CASE 3:

TUBERCULOSIS
Prepared by:
Group 3
BSN 3-A
PULMONARY TUBERCULOSIS
Case Scenario
⮚Mrs. Reyes, a 35 year old female, rushed to the emergency room
after experiencing hemoptysis. Apparently she complained of low
grade fever, night sweats and loss of appetite.

⮚During physical examination, Mrs. Reyes looks pale, with dry and
flushed skin and looks older than her age. Her vitals showed
Temperature of 38˚C, Pulse rate of 90 bpm, Respiratory rate of 25
cpm and oxygen saturation of 90.

⮚Upon auscultation both lungs revealed crackles breath sound, She

also complained of chest tightness but upon auscultation heart has
no significant abnormalities.
⮚During palpation, there are enlarged lymph nodes and she has a
distended abdomen.

⮚A month prior to admission, She experienced easy fatigability ,

nocturnal sweats and weight loss. She sought consultation and
she was able to have an apicolordotic X-Ray result of PTB and a
GeneXpert result of POSITIVE.

⮚During her teenage years she was a smoker, alcohol drinker and a
drug user. Since then she manifested a smokers cough.
⮚The patient works as a laborer who asks her neighbors to let her
clean the house or even wash their laundry and she also works as
a street cleaner or sweeper in their barangay. She is married and
her husband is a jeepney driver. They had children ages 12, 9 and
5 year old. Her mother died of TB disease and her father
constantly experienced chronic asthma attacks.

⮚Laboratory findings showed Chest X-Ray with densities at both

lungs. Trachea is in midline. The cardiac silhouette is not enlarged.
The hemidiaphragms and costophrenic sulci are intact.
Appicolodortic views revealed Pulmonary Tuberculosis.
⮚The physician orders to start intravenous fluid of D5LRS 1 liter to run
for 45 gtts per minutes, Oxygen at 4 liters per minute via nasal
cannula, and started on her four drug regimen medications of
Isoniazid 300 mg, Rifampicin 600 mg, Pyrazinamide 2.0 G,
Ethambutol 25 mg/kg as her daily maintenance dose.

⮚After 5 days of hospitalization the patient is getting better and she

was referred to the local health department on the DOTS program for
her medication maintenance.

⮚Her condition improved well and she was discharged the following
day. She was advised to take her maintenance daily and isolate
herself or wear a mask until the 15th day of her drug regimen therapy
for she is still contagious to others.
⮚The physician orders to start intravenous fluid of D5LRS 1 liter to run
for 45 gtts per minutes, Oxygen at 4 liters per minute via nasal
cannula, and started on her four drug regimen medications of
Isoniazid 300 mg, Rifampicin 600 mg, Pyrazinamide 2.0 G,
Ethambutol 25 mg/kg as her daily maintenance dose.

⮚After 5 days of hospitalization the patient is getting better and she

was referred to the local health department on the DOTS program for
her medication maintenance.

⮚Her condition improved well and she was discharged the following
day. She was advised to take her maintenance daily and isolate
herself or wear a mask until the 15th day of her drug regimen therapy
for she is still contagious to others.
Introduction and Objectives
Presented by: Ryan Ramos
Introduction
⮚Tuberculosis is an infectious 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.

⮚According to Centers for Disease Control and Prevention (2021),

despite being preventable and treatable, TB remains the world’s
leading infectious disease killer, taking the lives of 1.4 million
people in 2019 alone.
⮚Two billion people – one fourth of the world’s population – are
infected with the TB bacteria, with more than 10 million
becoming ill with active TB disease each year. In 2019, 1.2 million
children fell ill with TB globally and 465,000 people fell ill with
drug-resistant TB. TB knows no borders. It is present in all
countries around the world and in all age groups.

⮚In adults, tuberculosis is the second leading cause of death due

to an infectious disease (after AIDS), with 95% of deaths occurring
in low-income countries. Tuberculosis is a major problem of
children in poor countries where it kills over 100,000 children
each year.
⮚The treatment of tuberculosis remains a constraint for patients
and a heavy burden for the healthcare system. Drug-susceptible
tuberculosis requires at least six months of therapy under close
supervision. A treatment for multidrug-resistant tuberculosis
requires nearly two years of treatment with poorly tolerated and
less effective drugs.

