2. Pulmonary Tuberculosis
Objectives:
• Describe nursing management of patient with pulmonary
tuberculosis.
• Compare and contrast with regard to cause, assessment findings,
management and the significance of preventive health care.
• Use the nursing process as a framework for care of patients with
disorder.
• Identify the clinical significance and related nursing implications of
the various tests and procedures used for diagnostic assessment.
• Demonstrate appropriate documentation and reporting.
3. Pulmonary Tuberculosis (PTB)
• Highly communicable disease caused by Mycobacterium tuberculosis
• M. tuberculosis is a nonmotile, nonsporulating, acid-fast rod that
secretes niacin; when the bacillus reaches a susceptible site, it
multiplies freely.
• Because M. tuberculosis is an aerobic bacterium, it primarily affects the
pulmonary system, especially the upper lobes, where the oxygen
content is highest, but also can affect other areas of the body, such as
the brain, intestines, peritoneum, kidney, joints, and liver.
• An exudative response causes a nonspecific pneumonitis and the
development of granulomas in the lung tissue.
• Tuberculosis has an insidious onset, and many clients are not aware of
symptoms until the disease is well advanced.
• Improper or noncompliant use of treatment programs may cause the
development of mutations in the tubercle bacilli, resulting in a
multidrug-resistant strain of tuberculosis (MDR-TB).
• The goal of treatment is to prevent transmission, control symptoms, and
prevent progression of the disease.
4. Pulmonary Tuberculosis (PTB)
Risk Factors for Tuberculosis
• Child younger than 5 years of age
• Drinking unpasteurized milk if the cow is infected with bovine
tuberculosis
• Homeless individuals or those from a lower socioeconomic group,
minority group, or refugee group
• Individuals in constant, frequent contact with an untreated or
undiagnosed individual
• Individuals living in crowded areas, such as long-term care facilities,
prisons, and mental health facilities
• Older client
• Individuals with malnutrition, infection, immune dysfunction, or
human immunodeficiency virus infection; or immunosuppressed as
a result of medication therapy
• Individuals who abuse alcohol or are intravenous drug users
5. Pulmonary Tuberculosis (PTB)
Transmission
• Via the airborne route by droplet infection.
• When an infected individual coughs, laughs,
sneezes, or sings, droplet nuclei containing
tuberculosis bacteria enter the air and may be
inhaled by others.
• Identification of those in close contact with the
infected individual is important so that they can
be tested and treated as necessary.
• When contacts have been identified, these
persons are assessed with a tuberculin skin test
and chest x-rays to determine infection with
tuberculosis.
• After the infected individual has received
tuberculosis medication for 2 to 3 weeks, the
risk of transmission is reduced greatly.
6. Pulmonary Tuberculosis (PTB)
Disease progression
• Droplets enter the lungs, and the bacteria form a tubercle lesion.
• The defense systems of the body encapsulate the tubercle,
leaving a scar.
• If encapsulation does not occur, bacteria may enter the lymph
system, travel to the lymph nodes, and cause an inflammatory
response termed granulomatous inflammation.
• Primary lesions form; the primary lesions may become dormant
but can be reactivated and become a secondary infection when
re-exposed to the bacterium.
• In an active phase, tuberculosis can cause necrosis and cavitation
in the lesions, leading to rupture, the spread of necrotic tissue,
and damage to various parts of the body.
7. Pulmonary Tuberculosis (PTB)
Client history
• Past exposure to tuberculosis
• Client’s country of origin and travel to foreign countries in which
the incidence of tuberculosis is high
• Recent history of influenza, pneumonia, febrile illness, cough, or
foul-smelling sputum production
• Previous tests for tuberculosis; results of the testing
• Recent bacille Calmette-Guérin vaccine (a vaccine containing
attenuated tubercle bacilli that may be given to persons in
foreign countries or to persons traveling to foreign countries to
produce increased resistance to tuberculosis).
