management of TB

1. MR.GOPAL ,..MSC (N),
ASST.PROFESSOR
MEDICAL SURGICAL NURSING
GANGA COLLEGE OF NURSING
COIMBATORE

2. PULMONARY TUBERCULOSIS

3. CONTENT OVERVIEW
• Introduction
• Anatomy & physiology
• Definition
• Causative organism
• Risk factors
• Mode of transmission
• Classification
• Pathophysiology
• Signs & symptoms
• Diagnostic evaluation
• Complication
• Management

4. INTRODUCTION
Tuberculosis is a treatable, communicable
disease that has two general states: latent infection
and active disease. With few exceptions, only those
who develop active tuberculosis in the lungs or
larynx can infect others, usually by coughing,
sneezing, or otherwise expelling tiny infectious
particles that someone else inhales.

5. ANATOMY & PHYSIOLOGY

6. DEFINITION
Tuberculosis (TB) is a lung disease
caused by bacteria called Mycobacterium
tuberculosis or tubercle bacillus. The
bacteria usually attack the lungs, but they
can also damage other parts of the body.

7. INCIDENCE

8. CAUSATIVE ORGANISMS
• Mycobacterium tuberculosis- Human
• Mycobacterium Bovis- Animals
• Other causative organisms
– Mycobacterium africanum
– Mycobacterium microti

9. • M. tuberculosis complex
– M.africanum
– M. Bovis
– M. Canetti
– M. microti
• Non-Mycobacterium Genus
– Mycobacterium leprae
– Mycobacterium avium
– Mycobacterium asiaticum

10. RISK FACTORS
Weakened immune system
A healthy immune system often successfully
fights TB bacteria, but body can't mount an effective
defense if your resistance is low. A number of
diseases, conditions and medications can weaken
immune system, including:
• HIV/AIDS
• Diabetes
• Severe kidney disease & Certain cancers

11. • Cancer treatment, such as chemotherapy
• Drugs to prevent rejection of transplanted organs
• Some drugs used to treat rheumatoid arthritis,
and psoriasis
• Malnutrition
• Very young or advanced age
RISK FACTORS

12. MODE OF TRANSMISSION
All cases of TB are passed from person to person
via droplets. When someone with TB infection coughs,
sneezes, or talks, tiny droplets of saliva or mucus are
expelled into the air, which can be inhaled by another
person.

13. CLASSIFICATION
Primary Disease
Secondary Disease
 Lymph node & Pleural TB
 TB of upper airways
 Skeletal TB & Miliary TB
 Genitourinary TB
 Pericardial TB
 Gastrointestinal TB
 Tuberculous Meningitis
EXTRA PULMONARY TB
PULMONARY TB

14. PULMONARY TB
1. Primary Tuberculosis :-
• The infection of an individual who has not been
previously infected or immunized is called Primary
tuberculosis or Ghon’s complex or childhood
tuberculosis.
• Lesions forming after infection is peripheral and
accompanied by hilar which may not be detectable
on chest radiography.

15. 2. Secondary Tuberculosis :
The infection that individual who has
been previously infected or sensitized is
called secondary or post primary or
reinfection or chronic tuberculosis.
PULMONARY TB cont…

16. B} Extra Pulmonary TB :-
– 20% of patients of TB Patient
– Affected sites in body are :-
• Lymph node TB ( tuberculuous lymphadenitis):-
Seen frequently in HIV infected patients.
• Symptoms :-
– Painless swelling of lymph nodes most commonly
at cervical and Supraclavical (Scrofula)
– Systemic systems are limited to HIV infected
patients.

17. • Pleural TB :-
– Involvement of pleura is common in Primary TB and
results from penetration of tubercle bacilli into pleural
space.
• TB of Upper airways :-
– Involvement of larynx, pharynx and epiglottis.
Symptoms : Dysphagia, chronic productive cough
• Genitourinary TB :-
– 15% of all Extra pulmonary cases.
– Any part of the genitourinary tract get infected.
Symptoms : Urinary frequency, Dysuria, Hematuria.

