This document provides an overview of pulmonary tuberculosis. It discusses that tuberculosis is caused by Mycobacterium tuberculosis and primarily affects the lungs, causing symptoms like cough and weight loss. Diagnosis involves sputum smear examination and chest x-rays. Treatment follows the DOTS strategy of directly observed therapy with a combination of drugs over 6-9 months. Nursing care focuses on airway clearance, treatment adherence, nutrition, and educating patients on prevention.

1. PULMONARY
TUBERCULOSIS
Presentation By :
POOJA
BHANDARI
P Bhandari

2. PULMONARY
TUBERCULOSIS
 Tuberculosis is a bacterial disease caused
by Mycobacterium tuberculosis ( Tubercle
– lesion , Bacteria cause lesion so called
tubercle bacilli) .
 Mycobacterium Tuberculi can affect any
part of bodies like meninges , kidney ,
bones and lymph nodes.
P Bhandari

3. Cont….
 If it primarily affect the lungs parenchyma
, it is called pulmonary tuberculosis.
 It is one of the major health and social
problems in Nepal.
 It is characterized by pulmonary infiltrates
, formation of granulomas with fibrosis and
cavitation.
P Bhandari

4. P Bhandari

5. INCIDENCE
o Incidence is highest in people who live in
crowded , poorly ventilated , unsanitary
conditions such as prisons , homeless
shelter etc.
o Leading cause of death in adults in Nepal
is 15 – 49 years.
o IN THE WORLD:
o Around one third of the world’s population
has tuberculosis and that between 2002
P Bhandari

6. Cont…
o And 2020 an estimated 1000 million people
will become newly infected .
o NEPAL :
o 5000 – 7000 people die from TB every year.
o Over 80,000 people in Nepal have diseases.
o 22,000 people have sputum positive TB every
years.
o 5000 – 7000 people die from TB every year.
P Bhandari

7. O CAUSATIVE AGENT : Mycobacterium
Tuberculosis.
O ROUTE OF INFECTION : Two species of
mycobacterium causes TB.
M. Tuberculosis - spreads by droplet
M. Bovis – transmitted by milk from diseased
cows
P Bhandari

8. CHARACTERISTICS
O Mycobacterium tuberculosis : Organism is rod
shaped , aerobic ( required oxygen to live )
O Non motile, gram positive acid fast micro
organism.
O Reproduce very slowly in human body.
O Destroyed by heat , burning , boiling for 15
minutes , autoclaving , pasteurizing .
P Bhandari

9. Cont…
O Ultraviolet rays are very effective and
strong Sun rays can also kill this
organism.
P Bhandari

10. PREDOSPOSING FACTOR
O Close contact of patient with smear positive
pulmonary tuberculosis.
O Malnutrition ; overcrowded population: prison
O Chest radiographic evidence of self healed TB
O Patients have immunosupression : HIV ,
Corticosteriods drugs , cytotoxic agents.
O Chronic renal failure ; Silicosis and deficiency
of vitamins A & D.
P Bhandari

11. RISK FACTOR
O Reason for the increasing incidence of TB
1. Developed Countries;
- Immigration from high prevalence areas
- Human immuno deficiency virus.
- Social deprivation ( homelessness , poverty )
- Increasing proportion of elderly
- Drug resistance
P Bhandari

12. Cont….
O 2. Developing Countries ;
- Ineffective control programmes.
- Lack of access to health care.
- Poverty , civil unrest.
- HIV , Population increase.
- Drug resistance.
P Bhandari

13. Factors increasing the risk of
TB
OPatient related
- Age ( children > young adult < elderly )
- Factors increasing the risk of TB.
- First generation immigrants from high
prevalence countries.
- Close contact of patients with smear positive
pulmonary TB.
- Overcrowding : prisons, collective
dormitories.
P Bhandari

14. Cont..
O Chest radiographic evidence of self healed
tuberculosis.
O Primary infection < 1 years previously.
O Associated Disease
O Immunosuppression – HIV , infliximab , high
dose corticosteroids , cytotoxic agents.
O Malignancy ( especially lymphoma and
leukaemia)
P Bhandari

15. Cont…
O Type 1 diabetes mellitus.
O Chronic real failure.
O Silicosis
O Gastrointestinal disease associated with
malnutrition ( gastrectomy , jejuno – ideal
bypass.
O Deficiency of vitamin D or A.
P Bhandari

16. PATHOPHYSIOLOGY
O When the bacilli is inhale Bacilli implant on
bronchioles or alveoli
O Multiply bacilli
Many bacilli engulfed by the macrophage.
Some remain viable and proliferate
Some bacilli spread either by lymph or blood
throughout body (Millary TB )
P Bhandari

17. Cont…
O Macrophages being to elongate and fuse
together to form an epithelium cell ,
tubercle which surround by lymphocytes (
formation of granuloma tubercle ).
O Granuloma tubercle transformed to fibrous
tissue mass , surrounding an area of
cessation lead to the appearance of the
primary lesion in the lung , referred to as
the ‘Ghon focus’
P Bhandari

18. Cont…
O The material ( Bacteria and microphages )
become 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 diseases.
P Bhandari

19. Cont…
O If inadequate immune system response,
the person may develop active disease. In
this case , the Ghon tubercle ulcerates,
releasing the cheesy material into the
bronchi. The cheesy material liquefies
may drain into the tracheobronchial trees
and may be coughed out. Cough out
continue , more than 2 weeks.
P Bhandari

20. Exposure to TB
No infection (70-90%)
Dormant TB (90%) well
-Never develop TB
NOT Infectious
Active TB (10%) ill
- 5% develop TB within 2 years
-% develop TB many years later
Infection (10 – 30 %)
P Bhandari