⮚In most places the diagnosis still relies mainly on direct

microscopy that is unable to detect a large proportion of patients.
The BCG vaccine, developed almost a century ago, confers only
partial protection.
⮚After 40 years of minimal progress in the tools to fight
tuberculosis there are some reasons for hope. A few new drugs
are reaching the final phase of development; a new molecular
test that can be decentralized to some extent and allows the
rapid diagnosis of tuberculosis and of resistance to rifampicin has
been introduced.

⮚Though this is undeniable progress, much will be needed to bring

the new tools and drugs to the patients in need. Furthermore, a
true “point of care” diagnostic test still does not exist and little
progress has been made in research for a more effective vaccine.
⮚After 40 years of minimal progress in the tools to fight
tuberculosis there are some reasons for hope. A few new drugs
are reaching the final phase of development; a new molecular
test that can be decentralized to some extent and allows the
rapid diagnosis of tuberculosis and of resistance to rifampicin has
been introduced.

⮚Though this is undeniable progress, much will be needed to bring

the new tools and drugs to the patients in need. Furthermore, a
true “point of care” diagnostic test still does not exist and little
progress has been made in research for a more effective vaccine.
General Objective
At the end of this case study the students will be able to
obtain knowledge on providing care and be a reliable
educator for the patient.

Specific Objectives
Knowledge:
1. To be able to gain relevant knowledge
regarding pulmonary tuberculosis (TB).
2. To be able to perceive proper ways on assisting
the patient with TB.
Skills:
1. To be able to carry out a proper nursing care for the patient
in managing the signs and symptoms using the nursing
process procedure through interventions and management.
2. To be a competent nursing care provider to relieve our
patients from their pain and discomfort.

Attitude:
1. To establish rapport with the patient and with his/her
family members.
2. To acknowledge and assessed the spirituality of self
and others.
3. To develop personal goals for continued professional
development, self-care, and life-long learning.
Physical Assessment
Presented by: Sean Craig Susbilla
⮚CC: Mrs. Reyes, a 35 year old female, rushed to the
emergency room after experiencing hemoptysis (is when
you cough up blood from your lungs)

• TEMPERATURE: 38 degrees celsius

• PULSE RATE: 90 bpm
• RESPIRATORY RATE: 25 CPM
• 02 SATURATION OF 90%
•INSPECTION
✔Mrs. Reyes looks pale, with dry and flushed skin and looks
older than her age
•PALPATION
✔There are enlarged lymph nodes and she has a distended
abdomen
•AUSCULTATION
✔Both lungs revealed crackles breath sound
✔She also complained of chest tightness but upon auscultation
heart has no significant abnormalities.
✔A month prior to admission, She experienced easy
fatigability , nocturnal sweats and weight loss
Past and Present History
Presented by: April Rose Panes
BIOGRAPHIC DATA
Name : Patient R
Age : 35 years old
Sex : Female
Marital Status : Married
Occupation : Laborer
Admitting Impression: Hemoptysis
Final Diagnosis : Pulmonary Tuberculosis (TB)
Source of Data : Primary
A. Chief Complaint --- Low grade fever, night sweats, and loss of appetite.
B. History of Present Illness --- Experienced fatigability, nocturnal sweats, and
weight loss.
Apicolordotic X-ray result of PTB.
GeneXpert result of Positive
C. Past Medical History --- No medical history.
D. Family Health History ---- Mother died of TB disease.
Father constantly experienced chronic asthma
attacks.
E. Personal and Socioeconomic History
--- A smoker, alcoholic, and drug user during her teenage years, manifested
smokers cough. Works as a laborer who asks her neighbors to let her clean the
house or even wash their laundry and she also works as a street cleaner or
sweeper in their barangay.
Significant/Diagnostic Findings
Presented by: Jeza Ronia Jomelogo
VITAL SIGNS
⮚Temperature of 380 C it means that the patient has a fever
caused by an infection or illness.

⮚The Respiratory rate of 25 cpm it indicates tachypnea.

⮚Oxygen saturation of 90 % having low oxygen levels in the

patients’ blood is called hypoxemia.
PHYSICAL EXAMINATION
⮚The patients look pale, with dry and flushed skin and looks older than her
age.
oPale skin that result from weight loss and the lack of appetite caused by the
disease.