18. • Skeletal TB :-
– Involvement of weight bearing parts like spine,
hip, knee.
Symptoms :- Pain in hip joints n knees, swelling
of knees, trauma.
• Gastrointestinal TB :-
– Involvement of any part of GI tract.
Symptoms :- Abdominal pain, diarrhea,
weight loss

19. • TB Meningitis & Tuberculoma :-
– 5% of All Extra pulmonary TB
– Results from Hematogenous spead of 10 & 20
TB.
• TB Pericardiatis :-
– 1- 8% of All Extra pulmonary TB cases.
– Spreads mainly in mediastinal or hilar nodes or
from lungs.

20. • Miliary or disseminated TB :-
– Results from Hematogenous spread of Tubercle
Bacilli.
– Spread is due to entry of infection into
pulmonary vein producing lesions in different
extra pulmonary sites.
• Less common Extra Pulmonary TB
– Uveitis, panophthalmitis, painfull Hypersensitivity
related phlyctenular conjuctivis.

21. PATHOPHYSIOLOGY
Droplet nuclei
containing tubercle
bacilli are inhaled,
enter the lungs, and
travel to the alveoli.

22. Bronchiole
Tubercle bacilli
Alveoli
Tubercle bacilli
multiply in the
alveoli.
PATHOPHYSIOLOGY

23. Brain
Larynx
Lymph node
Lung
Spine
Kidney
Bone
A small number of
tubercle bacilli enter the
bloodstream and spread
throughout the body,
including areas where TB
disease is more likely to
develop (such as the brain,
larynx, lymph node, lung,
spine, bone, or kidney).
PATHOPHYSIOLOGY

24. Special immune cells form a
barrier shell
(in this example, bacilli are in
the lungs)
Within 2 to 8 weeks,
special immune cells called
macrophages ingest and
surround the tubercle bacilli.
The cells form a barrier
shell, called a granuloma,
that keeps the bacilli
contained and under control
(LTBI).
PATHOPHYSIOLOGY

25. Shell breaks down and tubercle
bacilli escape and multiply
If the immune system
cannot keep the tubercle
bacilli under control, the
bacilli begin to multiply
rapidly (TB disease). This
process can occur in
different areas in the body,
such as the lungs, kidneys,
brain, or bone
PATHOPHYSIOLOGY

26. EARLY WARNING SIGNS
• A persistent cough, lasting at least 3 weeks
• Coughing with bloody sputum
• A loss of appetite and weight
• A general feeling of fatigue and being unwell
• Swelling in the neck
• A fever & night sweats
• Chest pain
• Urine discoloration & Cloudy & reddish urine

27. LATER
Without treatment, TB can spread to other parts of
the body through the bloodstream:
• The bones: There may be spinal pain and joint
destruction.
• The brain: It can lead to meningitis.
• The liver and kidneys: It can impair the waste filtration
functions and lead to blood in the urine.
• The heart: It can impair the heart's ability to pump blood,
resulting in cardiac tamponade, a condition that can be
fatal.

28. DIAGNOSTIC EVALUATION
• History collection
• Physical examination
• Tuberculin skin test
• Imaging test
• Laboratory test

29. HISTORY COLLECTION
The following factors increases the tuberculosis:
• HIV infection
• History of a positive purified protein derivative
(PPD) test result
• History of prior TB treatment or TB exposure
• Travel to or emigration from an area where TB is
endemic
• Homelessness, shelter-dwelling, incarceration

30. PHYSICAL EXAMINATION
• Decreased breath sounds
• Rales
• Rhonchi
• Fever
• Weight loss
• Tachypnea
• Tachycardia

31. TUBERCULIN SKIN TEST (PPD)
• Injection of fluid into the skin of the lower arm.
• 48-72 hours later – Checked for a reaction.
• Diagnosis is based on the size of the wheal.
• 1 dose = 0.1 ml contains 0.04μg Tuberculin PPD.

