Tuberculosis is caused by the bacterium Mycobacterium tuberculosis and most commonly affects the lungs. It can be latent, meaning the person carries the bacteria but is not infectious, or active where the bacteria multiply causing symptoms and ability to spread. Common symptoms include cough, fever, night sweats and weight loss. Diagnosis involves tests of sputum, chest x-ray, and tuberculin skin test. Treatment requires taking multiple antibiotics for 6-9 months to prevent drug resistance. Nursing focuses on preventing spread, improving nutrition and compliance with the long treatment regimen.

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2. INTRODUCTION
•Tuberculosis is an infectious bacterial disease caused
by Mycobacterium tuberculosis.
•The lungs are the most common site of primary infection
by tuberculosis and are a major source of spread of the
disease and of individual morbidity and mortality.
Neo-latin word : -
•Tubercle” - Round nodule/Swelling
•“Osis” - Condition
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3. Pulmonary tuberculosis
•Is a contagious bacterial infection caused by
Mycobacterium tuberculosis that involves the lungs.
•It may spread to other organs.
Causes
Mycobacterium Tuberculosis : Human
 Mycobacterium Bovis : Animals
Mycobacterium Africanism
 Mycobacterium micros
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4. Mycobacterium Tuberculosis
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5. Tuberculosis is either latent or active
Latent TB
• Person carries the TB bacteria within their
body, but the bacteria are present in very small
numbers and are kept under control by the
body’s immune system.
• People with latent TB don't have any
symptoms of TB and can't spread the disease to
others.
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6. Contn…
Active TB
•Occurs when the TB bacteria have started to multiply
and they become numerous enough to overcome the
body’s immune system.
• It causes a person to feel ill and able to spread the
disease to others.
Incubation period:
•Varies between 4-12 weeks.
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7. Risk factors
•Close contacts of patients with smear-positive
pulmonary tuberculosis
•Overcrowding
•Poor environment and malnutrition
•Primary infection < 1 year previously
•IV drugs abusers, alcoholic, smokers, homeless
people and health workers
•Immigrants from high-prevalence countries
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8. Transmission
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9. Tuberculosis
Pulmonary TB
•Primary Disease
• Secondary Disease
Extra pulmonary
•Lymph node TB
•Pleural TB
•TB of upper airways
• Skeletal TB
•Genitourinary TB
•Miliary TB
•Pericardial TB
•Gastrointestinal TB
•Tuberculous Meningitis
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10. Extra pulmonary Pulmonary
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11. Pathophysiology
Primary infection occurs in the lungs, resulting in
granuloma formation
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Inhalation of infected droplets
Inflammatory response occurs, bacteria are engulfed
by macrophages
The lesion develop in lungs is called Ghon’s Focus
(primary lesion)
Transfer of bacilli to the hilar lymph node via
lymphatic, involving the lymph node(Ghon’s complex)

12. Contn…
The macrophage phagocytes the bacilli then ingested bacilli
aggregate and enlarge the lesion
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At 2-4weeks two distinct T-cell mediated immune response
start
A delayed type hypersensitivity reaction that destroy non
activated macrophages containing bacilli but also results in
necrosis an caseation
Granuloma formation which is a soft tubercle with central
caseation necrosis surrounded by epitheloid cells.

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15. Clinical Features
Constitutional
Symptoms
 Anorexia
Low grade fever
Night sweats
Fatigue
Weight loss
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16. Pulmonary Symptoms
Dyspnea
Non resolving bronchopneumonia
Chest tightness
Non productive cough
Mucopurulent sputum with hemoptpysis
Chest pain
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17. Diagnosis
History taking
Physical examination
Clubbing of the fingers or toes
Swollen or tender lymph nodes in the neck or
other areas
Fluid around a lung
Unusual breath sounds
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18. Diagnostic tests
Laboratory Diagnosis
•Tuberculin test
•Sputum smears and culture
•Gene Xpert
•Quanti FERON-TB (QFT)
•HIV test
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19. Diagnostic tests…
Imaging tests
•Chest X-ray
• Chest CT Scan
•Bronchoscopy
Others
•Thoracocentesis
•Biopsy of the affected tissue (done rarely)
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20. Tuberculin test
Tuberculin skin test (also called a PPD test)
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.
