notes on tuberculosis

1. TUBERCULOSIS
DR.VINOLI.S.G
PROFESSOR& HOD MEDICAL SURGICAL
NURSING DEPARTMENT
UNIVERSAL COLLEGE OF NURSING,
BANGALORE

2. Definition
 Tuberculosis (TB) is an infectious disease
caused by Mycobacterium tuberculosis. It
primarily affects the lung parenchyma.
 It also may be transmitted to other parts of the
body, including the meninges, kidneys, bones,
and lymph nodes.

3. Incidence
 TB is a primary cause of death worldwide from
a potentially curable infectious disease.
 It is the leading cause of mortality in patients
with HIV infection.
 Worldwide, more than two billion people (one
third of the population) are currently infected
with TB
 TB is a worldwide public health problem that is
closely associated with poverty, malnutrition,
overcrowding, substandard housing, and
inadequate health care

4.  According to the WHO, an estimated 1.6
million deaths resulted from TB in 2005 (WHO,
2007).
 In the United States, almost 15,000 cases of
TB are reported annually to the CDC (2005a).

5. Transmission
 TB spreads from person to person by airborne
transmission.
 An infected person releases droplet nuclei
(usually particles 1 to 5 micro meters in
diameter) through talking, coughing, sneezing,
laughing, or singing.
 Larger droplets settle; smaller droplets remain
suspended in the air and are inhaled by a
susceptible person.

6. Risk factors
 Close contact with someone who has active
TB.
 Immuno compromised patients
 Substance abuse (IV or injection drug users
and alcoholics)
 Any person without adequate health care
 Preexisting medical conditions or special
treatment (eg, diabetes, chronic renal failure,
malnourishment, selected malignancies,
hemodialysis, transplanted organ,
gastrectomy, or jejunoileal bypass)

7.  Immigration from countries with a high
prevalence of TB
 Institutionalization (eg, long-term care
facilities, psychiatric
 institutions, prisons)
 Living in overcrowded, substandard housing
 Being a health care worker performing high-
risk activities

8. Pathophysiology

9. A susceptible person inhales mycobacterium bacilli
and becomes infected.
The bacteria are transmitted through the airways to
the alveoli, where they are deposited and begin to
multiply.
The bacilli also are transported via the lymph system
and bloodstream to other parts of the body (kidneys,
bones, cerebral cortex) and other areas of the lungs
(upper lobes).
The body’s immune system responds by initiating an
inflammatory reaction.
.

10. Phagocytes (neutrophils and macrophages) engulf
many of the bacteria, and TB-specific lymphocytes
lyse (destroy) the bacilli and normal tissue.
This tissue reaction results in the accumulation of
exudate in the alveoli, causing bronchopneumonia.
The initial infection usually occurs 2 to 10 weeks
after exposure
Granulomas, new tissue masses of live and dead
bacilli, are surrounded by macrophages, which
form a protective wall around the granulomas.
Granulomas are then transformed to a fibrous tissue
mass, the central portion of which is called a Ghon
tubercle.

11. The material (bacteria and macrophages)
becomes necrotic, forming a cheesy mass.
This mass may become calcified and form a
collagenous scar.
At this point, the bacteria become dormant, and
there is no further progression of active
disease

12. Active disease also may occur with reinfection and
activation of dormant bacteria.
In this case, the Ghon tubercle ulcerates, releasing
the cheesy material into the bronchi.
The bacteria then become airborne, resulting in
further spread of the disease.
Then the ulcerated tubercle heals and forms scar
tissue.
This causes the infected lung to become more
inflamed, resulting in further development of
bronchopneumonia and tubercle formation.

13. Classification
 TB can also be classified according to its (1)
presentation (primary, latent, or reactivated)
and (2) whether it is pulmonary or
extrapulmonary.
 Primary infection occurs when the bacteria
are inhaled and initiate an inflammatory
reaction
 Latent TB infection (LTBI) occurs in a person
who does not have active TB disease. These
individuals are asymptomatic and cannot
transmit the TB bacteria to others

14.  If the initial immune response is not adequate,
the body cannot contain the organisms, the
bacteria replicate, and active TB disease
results.
 When active disease develops within the first 2
years of infection, it is termed primary TB.
 Post primary TB, or reactivation TB, is
defined as TB disease occurring 2 or more
years after the initial infection.