32. TUBERCULIN SKIN TEST

33. CHEST RADIOGRAPH
A posterior-anterior chest
radiograph is used to detect chest
abnormalities. Lesions may appear
anywhere in the lungs and may differ
in size, shape, density, and
cavitation. These abnormalities may
suggest TB, but cannot be used to
definitively diagnose TB.

34. DIAGNOSTIC MICROBIOLOGY
The presence of acid-fast-bacilli (AFB) on
a sputum smear or other specimen often indicates
TB disease. Acid-fast microscopy is easy and quick,
but it does not confirm a diagnosis of TB because
some acid-fast-bacilli are not M. tuberculosis.
Therefore, a culture is done on all initial samples to
confirm the diagnosis. A positive culture for M.
tuberculosis confirms the diagnosis of TB disease.

35. OTHER LABORATORY TEST
• Cell count(lymphocytes)
• Protein(Pandy and Rivalta tests) – Ascites, pleural
effusion and meningitis.
• Nucleic acid amplication (NAA) testing
• Polymerase chain reaction
• Temperature
• SPO2 Monitoring
• Arterial blood gas analysis

36. COMPLICATION
• Bones. Spinal pain and joint destruction may result
from TB that infects your bones(TB spine or pot’s
spine)
• Brain(meningitis) & Liver or kidneys failure
• Heart(cardiac tamponade)
• Pleural effusion & Tb pneumonia
• Serious reactions to drug therapy(hepato-toxicity;
hypersentivity)

37. MANAGEMENT
• General management
• Pharmacological management
• Surgical management
• Nutritional management
• Nursing management

38. GENERAL MANAGEMENT
• Fowlers/ semi fowlers position
• Oxygen administration
• Incentive spirometry exercise
• Deep breathing exercises
• Pursed-lip breathing
• Steam inhalation

39. PHARMACOLOGICAL MANAGEMENT
DRUG: ISONIAZID (INH) – 5mg/kg maximum daily
• MOA: Inhibits mycolic acid synthesis.
Side effect
• peripheral neuritis
• hepatic enzyme elevation
• Hypersensitivity

40. DRUG: RIFAMBICIN (Rifadin) :
– 10mg/kg (600mg daily)
• MOA: Blocks RNA synthesis by blocking DNA
dependent RNA polymerase
Side effect
• Hepatitis
• Nausea , vomitting
PHARMACOLOGICAL MANAGEMENT

41. DRUG: PYRAZINAMIDE :
– 15-30 mg/kg (2g max. daily)
• MOA: Bactericidal-slowly metabolizing organism
within acidic environment of Phagocyte or caseous
granuloma.
Side effect:
• Hyperuricemia & Skin rash
• Arthalgia & GI distress
PHARMACOLOGICAL MANAGEMENT

42. DRUG: ETHAMBUTOL (MYAMBUTOL):
– 15-25mg/kg ( 1.6g max.daily)
• MOA: Bacteriostatic Inhibition of Arabinosyl
Transferase
Side effect:
• Blindness (optic neuritis)
PHARMACOLOGICAL MANAGEMENT

43. DRUG: Streptomycin : 15mg/kg/day
• MOA: Inhibition of Protein synthesis by
disruption of ribosomal function
• Side effect
– Ototoxicity
– Renal toxicity
PHARMACOLOGICAL MANAGEMENT

44. • Combination : INH + RIFAMBIN :
– 150 and 300 mg cap. (2 cap daily).
• RIFAPENTINE – 10mg/kg (600mg twice
weekly).
PHARMACOLOGICAL MANAGEMENT

45. Second line medications
• Capreomycin 12 -15 mg/kg
• Ethionamide 15mg/kg
• Para-aminosalycilate sodium 200 - 300 mg/kg
• Cycloserine 15 mg/kg
• Vitamin b(pyridoxine) usually adminstered with
INH

46. NUTRITIONAL MANAGEMENT
S.NO Major Nutrients Foods
1. Carbohydrates &
fats
Whole grain cereals, millets.
Vegetable oils, ghee, butter.
Nuts and oil seeds. Sugars
2. Proteins Pulses, nuts and some oilseeds.
Milks & milk products
Meat, fish, poultry
3. Vitamins &
minerals
Green leafy vegetables.
Other vegetables & fruits.
Eggs, milk & milk products and flesh
foods.

