Respiratory

1. Care of the patient with
Tuberculosis
Shangwe Kibona

2. Outline
• Introduction
• Definition
• Types
• Transmission
• Risk factors
• Pathophysiology
• Clinical manifestation
• Diagnostic evaluation
• Medical management
• Nursing management
• Complications

3. Introduction
• Tuberculosis (TB) is one of the most prevalent
infections of human beings and contributes
considerably to illness and death around the world.
• It is spread by inhaling tiny droplets of saliva from the
coughs or sneezes of an infected person.
• It is a slowly spreading, chronic, granulomatous
bacterial infection, characterized by gradual weight
loss.
• TB is the world’s second most common cause of death
from infectious disease after HIV/AIDS.
• With the increased incidence of AIDS, TB has become a
great problem in the world

4. INTRODUCTION
Tuberculosis (TB) is an infectious disease that primarily
affects the lung parenchyma
The primary infectious agent, Mycobacterium tuberculosis
• These microrganisms are also known as Acid-Fast Bacilli
(AFB).
M. bovis and M. avium rarely associated with the
development of a TB infection.

5. Definition
• Tuberculosis is the infectious disease primarily
affecting lung parenchyma is most often caused by
Mycobacterium Tuberculosis.
• It may spread to any part of the body including
meninges, kidney, bones and lymph-nodes.

6. Types
• 1. Pulmonary tuberculosis
• 2. Avian tuberculosis (micobacterium avium; of
birds)
• 3. Bovine tuberculosis (mycobacterium bovis; of
cattle)
• 4. Miliary tuberculosis /disseminated tuberculosis
(invade the blood stream and spread to all body
organs.

7. Sites of TB Disease
Pulmonary TB occurs in the lungs
– 85% of all TB cases are pulmonary
Extra-pulmonary TB occurs in places other than the lungs, including the:
– Larynx
– Lymph nodes
– Brain and spine
– Kidneys
– Bones and joints
– Reproductive organs
Miliary TB occurs when tubercle bacilli enter the bloodstream and are carried to
all parts of the body

8. TB Transmission
How can you acquire TB?
TB is spread through tiny drops sprayed into the air when an
infected person coughs, sneezes, or speaks.
TB droplets are more easily spread in areas with poor air
circulation.
The lungs are the most common place for TB.
This is known as pulmonary TB

9. Risk Factors for Tuberculosis
Close contact with someone who has active TB.
Immunocompromised status (eg, elderly,cancer,)
 Substance abuse (IV or injection drug users and alcoholics)
Immigrants from countries with higher incidence of TB.
Pre existing medical conditions (diabetes mellitus, chronic renal
failure)
Living in overcrowded or substandard housing
Occupation (health care workers)

10. Pathophysiology
Characterized by three stages
–Early infection(or primary TB)
» Immune activation
» Healing of the primary lesion
–Latent period
–Secondary TB

11. Pathophysiology
1. Early infection
TB is spread person to person through the air via droplet nuclei
M. tuberculosis may be expelled when an infectious person:
– coughs
– sneezes
– speaks
– sings

12. Pathophysiology
Bacteria are transmitted to the alveoli; begin to multiply.
The bacilli also are transported via the lymph system and
bloodstream to other parts of the body
Most common (kidneys, bones, cerebral cortex)

13. Pathophysiology
Immune activation
Cellular immune response limits further multiplication and
dissemination of the bacilli by initiating an inflammatory
reaction
–phagocytes (neutrophils and macrophages)
–These cells engulf the bacteria and destroy the bacilli and
normal tissue

14. Pathophysiology
 This tissue reaction results in the accumulation of infectious
fluid (exudate) in the alveoli, causing bronchopneumonia.
The initial infection usually occurs 2 to 10 weeks after
exposure
Tissue reaction results into new tissue masses of live and
dead bacilli (granuloma) which cause inflammation

15. Pathophysiology
Granulomas leads to calcification in pulmonary parenchyma
known as Ghon tubercle.
Lymphocytes surround the G. tubercle, central portion undergoes
necrosis.
– forming gaseous necrotic tissue with cheesy appearance
– may liquefy and slough into the bronchus and may enter the
tracheobronchial tree promoting airborne transmission
of infectious particles

16. Healing of the primary lesion
 Occurs due to damaged and scarring (fibrosis) also
hardening (calcification) of lung tissues which Becomes
more fibrous and creates a scar around the tubercle (nodule).
–This is referred to the lesion seen in the lung (Ghon
complex) and is visible on radiography.