15. CLASSIFICATION OF
TUBERCULOSIS (TB)

16. Clas
s
Exposure
or Infection
Description
0 No TB
exposure
No TB exposure, not infected (no history of exposure,
negative tuberculin skin test)
1 TB
exposure,
no infection
TB exposure, no evidence of infection (history of
exposure, negative tuberculin skin test)
2 Latent TB
infection,
no disease
TB infection without disease (significant reaction to
tuberculin skin test, negative bacteriologic studies, no x-
ray findings compatible with TB, no clinical evidence of
TB)
3 TB, clinically
active
TB infection with clinically active disease (positive
bacteriologic studies or both a significant reaction to
tuberculin skin test and clinical or x-ray evidence of current
disease)
4 TB, but not
clinically
active
No current disease (history of previous episode of TB or
abnormal, stable x-ray findings in a person with a
significant reaction to tuberculin skin test; negative
bacteriologic studies if done; no clinical or x-ray evidence
of current disease)

17. LATENT TUBERCULOSIS (TB)
INFECTION COMPARED WITH
TB DISEASE

18. Latent TB Infection TB Disease
Has no symptoms Has symptoms that may include
the following:
• Bad cough that lasts ≥3 wk
• Pain in the chest
• Coughing up blood or sputum
• Weakness or fatigue
• Weight loss
• No appetite
• Chills
• Fever
• Sweating at night
Does not feel sick Usually feels sick
Cannot spread TB bacteria to others May spread TB bacteria to others
Usually has a skin test or blood
test result indicating TB infection
Usually has a skin test or blood
test result indicating TB infection
Has a normal chest x-ray and a
negative sputum smear
May have an abnormal chest x-ray
or positive sputum smear or culture
Needs treatment for latent TB
infection to prevent active TB
disease
Needs treatment for active TB
disease

19. Clinical Manifestations
Symptoms of pulmonary TB usually do not
develop until 2 to 3 weeks after infection or
reactivation.
 The characteristic pulmonary manifestation is an
initial dry cough that frequently becomes
productive with mucoid or mucopurulent sputum.
 fatigue,
 malaise,
 anorexia,
 unexplained weight loss,
 low-grade fevers, and
 night sweats.

20.  Dyspnea is a late symptom that may signify
considerable pulmonary disease or a pleural
effusion.
 Hemoptysis, which occurs in less than 10% of
patients with TB, is also a late symptom
 Auscultation of the lungs may be normal or
reveal crackles, rhonchi, and/or bronchial
breath sounds

21. Complications
 Miliary TB is the widespread dissemination of
the mycobacterium. The bacteria are spread
via the bloodstream to distant organs.
 Pleural TB can result from either primary
disease or reactivation of a latent infection.
 A pleural effusion
 Acute pneumonia

22. Diagnostic evaluation
 A complete history,
 physical examination,
 tuberculin skin test,
 acid-fast bacillus smear contains
mycobacterium
 sputum culture are used to diagnose TB.
 the chest x-ray usually reveals lesions in the
upper lobes
 Interferon-γ Release Assays

23. TUBERCULIN SKIN TEST
 The Mantoux test is used to determine if a person has been
infected with the TB bacillus.
 Tubercle bacillus extract (tuberculin), purified protein
derivative (PPD), is injected into the intradermal layer of the
inner aspect of the forearm, approximately 4 inches below the
elbow .
 Then 0.1 mL of PPD is injected, creating an elevation in the
skin, a wheal or bleb. The site, antigen name, strength, lot
number, date, and time of the test are recorded.
 The test result is read 48 to 72 hours after injection.
 A reaction occurs when both induration and erythema
(redness) are noted.
 The diameter of the induration (not erythema) is measured in
millimeters at its widest part, and the size of the induration is
documented.
 Erythema without induration is not considered significant.

24.  A reaction of 0 to 4 mm is considered not
significant;
 a reaction of 5 mm or greater may be
significant in individuals who are considered at
risk. (HIV patients)
 An induration of 10 mm or greater is usually
considered significant in individuals who have
normal or mildly impaired immunity.

25. Interferon-γ Release Assays
 Interferon-γ (INF-γ) release assays (IGRAs)
provide another screening tool for TB.
 These whole blood assays detect INF-γ
released from T lymphocytes in response to
mycobacterial antigens.
 Examples of IGRAs include
 QuantiFERON-TB test and the T-SPOT. TB
test.
 Test results are available in a few hours.

26. Management
 Most patients with TB are treated on an outpatient
basis
 Many people can continue to work and maintain
their lifestyles with few changes.
 Patients with sputum smear–positive TB are
generally considered infectious for the first 2
weeks after starting treatment.
 Advise these patients to restrict visitors and avoid
travel on public transportation and trips to public
places.
 Hospitalization may be needed for the severely ill
or debilitated.

27.  Pulmonary TB is treated primarily with
chemotherapeutic agents (antituberculosis
agents) for 6 to 12 months.
 A prolonged treatment duration is necessary to
ensure eradication of the organisms and to
prevent relapse.

28. First-Line Antitubercular
Medications
COMMONLY USED
AGENTS
ADULT DAILY DOSAGE*
isoniazid (INH) 5 mg/kg (300 mg maximum daily)
rifampin (Rifadin) 10 mg/kg (600 mg maximum daily)
Rifabutin
(Mycobutin)
5 mg/kg (300 mg maximum daily)
streptomycin 15 mg/kg (1 g maximum daily)*
pyrazinamide 15 to 30 mg/kg (2.0 g maximum
daily)*
ethambutol
(Myambutol)
15 to 25 mg/kg (no maximum daily
dose, but base on lean body wt)*
Combinations:
INH + rifampin (eg,
150-mg & 300-mg caps (2 caps daily)

29.  Vitamin B (pyridoxine) is usually administered
with INH to prevent INH-associated peripheral
neuropathy
 INH also may be used as a prophylactic
(preventive) measure for those at risk for
significant disease,
 Prophylactic INH treatment involves taking daily
doses for 6 to 12 months.
 Liver enzyme, blood urea nitrogen, and creatinine
levels are monitored monthly.
 Sputum culture results are monitored for acid-fast
bacillus to evaluate the effectiveness of treatment
and the patient’s compliance with therapy.

