Tuberculosis (TB) - Study / Research Notes by Rhod Vincent J.

Tayong

1. DESCRIPTION/ DEFINITION/ CLASSIFICATION & DIFFERENTIATION

What is TB?

Tuberculosis (TB) is a potentially fatal infectious disease affecting mostly the lungs.
Tuberculosis bacteria are transmitted from person to person via minute droplets discharged into
the air by coughs and sneezes. TB most commonly affects the lungs, but it can also damage the
brain, kidneys, or spine. If a patient with tuberculosis is not treated, they may die. It may lead to
death

Many tuberculosis strains are resistant to the most commonly used antituberculosis
medications. Active tuberculosis patients must take a variety of treatments for months to clear
the infection and avoid antibiotic resistance.

What causes TB?

Mycobacterium tuberculosis is the bacteria that causes tuberculosis. TB bacteria most

commonly attack in the lungs, although they can also affect the kidney, spine, and brain. Many
patients who are infected with these bacteria do not develop active tuberculosis. They are still in
the latent (inactive) stage of tuberculosis. However, TB organisms can escape the body's
defenses, reproduce, and create an active disease in patients with weakened immune systems,
particularly those with HIV (human immunodeficiency virus) or those using immune-suppressing
medications.

How is TB spread?

When an infected person coughs, sneezes, speaks, sings, or laughs, the TB bacteria is
transmitted via the air. These bacteria can persist in the air for several hours, depending on the
environment. They are unlikely to be shared through personal goods such as clothing, bedding,
a drinking glass, eating utensils, a handshake, a toilet, or other items touched by a patient with
tuberculosis.

Types of Tuberculosis

Latent tuberculosis infection

Patients with latent tuberculosis have TB bacteria in their bodies, but they are not active, hence
they are not sick. These people don't show any signs or symptoms of tuberculosis, and they
can't pass the disease on to others. They may, however, develop tuberculosis disease in the
future. They are frequently prescribed medication to keep them from contracting tuberculosis.
This patient will have a positive skin test, but a normal chest X-ray.

Active tuberculosis / TB disease

Patients with active TB bacteria are infected with TB disease, this means that the TB bacteria
are multiplying, and damaging tissue in the body. Patients with active TB usually develop s/sx of
TB disease. Furthermore, people who have tuberculosis of the lungs or throat can spread germs
to others. They are given medications to treat tuberculosis (TB). This patient will have a positive
skin test and a positive chest X-ray.

Drug Resistant TB
When bacteria grow resistant to the medications used to treat tuberculosis, it is known as
drug-resistant tuberculosis (DRTB). This signifies that the medicine or combination of
medications is no longer effective against tuberculosis bacteria. There are two main types of
DRTB. Multi Drug-Resistant TB (MDR TB) and Extensively drug-resistant TB (XDR-TB)

Tuberculosis Disease During Pregnancy

Dealing with TB diagnosis during pregnancy is difficult, the pregnant woman and her baby are
at greater danger if the condition is not treated. Babies born to mothers who have untreated
tuberculosis may have a lower birth weight than babies delivered to women who do not have the
disease. A baby with tuberculosis may be born in rare cases.

Untreated tuberculosis (TB) poses a larger risk to a pregnant woman and her unborn child than
does treatment. When the risk of tuberculosis is moderate to high, pregnant women should
begin treatment. Infants born to women who have untreated tuberculosis may have a lower birth
weight than those born to women who do not have tuberculosis, and in rare cases, the newborn
may be born with tuberculosis. The medications used in the initial treatment regimen for
tuberculosis (TB) pass the placenta but do not appear to harm the fetus.

Contraindications

The following antituberculosis drugs are contraindicated in pregnant women:

Streptomycin
Kanamycin
Amikacin
Capreomycin
Fluoroquinolones

Women who are being treated for drug-resistant TB should receive counseling concerning the
risk to the fetus because of the known and unknown risks of second-line antituberculosis drugs.

S/Sx of Active TB

● A cough that lasts more than three weeks

● Loss of appetite
● Unintentional weight loss
● Fever
● SOB
● Dyspnea
● Chest pain
● Fatigue
● Poor growth in children
● Chills
● Night sweats

Patients may experience other symptoms related to the function of a specific organ or system
that is affected such as:

● Coughing up blood or mucus (sputum) is a sign of TB of the lungs.

● Bone pain may mean that the bacteria have invaded your bones.

2. DIAGNOSTIC/ LABORATORY TESTS

Chest Radiography
Chest abnormalities are detected using a posterior-anterior chest radiograph. Lesions can
develop in any part of the lungs and vary in size, shape, density, and cavitation. These
anomalies may indicate tuberculosis, but they cannot be used to confirm the diagnosis. A chest
radiograph can be used to rule out the possibility of pulmonary TB in someone who has had a
positive TST or TB blood test but no symptoms of the disease.