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21. Interpretation of Mantoux test
Size of induration <5 mm : Negative; no active
disease
5-10 mm : Borderline; consider positive in
immunocompromised host; contact with adult
patient with sputum AFB positive tuberculosis.
≥10 mm :Positive; suggests disease in presence
of clinical features.
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22. Drug resistent tuberculosis
Multidrug-resistant tuberculosis (MDR-TB):
•Tuberculosis caused by organisms that are
resistant to isoniazid and rifampicin, two first-
line anti -TB drugs is defined as MDR TB.
Extensively drug-resistant TB (XDR-TB):
•Defined as MDR-TB that is resistant as well to
any one of the fluoroquinolones and to at least
one of three injectable second-line drugs
(amikacin, capreomycin or kanamycin),
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23. Complications
•Pleural effusion
•TB pneumonia
•Serious reactions to drug therapy: hepatitis, skin
rashes, GI upset, deafness or neuritis
•Multidrug resistance TB
•Spread of TB infection( miliary TB)
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24. Treatment
First line drugs
•Isoniazid (H)
•Rifampicin (R)
•Pyrazinamide (Z)
•Ethambutol (E)
•Streptomycin (S)
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Second line drugs
• Kanamycin
• Capreomycin
• Amikacin
• Ethionamide
• Para Aminosalicylic acid
(PAS)
• Cycloserine
• Ciprofloxacin

25. Relative activity of first line drugs
•INH: potent bactericidal (Synergistic
effect)
•Rifampicin (R): potent bactericidal
(Synergistic effect)
•Pyrazinamide (Z) : weak bactericidal
•Ethambutol (E): bacteriostatic
•Streptomycin (S) : bactericidal
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26. Medicines are available in fixed dose
combination (FDC)
HRZE
• Isoniazide [75 mg]
• Rifampicin [150 mg]
• Pyrazinamide [400mg}
• Ethambutol [275mg]
HR
•Isoniazide (150mg)
•Rifampicin (150mg)
HRE
• Isoniazide [75 mg]
• Rifampicin [150 mg]
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27. CATEGORY I
•New sputum smear-positive, sputum smear-
negative and extra-pulmonary TB cases.
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28. CATEGORY II
•Retreatment TB cases including failures,
relapse and return after default.
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29. WHO updates of tuberculosis
regimen
Only 2 regimen
Drug susceptibility regimen
Drug resistant regimen
1. All forms of new TB cases
2HRZE+4HR
2. Severe case ( CNS TB, Pericarditis TB, Musculoskeletal TB, Miliary
TB)
2HRZE+7-10 HRE
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30. WHO updates of tuberculosis regimen
3. Retreatment all type of TB cases
2HRZE+ 4HR
4. Isoniazide Resistant + Rifampicin Sensitive
6RZE + Levofloxacin
5. Isoniazide not known + Rifampicin sensitive
6HRZE
6. Rifampicin sensitive ISH resistant and fluroquinolones resistant
6RZE
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31. Main adverse reaction of drugs
Name of drug Adverse reaction
Isoniazid Peripheral neuropathy
Hepatitis
Rash
Rifampicin Febrile reactions
Hepatitis
Rash
Gastrointestinal disturbance
Red discoloration of all body
fluids
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32. Contn…
Pyrazinamide Hepatitis
Gastrointestinal
disturbance
Hyperuricaemia
Streptomycin 8th nerve damage
Rash
Ethambutol Optic neuritis
Arthralgia
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33. Second Line Drugs
Drugs used in MDR
For intensive phase, 8months duration
•Injection Kanamycin
•Tab Cycloserine
•Tab Levofloxacin
•Tab Ethionamide
•Tab Pyrizinamide
•For continuation phase, 12 months duration: Except
inj Kanamycin, all oral drugs are used.
