KABWE SCHOOL OF NURSING

TUBERCULOSIS
(For July 2014 Intake)
General Objective
At the end of this lecture/discussion,
students should be able to demonstrate
their basic knowledge of tuberculosis
and be able to manage a patient with
tuberculosis.
Specific Objectives

At the end of the lecture/discussion students

should be able to:
Define tuberculosis, state its cause and
discuss mode of transmission
Outline the types of tuberculosis
State the risk for tuberculosis
Describe the pathophysiology of
tuberculosis
State the clinical manifestation of
Pulmonary Tuberculosis
Describe the medical management of a
patient with pulmonary tuberculosis.
Describe the nursing management of a
patient with pulmonary tuberculosis
Discuss the control and prevention of
tuberculosis
Definition, cause and mode of transmission
of tubeculosis

Tuberculosis also known as “Koch’s disease” is

a communicable, chronic infectious and
inflammatory disease that can affect any part of
the body. Tuberculosis is caused by
mycobacterium tuberculosis, the organism is
strict aerobe and thrives best in tissues with
high oxygen tension like in the apex of the
lungs.
The organism is a gram positive
bacillus, and is transmitted from one
person to another by;
Inhalation(micro-droplets) of
organisms present in fresh cough
droplets or in dried sputum from an
open case of pulmonary tuberculosis,
Ingestion of bovine tubercle bacilli
from infected cow’s milk
Inoculation of the organisms into the
skin may rarely occur from infected
postmortem tissue.
Transplacental route result in
development of congenital tuberculosis in
foetus from infected mother and is rare
mode of transmission
Risk/ Predisposing Factors

Poor housing; small houses with poor

ventilation play a major role in TB
transmission.
Poor nutritional status; undernourished
are predisposed to TB as resistance to
infection is reduced.
Overcrowding in places like markets,
schools, and these make it easier to
contract TB.
Age; reduced immunity in the young
and old make them prone to TB
Smoking; the smoke destroys the lung
resulting in parenchymal dysfunction
leading to diseases like TB.
Alcoholism; alcohol reduces the immunity of
an individual making him or her prone to TB
Drugs; patients who take immuno-
suppressive drugs like steroids (e.g.
prednisolone) are prone to TB due to reduced
immunity.
Immuno suppression caused by diseases like
HIV/AIDS, cancer, age the youngest and oldest
being at risk.
Types of Tuberculosis

Pulmonary Tuberculosis (PTB)

This is a chronic infectious disease of the
respiratory tract which is characterized by
formation of granulomas in the lungs.
Extra Pulmonary tuberculosis: This
tuberculosis which occurs anywhere in
the body but outside the lungs e.g. TB
spine, TB abdomen, TB meningitis.

Milliary tuberculosis: This is

tuberculosis in which there is widespread
dissemination of TB throughout the body
from a primary focus or later stages of
tuberculosis
Clinical Features
Cough – The cough is initially dry due
to the irritation by the bacilli that is
foreign to the system. Later becomes
productive when the cheesy material spills
into the bronchus and cough up, usually
purulent sputum. Later there is
haemoptysis due to erosion of blood
vessels
Chest pain – Is due to the destruction
of tissue by disease process exposing the
nerve endings and also due to a reduction
of oxygen causing ischaemia leading to
pain. Pain is dull or pleuritic in nature and
chest tightness may be present.
Dyspnoea – Is due to a reduction in
lung surface area, the destruction of
blood vessels, infection and
inflammation of alveoli. If this persists
and becomes severe there may be
cyanosis.
Fever – Is due to the stimulation of the
temperature –regulation center in the
hypothalamus by the toxins of the
bacilli. Fever is cyclic, present around
midday and in the night. Fever is long
term and low grade.
Chills and Sweats – Are due to fever,
there may be sweat around midday and
at night when there is fever.
Fatigue and anorexia – Due to
massive destruction of tissue by bacilli
and a high adenosine triphosphate (ATP)
requirement. Prolonged anorexia leads to
weight loss.
PATHOPHYSIOLOGY

Primary Infection TB
In primary infection the bacilli enter the
lungs of a person who has not previously
suffered from tuberculosis or immunized
with TB bacilli and this gives rise to the
primary lesion (Ghons Focus) at the point
of entry in the lung, tonsil or small
intestine.
Pathophysiology Cont…….

This usually remains small and

commonly heals without becoming
detectable Although a primary infection
may be only microscopic in size, the
following sequence of events typically
occurs.
Many of the infecting mycobacterium TB
is phagocytosed by macrophages.
Pathophysiology Cont…….

