those obtained from pulmonary tuberculosis patients

with coughing or sputum that contain BTA (Amin, 2007).

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Penyebab TB adalah Mycobacterium tuberculosis, sejenis kuman

berbentuk batang dengan ukuran panjang 1-4 μm dan tebal 0,3-0,6 μm. Sebagian

besar dinding kuman terdiri atas asam lemak (lipid), peptidoglikan, dan

arabinomannan. Lipid inilah yang membuat kuman lebih tahan terhadap asam

(asam alkohol) sehinga disebut bakteri tahan asam (BTA) dan dia juga lebih tahan

tehadap gangguan kimia dan fisis. Hal ini terjadi karena kuman berada dalam sifat

dormant. Dari sifat dormant ini kuman dapat bangkit lagi dan menjadikan

penyakit TB menjadi aktif lagi (Alsagaff, 2008).

2.1.3 Pathogenesis

The pathogenesis of pulmonary tuberculosis according to PDPI (2007) is

divided into primary and secondary tuberculosis.

2.1.3.1 Primary tuberculosis

Tuberculosis germs that enter through the airways will nest in the lung

tissue so that will form a pneumonic nest, called the primary nest or affek primary.

This primary nest may arise in any part of the lung, in contrast to the reactivation

nest. From the primary nest will appear inflammation of the lymph channels to the

hilus (local lymphangitis). The inflammation is followed by enlarged lymph nodes

in the hilus (regional lymphadenitis). The primary affects together with regional

lymphangitis are known as primary complexes. This primary complex will

experience one of the following fates:

1) Recovered by leaving no defects at all (restitution ad integrum)

2) Heal by leaving little traces (including Ghon's nest, fibrotic line, hilus

breeding nest)
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3) Spread by:

a. Perkontinuitatum, spread around it.

b. Spreading bronchogenically, either in the lung in question or to the next

lung or swallowed.

c. Haematogenous spread and lymphogen. This spread can also cause

tuberculosis in other body devices, such as bone, kidney, adrenal, genitalia

and so on.

2.1.3.2 Secondary tuberculosis

This postprimer tuberculosis will appear years later of primary

tuberculosis, usually at the age of 15-40 years. Post-primer tuberculosis begins

with an early nest, which is generally located in the apical segment of the superior

lobe as well as the inferior lobe. This early nest originally shaped a small

pneumonic lair. The fate of this pneumonic nest will follow one of the following

paths:

1) The pneumonic nest is re-admitted, and recovered by leaving no defects.

2) The nest was initially widespread, but soon there was a healing process with

fibrosis tissue infiltration. This tissue will then occur liming and will recover

in the form of a spawn and can be re-activated by forming cheese tissue

(kaseosa). Cavities may form when cheese tissue is coughed out.

3) The pneumonic nest extends, forming a cheese tissue (caseous tissue). The

cavities will come with the cultivation of cheese tissue out. The cavity was

originally thin-walled, then the walls would become thick (sclerotic

cavities).
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2.1.4 Clinical Manifestations

Symptoms revealed by patients with pulmonary tuberculosis consist of

major symptoms and additional symptoms. The main symptom of this infectious

disease is a continuous cough and phlegm for 3 more weeks. Additional

symptoms that are often found are sputum exposure mixed with blood, coughing

up blood, breathlessness and chest pain, body weakness, decreased appetite,

decreased weight, malaise, night sweats without activity and fever fever for more

than a month DepKes RI, 2007).

Price and Wilson (2008) explain no signs and symptoms that are typical

in the early stages of Pulmonary TB. The disease can only be detected by

tuberculin test, radiogram and bacteriological examination. New symptoms are

seen after the onset of the disease and the destruction of the lung tissue extends so

that the production of high sputum and cough increases weight. Generally not

found chest pain and coughing blood only occurs in cases that are very advanced.

Symptoms that can be experienced by some patients such as productive cough,

fatigue, weakness, night sweats and weight loss.

2.1.5 Complication

Untreated pulmonary TB according to Mayo Clinic (2012), can be fatal.