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34. Drugs used in XDR
•For intensive phase, 12months duration
•Injection Capreomycin
•Tab PAS (4 gm sachet)
•Tab Moxifloxacin
•Tab Clofazimine
•Tab Cycloserine
•Tab Pyrizinamide
•Tab Clavuam ( Amoxicillin 500mg+ Clavulanate 125mg)
•For continuation phase, 12-18 months duration:
Except inj capreomycin, all oral drugs are used.
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35. Supportive management
•Vitamin supplementation (esp. Vit B6)
•Rest and sleep
•Nutrition – High protein diet
•Oxygen therapy (if required)
Prognosis
•Symptoms often improve in 2 to 3 weeks after starting
treatment.
•A chest x-ray will not show this improvement until
weeks or months later
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36. DOTS AND TREATMENT OF TB IN NEPAL
 Directly Observed Treatment Short course (DOTS) is
the most effective strategy available today for
tuberculosis control.
The World Health Organization (WHO) recommended
treatment strategy for detection and cure of TB.DOTS
service was implemented in Nepal from 1996.
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37. Contn..
•Total of 4,321 TB treatment centers ( including BPKIHS),
96 urban health centers, 581 microscopy centers and 27
Gene Xpert centers have been providing the TB services
in the country.
•The drug resistant TB have been provided through 14
drug resistant TB treatment centers and 81 sub-centers.
• Vision of END TB Strategy-2016-35:
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38. Nursing Management
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39. Nursing assessment
•Obtain history of exposure to TB.
Assess symptoms like
•productive cough,
•night sweats,
•afternoon temperature elevation,
• weight loss,
•chest pain.
Auscultate lungs for crackles
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40. Nursing Diagnosis
•Ineffective breathing pattern related to pulmonary
infection and potential for long-term scarring with
decreased lung capacity
•Risk for infection related to nature of the disease and
patient's symptoms
•Imbalanced nutrition less than body requirements
related to poor appetite, fatigue and productive cough
•Noncompliance related to lack of motivation and long-
term treatment
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41. Improving breathing pattern
•Provide adequate rest and avoidance of
exertion.
•Monitor breath sounds, respiratory rate,
sputum production, and dyspnea.
•Provide supplemental oxygen as ordered.
•Administer and teach self-administration
of medications as ordered
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42. Preventing transmission of infection
•Enforce rule that all staff and visitors use well-fitted
standard masks for contact with patient.
•Use high-efficiency particulate masks, such as HEPA
filter masks,
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43. •Provide care for
hospitalized patient in a
negative-pressure room
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44. Contn…
•Use standard precautions for additional protection.
•Educate the patient to control spread of infection through
secretions.
•Cover mouth and nose with double-ply tissue when
coughing or sneezing.
•Do not sneeze by bare hand.
•Wash hands after coughing or sneezing.
•Dispose of tissues promptly into closed plastic bag.
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45. Improving nutritional status
•Explain the importance of eating a nutritious diet to
promote healing and improve defense against infection.
•Provide small, frequent meals and liquid supplements
during symptomatic period.
•Monitor weight.
•Administer vitamin supplements, as ordered, particularly
pyridoxine (vitamin B6) to prevent peripheral neuropathy
in patients taking isoniazide.
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46. Improving compliance
•Stress the importance of continuing to take medicine.
•Review adverse effects of the drug therapy.
•Question the patient specifically about common
toxicities of drugs being used.
•Immediate reporting of toxicities.
•Participate in observation of medication taking,
weekly pill counts.
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47. Patient Education and Health Maintenance
• Review possible complications
• Instruct patient on avoidance of job-related exposure to excessive
amounts of silicone
• Encourage patient to report at specified intervals for bacteriologic
(smear) examination of sputum
• Educate asymptomatic people about PPD testing and treatment of
latent TB for positive results, based on risk grouping.
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48. THANK-YOU
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