Medical nursing for students

2.  Tuberculosis (TB) is an infectious droplet
disease caused by Mycobacterium tuberculosis
 It may affect any part of the body but the
commonest site is the lungs (70 – 80%)
 The patient is said to have pulmonary TB if site
affected is the lungs

3.  Pulmonary TB is an infectious disease that
primarily affects the lung parachyma
 TB may affect other parts of the body,
including the meninges, kidneys, bones and
lymph nodes systems(extra pulmonary TB).

4.  Bones
 lymph nodes
 the spine
 urinary tract
 Brain
 joints
 abdomen

5.  Mycobacterium tuberculosis
 Mycobacterium bovis (bovine TB)
 Mycobacterium africanum I and II

6.  Close contact with an active TB patient: close
proximity, poor ventilation
 Immune-compromised state e.g. HIV, cancer, organ
transplant, prolonged high doses of corticosteroids
 Vulnerable groups – homeless people, impoverished
state
 Pre-existing medical conditions e.g. DM, CRF,
malnutrition
 Migration from a country with high TB prevalence e.g.
Africa, South America, Caribbean.
 Institutionalisation e.g. prisons, psychiatric homes
 Healthcare workers – are at high risk
 Living in crowded substandard houses

7.  TB is a worldwide public health problem and
the leading cause of death among HIV-positive
people (World Health, Organization, 2014)
 Globally, about 9 million people were ill with
TB in 2013 and 1.5million died from TB (WHO
2014)

8. AIRBORNE SPREAD
 This occurs when germs float through the air
after a person talks, coughs, or sneezes.
 The germs can be inhaled even after the person
who produced them is no longer nearby.
 Direct contact with infectious person is NOT
needed for someone else to get sick
(CDC 2014)

9. DROPLET SPREAD
 Droplet spread happens when fluids in large
droplets from a sick person splash the eyes, nose,
or mouth of another person or through a cut in the
skin.
 Droplets may cause short-term environmental
contamination eg:
- Soiled bathroom surface or
- handrails,
 Another person can then pick up the infectious
organism from such contaminated
material/surface.

10.  TB is spread through airborne, droplets when
an infectious patient coughs, spits, sneezes,
speaks or sings the bacteria are released.
 The tiny droplets could remain suspended in
air for several hrs
 Bovine TB is acquired by drinking
unpasteurized cow's milk and manifests as
abdominal TB

11. The infectiousness of a person with TB is directly
related to the number of tubercle bacilli that
he/she expels into the air. Persons who expel
many tubercle bacilli are more infectious than
patients who expel few or no bacilli

12.  Duration of exposure to a person with
infectious TB
- The longer the duration of exposure, the higher the
risk for transmission
 Frequency of exposure to infectious person
- The more frequent the exposure, the higher the risk
for transmission
 Physical proximity to infectious person
- The closer the proximity, the higher the risk for
transmission

13.  TB may be the initial illness in a patient with
AIDS.
 There should be a high index of suspicion in
patients who are HIV positive – they tend not
to have the typical symptoms and signs of TB.
 TB diagnosis and treatment in Ghana is free
- In public and private health facilities.

14.  A susceptible person inhales mycobacterium bacilli
and becomes infected.
 The bacteria are transmitted through the airways to the
alveoli, where they are deposited and begin to
multiply.
 The bacilli also are transported via the lymph system
and bloodstream to other parts of the body (kidneys,
bones, cerebral cortex) and other areas of the lungs
usually the upper lobes.
 The body’s immune system responds by initiating an
inflammatory reaction.

15.  Phagocytes (neutrophils and macrophages)
engulf many of the bacteria and TB-specific
lymphocytes destroy the bacilli and normal
tissue.
 This tissue reaction results in the accumulation
of exudate in the alveoli, causing
bronchopneumonia.
 The initial infection usually occurs 2 to 10
weeks after exposure.