30. DRUG THERAPY
Tuberculosis Disease Regimens
Initial Phase Continuation Phase
Option 1
4-drug regimen consisting of INH,
rifampin, pyrazinamide,
ethambutol
Given daily for 56 doses (8 wk)
OR 5
days/wk DOT for 40 doses (8 wk)
INH, rifampin daily for 126 doses
(18 wk) OR
5 days/wk DOT for 90 doses (18
wk)
Option 2
4-drug regimen consisting of INH,
rifampin, pyrazinamide,
ethambutol
Given daily for 14 doses (2 wk),
followed by twice weekly for 12
doses (6 wk) OR 5 days/wk DOT
for 10 doses (2 wk), then twice
INH, rifampin twice weekly for 36
doses (18 wk) OR once
weekly for 18 doses (18 wk)

31. Initial Phase Continuation Phase
Option 3
4-drug regimen consisting of INH,
rifampin, pyrazinamide,
ethambutol
Given 3 times weekly for 24 doses
(8 wk)
INH, rifampin 3 times
weekly for 54 doses
(18 wk)
Option 4
3-drug regimen consisting of INH,
rifampin, ethambutol
Given daily for 56 doses (8 wk)
OR 5
days/wk DOT for 40 doses (8 wk)
INH, rifampin daily for 217 doses
(31 wk) OR 5 days/wk DOT for
155 doses (31 wk)
OR twice weekly for
62 doses (31 wk)

32. Latent Tuberculosis Infection
Regimens
Drugs Duration Interval Minimum
Doses
isoniazid 9 mo Daily
Twice
weekly*
270
76
isoniazid 6 mo Daily
Twice
weekly*
180
52
isoniazid and
rifapentine
3 mo Once weekly* 12

33. Directly observed therapy
(DOT)
 Directly observed therapy (DOT) involves
providing the anti tuberculous drugs directly to
patients and watching as they swallow the
medications.
 It is the preferred strategy for all patients with
TB to ensure adherence and is recommended
for all patients at risk for non adherence.
 The risk for reactivation of TB and MDR-TB is
increased in patients who do not complete the
full course of therapy.

34. Nursing Assessment
 Obtain history of exposure to TB.
 Assess for symptoms of active disease productive
cough, night sweats, afternoon temperature
elevation, unintentional weight loss, pleuritic chest
pain.
 Auscultate lungs for crackles.
 During drug therapy, assess for liver dysfunction.
 Question the patient about loss of appetite, fatigue,
joint pain, fever, tenderness in liver region, clay-
colored stools, and dark urine.
 Monitor for fever, right upper quadrant abdominal
tenderness, nausea, vomiting, rash, and persistent
paresthesia of hands and feet.
 Monitor results of periodic liver function studies.

35. NURSING DIAGNOSES
 Ineffective breathing pattern related to decreased lung
capacity
 Ineffective airway clearance related to increased
secretions, fatigue, and decreased lung capacity
 Activity intolerance related to fatigue, altered nutritional
status, and fever
 Imbalanced Nutrition: Less Than Body Requirements
related to poor appetite, fatigue, and productive cough
 Noncompliance related to lack of knowledge of disease
process, lack of motivation, long-term nature of treatment,
and lack of resources
 Ineffective self-health management related to lack of
knowledge about the disease process and therapeutic
regimen
 Risk for Infection related to nature of the disease and
patient's symptoms

36. Patient Education and Health
Maintenance
 Review possible complications: hemorrhage,
pleurisy, symptoms of recurrence (persistent
cough, fever, or hemoptysis).
 Instruct patient on avoidance of job-related
exposure to excessive amounts of silicone
(working in foundry, rock quarry, sand
blasting), which increases risk of reactivation.

37.  Encourage patient to report at specified
intervals for bacteriologic (smear) examination
of sputum to monitor therapeutic response and
compliance.
 Instruct patient in basic hygiene practices and
investigate living conditions. Crowded, poorly
ventilated conditions contribute to
development and spread of TB.

38.  Encourage regular symptom screening and
follow-up chest X-rays for rest of life to
evaluate for recurrence.
 Instruct patient on prophylaxis with isoniazid
for people infected with the tubercle bacillus
without active disease to prevent disease from
occurring, or to people at high risk of becoming
infected.
 Educate asymptomatic people about PPD
testing and treatment of latent TB for positive
results, based on risk grouping.

39. Thank you