I.

Introduction and Objectives

Tuberculosis (TB) is an infectious disease caused primarily by Mycobacterium tuberculosis. TB
disease most commonly affects the lungs; this is referred to as pulmonary TB. Tuberculosis is a
leading infectious cause of morbidity and mortality in adults worldwide. HIV/AIDS is the most
important factor predisposing to TB infection and mortality in parts of the world where both
infections are prevalent. In 2018, an estimated 10.0 million people around the world fell ill with
TB, a number that has been relatively stable in recent years. Geographically, most TB cases in
2018 were in the WHO regions of South-East Asia (44%), Africa (24%) and the Western Pacific
(18%), with smaller percentages in the Eastern Mediterranean (8%), the Americas (3%) and
Europe (3%). Eight countries accounted for two thirds of the global total: India (27%), China
(9%), Indonesia (8%), the Philippines (6%), Pakistan (6%), Nigeria (4%), Bangladesh (4%) and
South Africa (3%). These and 22 other countries in WHO’s list of 30 high TB burden countries
accounted for 87% of the world’s cases (WHO:Global Tuberculosis Report 2019). Meanwhile, an
estimated number of 591,000 cases for the total TB incidence in the Phillipines. From which
59.1% are those that were HIV-positive related TB incidence, 32.83% MDR/RR TB incidence,
22.7% HIV-negative TB mortality.
Symptoms of TB include productive cough, fever, weight loss, and malaise. Diagnosis is most
often by sputum smear and culture and, increasingly, by rapid molecular-based diagnostic tests.
Treatment is with multiple antimicrobial drugs given for at least 6 mo.
General objective:
At the end of this activity, I aim to have a comprehensive understanding of tuberculosis
pathophysiology.
Specific objectives:
1. Identify risk factors for tuberculosis.
2. List signs and symptoms of pulmonary tuberculosis.
3. Differentiate between Latent Tuberculosis Infection and Active TB Infection.
4. Identify pathogen associated with tuberculosis.
5. Describe how to do an assessment on a tuberculosis patient.
6. Identify actions that fulfill nursing care objectives for tuberculosis patients.
7. State signs and expectations associated with recovery from tuberculosis patient.

II. Pathophysiology
 Etiology
Tuberculosis properly refers only to disease caused by Mycobacterium tuberculosis (for which humans are
the main reservoir). Tuberculosis results almost exclusively from inhalation of airborne particles (droplet
nuclei) containing M. tuberculosis. They disperse primarily through coughing, singing, and other forced
respiratory maneuvers by people who have active pulmonary TB. Droplet nuclei containing tubercle bacilli
may remain suspended in room air currents for several hours, increasing the chance of spread. However,
once these droplets land on a surface, it is difficult to resuspend the organisms (eg, by sweeping the floor,
shaking out bed linens) as respirable particles. Although such actions can resuspend dust particles containing
tubercle bacilli, these particles are far too large to reach the alveolar surfaces necessary to initiate infection.
Contact with fomites (eg, contaminated surfaces, food, and personal respirators) do not appear to facilitate
spread.
History/risk factors for developing active TB include immunocompromised state; injection drug use;
radiographic evidence of prior, healed TB; weight loss of 10% or more of ideal body weight; and other
medical conditions, including diabetes mellitus, silicosis, end-stage renal disease, some types of cancers,
elders, infants, and certain immunosuppressive therapies. Additional factors also include being a smoker and
alcoholic drinker.
Environmental factors also are important. Transmission is enhanced by frequent or prolonged exposure to
untreated patients who are dispersing large numbers of tubercle bacilli in overcrowded, poorly ventilated
enclosed spaces; consequently, people living in poverty or in institutions are at particular risk. Health care
practitioners who have close contact with active cases have increased risk. Contagiousness decreases rapidly
once effective treatment begins; organisms are less infectious even if they persist in sputum, and cough
decreases. Studies of household contacts indicate that transmissibility ends within 2 weeks of patients
starting effective treatment.