⮚The patient rushed to the emergency room after experiencing hemoptysis.

oHemoptysis is the spitting of blood that originated in the lungs or bronchial
tubes. Rupture of a Rasmussen's aneurysm (a dilated bronchial vessel in the
wall of a tuberculous cavity) is a relatively rare cause of hemoptysis.
Necrosis of pulmonary parenchyma can be seen in chronic infections such as
tuberculosis and in malignant tumors of the lung.
⮚The patient Both lungs revealed crackles breath sound.

o It is important to distinguish normal respiratory sounds from abnormal ones for

example crackles, wheezes, and pleural rub in order to make correct diagnosis.

⮚The patient complained of chest tightness.

o Pulmonary TB is a bacterial infection of the lungs that can cause a range of

symptoms, including chest pain.

⮚During palpation, there are enlarged lymph nodes and she has a distended
abdomen.
o Swollen lymph nodes usually occur as a result of infection from bacteria or
viruses. Abdominal distension occurs when substances, such as air (gas) or fluid,
accumulate in the abdomen causing its expansion.
⮚A month prior to admission, the patient experienced easy
fatigability, nocturnal sweats and weight loss.
oPulmonary tuberculosis can also cause night sweats, which is
when a person wakes up drenched in sweat. Sweating profusely
during the night is one of them and is often an indicator that the
body's levels of infection are potentially very high.
Anatomy and Pathophysiology
Presented by: Rynevelle Labiano
⮚THE LUNGS
They occupy the entire thoracic cavity
The left lung has two lobes; the right lung has three lobes
⮚APEX
The narrow superior portion of each lung
Located just deep to the clavicle
⮚BASE
Broad lung area resting on the diaphragm
⮚Pleural Membranes
• The surface of each lung is covered with its own visceral
serosa, called the pulmonary pleura or visceral pleura.
• The walls of the thoracic cavity are lined by the parietal
pleura.
• The pleural membranes produce pleural fluid.
• A slippery serous fluid
• Allows the lungs to glide easily over the thorax wall during breathing
• Causes the two pleural layers to cling together
 CHEST X-RAY LANDMARKS
Hemidiaphragm
• Half of the diaphragm, the muscle that
separates the chest cavity from the abdomen
and that serves as the main muscle of
respiration.
• Both hemidiaphragms are visible on X-ray
studies from the front or back.
• The right hemidiaphragm is protected by the
liver and is stronger than the left.

Costophrenic Sulci
• The recess between the ribs and the lateral-
most portion of the diaphragm
• Partially occupied by the most caudal part of the
lung
• Seen on radiographs as the costophrenic angle.
PREDISPOSING PRECIPITATING FACTORS
FACTORS Exposure to her mother who died of TB
Smoking habit TUBERCULOSIS Exposure to unknown microorganisms
Alcohol drinking by working as a street sweeper/cleaner
Drug usage The susceptible person inhales M. tuberculosis
and becomes infected.

Body’s immune system responds by initiating an

inflammatory reaction.

Granulomas are formed which are clumps of live and dead bacilli
surrounded by macrophages forming a protective wall.

Granulomas are transformed to a fibrous tissue mass. The central

portion of the fibrous mass is called Ghon’s tubercle.

The material becomes necrotic, forming a cheesy mass, may

become calcified, forming a collagenous scar.

The bacteria become dormant with no further progression of active

disease.
Source: https://semanticscholar.org/
Laboratory Results
Presented by: Anna Carmela Melendez
 T
r
AP LORDIC VIEW a
COMPARISON c
h
e
Actual Findings: a

• Densities at both lungs

• Trachea is in midline.
• The cardiac silhouette is not
enlarged.
• The hemidiaphragms and
costophrenic sulci are intact.
Cardiac
• Appicolodortic views revealed Apex
R hemidiaphragms
Pulmonary Tuberculosis.
L hemidiaphragms