47. NURSING MANAGEMENT
• Ineffective breathing pattern related to pulmonary
infection and potential for long term scarring with
decreased lung capacity as evidenced by tachypnea
• Hyperthermia related to pulmonary infection as
evidenced by increased temperature
• Imbalanced nutrition less than body requirement
related to poor appetite ,fatigue and productive
cough as evidenced by loss of weight

48. • Ineffective airway clearance related to
increased mucus production, hemoptysis as
evidenced by oral secretion
• Acute pain on chest related to increased effort
of breathing as evidenced by pain scale.
• Activity intolerance related to breathing
difficulty and hyperthermia as evidenced by
patient daily activity
NURSING MANAGEMENT

49. PREVENTION
• The BCG vaccine:
– The BCG vaccine is generally used to protect
children, rather than to interrupt transmission among
adults.
• Wear N95 mask when contact with TB patients
• Good ventilation
• Healthy life style & good environment
• Avoid direct contact
• Take healthy diet

50. DOTS THERAPY
DOTS (directly observed treatment, short-course),
is the name given to the World Health Organization-
recommended tuberculosis control strategy that
combines five components:
• Government commitment (including both political will
at all levels, and establishing a centralized and
prioritized system of TB monitoring, recording and
training)

51. • Case detection by sputum smear microscopy
• Standardized treatment regimen directly observed by a
healthcare worker or community health worker for at
least the first two months
• A regular drug supply
• A standardized recording and reporting system that
allows assessment of treatment results
DOTS THERAPY

52. TUBERCULOSIS ELIMINATION PROGRAMME
• It is no longer known as the Revised National TB Control
Programme (RNTCP), and has been rechristened as the
National Tuberculosis Elimination Programme
• The change in name is in line with the larger goal of
eliminating the disease by 2025, five years ahead of the
Sustainable Development Goals target. In March 2018,
Prime Minister Narendra Modi had announced 2025 as the
target year for ending TB.

53. NIKSHAY
NI-KSHAY-(Ni=End, Kshay=TB) is the web
enabled patient management system for TB control
under the National Tuberculosis Elimination
Programme (NTEP). It is developed and maintained
by the Central TB Division (CTD), Ministry of Health
and Family Welfare, Government of India, in
collaboration with the National Informatics Centre
(NIC), and the World Health Organization Country
office for India.

54. Nikshay is used by health functionaries at
various levels across the country both in the public
and private sector, to register cases under their
care, order various types of tests from Labs across
the country, record treatment details, monitor
treatment adherence and to transfer cases
between care providers.
• Contact Us
For queries regarding the use of Nikshay, you
may use the training materials provided or call our
National Help Desk 1800-11-6666 or write to us at.
NIKSHAY cont..

55. REFERENCE
• Lewis & dirksen, (2015) textbook of medical –
surgical nursing, 2nd South asian edition,
elsevier publication.(Pg no:610 - 627)
• Brunner & suddarth’s, (2014) textbook of
medical – surgical nursing, 13th edition, wolters
kluwer publications.

56. • Hawn TR, Day TA, Scriba TJ, Hatherill M, Hanekom
WA, Evans TG, et al. (December 2014). "Tuberculosis
vaccines and prevention of infection". Microbiology and
Molecular Biology Reviews.
• Organization, World Health (2008). Implementing the
WHO Stop TB Strategy: a handbook for national TB
control programmes. Geneva: World Health
Organization(WHO).
REFERENCE