• An individual who has received a bacille Calmette-Guérin (BCG)
vaccine will have a positive tuberculin skin test result and should
be evaluated for tuberculosis with a chest x-ray.
8. Pulmonary Tuberculosis (PTB)
Assessment Findings:
• May be asymptomatic in primary infection
• Fatigue
• Lethargy
• Anorexia
• Weight loss
• Low-grade fever
• Chills
• Night sweats
• Persistent cough and the production of mucoid and
mucopurulent sputum, which is occasionally streaked with blood
• Chest tightness and a dull, aching chest pain may accompany the
cough.
10. Tuberculosis
Diagnostic Evaluation:
Chest assessment
• A physical examination of the chest does not provide conclusive
evidence of tuberculosis.
• A chest x-ray is not definitive, but the presence of multinodular
infiltrates with calcification in the upper lobes suggests tuberculosis.
• If the disease is active, caseation and inflammation may be seen on
the chest x-ray.
• Advanced disease
• Dullness with percussion over involved parenchymal areas,
bronchial breath sounds, rhonchi, and crackles indicate advanced
disease.
• Partial obstruction of a bronchus caused by endobronchial
disease or compression by lymph nodes may produce localized
wheezing and dyspnea.
11. Tuberculosis
Diagnostic Evaluation:
QuantiFERON-TB Gold test
• A blood analysis test by an enzyme-linked immunosorbent assay.
• A sensitive and rapid test (results can be available in 24 hours) that
assists in diagnosing the client.
Sputum cultures
• Sputum specimens are obtained for an acid-fast smear.
• A sputum culture identifying M. tuberculosis confirms the diagnosis.
• After medications are started, sputum samples are obtained again to
determine the effectiveness of therapy.
• Most clients have negative cultures after 3 months of treatment.
12. Tuberculosis
Tuberculin skin test (TST): (Mantoux Test/
Purified Protein Derivative [PPD])
• A positive reaction does not mean that
active disease is present but indicates
previous exposure to tuberculosis or the
presence of inactive (dormant) disease.
• Once the test result is positive, it will be
positive in any future tests.
• Skin test interpretation depends on two
factors: Measurement in millimeters of
the induration, and the person’s risk of
being infected with TB and progression
to disease if infected.
• Once an individual’s skin test is positive,
a chest x-ray is necessary to rule out
active tuberculosis or to detect old
healed lesions.
13. Tuberculosis
CLASSIFICATION OF TB
• Data from the history, physical examination, skin test, chest x-
ray, and microbiologic studies are used to classify TB into one of
five classes. A classification scheme provides public health
officials with a systematic way to monitor epidemiology and
treatment of the disease (American Thoracic Society, 2000).
• Class 0: no exposure; no infection
• Class 1: exposure; no evidence of infection
• Class 2: latent infection; no disease (eg, positive PPD reaction
but no clinical evidence of active TB)
• Class 3: disease; clinically active
• Class 4: disease; not clinically active
• Class 5: suspected disease; diagnosis pending
14. Tuberculosis (TB)
Nursing Evaluation: Expected Outcomes
• Demonstrates adequate oxygenation through improvement in pulse
oximetry and ABG levels.
• Verbalizes understanding of the disease process, transmission, and
treatment, and follows the medication regimen.
• Maintains a normal weight.
• Client adheres to isolation precautions.
Nursing Diagnosis:
• Ineffective airway clearance related to thick, tenacious secretions
• Ineffective breathing pattern related to airway inflammation
• Altered nutrition less than body requirements related to anorexia
and fatigue
• Anxiety related to social isolation secondary to isolation protocols
Planning and Goals:
• Maintain a patent airway with adequate ventilation and oxygenation.