This is contraindicated to pregnant patients, unless the benefits outweigh the risk of exposing
the fetus to radiation

Pre
● Remove all metallic objects. Items such as jewelry, pins, buttons etc can hinder the
visualization of the chest.
● No preparation is required. Fasting or medication restriction is not needed unless
directed by the health care provider.
● Assess the patient’s ability to hold his or her breath. Holding one’s breath after inhaling
enables the lungs and heart to be seen more clearly in the x-ray.
● Provide appropriate clothing. Patients are instructed to remove clothing from the waist up
and put on an X-ray gown to wear during the procedure.
● Instruct patients to cooperate during the procedure. The patient is asked to remain still
because any movement will affect the clarity of the image.
Intra
● Ater the patient is correctly positioned, tell him or her to take a deep breath and hold it
until the x-ray films are obtained.

Post
● No special care. Note that no special care is required following the procedure
● Provide comfort. If the test is facilitated at the bedside, reposition the patient properly.

There are tests that can be used to help detect TB infection:

Tuberculin Skin Test (TST)

The Mantoux tuberculin skin test is performed by injecting a small amount of fluid (called
tuberculin) into the skin in the lower part of the arm. A person given the tuberculin skin test must
return within 48 to 72 hours to be checked for a reaction.

A tuberculin skin test will find out if a patient is positive with TB bacteria but will not determine if
it is latent or active. Further testing such as chest x-ray and sputum culture will be required.

Pre
● Determine if the patient has ever had bacille calmette Guerin (BCG) vaccine, recent viral
disease, immunosuppression by disease, drugs, or steroids. Any of these may cause
false reading. Previous BCG vaccines or the other factors should not preclude PPD
testing, but will be considered with the result.
● Do not give PPD to a person who has had a positive test or TB in the past
● Prepare PPD beforehand
Intra
● Follow proper infection control
● Clean the skin of the inner aspect of the forearm with alcohol. Allow to dry.
● Stretch the skin taut. And follow procedures for administering TST

Post
● Read the test within 48 to 72 hours when the induration is most evident.
● Have a good light available. Flex the patient's forearm slightly at the elbow.
● Inspect for the presence of induration; inspect from a side view against the light; inspect
by direct light.
 ● Palpate: Lightly rub the finger across the injection site from the area of normal skin to the
area of induration. Outline the diameter of induration.Erythema (redness) without
induration is generally considered to be of no significance.
● Measure the maximum transverse diameter of induration (not erythema ) in millimeters.

TB Blood Test

To diagnose active or latent tuberculosis infection, blood tests such as interferon gamma
release assays (IGRA), nucleic acid amplification tests (NAAT), and serologic TB testing are
utilized.

The IGRA is a whole-blood test used in diagnosing Mycobacterium tuberculosis infection. The
NAAT is a rapid and accurate test of sputum and is used as corroborative information in the
diagnosis of TB. Serology testing on blood is also a rapid test used to identify active TB disease
infection.

Pre
● Explain the procedure to the patient or the family. 

Intra
● Collect 1 mL whole blood in each of three lab-specimen collection tubes. The accuracy
of the IGRA is dependent on the proper collection and incubation of the blood specimen.
Blood should fill the tube as close to the 1-mL mark as possible. Underilling or overilling
the tubes outside the 0.8- to 1.2-mL range may lead to erroneous results.
● Immediately following collection, each specimen tube must be shaken vigorously by
shaking the tube up and down 10 times to ensure that the entire inner surface of the
tube has been coated with blood.
● For NAAT testing, 1 to 3 mL of sputum or body luid is required. his should be refrigerated
in a screw cap sterile container. 

Post
● Apply pressure or a pressure dressing to the venipuncture site.
● If the patient’s results are positive, educate him or her about the necessary follow-up
studies, such as chest radiograph and sputum cultures. 

Diagnostic Microbiology

Acid-Fast Bacili Smear (AFB)

The presence of acid-fast bacteria (AFB) on a sputum smear or other specimen frequently
suggests tuberculosis (TB) infection. Ater taking up the fuchsin dye, M. tuberculosis is not
decolorized by acid alcohol (ie, it is acid-fast). It is seen under the microscope as a red or pink,
rod-shaped organism. If this bacillus is seen, the patient may have active TB. Although acid-fast
microscopy is simple and quick, it does not guarantee a diagnosis of tuberculosis because
certain acid-fast bacteria are not M. TB. As a result, all initial samples are cultured to confirm the
diagnosis.

Pre
● Explain the procedure for sputum collection.
 ● Remind the patient that the sputum must be coughed up from the lungs and that saliva is
not sputum. The first morning specimen is usually best.
● Give the patient a sterile sputum container the night before the sputum is to be collected
so that the morning specimen may be obtained when the patient awakens.
● Instruct the patient to rinse out his or her mouth with water before the sputum collection
to decrease contamination. Do not use antiseptic mouthwash. 
Intra
● For best results, obtain sputum collection when the patient awakens in the morning.
● Collect at least 1 teaspoon of sputum in a sterile sputum container.
● Obtain sputum by having the patient cough after taking several deep breaths.
● If the patient is unable to produce a sputum specimen, stimulate coughing by lowering
the head of the patient’s bed or by giving the patient an aerosol administration of a
warm hypertonic solution.
Post
● Avoid personal contamination and wear gloves when handling all patient secretions.
● Tell the patient to notify the nurse as soon as the specimen is collected.
● Label the specimen and send it to the laboratory as soon as possible.