16.  New tissue masses of live and dead bacilli called
granulomas are formed surrounded by macrophages, which
form a protective wall around the granulomas.
 Granulomas are then transformed to a fibrous tissue mass,
the central portion of which is called a Ghon tubercle.
 The material (bacteria and macrophages) becomes necrotic,
forming a cheesy mass. This mass may become calcified and
form a collagenous scar.
 The bacteria at this piont, become dormant, and there is no
further progression of active disease.
 After initial exposure and infection, the person may develop
active disease because of a compromised or inadequate
immune system response.

17.  Active disease also may occur with reinfection and
activation of dormant bacteria.
 In this case, the Ghon tubercle ulcerates, releasing the
cheesy material into the bronchi.
 The bacteria then become airborne, resulting in further
spread of the disease.
 Then the ulcerated tubercle heals and forms scar tissue.
 This causes the infected lung to become more inflamed,
resulting in further development of
bronchopneumonia and tubercle formation.
 Unless the process is arrested, it spreads slowly
downward to the hilum of the lungs and later extends
to adjacent lobes.

18.  The clinical features are insidious.
 low-grade fever
 Cough
 Night sweats
 Fatigue
 Weight loss
 The cough may be nonproductive, or productive.
 Hemoptysis also may occur
 Chest pain
 Shortness of breath
 Both the systemic and pulmonary symptoms are usually
chronic and may be present for weeks to months.
 Blood stained sputum
 Malaise

19.  A complete history taking
 Physical examination
 Tuberculin skin test
 Sputum AFB test- early morning sputum for test
for presence of acid fast bacilli (AFB)
 Chest x-ray usually reveals lesions in the upper
lobes
 FBC
 The tuberculin skin test
 Sputum culture-6 to 8 weeks

20.  The test is done by injecting 0.1ml of purified
protein derivative (PPD) into the inner aspect
of the forearm, approx. 4 inches below the
elbow.
 It is an intradermal injection
 Using tuberculin syringe with needle bevel up!
 The reaction to the test usually consists of a
wheal 6 to 10mm diameter

21.  The test result is read within 48 to 72 hours
after injection.
 The size of the induration determines the
significance of the reaction.
 A reaction of 0 to 4 mm= not significant;

22.  A reaction of ≥5 mm = significant in
individuals who are considered at risk.
 An induration of ≥ 10 mm = significant in
individuals who have normal or mildly
impaired immunity.
 A significant reaction indicates that a patient
has been exposed to M. tuberculosis recently or
in the past or has been vaccinated with bacille
Calmette-Guerin (BCG) vaccine. The BCG
vaccine is given to produce a greater resistance
to developing TB.

23.  A significant (positive) reaction does not necessarily
mean that active disease is present in the body.
 Most (more than 90%) people who are tuberculin-
significant reactors do not develop clinical TB.
However, all significant reactors are candidates for
active TB.
 In general, the more intense the reaction, the greater
the likelihood of an active infection.
 A non-significant (negative) skin test does not exclude
TB infection or disease because patients who are
immunosuppressed cannot develop an immune
response adequate to produce a positive skin test. This
is referred to as anergy.

24. Treatment objectives
 To cure the disease
 To prevent further transmission
 To prevent the development of drug resistance
 To offer psychosocial support
 To investigate close contacts

25.  Pulmonary TB is treated primarily with
chemotherapeutic agents (antituberculosis agents)
for 6 to 12 months.
 A prolonged treatment duration is necessary to
ensure eradication of the organisms and to prevent
relapse.
 A worldwide concern and challenge in TB therapy
is the continuing (since the 1950s) and increasing
resistance of M. tuberculosis to TB medications.