• Maintain adequate body weight
• Verbalize understanding of the disease process and transmission and
will comply with therapy
15. Tuberculosis
Pharmacology
• First-line medications: isoniazid or INH
(Nydrazid), rifampin (Rifadin), pyrazinamide,
and ethambutol (Myambutol) daily for 8
weeks and continuing for up to 4 to 7 months
• Second-line medications: capreomycin
(Capastat), ethionamide (Trecator), para-
aminosalicylate sodium, and cycloserine
(Seromycin)
• Vitamin B (pyridoxine) usually administered
with INH
Treatment:
• Pulmonary TB is treated primarily with
antituberculosis agents for 6 to 12 months.
• A prolonged treatment duration is necessary
to ensure eradication of the organisms and to
prevent relapse.
16. Treatment Regiment for Drug-susceptible TB:
• Regimens for treating TB disease have an intensive phase of 2 months, followed by
a continuation phase of either 4 or 7 months (total of 6 to 9 months for treatment).
Preferred Regimen: (Isoniazid [INH]; Rifampin [RIF]; Ethambutol [EMB]; Pyrazinamide [PZA])
Intensive Phase
Daily INH, RIF, PZA, and EMB* for 40-56 doses**
(8 weeks)
Continuation Phase
Daily INH and RIF for 90-126 doses** (18 weeks) or three-
times-weekly INH and RIF for 54 doses (18 weeks)
Alternative Regimen
Intensive Phase
Daily INH, RIF, PZA, and EMB* for 14 doses (2 weeks),
then three-times-weekly for 18 doses (6 weeks)
Continuation Phase
Three-times-weekly INH and RIF for 54 doses (18
weeks)
Alternative Regimen
Intensive Phase
Three-times-weekly INH, RIF, PZA, and EMB* for 24
doses (8 weeks)
Continuation Phase
Three-times-weekly INH and RIF for 54 doses (18
weeks)
Drug Susceptible TB Disease Treatment Regimens
* EMB can be discontinued if drug susceptibility studies demonstrate susceptibility to first-line drugs.
** Guidelines allow dosing 5 or 7 days-a-week; 5 days-a-week administration by Direct Observe Therapy (DOT)
is an acceptable alternative to 7 days a-week administration.
Note: A continuation phase of once-weekly INH/rifapentine can be used for HIV-negative patients who do not
have cavities on the chest film and who have negative acid-fast bacilli (AFB) smears at the completion of the
intensive phase of treatment.
17. Continuation Phase of Treatment
• The continuation phase of treatment is given for either 4 or 7 months.
The 4-month continuation phase should be used in the large majority of
patients. The 7-month continuation phase is recommended only for
three groups:
• Patients with cavitary pulmonary tuberculosis caused by drug-
susceptible organisms and whose sputum culture obtained at the
time of completion of 2 months of treatment is positive;
• patients whose intensive phase of treatment did not include PZA;
and
• patients being treated with once weekly INH and rifapentine and
whose sputum culture obtained at the time of completion of the
intensive phase is positive.
Treatment Completion
• Treatment completion is determined by the number of doses ingested
over a given period of time.
18. Treatment for Drug Resistant TB:
• Drug-resistant TB is caused by TB bacteria that are resistant to at least
one first-line anti-TB drug. Multidrug-resistant TB (MDR TB) is resistant
to more than one anti-TB drug and at least isoniazid (INH) and rifampin
(RIF).
• Extensively drug-resistant TB (XDR TB) is a rare type of MDR TB that is
resistant to isoniazid and rifampin, plus any fluoroquinolone and at least
one of three injectable second-line drugs (i.e., amikacin, kanamycin, or
capreomycin).
• Treating and curing drug-resistant TB is complicated. Inappropriate
management can have life-threatening results. Drug-resistant TB should
be managed by or in close consultation with an expert in the disease.
• For more information on drug-resistant TB, visit the Drug-Resistant TB
Page (https://www.cdc.gov/tb/topic/drtb/default.htm)
19. Latent TB Infection Treatment Regimens:
• Treatment must be modified if the patient is a contact of an individual
with drug-resistant TB disease.