TB culture test

A culture test is a method of examining germs by growing them on various surfaces. This is
done to see if any specific bacteria are present. The purpose of a tuberculosis culture test is to
determine whether the TB bacteria Mycobacterium tuberculosis is present. Samples will be
placed in a tiny dish containing a chemical that aids in the growth of bacteria. The samples are
then examined under a microscope to determine whether the bacteria that cause tuberculosis
have developed. A tuberculosis culture can take weeks to produce findings. The results of rapid
culture testing are available in 36 to 48 hours.

Pre
● Explain the procedure to the patient.
● Tell the patient that no fasting is required. 

Intra
● For sputum, obtain an early morning specimen. It is best to induce sputum production
with an ultrasonic or nebulizing device.
● Collect three to five early morning specimens. All specimens must contain mycobacteria
to make the diagnosis of TB.
● For urine collection, obtain three to five single, clean-voided specimens early in the
morning.
● Note that swabs, intestinal washings, and biopsy specimens should be transported to
the laboratory immediately for preparation.
● Follow the institution’s policy for universal specimen handling.
● Ensure to wear the proper PPE

Post
● Instruct the patient in appropriate isolation of sputum and other body luids to avoid
potential spread of suspected TB. 

3. TREATMENT REGIMEN

a. Medications/ Supplements/ Vaccines

i. BCG Vaccine
BCG vaccine is an immunization agent for tuberculosis (TB). It is an attenuated strain of the
bacillus Calmette and Guérin strain of Mycobacterium bovis. BCG vaccine stimulates the
reticuloendothelial system (RES) to produce macrophages that do not allow mycobacteria to
multiply. BCG is active immunotherapy, which stimulates the immune mechanism. It enhances
the cytotoxicity of macrophages. BCG vaccination is contraindicated in pregnant patients
because it uses live bacteria.

Contraindications:

● Patients or persons with congenital or acquired immune deficiencies,

whether due to concurrent disease (e.g., AIDS, leukemia, lymphoma)
● Cancer therapy (e.g., cytotoxic drugs, radiation)
● Immunosuppressive therapy (e.g., corticosteroids).
● BCG vaccine should not be given to individuals with a positive tuberculin
test.
● The vaccine should be given on healthy skin and no other treatment
should be given to the limb for at least 3 months.

Adverse Effect:

● A mild local reaction occurs following most intradermal BCG injections,

over 1-2 months, and sometimes a shallow ulcer may occur.
● Exaggerated reactions like abscess and large ulcers result due to
injection being administered too deeply.
● Minor regional adenitis is common. Disseminated BCG infection can
occur in the immunocompromised.

Nursing Responsibilities
Pre
● Review potential adverse effects.
● Assess patient for possible contraindication
● Explain the procedure to the patient
● Ensure that injection site is clean before administering

Post
● Monitor for S&S of systemic BCG infection: Fever, chills, severe malaise,
or cough.
● Culture blood and urine, if systemic infection is suspected.
● Assess for regional lymph node enlargement and report fistula formation.
● Do not breastfeed until cleared to do so by a physician.

ii. First Line anti-TB medications

These medications are taken in combination and aim to kill all the TB bacteria in the person's
body. This means that the person is then cured of TB. However TB bacteria die very slowly, and
so the drugs have to be taken for quite a few months. Even when a patient starts to feel better
they can still have bacteria alive in their body.

The first-line agents for the treatment of TB (i.e., INH, rifampin, and ethambutol) are
considered safe in pregnancy. They are used in combination with each other, for
example:
Latent TB Infection (LTBI) – Isoniazid (INH) administered either daily or twice weekly for 9
months is the standard regimen for the treatment of LTBI in pregnant women. Women taking
INH should also take pyridoxine (vitamin B6) supplementation.

TB Disease - Pregnant women should start treatment as soon as TB is suspected. The

preferred initial treatment regimen is INH, rifampin (RIF), and ethambutol (EMB) daily for 2
months, followed by INH and RIF daily, or twice weekly for 7 months (for a total of 9 months of
treatment). Streptomycin should not be used because it has been shown to have harmful effects
on the fetus.