26.  Non Pharmacological
 Counselling
 Good nutrition – high calorie and high protein
diet
 Adequate rest –advise them of the need to rest
adequately
 Assessing and addressing concerns of
stigmatization
 Admission for severely ill patients - isolation

27.  TB treatment is a Directly Observed Therapy
(DOT) – meaning patient is observed daily by a
treatment supporter or a health worker to take
the TB drugs.
 There is growing prevalence of multidrug
resistance (MDR) TB and noncompliance is a
major factor in emergence of MDR and
treatment failures
 Drug combination is used in TB treatment to
reduce incidence of MDR TB & treatment
failure

28.  There are two main types of treatment
regimen:
-Standard regimen
-Retreatment regimen

29.  For the newly diagnosed who had no
previous TB treatment
 Comprises a total of 6 months treatment
divided as follows
- 2 months intensive phase,(4 drugs are used
here) followed by
- 4 months continuation phase

30. Four drugs are used during the intensive phase
and include:
 Rifampicin (R)
 Isoniazid (H)
 Pyrazinamide (Z) and
 Ethambutol (E)
In a fixed dose combination which are taken daily
for 2 months
 Dosage is given per Kg of body weight

31.  For adults, each tablet contains H 75 mg, R 150
mg, Z 400 mg & E 275 mg and 2-5 tablets given
a day depending on weight.
 This is followed by a continuation phase of
Isoniazid and Rifampicin (HR) –called Rifinah*
-H75R150.
 To prevent the development of drug resistance
to Rifampicin, use of RIFINAH (Isoniazid +
Rifampicin) is recommended. Prescribing
Rifampicin alone must be discouraged

32.  During the Continuation Phase the patient
must swallow all the oral drugs preferably on
an empty stomach under direct observation.
 The patient needs to be under close supervision
by a health worker or any responsible person
or member of the community with support
from health staff during the full duration of
treatment

33. This is used in cases of:
 Relapse
 Treatment failure
 Patients who defaulted and who return after >1
month and are smear positive (and some smear
negative patients who have defaulted for
longer)
 All other previously treated patients

34. Consists of an initial intensive phase of five drugs;
 Rifampicin,
 Isoniazid,
 Pyrazinamide and
 Ethambutol (HRZ&E) daily for 3 months
 With Streptomycin added for the first 2 months
only.
 Streptomycin, IM,
- Adults -500 mg - 1 g daily (depends on weight)
- Children15 mg/kg daily for 2 months

35.  A continuation phase then follows with
Isoniazid, Rifampicin and Ethambutol taken
daily for an additional 5 months -
(H75/R150/E275)

36.  Side effects of TB drugs – nonviral hepatitis –
isoniazid, rifampicin, pyrazinamide
 Obtain baseline LFT result
 Monitor for signs of liver damage before and
during treatment – LFT
 Educate patient to avoid alcohol – it may
increase risk for hepatotoxicity caused by drug

37.  Malnutrition
 Adverse side effects of medication therapy:
hepatitis, neurologic changes (deafness or
neuritis), skin rash, gastrointestinal upset
 Miliary TB
 Meningitis
 Pleural effusion

38.  Plan a progressive activity schedule that focuses on
increasing activity tolerance and muscle strength.
 A nutritional plan that allows for small, frequent meals
may be required.
 Liquid nutritional supplements may assist in meeting
basic caloric requirements.
 The nurse collaborates with the dietitian, physician,
social worker, family, and patient to identify strategies
to ensure an adequate nutritional intake and
availability of nutritious food.
 Assess medication side effects because they are often a
reason the patient fails to adhere to the prescribed
medication regimen.

39.  Educate patient on disease process and treatment
regimen and the need for compliance
 Medications, schedule, and side effects and the
importance of taking medications as the most effective
means of preventing TB transmission.
 Instruct the patient about important hygiene
measures, including mouth care, covering the mouth
and nose when coughing and sneezing, proper
disposal of tissues
 Lifestyle modification – avoid drinking alcohol

40. - Signs of relapse – 5% of patients will relapse!
- Good nutrition – high calories (energy), high
protein (tissue repair)

41. •Ineffective airway clearance related to copious
tracheobronchial secretions
•Activity intolerance related to fatigue and
altered nutritional status
 Deficient knowledge related to treatment
regimen and preventive health measures

42.  Mechanism of action, side effects of each TB
drug and nursing responsibilities.