Costophrenic sulci
Significance
⮚Lung density is a radiologic term used to describe the
appearance of the lungs in their entirety or a specific
portion of lung
⮚Increase or a decrease in the lightness or darkness of
the lung “shadow”
⮚Decreased density (as with emphysema)
⮚INCREASED DENSITY (in the presence of inflammation
or increased lung water)
APICOLORDOTIC VIEW
LINDBLOM METHOD
• AP Lordotic (upright)
• Primarily to rule out calcifications
and masses beneath the clavicles or
in the apices of lungs.
❖GeneXpert result of POSITIVE

• The GeneXpert or Xpert MTB/RIF is a cartridge-based

nucleic acid amplification test (NAAT) or molecular test
for Tuberculosis.
• The GeneXpert diagnoses TB by detecting the presence
of TB bacteria, as well as testing for resistance to the
drug Rifampicin.
Medical and Surgical Management
Presented by: Rozyvell Montano
Pulmonary tuberculosis is treated primarily with
antituberculosis agents for 6 to 12 months to prevent relapse.

• Active TB. For most adults with active TB, the recommended
dosing includes the administration of all four drugs daily for 2
months, followed by 4 months of INH and RIF.
• Latent TB. Latent TB is usually treated daily for 9 months.
• Treatment guidelines. Recommended treatment guidelines for
newly diagnosed cases of pulmonary TB have two parts: an
initial treatment phase and a continuation phase.
• Initial/Intensive Phase. The initial phase consists of a multiple-
medication regimen of INH, rifampin, pyrazinamide, and
ethambutol and lasts for 8 weeks.
• Continuation/Maintenance Phase. The continuation phase of
treatment include INH and rifampin or INH and rifapentine, and
lasts for an additional 4 or 7 months.
• Prophylactic isoniazid. Prophylactic INH treatment involves
taking daily doses for 6 to 12 months.
• DOT. Directly observed therapy may be selected, wherein an
assigned caregiver directly observes the administration of the
drug.
Pharmacologic Therapy
The first line antituberculosis medications include:

• Isoniazid (INH). INH is a bactericidal agent that kills bacteria and stops its
growth. It decreases vitamin B6 levels.
• Rifampin (Rifadin). Rifampin is a bactericidal agent, which specifically stops
RNA- polymerase (kills bacteria) that turns the urine and other body secretions
into orange or red.
• Pyrazinamide. Pyrazinamide is a bactericidal agent and has common side effects
of increasing uric acid or gout.
• Ethambutol (Myambutol). Ethambutol is a bacteriostatic agent, specifically
prevent bacteria from reproducing that should be used with caution because it
can inflame optic nerve
Medical Management Based on the Case Includes:
• Streptomycin. Stops protein synthesis & kills bacteria.
• Intravenous fluid administration of D5LRS 1 liter to run for 45 gtts per minutes. It is to
replace fluid losses and and electrolytes in the body.
• Oxygen therapy at 4 liters per minute via nasal cannula. Oxygen is given due to low
oxygen saturation in which the patient develops.
• Administering of first line anti-tubercular medications. Started on her four drug
regimen medications of Isoniazid 300 mg, Rifampicin 600 mg, Pyrazinamide 2.0 G,
Ethambutol 25 mg/kg as her daily maintenance dose.
• Chest X-ray. This is to look at the structures and organs in the chest. Based on the case,
there was revealed densities at both lungs. Trachea is in midline. The cardiac silhouette
is not enlarged. The hemidiaphragms and costophrenic sulci are intact. Appicolodortic
views revealed Pulmonary Tuberculosis.
• Physical examination. The TB patient showed the loss in physical appearance.
Other Possible Medical Management Includes:
• BCG Vaccine. Bacillus Calmette–Guérin vaccine is a vaccine primarily used
against tuberculosis. In countries where TB or leprosy is common, one dose is
recommended in healthy babies as soon after birth as possible
• Sputum culture. Sputum examination to determine presence of acid-fast bacili.
• Quantiferon Gold Test. Measures interferon-gamma by white blood cells after
incubating the blood with specific antigens from M. Tuberculosis proteins, 24
hours’ results will be release.
• Tuberculin or Purified protein derivative (PPD) skin test- positive. Most
common procedure being done to determine exposure to tuberculosis by
assessing the induration.
• Assessment of liver function or liver enzymes. To determine if the drugs affect
the liver function.
Possible Surgical Management Includes:
• Lobectomy. A surgical procedure where an entire lobe of your lung is
removed
• Wedge Resection. The surgical removal of a wedge-shaped portion of
tissue from one, or both, lungs.
• Pneumonectomy. It is a type of surgery to remove one of your lungs.
• Decortication. It is a type of surgical procedure performed to remove a
fibrous tissue that has abnormally formed on the surface of the lung.
• Thoracoplasty. It is minimally invasive procedure in which a thin plastic
tube is inserted into the pleural space — the area between the chest wall
and lungs — and may be attached to a suction device to remove excess
fluid or air.
Possible Nursing Management Includes:
• Complete History. Past and present medical history is assessed as well as both of
the parents’ histories.
• Encourage patient for adequate rest and avoidance of exertion.
• Monitor breath sounds respiratory rates, sputum production and dyspnea.
• Monitor also the vital signs and observe for temperature changes.
• Encourage the patient to increased fluid intake.
• Explain to the client the importance of eating nutritious diet to promote healing
and defense against infection.
• Monitor weight of the patient.
• Make sure that the patient is aware that TB is transmitted by respiratory droplets.
• Explain the importance of hand hygiene, wear mask and proper disposal of tissue.
Nursing Care Plan
Presented by: Ryssa Marie Pelobello
Drug Study
Presented by: Shienneth Anne Senoson
Discharge Plan
Presented by: Alfelyn Grace Venus
KNOWLEDGE OF ILLNESS
Explain to patient that pulmonary TB is a bacterial
infection of the lungs that can cause a range of symptoms,
including chest pain, breathlessness, and severe coughing.
TB is contagious. This means the bacteria are easily spread
from an infected person to someone else. You can get TB
by breathing in air droplets from a cough or sneeze of an
infected person.
MANAGING PULMONARY
TUBERCULOSIS AT HOME
Home isolation is when a person must stay at home
because they have a contagious disease such as TB. If you
are on home isolation it means you are not sick enough to
need hospital care but you are able to spread TB to other
people.
Home isolation helps prevent the spread of TB because
you stay home and away from other people.
PERSONAL HYGIENE
⮚Remain in your home and avoid contact with others
⮚Take your TB medicines as directed, eat healthy foods, and get
plenty of rest
⮚Wear a mask that covers your nose and mouth if you must go to
medical appointments and when health care providers come to
your home
⮚Cover your mouth and nose with a tissue when you cough, sneeze
or laugh
⮚Air out rooms you are staying in by opening the window (if the
weather allows)
⮚Tell any new health care providers (such as ambulance
paramedics) that you have contagious active TB disease
⮚Do not have visitors, especially children and people with
weak immune systems
⮚Do not use buses, trains, taxis or airplanes
⮚Do not go to public places like work, school, church, stores,
shopping malls, restaurants or movie theatres
⮚Cancel or reschedule non-medical appointments (such as
the dentist or hair dresser) until after your home isolation
has ended.
MEDICATION
⮚Isoniazid 30 mg is a prescription medicine used to treat the
symptoms of Latent Tuberculosis Infection or Active Tuberculosis
Disease. Isoniazid may be used alone or with other medications.
Isoniazid belongs to a class of drugs called Antitubercular Agents.
⮚Take isoniazid on an empty stomach, at least 1 hour before or 2
hours after a meal. Use this medicine for the full prescribed length
of time. Your symptoms may improve before the infection is
completely cleared. Skipping doses may also increase your risk of
further infection that is resistant to antibiotics.
⮚Rifampin 600 mg is used with other medications to treat
tuberculosis (TB; a serious infection that affects the lungs and
sometimes other parts of the body). It is taken twice daily for
2 days or once daily for 4 days. Follow the directions on your
prescription label carefully, and ask your doctor or
pharmacist to explain any part you do not understand.
⮚Pyrazinamide kills or stops the growth of certain bacteria
that cause tuberculosis (TB). It is used with other drugs to
treat tuberculosis. This medication is sometimes prescribed
for other uses; ask your doctor or pharmacist for more
information. Pyrazinamide (along with other TB drugs) is
usually given once each day, this is usually in the morning.
⮚Ethambutol (along with other TB drugs) is usually given
once each day. This can be in the morning or the
evening. The currently recommended daily dose of
ethambutol (EMB) for the treatment of tuberculosis (TB).
NUTRITION AND DIET
⮚A healthy balanced diet.
⮚Drink plenty of water, to keep you hydrated but
also help keep mucus thin for easier removal. A
good goal for many people is to 6-8 glasses daily.
ACTIVITIES OF DAILY LIVING
⮚Get enough sleep. Get about 8 hours sleep every
night.
⮚Exercise regularly.
⮚Physical activity helps food intake to be converted
into muscle mass, and it also improves the appetite.
FOLLOW UP CHECK UP
During intensive phase : every day during the first
weeks if hospitalized and at least every week if treated
as outpatient, until the treatment is well tolerated.