Nursing Responsibilities

Pre

● Review for possible side effects

● Instruct patient about the possible side effects and to report if s/sx happens
● Perform necessary infection control and follow proper isolation techniques

Intra

● Ensure to follow proper infection control procedures and disinfect equipment to help
prevent the spread of infection. Utilize universal precautions or isolation procedures as
indicated for specific patients.
● Ensure the patient takes the medications and swallows every dose in order to follow
DOT (Directly Observed Therapy) Guidelines

Post

● Monitor for signs of drug-induced hepatitis, including anorexia, abdominal pain, severe
nausea and vomiting, yellow skin or eyes, fever, sore throat, malaise, weakness, facial
edema, lethargy, and unusual bleeding or bruising.
● Monitor for seizures and signs of peripheral neuropathy (numbness, tingling, decreased
muscle strength)
● Monitor signs of blood dyscrasias such as leukopenia (fever, sore throat, signs of
infection), thrombocytopenia (bruising, nosebleeds and bleeding gums), or unusual
weakness and fatigue that might be due to anemia.
● Assess ataxia or incoordination that might affect gait, balance, and other functional
activities and caution the patient and family/caregivers to guard against falls and trauma
● Assess any joint pain or muscle pain to rule out musculoskeletal pathology;
● Monitor confusion, drowsiness, fatigue, or weakness

First-line anti-TB medications include:

Isoniazid(INH) Isoniazid is in a Contraindications: Adverse Effects:

class of
medications called ● Hypersensitivity; ● CNS: psychosis,
antituberculosis ● Acute liver seizures.
agents. It works disease; ● EENT: visual
by killing the ● Previous hepatitis disturbances.
bacteria that from isoniazid. ● GI:
cause DRUG-INDUCED
tuberculosis. The ● Use Cautiously in: HEPATITIS,
medication is History of liver nausea, vomiting.
 bactericidal damage or chronic ● Derm: rashes.
against actively alcohol ingestion ● Endo:
growing gynecomastia.
intracellular and ● Hemat: blood
extracellular dyscrasias.
Mycobacterium ● Neuro: peripheral
tuberculosis neuropathy.
organisms. It ● Misc: fever.
works by killing
the bacteria that
cause the
disease. It
prevents the
tuberculosis
bacteria from
making
substances called
mycolic acids,
which are needed
to form the cell
walls of the
bacteria.

Rifampin Rifampin is in a Contraindications

(RIF) class of ● Hypersensitivity to Adverse Effects
medications called rifamycins ● Elevated liver
Antitubercular ● Concomitant function test (LFT)
Agents. Rifampin administration of results
is a common live bacterial ● Rash
medicine used to vaccines ● Epigastric distress
treat Latent TB. It ● Contraindicated in ● Anorexia
kills dormant TB patients receiving ● Nausea
germs before they ritonavir-boosted ● Vomiting
become active. It saquinavir, ● Diarrhea
does this by because of ● Cramps
targeting and increased risk of ● Pseudomembrano
inactivating a severe us colitis
bacterial enzyme hepatocellular Pancreatitis
called toxicity
RNA-polymerase. ● Contraindicated in
The bacteria use patients receiving
RNA-polymerase atazanavir,
to make essential darunavir,
proteins and to fosamprenavir,
copy their own saquinavir, or
genetic tipranavir, because
information rifampin may
(DNA). cause substantial
decreases in
plasma
concentrations of
these antiviral
drugs, which may
result in loss of
antiviral efficacy or
development of
viral resistance
Ethambutol Ethambutol is part Contraindications Adverse Effects
(EMB) of a class of drugs ● Hypersensitivity ● CNS: confusion,
called ● Known optic dizziness,
Antitubercular neuritis (unless hallucinations,
Agents clinical judgment headache,
Ethambutol is determines that it malaise.
used with other may be used) ● EENT: optic
medications to ● Patients unable to neuritis.
treat tuberculosis appreciate and ● GI: HEPATITIS,
(TB). Ethambutol report visual side abdominal pain,
is an antibiotic effects or changes anorexia, nausea,
and works by in vision (eg, vomiting.
stopping the young children, ● Metab:
growth of bacteria. unconscious hyperuricemia.
Ethambutol is patients) ● MS: joint pain.
bacteriostatic ● Neuro: peripheral
against actively neuritis.
growing TB bacilli. ● Misc:
It works by anaphylactoid
obstructing the reactions, fever.
formation of cell
walls.

Pyrazinamide Pyrazinamide Contraindications: Adverse effects

(PZA) belongs to a class ● Severe hepatic ● GI:
of drugs called damage HEPATOTOXICITY
Antitubercular ● acute gout , anorexia,
Agents. It is an ● hypersensitivity diarrhea, nausea,
antibiotic and vomiting.
works by stopping ● GU: dysuria.
the growth of ● Derm: acne,
bacteria. itching,
Pyrazinamide is a photosensitivity,
chemically skin rash.
synthesized ● Hemat: anemia,
bactericidal thrombocytopenia.
antibiotic. It ● Metab:
converts a special hyperuricemia.
enzyme to an ● MS: arthralgia,
active form which gouty arthritis.
inhibits the
synthesis of fatty
acids; this disrupts
the cell membrane
and disables
energy production
which is
necessary for the
survival of the TB
bacteria.

iii. Second-line antituberculosis drugs

Second-line antituberculosis drugs are used for drug resistant TB. Drug-resistant TB occurs
when bacteria become resistant to the drugs used to treat TB. This means that the drug can no
longer kill the TB bacteria. They are also taken in combinations as part of TB treatment.