17. Pathophysiology
2. Latent period
As the lesion heals
–the infection enters a latent period that
Patient may live many years or even an entire lifetime
without producing clinical symptoms.
If the immune response has been inadequate, affected person
develops clinical disease.

18. Pathophysiology
Approximately 10% of people who are initially infected
develop active disease
Clients at particular risk
–HIV infection
–On chemotherapy
–long-term steroids

19. Pathophysiology
3. Secondary infection
• Active disease occurs with reinfection or decreased body
immunity
− leading to activation of dormant bacteria.
• Bacteria then become airborne, resulting in further spread of
the disease.

20. Pathophysiology
Infected lung become more inflamed
TB gradually spreads throughout the lungs and into the rest
of the respiratory structures, as well as to other organs
through the lymph system.

21. Summary of pathophysiology
Droplet nuclei containing tubercle bacilli are
inhaled, enter the lungs, and travel to small air
sacs (alveoli)

22. 22
bronchiole
blood vessel
tubercle bacilli
alveoli
2
Tubercle bacilli multiply in alveoli, where infection
begins

23. A small number of tubercle bacilli enter
bloodstream and spread throughout body
brain
lung
kidney
bone
3

24. special
immune cells
form a barrier
shell (in this
example,
bacilli are
in the lungs)
4
Within 2 to 8 weeks the immune system produces special immune
cells called macrophages that surround the tubercle bacilli
These cells form a barrier shell that keeps the bacilli contained
and under control (Latent period)

25. shell breaks
down and
tubercle
bacilli escape
multiply
(in this example,
TB disease
develops in
the lungs)
and
5
If the immune system CANNOT keep tubercle
bacilli under control, bacilli begin to multiply
rapidly and cause TB disease

26. Clinical manifestations
Productive prolonged cough (2-3 weeks or more)
Chest pain
Hemoptysis
Fever for more than 2 weeks
Night sweats
Swelling of lymph nodes

27. Clinical manifestations
Fatigue
Dyspnea
Non resolving bronchopneumonia
Loss of appetite
Unexplained weight loss (more than 1.5 kg in a month)

28. The symptoms for extra-pulmonary tuberculosis
Depend on the organs involved
Swelling of lymph nodes in tuberculosis lymphadenitis,
Pain and swelling of joints in tuberculosis arthritis, deformity
of the spine in Pott’s disease,
Headache, fever, stiffness of the neck and mental confusion
when there is tuberculous meningitis.

29. Diagnostic Measures
Sputum smear microscopy Mycobacteria are “acid-fast bacilli”
(AFB)
Sputum culture Culture is a more sensitive than AFB
microscopy and can detect as low as 10 bacilli/ml of sputum.
Chest X-ray Diagnosis of tuberculosis using sometimes not
reliable because there are other chest diseases that may produce
similar changes.
Tuberculin skin test (Mantoux test). 0.1 mL of 5-TU of purified
protein derivative (PPD)

30. Other diagnostic test
Blood culture
Erythrocyte Sedimentation Rate (ESR)
Interferon gamma Release Assays (IGRA)
Molecular testing
Nucleic acid amplification
Biopsy (for diagnosis of extra-pulmonary tuberculosis).

31. Medical management
Aims of tuberculosis treatment
Specifically, TB treatment aims to:
Cure the patient and restore quality of life and productivity.
Prevent relapse of TB.
Reduce transmission of TB to others.
Prevent the development and transmission of drug-resistant
tubercle bacilli.
Prevent death from active TB or its late effects.

32. Medical management
Most TB is curable
–four or more drugs required for the simplest
regimen
–6-9 or more months of treatment required
–patient must be isolated until non-infectious
–directly observed therapy to assure
adherence/completion recommended

33. Medical management
–side effects common
»may prolong treatment
»may prolong infectiousness
−drug-drug interactions common
Drugs used to treat TB; Rifampicin
Isoniazid, pyrazinamide, ethambutol and
streptomycin injection

34. Medical management
TB treatment categories
These guidelines are given according to the
National TB and Leprosy programme (NTLP)
Category determine drugs to be used and
duration

35. Medical management
Category I
 New sputum smear PTB (positive pulmonary TB) and new
patients with severe forms of EPTB
Category II
 When there is relapse
 Treatment failure and Sputum smear positive