Once stable, the patient is seen once or twice monthly.

Related Theory
Presented by: Tracy Villaruz
Florence Nightingale’s
Environmental Theory
Florence Nightingale’s Environmental Theory defined Nursing as “the
act of utilizing the patient’s environment to assist him in his
recovery.”

The work of Florence Nightingale has laid the foundation for

contemporary nursing practice, bringing the fundamental art and
science of nursing into the 21st century. Her Environmental Theory
was the beginning of a lifetime's work, being one of her many
healthcare reforms which survive to this day as the practice of
infection control.
TB has been linked to certain environmental risk
factors related with poverty. These include indoor air
pollution, tobacco smoke, malnutrition,
overcrowded living conditions, and excessive alcohol
consumption. If nurses can modify patient’s
environment according to Nightingale’s canons of
environment, they can help patient to restore their
usual health or bring patient in recovery.
Florence Nightingale’s Environmental Theory correlates with this case
study because Mrs. Reyes acquired Pulmonary Tuberculosis due to
environmental factors that contributed to acquiring such disease.

In this case, it was stated that during Mrs. Reyes teenage years she
was a smoker, alcohol drinker and a drug user. Since then, she
manifested a smoker’s cough. She also works as a laborer who asks
her neighbors to let her clean the house or even wash their laundry
and she also works as a street cleaner or sweeper in their barangay
which belongs to those environmental factors that may cause her to
have Pulmonary Tuberculosis.
As of today, contemporary infection control is an integral part of
nursing and nursing practice. With this, Mrs. Reyes’ condition improved
well and was discharged the following day. She was advised to take her
maintenance daily and isolate herself or wear a mask until the 15th day
of her drug regimen therapy for she is still contagious to others.

Contemporary infection control is an essential part of creating safe

environments that help to promote good healing, good health and
wellbeing and good patient outcomes, along with the opportunity for
continued development to keep in step with changing patient and
global need.
Review of Related Literature
Presented by: Carla Ygan
 DECLINE IN REPORTED TB CASES
AN EFFECT OF THE PANDEMIC – DOH
The Department of Health (DOH) reported that although the number of
tuberculosis (TB) cases reported in the country in the first three months
of 2020 has drastically gone down, this does not necessarily mean good
news.

❖January to March this year

⮚The National Tuberculosis Control Program (NTP) of the DOH recorded a total of
88,662 new and relapse TB cases, declining steeply by almost 20% between
February (30,728) and March (24,782).
❖2017-2019
⮚DOH reached, on the average, 93% of its annual target of notified
cases.
⮚COVID-19 quarantine has restricted such interventions to find, test,
treat and prevent TB cases in hospitals, health facilities and
communities.

❖2019
Philippines had the highest TB incidence in Asia
⮚554 cases per 100,000 people, according to a World Health
Organization (WHO) report.
⮚Approximately, 74 Filipinos die of TB every day
⮚top 10 causes of death in the country.
❖March 16, 2020
⮚DOH-NTP issued Department Memorandum 2020-
0128 entitled “Ensuring Continuous TB Services
During Community Quarantine”
Guidelines:
a. Screening of Presumptive TB, through passive, active, intensified, or
enhanced case finding, shall continue subject to mandated social
distancing and usual infection control procedures. Avoid gathering
people in one place for TB screening and provide masks for healthcare
staff and patients.
b. Usual contact tracing efforts are still to be implemented with strict
compliance on infection control measures.
c. Reporting or notification of cases are still through the Integrated TB
Information System(ITIS).
END
Prepared by:
Group 3
BSN 3-A