A. Second-line injectable antituberculosis drugs

Nursing Responsibilities

Pre

● Review for possible side effects

● Instruct patient about the possible side effects and to report if s/sx happens
● Perform necessary infection control and follow proper isolation techniques

Intra

● Ensure to follow proper infection control procedures and disinfect equipment to help
prevent the spread of infection. Utilize universal precautions or isolation procedures as
indicated for specific patients.

Post
● Monitor signs of hypersensitivity reactions, including pulmonary symptoms (tightness in
the throat and chest, wheezing, cough dyspnea) or skin reactions (rash, pruritus,
urticaria).
● Assess respiration and notify physician immediately if patient exhibits any interruption in
respiratory rate (apnea) or other signs of respiratory failure
● Report any muscle weakness or paralysis that occurs following injection of high doses.
● Monitor signs of ototoxicity, including hearing loss, tinnitus, and balance problems

Kanamycin Kanamycin is an Contraindications Adverse effects

(KAN) aminoglycoside ● Hypersensitiv ● EENT: ototoxicity
bactericidal antibiotic. It is ity (vestibular and
known to be used to treat ● Auditory cochlear).
serious bacterial infections toxicity more ● GU:
It inhibits protein synthesis common with nephrotoxicity.
by binding to the 70S kanamycin ● MS: muscle
ribosomal unit, making TB than with paralysis (high
unable to grow. streptomycin parenteral
and doses).
capreomycin ● Misc:
● Renal hypersensitivity
impairment reactions.
● Myasthenia
gravis
● Vestibular/co
chlear
implant
● Nephrotoxic
agents
Amikacin Amikacin is a Adverse effects Contraindications
(AMK) semi-synthetic ● CNS: vertigo. ● Caution in
aminoglycoside antibiotic ● EENT: patients with
medication used for a
ototoxicity renal impairment
number of bacterial
infections. It binds to (vestibular ● Not intended for
bacterial 30S ribosomal and long-term
subunits and interferes cochlear). therapy
with mRNA binding and ● GU: ● Serious and
tRNA acceptor sites, nephrotoxicity potentially
interfering with bacterial . life-threatening
growth.
● Neuro: hypersensitivity
enhanced reactions,
neuromuscul including
ar blockade. anaphylaxis,
● Resp: apnea. reported; before
● Misc: therapy
hypersensitivi instituted,
ty reactions. evaluate for
previous
hypersensitivity
reactions to
aminoglycosides
;
● Hypersensitivity
pneumonitis
reported; if
hypersensitivity
pneumonitis
occurs
● Higher
frequency of
hemoptysis and
bronchospasm
● Aminoglycosides
can cause
nephrotoxicity

Capreomycin Capreomycin is a Use cautiously in Adverse effects

(CAP) aminoglycoside antibiotic. ● Renal ● Skin: Urticaria,
It works by preventing the insufficiency maculopapular
growth of TB bacteria. It (extreme rash,
inhibits protein synthesis caution) photosensitivity.
by binding to the 70S ● acoustic ● Hematologic:
ribosomal unit. nerve Leukocytosis,
impairment; leukopenia,
history of eosinophilia.
allergies ● CNS:
(especially to Neuromuscular
drugs) blockage
● preexisting ● Urogenital:
liver disease Nephrotoxicity
● myasthenia (long-term
gravis therapy), tubular
● parkinsonism. necrosis.
● Special Senses:
Ototoxicity,
eighth nerve
 (auditory and
vestibular)
damage.
● Metabolic:
Hypokalemia,
and other
electrolyte
imbalances.

B. Fluoroquinolones

Nursing Responsibilities
Pre

● Review for possible side effects

● Instruct patient about the possible side effects and to report if s/sx happens
● Perform necessary infection control and follow proper isolation techniques

Intra

● Ensure to follow proper infection control procedures and disinfect equipment to help
prevent the spread of infection. Utilize universal precautions or isolation procedures as
indicated for specific patients.
Post
● Watch for seizures
● Monitor signs of hypersensitivity reactions and anaphylaxis, including pulmonary
symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin
reactions (rash, angioedema, pruritus, urticaria).
● Assess heart rate, ECG, and heart sounds, especially during exercise
● Monitor signs of pseudomembranous colitis, including diarrhea, abdominal pain, fever,
pus or mucus in stools, and other severe or prolonged GI problems (nausea, vomiting,
heartburn).
● Assess any tendon pain or joint pain.
● Monitor signs of peripheral neuropathy (numbness, tingling). Perform objective tests
(nerve conduction, monofilaments) to document any neuropathic changes.
● Assess dizziness and drowsiness that might affect gait, balance, and other functional
activities
● Be alert for confusion, agitation, or other alterations in mental status.
● Be alert for signs of hepatotoxicity, including anorexia, abdominal pain, severe nausea
and vomiting, yellow skin or eyes, fever, sore throat, malaise, weakness, facial edema,
lethargy, and unusual bleeding or bruising.
● Monitor signs of hypoglycemia (weakness, malaise, irritability, fatigue) or hyperglycemia
(drowsiness, fruity breath, increased urination, unusual thirst).