36. Medical management
Category III
 New sputum smear negative
 EPTB (less severe forms)

37. Treatment regimen category I and III
Drug Duration
Rifampicin, Isoniazid,
Pyrazinamide and Ethambutol
Two months of intensive phase,
daily observed treatment (DOT)
Rifampicin and Isoniazid Four months of continuation
phase, daily observed

38. Treatment regimen category II
Drugs Duration
Streptomycin Inj IM,
Rifampicin, Isoniazid,
Pyrazinamide and Ethambutol
Two months of intensive phase,
daily observed treatment
Rifampicin, Isoniazid,
Pyrazinamide and Ethambutol
One month, intensive phase
daily observed
Rifampicin, Isoniazid and
Ethambutol
Five months of continuation
phase

39. NURSING MANAGEMENT
Assessment
• Obtain history of exposure to TB
• Assess for symptoms of active disease
• Auscultate lungs for crackles
• During drug therapy assess for liver function

40. Nursing Diagnosis
• Based on the assessment data, the
major nursing diagnosis for the patient
include:
• Risk for infection related to inadequate
primary defenses and lowered resistance.
• Ineffective airway clearance related to thick,
viscous, or bloody secretions.

41. Nursing Diagnosis
• Risk for impaired gas exchange related to
decrease in effective lung surface.
• Activity intolerance related to imbalance
between oxygen supply and demand.
• Imbalanced nutrition: less than body
requirements related to inability to ingest
adequate nutrients.

42. Goals
• The major goals for the patient management
include:
• Promote airway clearance.
• Adhere to treatment regimen.
• Promote activity and adequate nutrition.
• Prevent spread of tuberculosis infection.

43. Nursing interventions
1. Promoting airway clearance
 Thick secretions may disturb patency of the airways
 Encourage fluid intake (3 to 4 L/day)

44. Nursing interventions cont…
2. Pain management
 Chest pain very common
 Assess pain level provides a baseline for treatment
 Administer analgesics as prescribed

45. Nursing interventions cont…
3. Promoting activity tolerance
 Activity Intolerance may be due to general weakness,
respiratory difficulties and severity of illness
 Encourage rest periods, particularly before performing
activities of daily living (ADLs), and exercise
 Assist patient with activities as required

46. Nursing interventions cont…
4. Advocating adherence to treatment regimen
 Risk for non adherence is high
– multiple-medication regimen is very complex.
 Understanding the medications, schedule, and side effects is
important.
 The major reason treatment fails is that patients do not take
their medications regularly and for the prescribed duration

47. Nursing interventions cont…
5. Promoting adequate nutrition
 Anorexia, weight loss, and malnutrition are common
 Willingness to eat maybe altered by fatigue from excessive
coughing, generalized weakness
 Small, frequent meals may be required.

48. Nursing interventions cont…
6. Manage side effects of medication therapy
 Assess medication side effects
– often is a reason the patient fails to adhere to the prescribed
medication regimen
 Efforts should be made to reduce the side effects
– to increase willingness to take the medications as prescribed

49. Nursing interventions cont…
 Take medication either on an empty stomach or at least 1 hour
before meals
– food interferes with medication absorption
– Monitors other side effects of anti-TB medications,
including hepatitis, neurologic changes (hearing loss,
neuritis), and rash

50. Nursing interventions cont…
7. Teaching patients self-care
 Teaching should include;
– patient’s ability to continue therapy at home.
– about infection control procedures, such as proper disposal
of tissues, covering the mouth during coughing, and hand
hygiene.

51. Complications
• Spinal pain. Back pain and stiffness are
common complications of tuberculosis.
• Joint damage. Arthritis that results from
tuberculosis (tuberculous arthritis) usually
affects the hips and knees.
• Swelling of the membranes that cover your
brain (meningitis). This can cause a lasting or
intermittent headache that occurs for weeks
and possible mental changes.

52. Complications
• Liver or kidney problems. liver and kidneys
help filter waste and impurities from your
bloodstream.
• Heart disorders. Rarely, tuberculosis can infect
the tissues that surround your heart, causing
inflammation and fluid collections that might
interfere with heart's ability to pump
effectively.
This condition, called cardiac tamponade, can
be fatal.

53. Prevention
• Vaccination
• Proper nutrition
• Prevention of other diseases
• Stay home.
• Ventilate the room.
• Cover mouth during coughing.
• Proper disposal of sputum
• Wear a face mask.
• Finish your medication

54. THE END
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