CHAPTER ONE

1.1 Introduction

This is a case study of a 45 year old Mr. Sunny Holiday who was presented at the accident
and emergency ward of Taraba State Specialist Hospital Jalingo on 11/11/2023 in the
company of his wife, with history of night sweating, fever, productive cough, headache, loss
of appetite. On examination, the client was looking very weak, vital signs read temperature
380C. Pulse 108b/m, respiration 26cm, blood pressure 119/70mmHg. Tuberculosis was
suspected hence Chest X-ray was done which confirmed the diagnosis

First contact with Mr. Sunny Holiday was at the village market during community
mobilization on 11 November, 2023 where he complained of weakness and headache, cough
he was directed to the health centre for proper care, he reported to the health centre the next
day being 11th Nov, 2023.

1.2 Case Study Background

Mr. Sunny Holiday hails from Jekadafari, community Turaki B ward of Jalingo town. He
came into the health center in the company of his wife on 11/11/2023. He was seen and
checked. On history taking he complained of fever, cough, loss of body weight, loss of
appetite generalized body weakness.

Tuberculosis (TB), is an infectious disease caused by the bacteria Mycobacterium

tuberculosis. The bacteria spreads through the air droplet, contaminated utensil from person
to person and mainly attacks the lungs, but it can affect other areas of the body, according to
the American Lung Association.

Tuberculosis (TB) is contagious infection that usually attacks your lungs. It can be spreads to
other parts of your body like your brain and spine. A type of bacteria that causes it, is called
Mycobacterium.

1.3 Family History

The patient is from polyamine family but presently living with siblings.

Client's Occupation: Business man

Sex: Male

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Age: 45years

LGA: Jalingo

State: Taraba

Address: Anguwan Jeka-Dafari

Next of Kin: Moses Holiday

D.O.B: 03/05/1978

Age: 45 years

Religion: Christian

Nationality: Nigerian

Fathers name: Holiday Daniel

Father's Occupation: Civil Servants

1.2 Medical history: No history of TB in the family

1.3 Family Planning: Utensils and other items should be kept within the patient also isolate
the patient is necessary.

1.4 Family Data

Mr. Sunny Holiday is married to Mrs. Ruth and they are blessed with three children. One
male and two females: Both parents are dead, but all four siblings are alive. He has no history
of hypertension but, has been suffering from Rheumatism for a long time. Socially, the
patient drinks locally brewed bear and occasionally bottled bear and Smokes a pack of
cigarettes per day. He loves to steep without clothes on and always put the Air conditioner on
irrespective of the weather.

1.5 Health History

The patient is always looking matiated and weak.

1.5.1 Present Medical Health History

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Productive cough for more than 2weeks, night sweat, fever, weight loss and lethargic.
According to the patient, he experienced increase fatigue, occasional shortness of breath on
exertion, and mild chest discomfort.

1.5.2 Past Medical Health History

His chart indicates he was in the emergency department last week with similar symptoms and
was diagnosed with community-acquired pneumonia and discharged with azithromycin. He
denies having hypertension or diabetes.

1.5.3 Past Surgical History

Patient had appendectomy done.

1.6 Aims/Objectives

The case study is aimed at achieving the following objectives: to

 Define Tuberculosis (TB).

 Evaluate drugs used to treat Tuberculosis.

 Describe the pathophysiology of Tuberculosis.

 Complication of Tuberculosis.

 Evaluate the effectiveness of nursing care among people with Tuberculosis.

 Describes the role of the inter-professional team in the care of patients with
Tuberculosis

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 CHAPTER TWO

Literature Review

2.1 Definition of Tuberculosis

Tuberculosis is an infection disease caused by mycobacterium Tuberculosis.

Tuberculosis typically attacks the lungs, but can also affect other parts of the body. The
disease has become rare in high income countries, but is still a major public health problem in
low and middle income countries. It is estimated the between the years 2000 and 2010, eight
to mine million new cases emerged each year.

Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. The bacteria

usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney,
pine, and brain (WHO, 2018)

2.2 Causes of tuberculosis

 Close contact: Having close contact with someone who has an active pulmunary
tuberculosis.
 Low immunity: Immunity compromised status like those with HIV. Cancer or
transplanted organs increases the risk of acquiring tuberculosis.
 Substance abuse: People who are IV injection drug users and alcoholic have a greater
chance of acquiring tuberculosis.
 Inadequate health care: Any person without adequate healthcare like the homeless,
impoverished, and the minorities often develop active tuberculosis
 Immigration: Immigration from countries with a high prevalence of Tuberculosis could
affect the patient
 Overcrowding: Living in an over-crowed, substandard housing increases the spreading
of the infection
 People with a weakened immune system have the highest risk of getting Infected with
Tuberculosis "We particularly worry about people with HIV or AlDs because their
immune system can be overwhelmed by Tuberculosis,"

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Risk factors for Tuberculosis include:

 Poverty

 HIV infection

 Homelessness

 Being in jail or prison (where close contact can spread infection)

 Substance abuse

 Taking medication that weakens the immune system

 Kidney disease and diabetes

 Organ transplants

 Working in healthcare

 Exposure to air pollution

 Cancer

 Smoking tobacco

 Age, specifically babies, young children, and elderly people

2.2.3 Mode of Transmission

TB bacteria is spread through the air from one person to another. When a person with TB
disease the lungs or throat coughs, speaks, or sings, TB bacteria can get into the air. People
nearby may breathe in these bacteria and become infected.

TB is NOT spread by

 shaking someone's hand

 sharing food or drink

 touching bed linens or toilet seats

 sharing toothbrushes

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  kissing

When someone who has TB coughs, sneezes, talks, laughs, or sings, they release tiny droplets
that contain the germ

2.2.4 Life cycle of mycobacterium tuberculosis bacteria

Highly pathogenic species such as M. tuberculosis are slow growing mycobacteria.

Specifically, the generation time for M. tuberculosis is between 15 to 20 hours or 900 to 1200
min (Ozimek, 2013).

Because M. tuberculosis has an extremely slow growth rate and has the tendency to pump
together in liquid growth media, it is much more difficult to study its bacterial growth by
additional methods used for other bacteria (Groll, 2014).

Additionally. M. tuberculosis bacteria are heterotrophs and strict aerobes. These bacteria are
metabolically adaptable organisms, as they can grow on a variety of components such as
carbohydrates, alcohols, organic acids, and much more (Mycobacterium). Uniquely, once
M.tuberculosis infects macrophages in culture or in animal models, the bacteria reorients its
hetabolism in response to the brand new environments it comes across (Abramovitch, 2014).

For pathogenic bacteria like M. tuberculosis to thrive and cause disease in us, the bacteria
must compete for its supply of iron within our bodies. M. tuberculosis depends on iron for
normal growth but is limited to the metal due to its low solubility at biological pH and
because we don't like to share it with bacteria! Iron is an incredibly essential nutrient for a
plethora of aerobic bacteria like M. tuberculosis because it plays a critical role in electron
transport, specifically in oxidation and reduction reactions (Sritharan, 2016).

Furthermore, binary fission is the process in which bacteria divide and form two new
identical daughter cells. The diagram below depicts all the steps in detail of binary fission.

M. tuberculosis bacteria divide through binary fission but the process is a little bit more
unique. The bacteria produces cells with a new pole closer to the invagination and an old pole
further away from the invagination. Primarily, all cell divisions in rod-shaped bacteria are
unsymmetrical, meaning that one daughter cell inherits the new pole from a preceding
division and the other daughter cell inherits the old pole. In M. tuberculosis, bacterial cells
more favorably grow at the old pole. The daughter cells that inherit the old pole are deemed.

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2.2. Clinical Manifestation according to Robert, 2023

Signs and symptoms of active Tuberculosis include;

 Coughing for three or more weeks.

 Coughing up blood or mucus

 Chest pain, or pain with breathing or coughing

 Unintentional weight loss.

 Fatigue.

 Fever.

 Night sweats.

 Chills.

 Loss of appetite.

2.3 Diagnosis and Laboratory Investigation

Hb: 13.5g/dl

RBC: 4.9million cells/cu mm

PCV: 39.4%

WBC: 6,400 cells/cu mm

Platelet count: 3.02 lakhs/cu mm

Electrolyte profile: Bicarbonate: 27 mmol/L

Liver function test:Bilirubin Total:0.9mg/dl :Bilirubin Direct: 0.2 mg/dl

SGOT (AST) 9U/L

SGPT (ALT): 17UL

Total Protein: 7.1 g/dl (Albumin: 3.7 g/dl Globulin: 3.4g 40

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Alkaline Phosphatase: 115 U/L

Chest X ray: Significant cavities found

Based on the Laboratory results and findings, he was diagnosed with Tuberculosis.

2.4 Pathophysiology

In tuberculosis (TB) infection, exposure occurs through inhalation of aerosols containing

Mycobacterium tuberculosis (Mtb). Typically, 1-5 μm droplets, generated, for example, by a
single cough in an individual with active pulmonary TB, can initiate infection. The primary
site of infection is often the lungs, where Mtb enters pulmonary alveolar macrophages via
endocytosis.