Ofloxacin Ofloxacin is a synthetic Contraindications Adverse effects

(OFX) fluoroquinolone antibacterial ● Nausea
 agent. It works by ● Hypersensitivi ● Headache
preventing cell replication by ty to ofloxacin ● Insomnia
blocking enzymes that are or any ● Dizziness
required to separate member of ● Vaginitis
bacterial DNA. the quinolone ● Diarrhea
class of ● Vomiting
antibacterials ● Appetite
decreased
● Abdominal
cramps
● Chest pain
● External
genital
pruritus in
women
● Fatigue
● Flatulence
● GI distress

Levofloxacin Is a similar drug class to Contraindications:

(LEV) OFX and also functions by ● Documented Adverse effects
inhibiting enzymes which hypersensitivit ● Headache
are necessary to separate
y ● Diarrhea
bacterial DNA, thereby
inhibiting cell replication ● Insomnia
● Constipation
● Dizziness
● Dyspepsia
● Rash
● Vomiting
● Chest pain
● Dyspnea
● Edema
● Fatigue
● Injection-site
reaction
● Moniliasis
● Pain
● Pruritus
● Vaginitis

Moxifloxacin Moxifloxacin is part of Contraindications Adverse Effects

(MOX) fluoroquinolones.It ● Hypersensitivi ● Nausea
improves the clinical ty to ● Diarrhea
outcome of tuberculosis moxifloxacin ● Dizziness
treatment by increasing the or any ● Decreased
sputum culture conversion member of amylase
rate. Moxifloxacin also the quinolone ● Decreased
significantly reduces class of basophils,
tuberculosis recurrence after antibacterials eosinophils,
treatment. Moxifloxacin will hemoglobin,
not cause more adverse prothrombin
events during tuberculosis time, red
blood cells,
neutrophils
Decreased
 serum
glucose
● Increased
serum
chloride
● Increased
serum ionized
calcium
● Immune
hypersensitivit
y reaction
● Prolonged QT
interval

Ciprofloxacin Ciprofloxacin is also part of Contraindications Adverse effects

(CIP) the fluoroquinolones class. It ● Documented ● Nausea
inhibits DNA replication by hypersensitivit ● Abdominal
inhibiting bacterial DNA y pain
topoisomerase and ● concurrent ● Diarrhea
DNA-gyrase tizanidine ● Increased
administration aminotransfer
ase levels
● Vomiting
● Headache
● Increased
serum
creatinine
● Rash
● Restlessness

iv. Pyridoxine (Vit. B6) supplementation

Pyridoxine is taken together with Isoniazid in order to lessen its adverse effects. Isoniazid can
interfere with the activity of vitamin B6. Vitamin B6 supplementation is recommended, especially
in people with poor nutritional status, to prevent development of isoniazid-induced peripheral
neuritis (inflamed nerves).

Pregnancy Category A and C if RDA is exceeded

Contraindications
● Hypersensitivity

Adverse effects
● Headache
● Seizure (from very large IV dose)
● Somnolence
● Decreased folic acid
● Acidosis
● Increased hepatic AST
● Nausea
● Paresthesia
● Neuropathy

Nursing responsibilities
Pre
 ● Obtain patient’s electrolyte levels
● Monitor for possible adverse effects from TB medications to determine deficiency
● Assess patient’s nutritional status and eating habits
● Do not self-medicate with vitamin combinations (OTC) without first consulting a
physician.
Intra
● Integrate foods rich in vitamin B6 to the patient’s die
Post
● Monitor I & O by using I&O chart and food chart
● Do not breast feed while taking this drug without consulting a physician.

b. Surgery

i. Surgical Resection

It is a surgery to remove tissue or part or all of an organ. It is recommended for infectious TB

patients after at least 6–8 months of appropriate anti-TB therapy. It is the partial lung resection
(lobectomy or wedge resection) , in this procedure, one lobe of a lung is removed. A lobe may
be removed to prevent the spread of TB to another lobe.

Nursing Responsibilities

Pre

● Assess the patient's level of understanding regarding the procedure

● Ensure and educate patient understands the surgery procedure
● Ensure patient has complete paperwork
● Review specific pathology and anticipated surgical procedure.
● Evaluate surgery schedule, patient identification band, chart, and signed operative
consent for surgical procedure.

Intra
● Ensure surgical equipment is clean and the OR remains a sterile environment
● Prevent unnecessary body exposure during transfer and in OR.
● Follow individualized preoperative teaching program

Post
● Routinely assess surgical site and drainage tubes
● Monitor vital signs, airway patency, and neurologic status
● Maintain fluid and electrolyte balance
● Assist in patient’s pain management
● Monitor rate and patency of IV fluids and access

c. Diet or Nutrition
i. Increase intake of protein rich foods, this is because TB patients tend to
experience loss in appetite, therefore in order to avoid weight loss integrating
protein rich foods to the diet. These foods can be absorbed easily by the body
and can give you the required energy.
ii. Foods rich in vitamin B complex specially vitamin B6 in order to minimize adverse
effects of TB treatment. However, these foods should be taken in moderation
iii. Increase intake of calorie dense foods in order to meet the metabolic demands of
the TB patient and also avoids weight loss
iv. Foods rich in vitamin A,C, and E helps boost immunity and contributes to the
elimination of the TB bacteria.