Diseases that infect these lungs can spread to other parts of the body through the

bloodstream such as bone (with symptoms and signs including pain and bone

damage, mostly of the rib cage), the brain (can cause meningitis, membrane

swelling which can be fatal because suppress the brain and spine), as well as the
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liver or kidneys (disrupting the work of the liver and kidneys as a place to filter

waste products out of the bloodstream)

Patients with pulmonary tuberculosis may experience complications such

as pleuritis, pleural effusion, empyema, laryngitis, spread to other organs, airway

obstruction, severe parenchymal damage, amyloidosis, lung carcinoma and adult

respiratory failure syndrome (Bahar, 2008).

2.1.6 Treatment of Pulmonary Tuberculosis

Millennium Development Goals (MDGs) by 2015 that the government

has set to reduce TB prevalence and death rates by half will be achieved if TB

treatment programs run well. One of the things that can support the

implementation of the above goals is the provision of Anti Tuberculosis (OAT) in

accordance with the criteria of the patients who have been determined (Kemenkes

RI, 2011).

2.2 Concept of Compliance

2.2.1 Definition

Compliance is defined as the extent to which a person follows the instructions

given for prescribed treatment, involves consumer choice and is meant not to judge such

compliance or the fulfillment of a desire that reinforces a passive attitude and blames the

patient. The agreement on the other hand refers to the consultation and consensus of

emerging cooperation between consumers and doctors (Bosworth, 2010).

Another definition of adherence, particularly those related to medicine and

health, is defined as active, voluntary collaborative involvement of patients in mutually

agreed behaviors to achieve the desired outcome of prevention or therapeutic measures

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(Meichenbaum & Turk, 1987 in Granquist, 2008). Compliance in this domain is

interpreted as well as the extent to which the patient's behavior is in accordance with the

recommendations of the health care provider (Vitolins et al 2000, as cited Granquist,

2008).

2.2.2 Level of Non-compliance

Non-compliance of patients to treatment in terms of self-management aspects

can be distinguished on:

1) Non-intentional non-adherence degree

Patients belonging to this classification such as patients who forget to take the

drug and do not consume the drug because they forget the instructions given. The

given drug instructions should be easy to understand, particularly unusual and using

understandable language. Patients who tend to forget have higher frequency in

patients with difficult lives.

2) Non-adherence based on reasoning

Patients in this category, use certain reasons not to comply with the rules of

treatment such as comparing the benefits obtained with the cost of the family or

aware of the severity of the disease. Patients with low severity, feel they do not need

to take any medication or depend on the drug at any time, and some feel able to

control the disease without drugs.

3) Non-adherence due to denial

Patients who deny themselves a particular disease will not be able to consume

drugs effectively. Refusal is based on anger due to a particular illness and is unable

to manage the stress associated with a diagnosed informed illness..

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2.3 Family Support

2.3.1 Definition

Family support according to Canavan et al (2007) as well as social support

in this case is based on the same theory, so that family support can be interpreted

as social support from within a smaller scope that is among family members. This

causes the definition of social support to be used as a basis of family support

which, according to Peterson and Bredow (2009) is the support given and

received by and from members of that environment to support one's integrity and

existence. Recipients of support perceive that the support provided facilitates

coping with stress in life. Support from and by the family has been understood by

both parties to improve the welfare of the recipients, so support can be given

structruralally, which emphasizes the supporters or functionally who emphasize

the actions given..

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Figure 2.1 Family Support Model (Canavan et al, 2007)

2.3.2 Family Support Types

Family support according to Cutrona (2000) in Canavan et al (2007) are:

1) Concrete or real support

The support provided relates to concrete actions that help between families

such as helping to keep a baby when other family members go somewhere.

2) Emotional support

Emotional support includes empathy, listening or overall action when it is

needed. Emotional support should be done wisely and should be perceived as

an act of help.

3) Support in suggestion form

Support in the form of suggestions is more complex and generally done to

gain peace and confidence compared to the need for the advice itself.
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Someone generally ask for advice among family such as when suffering ill

for example when faced with cancer. Families will seek treatment by

convincing sick family members that all acts done for the good of the

individual or family assure that the actions taken are the best.

4) Support to self-esteem

The central part of this support is how families express the meaning and value

of one's self to the family and prove it. Recognition of one's existence is the

foundation of the family system.