 Pathophysiology
Primary infection requires inhalation of particles small enough to traverse the upper respiratory defenses and
deposit deep in the lung, usually in the subpleural airspaces of the middle or lower lobes. Larger droplets
tend to lodge in the more proximal airways and typically do not result in infection. Infection usually begins
from a single droplet nucleus, which typically carries few organisms. Perhaps only a single organism may
suffice to cause infection in susceptible people, but less susceptible people may require repeated exposure to
develop infection.
To initiate infection, M. tuberculosis bacilli must be ingested by alveolar macrophages. Bacilli that are not
killed by the macrophages actually replicate inside them, ultimately killing the host macrophage (with the
help of CD8 lymphocytes); inflammatory cells are attracted to the area, causing a focal pneumonitis that
coalesces into the characteristic tubercles seen histologically. In the early weeks of infection, some infected
macrophages migrate to regional lymph nodes (eg, hilar, mediastinal), where they access the bloodstream.
Organisms may then spread hematogenously to any part of the body, particularly the apical-posterior portion
of the lungs, epiphyses of the long bones, kidneys, vertebral bodies, and meninges. Hematogenous
dissemination is less likely in patients with partial immunity due to vaccination or to prior natural infection
with M. tuberculosis or environmental mycobacteria.
Latent infection occurs after most primary infections. In about 95% of cases, after about 3 weeks of
uninhibited growth, the immune system suppresses bacillary replication, usually before symptoms or signs
develop. Foci of bacilli in the lung or other sites resolve into epithelioid cell granulomas, which may have
caseous and necrotic centers. Tubercle bacilli can survive in this material for years; the balance between the
host’s resistance and microbial virulence determines whether the infection ultimately resolves without
treatment, remains dormant, or becomes active.
 Person with LTBI (Infected)
 Has a small amount of TB bacteria in his/her
body that are alive, but inactive
 Cannot spread TB bacteria to others
 Does not feel sick, but may become sick if the
bacteria become active in his/her body
 Usually has a TB skin test or TB blood test
reaction indicating TB infection
 Radiograph is typically normal
 Sputum smears and cultures are negative
 Should consider treatment for LTBI to prevent
TB disease
 Does not require respiratory isolation
 Not a TB case
Person with TB Disease (Infectious)
 Has a large amount of active TB bacteria in
his/her body
 May spread TB bacteria to others
 May feel sick and may have symptoms such as a
cough, fever, and/or weight loss
 Usually has a TB skin test or TB blood test
reaction indicating TB infection
 Radiograph may be abnormal
 Sputum smears and cultures may be positive
 Needs treatment for TB disease
 May require respiratory isolation
 A TB case

Diagnosis: For an accurate diagnosis of TB, a complete medical and psychosocial history should be taken
along with a physical examination that includes a tuberculin skin test or an interferon gamma release assay
(IGRA) blood test, chest x-ray and CT scan examinations, and sputum examination (including acid-fast
bacilli [AFB] smears, cultures, and drug sensitivity studies).

Diagnostic Test
Tuberculin Skin Test (TST) -
Mantoux or PPD—purified
protein derivative
Interferon gamma release assays
(IGRAs) The two available tests
are the QuantiFERON-TB Gold
In-Tube test and the T-SPOT TB
test.
Sputum examination, culture, and
testing
Two types of NAAT are available
for TB diagnosis:
 Xpert MTB/RIF
 Line probe assay
The tuberculin test (Mantoux
test) is the most commonly used
reliable screening test for TB. A
small amount (0.1 mL) of
purified protein derivative (PPD)
is placed intradermally in the
forearm.
Both tests show how the patient's
immune system responds to the
TB bacterium.
Xpert MTB/RIF is an automated
rapid nucleic acid amplification
test (NAAT) that can
simultaneously identify M.
tuberculosis DNA in a sputum
sample and detect resistance
to rifampin (rifampicin) in as
The test is “read” in 48 to 72
hours. An area of induration
(localized swelling with hardness
of soft tissue), not just redness,
measuring 10 mm or greater in
diameter, indicates exposure to
and possible infection with TB
A positive result means that the
person is infected with TB but
does not indicate whether the
infection is latent or active.
If an Xpert MTB/RIF test on a
sputum sample is positive, the
diagnosis of pulmonary TB is
considered confirmed. In such
cases, treatment can be started
based on rifampin susceptibility.
If NAAT and AFB smear results
 little as 2 h. The Xpert MTB/RIF are negative or if AFB smear
is more sensitive than sputum results are positive and NAAT
smear microscopy and about as results are negative, clinical
sensitive as culture for judgment is used to determine
diagnosing TB. whether to begin anti-TB
The line probe assay can identify treatment while awaiting results
the presence of M. of culture.
tuberculosis and resistance
to rifampin and isoniazid.
However, sensitivity is lower
than that of Xpert MTB/RIF. This
test is usually done only on
smear-positive specimens.