Mtb's high antigenicity triggers a robust immune response, involving Langerhans cells,
lymphocytes, and polymorphonuclear leukocytes. The bacterium disrupts phagosome
maturation in macrophages, delaying T cell responses. Granuloma formation, a hallmark of
TB, results from an intricate interplay between infected and uninfected macrophages,
epithelioid cells, multinucleated giant cells, dendritic cells, monocytes, eosinophils, mast
cells, B and T lymphocytes, neutrophils, and nonhematopoietic cells.

Granulomas may exhibit various phenotypes, such as fibrotic, calcified, suppurative, cellular,
or non-cellular, depending on the predominant cell type and the presence or absence of Mtb.
Macrophages continue to be recruited to granulomas through chemotactic pathways, leading
to their formation.

As granulomas mature, macrophages undergo apoptosis or necrosis. Apoptotic macrophages

attract new macrophages through signaling involving RD1/MMP9. Alternatively, foamy
macrophages are induced by ESX-1 competent mycobacteria, leading to caseous necrosis.
MMP-1 is implicated in matrix degradation, contributing to cavitation.

The immune system, when activated, can suppress Mtb into latent tuberculosis infection
(LTBI). Individuals may eliminate the infection without developing LTBI, termed "resistors."
Subclinical TB, characterized by intermittent positive cultures and low bacillary load, may be
contagious and necessitates multi-drug therapy.

TB primarily affects the lungs, with the majority of patients presenting with pulmonary
complaints. However, extrapulmonary TB can also occur, either as part of a primary or late

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 generalized infection, serving as a reactivation site. Extrapulmonary reactivation may coexist
with pulmonary reactivation, adding complexity to the pathophysiology of TB.

Fig. 1: Pathophysiology of Tuberculosis. Adapted from “Granuloma”,

2.5 Prevention and Control of Tuberculosis according to Andrew et al, 2019

Prevention of Tuberculosis involves screening these at high risk, early detection and
treatment of cases, and vaccination with the bacillus Calmette-Guérin (BCG) vaccine, Those
at high risk include household, workplace, and social contacts of people with active
Tuberculosis

The following steps can be taken to prevent Tuberculosis infection:

 connecting with a healthcare professional for testing if you believe you've been exposed to
Tuberculosis

 getting tested for Tuberculosis if you have HIV or any condition that increases your risk for
infection

 visiting a travel clinic or check with your doctor about testing before and after traveling to a
country with a high Tuberculosis rate

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 asking about your workplace infection prevention and control program and follow the
precautions provided if your job carries a risk of exposure to Tuberculosis

. avoiding close or prolonged contact with someone who has active Tuberculosis.

These steps can help prevent the transmission of Tuberculosis:

Get tested if you have a higher risk of Tuberculosis or think you may have been exposed.

. If you test positive for latent or active Tuberculosis, take all the medication prescribed.

• If you've been diagnosed with active Tuberculosis, avoid crowds and close contact with
others until you're no longer contagious

. Wear a mask if you have active Tuberculosis and have to spend time around others.

2.6 Nursing Management

2.6.1 Interpersonal Relationship

On Monday 6th/11/ 2023, Mr Sunny arived in the TB Unit accompanied by his daughter and a
Nurse from the emergency unit where he had already been detained for 2 days happened to be
at the nurse's station with the nurse in charge at the time of his arrival, I was subsequently
charged with the responsibility to take his vitals and carry out his admission to the ward.
Thus began my Nurse-patient relationship with the patient that has resulted in this case study.

Nursing care spanned about five days from the time of admission to the ward till discharge on
22nd of November 2023. His condition at the time of discharge was satisfactory. Contact with
Mr. Sunny and his family continued after discharge with home visit and regular phone
communication till nurse-patient relationship was terminated finally on 20th February, 2023.

2.6.2 Physical Examination

On admission, physical examination showed decreased breath sounds and coarse crackles in
the right lower lung field. His blood test results were unremarkable. Chest X-ray and CT scan
showed diffuse reticular pattern and a 4 cm cavity lesion in his right lower lobe. Dullness to
chest percussion. Auscultation revealed vocal fremitus sound.

2.6.3 Vital signs

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His vital signs on admission were 146/78 mmHg: HR 92 bpm; RR 24 bpm; Temp 101.2°F;
SpO2 90% on room air.