The macrophages aggregate in increasing

numbers to form a macrophage
granuloma or nodule. The lymphocytes
surround the macrophage granuloma
after 10 days of infection and this is
termed a tubercle.
Pathophysiology Cont…….
Most primary tubercles heal over a
period of months through the formation
of fibrous scars and ultimately calcified
lesions. These lesions may contain
living bacilli that can reactivate (even
after many years) when the immunity is
lowered to cause re-infection or
secondary TB.
Primary TB infection may not be
controlled, in this situation, the primary
complex sites progress and worsen,
possibly causing cavitations and spread
of active infection, the client becomes
clinically ill.
Pathophysiology Cont…….
Secondary or Re-infection TB
In addition to progressive primary
disease. Re-infection may also lead to a
clinical form of active TB. Primary sites
of infection containing TB bacilli may
remain latent for years and then
reactivate if the client’s resistance is
lowered.
Pathophysiology Cont…….

The re-infection lesion is usually in the

apex of the lung and may extend to give
a large local lesion with one or more
cavities. There may be involvement of
the local lymph nodes.
INVESTIGATIONS AND DIAGNOSIS
History of exposure to TB and
presenting symptoms.
Skin testing with either tuberculin –
purified protein derivative (PPD) old
tuberculin (OT) is most common. The
primary purpose is to detect individuals
who are infected but not necessarily
diseased.
Used as s screening device, can provide
false positive and false negative results.
Mantoux test used for diagnosis and jet
gun/ multiple puncture for screening.

Chest x-ray –posteranterior (PA ) and

lateral are the standard views.
They will show cavities in the lungs.

Sputum smear –Acid Alcohol fast

bacilli –determine the presence of
mycobacterium tuberculosis, which after
taking up dye is not decolorized by acid
alcohol.
Sputum culture and sensitivity –
culture identifies the specific organism to
enable making a specific diagnosis. It
should be collected before initiation of
antibiotic therapy and thereafter to
monitor effectiveness of antibiotic
therapy.
Sensitivity serves as a guide to anti-
microbial therapy by identifying
antibiotics that prevent the growth of the
organism present in the sputum.
Gastric washing –most patients
swallow sputum when coughing in the
morning or during sleep, an examination
of gastric content can reveal causative
organism.
Cerebral Spinal fluid or aspirates
from abscess analysis shows the TB
bacilli.

Blood – FBC, there is raised white

cell count, ESR is raised. It is above
20mm
DRUGS
Isoniazid
Classification: Bactericidal, penetrates all
body tissues including CSF
Dosage : 15mg/kg per oral or im
Side effects: Peripheral neuritis, hepatitis,
fever, hypersensitivity (rash)
Comments/ interventions
Daily alcohol intake interferes with
metabolism in isoniazid and increase risk
of hepatitis; antacids containing
aluminum interfere with absorption of
isoniazid
Rifampicin
Classification: Bactericidal, penetrates
all body tissues including CSF
Dosage: 600mg PO
Side effects: Hepatitis, febrile
reactions, thrombocytopenia (rare) and
hepatotoxicity increase when given with
isoniazid
Comments / interventions
Urine, sweat tears may turn orange
temporally, decrease effectiveness of
oral contraceptives, anticoagulants,
corticosteroids, barbiturates
hypoglycemic and digitalis.
Ethambutol
Classification : Bacteriostatic does not
penetrate CSF, penetrate other body fluids
Dosage: 50mg/kg po
Side effect: Optic neuritis, (reversible
with discontinuation of drug ) skin rash
Comments / interventions
No significant reaction with other drugs,
check vision monthly; give with food.

Pyrazinamide
Classification: Bacteriostatic or
bactericidal, depending on susceptibility
of mycobacterium
Dosage: 50mg /kg up to 3.5 g po
Side effect: Hyperuricemia , hepatitis,
arthralgia, G.I irritation

Comments /interventions
Obtain baseline liver function tests and
repeat regularly give with food; drink 2L
of fluid daily.
STREPTOMYCIN
Classification: Bactrricidal, amino
glycoside, disrupt proteins synthesis,
poor penetration into body tissues
including CSF
Dosage: 25-30 mg/kg im
Side effects: 8th cranial nerve damage
(vestibular or ocular), damage often
irreversible nephrotoxicity.