 Symptomatology:
Assessment: Early detection of TB depends on subjective patient reports rather than observable signs
or symptoms. TB has a slow onset, and patients are not aware of problems until the disease is
advanced
 History. Assess the patient's past exposure to TB. It is important to ask about the results of any
previous tests for TB. Also ask whether the patient has had bacille Calmette-Guérin (BCG)
vaccine (often given in 1226 childhood overseas), which contains attenuated tubercle bacilli.
Anyone who has received BCG vaccine within the previous 10 years will have a positive skin
test that can complicate interpretation. Usually the size of the skin response decreases each year
after BCG vaccination. These patients should be evaluated for TB with a chest x-ray or the
QuantiFERON-TB Gold test.
 Physical Assessment/Signs and Symptoms. The patient with TB has progressive fatigue,
lethargy, nausea, anorexia, weight loss, irregular menses, and a low-grade fever. Symptoms may
have been present for weeks or months. Night sweats may occur with the fever. A cough with
mucopurulent sputum, which may be streaked with blood, is present. Chest tightness and a dull,
aching chest pain occur with the cough. Ask about, assess for, and document the presence of any
of these symptoms to help with diagnosis, establish a baseline, and plan nursing interventions.
When assessing the patient, you may note dullness with percussion over the involved lung fields,
bronchial breath sounds, crackles, and increased transmission of spoken or whispered sounds.
Partial obstruction of a bronchus from the disease or compression by lymph nodes may produce
localized wheezing.
 Psychosocial Assessment. Tuberculosis is a frightening diagnosis. Explain the disease
thoroughly, including the need to maintain good hygiene and avoid infecting others. The patient
may feel isolated and shunned. Take time to listen to him or her and help to resolve any
concerns. The family and friends of the patient may have similar concerns as well. Often close
contacts will be afraid they have contracted the illness. Encourage all close contacts to get tested.
Help the patient notify his or her employer if needed about required time off. Directly observed
 therapy may feel threatening. Explain how this helps improve adherence to the long treatment
schedule.
 Imaging Assessment. Once a person's skin test is positive for TB, a chest x-ray is used to detect
active TB or old, healed lesions. Caseation and inflammation may be seen on the x-ray if the
disease is active. The chest xrays of HIV-infected patients may be normal or may show
infiltrates in any lung zone and lymph node enlargement.
 Treatment/ Management – Nursing Intervention
 Combination drug therapy is the most effective method of treating TB and preventing
transmission. Active TB is treated with a combination of drugs to which the organism is
sensitive. Therapy continues until the disease is under control. Multiple-drug regimens destroy
organisms as quickly as possible and reduce the emergence of drug-resistant organisms. First-
line therapy uses isoniazid (INH, Nidrazid), rifampin (Rifadin), pyrazinamide, and ethambutol
(Myambutol) for the first 8 weeks, which is called the initial phase of treatment. The
continuation phase lasts another 18 weeks, and the patient takes INH and rifampin either daily or
twice a week (CDC, 2015l) (Chart 31-3). These drugs are now available in two- or three-drug
combinations. One example is Rifater, which combines isoniazid, pyrazinamide, and rifampin.
Variations of the first-line drugs along with other drug types are used when the patient does not
tolerate the standard first-line therapy.
 Instruct the patient to drink plenty of fluids unless another condition requires restriction.
 Teach him or her to take a deep breath before coughing. An incentive spirometer may facilitate
effective coughing.
 Strict adherence to the prescribed drug regimen is crucial for suppressing the disease.
Adherence is difficult because of the long duration of treatment. (Duration of therapy is often 26
weeks but can be as long as 2 years for multidrug-resistant [MDR] TB.)
 Teach the patient about drug therapy - emphasising the importance of taking each drug regularly,
exactly as prescribed, for as long as it is prescribed. Provide accurate information in multiple
formats, such as pamphlets, videos, and drug-schedule worksheets. To determine whether the
patient understands how to take the drugs, ask him or her to describe the treatment regimen, side
effects, and when to call the health care agency and physician.
 Teach the patient about infection prevention and what to expect about disease monitoring and
participating in activities. TB is often treated outside the acute care setting, with the patient
convalescing at home. Airborne Precautions are not necessary in this setting because family
members have already been exposed; however, all members of the household need to undergo
TB testing.
 Teach the patient to cover the mouth and nose with a tissue when coughing or sneezing, to place
used tissues in plastic bags, and to wear a mask when in contact with crowds until the drugs
suppress infection. Tell the patient that sputum specimens are needed usually every 2 to 4 weeks
once drug therapy is initiated. When the results of three consecutive sputum cultures are
negative, the patient is no longer infectious (contagious) and may return to former activities.
 Remind him or her to avoid exposure to any inhalation irritants because these can cause further
lung damage.
III. Nursing Care Plan
IV. Drug Study
V. Discharge Planning