Nursing responsibilities
Pre
● Obtain patient’s nutritional status
● Review patient’s food preferences and allergies
● Assess patient’s weight, height, and BMI
● Work together with nutritionist for a more appropriate meal plan
Intra
● Ensure patient follows the diet plan
● Monitor patients I&O using I&O chart and food chart
● Ensure patient does not consume foods or substances that restricted

Post
● Monitor patient’s weight, height, and BMI

d. Physical Therapy or Exercise

i. Chest Percussion

Percussion is a physical technique used by respiratory physiotherapists to

promote airway clearance by mobilizing sputum in one or more lung segments
and directing them to the central airways. Percussion on an affected area
generates an energy wave that travels to the lungs and airways. It is used to
release thick, sticky, or stuck sputum from the chest wall.

ii. Postural Drainage

This procedure is done by a respiratory physiotherapist. The placement of

a patient with an affected lung segment so that gravity has the greatest effect in
helping the drainage of broncho-pulmonary sputum from the tracheobronchial
tree is known as postural drainage. It works on the principle of gravity-assisted
secretion sputum mobilization and transport for elimination. It's a bronchial
secretion mobilization technique that involves positioning.

iii. Integrate light exercises during TB treatment. One good example is slow walking
which also allows the patient to take in fresh air Postural exercises, deep
breathing, and relaxation techniques like yoga may also be beneficial. Physical
activity has been found in clinical trials to boost maximum oxygen intake and
exercise tolerance while also lowering chest discomfort during the active phase
of TB.

Nursing Responsibilities

Pre

● Assess patient’s ability to tolerate light exercise

● Collaborate with respiratory physiotherapist for physical therapy
● Ensure to use proper PPE when accompanying patient in light exercise

Intra

● Ensure patient does not come in contact with people in order to avoid infection
● Assess for client’s comfort during the session
● Ensure that the patient does not over exert during exercise

Post
● Ensure patient’s comfort is restored
● Encourage adequate rest after exercise
● Record patient progress
 e. Palliative

i. In TB palliative care is usually given to patients with drug-resistant TB (DR-TB).

Whether it can be multi-drug resistant (MDR-TB) or may be extensively drug
resistant (XDR-TB). WHO (2014), stated that there are at least three important
considerations in suspending anti-TB therapy and changing to palliative care:

1. The patient's quality of life: the drugs used in MDR-TB treatment have
significant adverse effects, and continuing them while the treatment is
failing may cause additional unnecessary suffering.
2. The public health interest: continuing a treatment that is failing can
amplify resistance in the patient's strain, and will result in a waste of
resources. Patients in whom drug-resistant TB regimens fail are likely to
already have highly resistant strains, and ongoing therapy can result in
resistance to all the drugs that are used for TB treatment
3. The model of care available to provide end-of-life care and proper TB
infection control to patients who have no effective treatment alternatives,
they remain as a source of infection

Palliative care for MDR-TB patients has the following advantages:

● Gives relief from symptoms such as respiratory distress, discomfort, and other aches
and pains;
● Affirms life and accepts death as a natural occurrence;
● Neither wants to hurry nor postpone death;
● Combines the mental and spiritual components of health care;
● Provides a support system to assist patients in living as active a life as feasible until they
die;
● Provides a support structure to assist the family in coping with the patient's illness and
loss;
● Uses a multidisciplinary approach to meet the needs of patients and their families,
including bereavement counseling as necessary;
● Improves one's quality of life and may have a favorable impact on the course of
sickness;

Nursing Responsibilities

Pre

● Suspension of therapy should begin with a discussion among the clinical team, which
should include all physicians, nurses, and direct observed therapy (DOT) providers
participating in the patient's care.

● When the clinical team concludes that therapy should be halted, a clear strategy for
approaching the patient and his or her family should be devised.

Intra

Provide End-of-life supportive methods such as:

● Providing relief from dyspnoea through oxygen may be used to alleviate shortness of
breath.
● Provide relief from pain and other symptoms by providing Paracetamol, or codeine with
paracetamol. If possible, stronger analgesics, including morphine, should be used when
appropriate to keep the patient comfortable. Analgesic guides, pain scales, and a
three-step "ladder" for pain management have all been established by the WHO.
● Infection control measures should be maintained since a patient who has been taken off
anti-TB treatment due to failure is often contagious. Efforts to prevent infection should be
maintained.
 ● Providing nutritional support in the form of small, regular meals is frequently the best
option for a person nearing the end of their life. It should be expected that when the
patient's condition deteriorates and during end-of-life care, the intake would decrease.
Treatment should be given for nausea and vomiting, as well as any other conditions that
interfere with nutritional support.
● At this stage, psychological counseling for the patient and family caregivers is crucial,
especially to assist patients in making end-of-life decisions and provide emotional
support.
● At the end of life, a patient's beliefs and values should be respected. Once the patient
and family caregivers realize that death is approaching, it is usual for them to develop or
intensify their interest in spiritual and religious subjects. Healthcare practitioners should
respect their views and not impose personal ideas and practices that are incompatible
with them.prevent the patient to seek and find comfort in the services delivered by
faith-based organizations.