21. Active TB
Untreated
50% die
within 2
years
Treated
Cured
P Bhandari

22. Clinical Features
OMost important symptoms are: cough
for 2-3 weeks ; Sputum production,
weight loss.
OHaemoptysis , chest pain ,
breathlessness
OFever ( Evening low grade ) for 3
weeks.
ONight sweats , tiredness , fatigue and
anorexia.P Bhandari

23. P Bhandari

24. Diagnostic Procedure
O History and physical examination.
O Sputum smear examination for AFB : Time :
0,2,5,6 or 8 months.
O Samples are necessary. 2 sputum samples most be
positive for diagnosis of pulmonary TB.
O Chest X-ray :Not significant but it is supportive for
one smear positive TB.
O Sputum culture.
O Pleural biopsy, tissue biopsy from affected site.
P Bhandari

25. P Bhandari

26. Tuberculin Test ( Mantoux
test )
O Low sensitivity , useful only in primary
infection.
O Purified Protein derivation ( PPD) is use
which is prepared by atypical mycobacteria.
O For mantoux test 0.1ml PPD is given
intradermally on the surface of forearm.
O The result of the test read after 72 hours.
O Tuberculin reactions consist of erythematic
and induration.
P Bhandari

27. Cont…
O Induration measure horizontally.
O Reactions exceeding 10mm are considered
positive; 6-9mm induration doubtful and less
than 6 negative.
P Bhandari

28. P Bhandari

29. Treatment
According to DOTS- Directly Observed
Treatment
Short Course
 Supervise therapy under the health personnel.
 TB patient falls 2 categories.
 Before starting the treatment, every patient
should be categorized.
P Bhandari

30. O Category 1:
New smear positive pulmonary TB,
severe ill extra pulmonary TB, Sputum smear negative
extra pulmonary TB.
Category 2:
Relapse , Treatment Failure, Default (
Interrupted treatment)
Common drugs used in DOTS
• Rifampicine (R) 150mg
• Isoniazide (H) 75 mg
• Streptomycin (S) .75-1gm
P Bhandari

31. • Pyrazinamide (Z) 400mg
• Ethambutol (E ) 400mg
Treatment regime on the basis of DOTS:
Category 1
Intensive Phase : 2 months, Drugs : HRZE
Continuation Phase : 4 months, Drugs : HR
Category 2
Intensive Phase: 3 months= 2 months SHRZE + 1
month HRZE
Continuation Phase: 5 months, Drugs HRE
P Bhandari

32. Drugs used
First Line Drugs Second Line
Drugs
Isoniazid Floroquinolones
Rifampicin Amino salicylic acid
Pyrazinamide Ethionamide
Streptomicin Capreomycin
Cycloserin
P Bhandari

33. Nursing Management
O Assessment: History taking, Personal history
, Physical examination – lungs consolidation
diminished bronchial sounds , crackles,
dullness on percussion.
Enlarged painful lymph nodes may be palpable.
P Bhandari

34. Nursing Diagnosis
O Infectiveness airway clearance related to copious
tracheobronchial secretion.
O Deficient knowledge related to treatment regimen.
O Activity intolerance related to fatigue, altered
nutritional status.
O Potential nursing diagnosis: Deficient knowledge
about side effect of medication.
O Deficient knowledge related to preventive
measures.
P Bhandari

35. Nursing Intervention
O Promoting airway clearance: Increase fluid
intake promotes systemic hydration and serves
as an effective expectorant.
O Instruct the patient about correct positioning.
O Instruct about postural drainage and give
steam inhalation.
P Bhandari

36. Advocate adherence to
treatment regimen
O Provide information and health education : TB
is communicable disease.
O DOTS is the most effective means of
prevention and curing of disease.
O Take medicine according to DOTS.
O Counseling to prevent treatment failure , return
after defaulter.
P Bhandari

37. Promoting Activities
O Chronic disease impaired nutritional status.
O Provide balance diet ; provide frequent meal,
plenty of fluid.
O Provide supplements of vitamins- Vitamin B
complex.
O Provide adequate protein diet.
O Plan a progress activity schedule that focuses
on increasing activity tolerance and muscle
strength.
P Bhandari

38. Monitor and Manage
O Complication
O Malnutrition
O Side effects of medications, lever function test
be done :-
- Give medicine in empty stomach , food affect
absorption.
- Rifampicin increase metabolism of B blockers,
anti – cougulants, oral contraceptic pill ,
digoxin, verapamil.
P Bhandari

39. Cont..
- Inform patient that rifampicin discolours urine,
colours eyes lens.
- Monitor for liver and kidney function.
o Sputum culture to see response and adherence to
therapy.
o Isoniazide : Peripherial neuritis.
o Streptomycin : Tinnitus
o Pyrazinamide : Hepatotoxicity ; jaundice
o Ethambutol : Blurred Vision ( visual disturbance)
P Bhandari

40. Provide Information on
Disease Prevention
O Milk parturition and milk boiling , do not take
raw milk.
O Compliance of treatment ( 1 sputum +ve TB
can transmit disease to 10-15 person each
year) so complete continue treatment is very
important.
P Bhandari

41. Cont…
O Protection against exposure to TB: well
ventilated room , hospital wards, offices. Good
ventilation helps reduce TB transmission.
Sunlight is a source of ultraviolet light which
can kill TB bacilli.
O Sputum disposes properly – use sputum pots
with lids, covering the mouth with hands when
coughing, sneezing.
P Bhandari

42. Cont..
O Use mask for preventing droplet enter into the
lungs.
O Give BCG vaccination to all children to
prevent tuberculosis.
O Prevention of malnutrition.
O Promote environmental sanitation , reduce
overcrowded.
P Bhandari

43. P Bhandari