Drugs Duration Interval Comments
Isoniazid 9 months Daily •Preferred treatment for:Persons living with HIV
•Children aged 2-11
•Pregnant Women (with pyridoxine/vitamin B6 supplements)
Twice weekly* •Preferred treatment for:
Pregnant Women (with pyridoxine/vitamin B6 supplements)
Isoniazid 6 months Daily
Twice weekly*
Isoniazid
and
Rifapentine
3 months Once weekly* Treatment for:
•Persons 12 years or older
•Not recommended for persons who are:
Younger than 2 years old,
•Living with HIV/AIDS taking antiretroviral treatment,
•Presumed infected with INH or RIF-resistant M. tuberculosis, and
•Women who are pregnant or expect to become pregnant within the
12–week regimen.
Rifampin 4 months Daily
*Use Directly Observed Therapy (DOT)
Note: Due to the reports of severe liver injury and deaths, CDC recommends that the combination of rifampin (RIF) and
pyrazinamide (PZA) should generally not be offered for the treatment of latent TB infection.
20. Tuberculosis
Nursing Intervention: The hospitalized client
• The client with active tuberculosis is placed under airborne
isolation precautions in a negative-pressure room; to maintain
negative pressure, the door of the room must be tightly closed.
• The room should have at least six exchanges of fresh air per hour
and should be ventilated to the outside environment, if possible.
• The nurse wears a particulate respirator (a special individually fitted
mask) when caring for the client and a gown when the possibility of
clothing contamination exists.
• Thorough hand washing is required before and after caring for the
client.
• If the client needs to leave the room for a test or procedure, the
client is required to wear a surgical mask.
• Respiratory isolation is discontinued when the client is no longer
considered infectious.
• After the infected individual has received tuberculosis medication
for 2 to 3 weeks, the risk of transmission is reduced greatly.
21. Tuberculosis
Client Education: Tuberculosis
• Provide the client and family with information about tuberculosis
and allay concerns about the contagious aspect of the infection.
• Instruct the client to follow the medication regimen exactly as
prescribed and always to have a supply of the medication on hand.
• Advise the client that the medication regimen is continued over 6 to
12 months depending on the situation.
• Advise the client of the side/adverse effects of the medication and
ways of minimizing them to ensure compliance.
• Reassure the client that after 2 to 3 weeks of medication therapy, it
is unlikely that the client will infect anyone.
• Inform the client to resume activities gradually.
• Instruct the client about the need for adequate nutrition and a well-
balanced diet to promote healing and to prevent recurrence of the
infection.
• Instruct the client to increase intake of foods rich in iron, protein,
and vitamin C.
22. Tuberculosis
Client Education: Tuberculosis
• Inform the client and family that respiratory isolation is not
necessary because family members already have been exposed.
• Instruct the client to cover the mouth and nose when coughing or
sneezing and to put used tissues into plastic bags.
• Instruct the client and family about thorough hand washing.
• Inform the client that a sputum culture is needed every 2 to 4
weeks once medication therapy is initiated.
• Inform the client that when the results of three sputum cultures
are negative, the client is no longer considered infectious and
usually can return to former employment.
• Advise the client to avoid excessive exposure to silicone or dust
because these substances can cause further lung damage.
• Instruct the client regarding the importance of compliance with
treatment, follow-up care, and sputum cultures, as prescribed.
23. References:
• Springhouse review for NCLEX RN. Lippincott Williams and Wilkins
• Lippincott Manual of Nursing Practice. Lippincott Williams and Wilkins
• Handbook for Brunner and Suddarth Textbook of Medical-Surgical Nursing
12th edition. LWW
• Brunner and Suddarth Textbook for Medical-Surgical Nursing 10th edition.
LWW
• Saunders Comprehensive Nursing Review
• https://www.cdc.gov/tb/topic/treatment/ltbi.htm
• https://www.cdc.gov/tb/topic/treatment/tbdisease.htm
• For images taken from https://www.google.com.sa