Comments/ interventions
Monitor kidney and vestibular function
monthly monitor hearing
Treatment is in categories that is,
and Fixed-Dose Combinations
(FDCs) Isoniazid–Rifampicin–
Pyrazinamide–Ethambutol (HRZE)
Category 1 (New patient)
(smear positive or negative)
4FDCs-RHZE for 2 months,
Then 2FDCs (RH) for 4 months
Category II (Relapse)
4FDCs plus streptomycin injection for 2
months then 1 month 4FDCs alone then
3FDCs(RHE) for 5months
Body Weight No. of Tablets
30 – 37Kgs 2 tablets
38 – 54Kgs 3 tablets
55 – 71Kgs 4 tablets
>71Kgs 5 tablets
NURSING CARE PLAN
Our nursing care will be based on the
following identified problems
1.Altered gas exchange
2.Knowledge deficit about the disease
3.Fear
4.High risk for infection
Problem One- Altered gas exchange

Nursing Diagnosis
Gas exchange impaired related to
decreased lung surface area evidenced by
dyspnoea and fatigue
Nursing Strategies
Encourage nutritious food (high protein,
carbohydrates, and vitamins) and fluid
intakes; encourage frequent mouth washed,
small frequent meals, well balanced and
client’s preferences. Monitor weight
daily .Monitor temperature every six hours.
Give antipyrtetics and Anti Tuberculosis
Drugs
Problem Two - Knowledge Deficit
Nursing Diagnosis
Knowledge deficit about spread and
treatment of TB related to lack exposure
to information a evidenced by anxiety.
Nursing Strategies
Nurse builds a trusting relationship so
that client’s education is an on going
process and behavioral changes are
made. All details of the disease and drug
therapy are carefully explained.
Encourage client to ask questions,
reassure them, and explain also to family
members .
Let patients doing well on TB treatment
discuss condition and treatment with the
patient.
Problem Three - Fear
Nursing Diagnosis
Fear relation to long-term illness
requiring long-term chemotherapy, life
style changes unit less infectious as
evidenced by withdrawal.
Nursing Strategies
Explain disease process to the client and
significant others, the necessity of long
term therapy and changes of life style
until less infectious. Explain treatment
and investigations encourage questions,
and build therapeutic relationship with
client.
Encourage supportive therapy from the
religious minister, social worker, and
counselor to reinforce and assist with
changes in life style. Give diversional
therapy (music, imagery)
Problem Four – High risk for infection
Nursing Diagnosis
High risk for spread of infection related
to denial and stigma of TB evidenced by
un protected cough
Nursing Strategies
Explain mode of infection spread,
importance of medication therapy, use
and disposal of tissues after cough or
sneeze, importance of contact tracing,
nutritional diet, good hygiene, ventilation
and avoidance of overcrowding. Monitor
vital signs and record, monitor signs of
infection spread.
Information, Education and
communication
Teach the client as follows ;
TB is infectious ,but it may be cured or
arrested if you take your medication as
prescribed.
TB is transmitted by droplet infection and
is not carried on articles such as
clothing, books or eating utensils. Cover your
nose and mouth when coughing, laughing or
sneezing
Wash your hands very carefully after any
contact with body substance masks or soiled
tissues. Sputum is highly contaminated.
Cough into tissues paper and dispose of them
properly
Wear masks inn appropriate situations
when advised. Make sure they are tight
fitting and change them frequently.
People with TB are usually not restricted
in their activities for more than 2 to 4
weeks after medications are begun and they
are not isolated from others as long as
compliance is maintained. TB is no longer
treated by isolation in sanatoriums.
Treatment may be necessary for long
time. Take your medication exactly as
prescribed and report all side effects to
your doctor. Do not stop the medication
for any reason without the doctor’s
supervision. Keep an adequate supply of
medication available at times to avoid
running out. Compliance with treatment
is essential.
EVALUATION
Define tuberculosis
What causes tuberculosis?
How can one prevent the spread of
tuberculosis
REFERENCES
1. Anderson .J.R (1985) Muir’s Textbook of
Pathology, 11th edition Butler and Tanner
Limited, London

2. Haesh Mohan (2002), Textbook of Pathology, 4th

edition, Jaypee Brothers medical publishers, New
Delhi, India
3. Nicholas A. B, Nicki R. C, Brian R. W and
John A. A. H (2007),Davidson’s principles &
practice of medicine, 20th edition, Churchill
Livingstone Elsevier. London. UK.

4. Suzanne C. S, Janice.L. H, Brenda G. B and

Kerry H. C (2010), Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing, 12th
edition, Wolters Kluwer Health, Hong Kong,
China