5. PREVENTION & PROGNOSIS

BCG Vaccine
BCG, or bacille Calmette-Guerin, is a vaccine for tuberculosis (TB) disease. It is a live vaccine
against tuberculosis. The vaccine is prepared from a strain of the weakened bovine tuberculosis
bacillus, Mycobacterium bovis.

The BCG is:

● 80% effective in preventing TB for 15 years

● more effective against complex forms of TB in children
● of limited effectiveness in people over the age of 35

In the Philippines BCG vaccine is part of the routine immunization for newborns.

Contraindication

Patients who are immunosuppressed such as those who are HIV infected should not receive the
BCG vaccine

Pregnant patients should not receive the BCG vaccine because it uses live bacteria. Even
though no harmful effects of BCG vaccination on the fetus have been observed, further studies
are needed to prove its safety.

Early Diagnosis

Early detection and treatment are the most effective ways to stop tuberculosis from spreading.
Infectious tuberculosis can infect up to 10–15 more persons every year. However, after being
identified with tuberculosis and starting treatment, the majority of individuals are no longer
contagious after just two weeks.

Case Finding
Limiting the spread of tuberculosis relies on successfully locating and treating those who have
the disease in order to prevent them from infecting others. This can be accomplished by
increasing TB awareness so that persons with TB symptoms are aware to seek help. In
communities with a high incidence of tuberculosis, outreach workers and volunteers look for
persons who have symptoms and send them for testing.
Contact tracing is when someone is diagnosed with contagious tuberculosis and their close
connections are examined for the disease.

Maintaining a Healthy Immune System

Having a healthy immune system is the best form of defense against TB bacteria. A strong
immune system is able to eliminate or kill off the TB bacteria upon exposure.

6. NURSING CARE PLANS

1. Ineffective Airway Clearance related to disease process of TB aeb productive

cough and greenish phlegm
● Assess respiratory function noting breath sounds, rate, rhythm, and
depth, and use of accessory muscles.
● Note ability to expel mucus and cough effectively; document character,
amount of sputum, presence of hemoptysis.
● Place the patient in a semi or high-Fowler’s position. Assist patients with
coughing and deep-breathing exercises.
● Clear secretions from mouth and trachea; suction as necessary.
● Administer medications as prescribed
● Humidify inspired air and oxygen

2. Risk for Impaired Gas Exchange possibly related to effective lung surface area
reduction, damage in the membrane of alveoli and capillary, thick and viscous
secretions, and edematous bronchi secondary to pulmonary TB
● Assess for dyspnea (using 0–10 scale), tachypnea, abnormal or
diminished breath sounds, increased respiratory effort, limited chest wall
expansion, and fatigue.
● Monitor patients for signs of cyanosis, such as change in skin color,
mucous membranes and the nail beds.
● Educate patient on pursed-lip breathing and deep breathing exercises
● Encourage adequate rest
● Monitor arterial blood gas and pulse oximetry routinely.
● Administer oxygen in addition to supportive measures, if needed.

3. Imbalanced Nutrition: Less than body requirements possibly related to improper

food intake secondary to pulmonary TB aeb weight loss, lack of appetite, and poor
muscle tone
● Assess the patient's nutritional status through noting skin elasticity, taking
current weight, assessing the amount of weight loss, assessing the oral
mucosa, check for signs of dysphagia, and check gastrointestinal
integrity.
● Determine patient’s preferred diet and food choices
● Monitor I & O by using I&O chart and food chart
● Encourage small, frequent meals with foods high in protein and
carbohydrates.
● Monitor for changes in weight and appetite
● Encourage rest and provide comfort measures
● Monitor lab tests that are indicative of the patient’s nutritional status
● Refer the patient to a dietitian

4. Risk for Spread of Infection related to disease transmission of tuberculosis

● Identify people who have close contact with the patient
● Teach patient about habits that prevent the spread of the disease such as
coughing in a tissue and throwing it away immediately
● Monitor temperature as indicated
● Consider placing patient in a comfortable airborne infection isolation room
away from other maternal patients
 ● Facilitate DOT, following prescribed TB medications from the physician
that is appropriate for the pregnant patient’s treatment.
● Identify individual risk factors that may contribute to the
activation/reactivation of tuberculosis
● Notify local health department

5. Acute Pain
● Assess patient’s V/S and pain scale rating
● Administer medications as prescribed
● Evaluate patient’s pain rating every 30 minutes
● Elevate the head of the bed and encourage the patient to position in
semi-fowler’s.
● Teach the patient pursed lip breathing and deep breathing exercises
● Provide comfort measures
● Teach the patient nonpharmacologic methods of managing pain
● Evaluate the patient’s response to pain and management strategies.

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