2.5.4 Health Education

The patient and his care giver were educated on vital issues of the sickness which include
Proper protocol for airborne isolation each family member is also required to wear a
particulate respirator when in the room with the patient-patient should not leave the room -
keep the door closed at all times

Information’s on signs and symptoms to report that may indicate worsening-further

hemoptysis, difficulty breathing, worsening cough

Information that this medication course could be 6-12 months long

2.6.5 Medication

The standard DOTS regimen for the treatment of drug-sensitive tuberculosis typically
involves a combination of four first-line anti-TB drugs. The drugs are:

 Isoniazid, (150mg),
 Rifampicin (225mg),
 Ethambutol (400mg),
 Pyrazinamide (750mg).

2.6.6 Diet and Nutrition

 Calorie dense foods: Calorie dense foods include banana, cereal porridge, peanut,
wheat Whole milk, yogurt, mayonnaise, sour cream etc.

 Protein rich foods increased protein needs are at by including groundnut. Eggs, meat,
tofu, soya milk, fish etc.

Vitamin A, E, C: Some of the best foods for The patients include the yellow orange frats
and vegetables such as orange, mango, papaya, sweet pumpkin, carrots which are rich in
Vitamin A, while Vitamin C is obtained from fresh fruits including guava, alma, orange.

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Uma to, sweet lime, lemon, capsicum, Vitamin E is orally found in wheat germ., suits,
seeds and vegetable oils

B complex vitamins: Most B complex vitamins are found in whole grain cereals and
pulses, nut and seeds. For non-vegetarians. B complex can be obtained from eggs, fish,
especially sea fish like salmon, tuna, mackerel, sardines, chicken and lean cuts of meat

Selenium and zinc: Mushrooms and most nuts and seeds including sunflower seeds, chia
seeds, pumpkin seeds, sesame, and flax are also good sources of both selenium and zinc,
.Non vegetarian options include oysters, fish and chicken

2.6.7 General Examination

The patient look matiated (weight loss), sweating, and rashes all over the body. Etc.

2.7 Medical management

Medical management is treatment primarily with ant tuberculosis agents for 6 to 12 months.

Medical management of tuberculosis is in two phases:

1. Non pharmacological management and

2. Pharmacological management.

In non-pharmacological management of the patient, the following rules were strictly followed
to prevent transmission of the bacterium to health workers and care givers as well as to help
the patient to recover through maintaining aseptic techniques e.g;

 Medical staff must wear high-efficiency disposable masks.

 Isolate patients with possible tuberculosis infection in a private room.
 Encouraged patients to follow good cough hygiene.
 Provide vitamins & minerals supplements when required.
 Integrated nutritional assessment counselling and support for the duration of the
illness.

Pharmacological management involves use of drugs like: Streptomycin 15mg/kg. Isoniazid or

INH(Nydrazid) 5 mg/kg(300 mg max per day); Rifampin 10 mg/kg; Pyrazinamide 15-30
mg/kg Ethambutol (Myambutol) 15-25 mg/kg daily for 8 weeks and continuing for up to 4 to

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7 months: Capreomycin 12-15 mg/kg: Ethionamide 15mg/kg; Paraaminosalycilate sodium
200-300 mg/kg

Cycloserine 15 mg/kg: Vitamin b (pyridoxine) usually administered with INH. (Andrew et al,
2019).

Patients usually undergo an initial intensive phase of treatment, usually lasting for two
months, during which all four drugs are administered. Subsequently, they enter a continuation
phase, typically lasting for four to six months, during which isoniazid and rifampicin are
continued, while ethambutol may be continued or stopped based on the patient's initial drug
susceptibility testing.

2.8 Community Mobilization and Education

A community is "a group of people who have something in common and will act together in
their common interest" (WHO 2023). Communities may find unity through common
backgrounds, geography, ethnicity, education, experiences, language, and with other social
themes. Community based TB programming can make a unique contribution to national
Tuberculosis programs. For too long, communities, households, and individuals have been
ignored even though they obviously the central actors in their own health. Historically, health
efforts have focused mainly on the formal health system of clinics and hospitals, and
biological approaches. These are obviously vitally important but they do not represent the
whole picture of health.

To prevent the spread of tuberculosis, each member of the community is expected to strictly
comply with the following rules:

 Isolate patient from members of the family with utensils

 Cover your mouth and nose with a tissue or handkerchief when you cough or sneeze.

 Put your used tissue in the waste basket.

 If you don't have a tissue, cough or sneeze into your upper sleeve or elbow, not your
hands.

 You may be asked to put on a facemask to protect others.

 Wash your hands often with soap and warm water for 20 seconds.

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 If soap and water are not available, use an alcohol-based hand rub, if available

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