This document provides an overview of pulmonary tuberculosis, including its definition, classification, types, incidence, risk factors, pathophysiology, signs and symptoms, diagnosis, treatment, nursing management, and complications. It classifies TB based on anatomical site, previous treatment history, and drug resistance. Key points include that TB is caused by the bacterium Mycobacterium tuberculosis and spreads through airborne droplets. Diagnosis involves chest x-rays, sputum smears and cultures, tuberculin skin tests, and interferon-gamma blood tests.

1. 7/24/2022 1

2. PULMONARY
TUBERCULOSIS
PREPARED BY :
RN Arpana Bhusal
BNS
7/24/2022 2

3. CONTENTS
1. INTRODUCTION
2. DEFINITION
3. CLASSIFICATION OF TB
4. TYPES
5. INCIDENCE
6. RISK FACTOR
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4. Contd….
7. PATHOPHYSIOLOGY
8. SIGN AND SYMPTOMS
9. DIAGNOSIS
10. TREATMENT/ MANAGEMENT
11. NURSING MANAGEMENT
12. COMPLICATIONS
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5. PULMONARY TUBERCULOSIS
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6. INTRODUCTION
• Tuberculosis is an infectious bacterial disease
that primarily affects the lung parenchyma but
may spread to other organs.
• It may be transmitted to other parts of the body,
including meninges, kidneys, bones and lymph
nodes.
• PTB can range from small infection of broncho-
pneumonia to diffuse intense inflammation,
necrosis, pleural effusion and extensive fibrosis.
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7. CONTD….
• It is characterized by pulmonary infiltrates,
formation of granulomas with casseation,
fibrosis and cavitations.
• The primary infectious agent is
M.tuberculosis, mycobacterium bovis and
mycobacterim avium have rarely been
associated with development of TB infection.
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8. MYCOBACTERIUM TUBERCULOSIS
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9. TUBERCULOSIS CASE DEFINITION
• A bacteriologically confirmed TB case is one
from whom a specimen is positive by smear
microscopy, culture or WHO-recommended
rapid diagnostics-WRD such as Xpert MTB/RIF.
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10. CONTD….
A clinically diagnosed TB case is one who does
not fulfil the criteria for bacteriological
confirmation but has been diagnosed with
active TB by a health worker based on strong
clinical evidence and has decided to give the
patient a full course of TB treatment.
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11. Classification based on Anatomical
site of disease
• Pulmonary tuberculosis (PTB) refers to any
bacteriologically confirmed or clinically diagnosed
case of TB involving the lung parenchyma or the
tracheo-bronchial tree.
• Miliary TB is classified as PTB because there are
lesions in the lungs.
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12. CONTD….
• Extra-pulmonary tuberculosis (EPTB)
– is any bacteriologically confirmed or clinically
diagnosed case of TB involving organs other than
the lungs, e.g. pleura, lymph nodes, abdomen,
genitourinary tract, skin, joints, bones and
meninges.
– Tuberculous intra-thoracic lymphadenopathy
(mediastinal and/or hilar) or tuberculous pleural
effusion, without radiographic abnormalities in
the lungs, constitutes a case of extra-pulmonary
TB.
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13. Classification based on the History of
previous TB treatment
New patients
• Patients who have never been treated for TB or have
taken anti- TB drugs for less than one month.
Relapse patients
• Patients who have previously been treated for TB were
declared cured or treatment completed at the end of
their most recent course of treatment, and are now
diagnosed with a recurrent episode of TB (either a true
relapse or a new episode of TB caused by reinfection).
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14. CONTD….
Treatment after failure patients
• Are those who have previously been treated for
TB and whose treatment failed at the end of their
most recent course of treatment.
Treatment after loss to follow-up patients
• Patients who have previously been treated for TB
and were declared lost to follow-up at the end of
their most recent course of treatment. (These
were previously known as Treatment After
Default patients)
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15. CONTD…..
Other previously treated patients
• Patients are those who have previously been
treated for TB but whose outcome after their
most recent course of treatment is unknown or
undocumented.
Patients with unknown previous TB treatment
history
• Patients with unknown previous TB treatment
history who do not fit into any other categories
listed above.
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16. Classification based on Drug
Resistance
1. Primary drug resistance: resistance to one of
the first line ATT agents in a person, who has
not had previous treatment.
2. Secondary or acquired drug resistance:
resistance to one or more antituberculosis
agents in a patient undergoing treatments.
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17. Contd….
3. Multi- drug resistance: resistance to two
agents, Isoniazid and Rifampicin.
• The populations at highest risk for multi-drug
resistance are those who are HIV- positive,
institutionalized or homeless.
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18. TYPES
• Pulmonary Tuberculosis
• Avian Tuberculosis( microbacterium avium ;of
birds)
• Bovine Tuberculosis(mycobacterium bovis ;of
cattle)
• Miliary Tuberculosis / disseminated tuberculosis
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19. PULMONARY TB
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20. MILIARY TB
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21. INCIDENCE
• With the increased incidence of AIDS, TB has
become more a problem in the U.S., and the
world.
• TB is one of the top 10 leading cause of death
and the leading cause of single infectious
agent (above HIV/AIDS) in the world.
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22. INCIDENCE
• Globally, nearly 10 millions people developed
TB in 2017 and TB caused an estimated 1.3
million deaths in the same year.
• By the end of 2020, TB case incident rate
needs to be falling at 4 to 5 % per year, and
case fatality ratio needs to fall to <= 5%.
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23. Tuberculosis Burden in nepal
• TB is one of the major public health problems
of nepal.
• In 2017/18, a total of 32,474 cases were
notified and registered at NTP.
• TB case notification: 152/100,000 (in 2018)
• Among the reported cases, Male: Female ratio
is 1.7:1.
NATIONAL TB MANAGEMENT GUIDELINES, 2019
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24. Transmission and Risk factors
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25. Transmission and Risk factors
• TB spreads from person to person by airborne
transmission.
• An infected person releases droplet nuclei (
usually particles 1 to 5 micrometer in diameter)
through talking, coughing, sneezing, laughing etc.
• Larger droplets settle, smaller droplets (Airborne
droplet nucluei- 1 -5 micometre in size are small and remains
suspended) remain suspended in air and are
inhaled by a susceptible person.
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26. 7/24/2022 26

27. RISK FACTORS
• Inhalation of airborne nuclei from an infected
person.
• Close contact with the person who has active TB
• Immuno-compromised status
– HIV infection
– Cancer
– Transplanted organ
– Prolonged high doses of corticosteroid therapy
• Substance abuse– I/V drug users, alcoholics
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28. RISK FACTORS
• Any person without inadequate health
care(Homeless, impoverished, children under the
age of 15, young adults between the age of 15 to 44
years.)
• Pre-existing medical conditions—
malignancies, CRF, DM, malnourishment,
hemodialysis, gastrectomy etc.
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29. RISK FACTORS
• Living in overcrowded , substandard housing
• Immigration from a countries with high
prevalence of TB( southeastern Asia)
• Being health worker performing high risk
activities- suctioning, coughing procedures,
bronchoscopy, intubation etc…)
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30. PATHOPHYSIOLOGY
Inhalation of mycobacterium by susceptible
person
Transmission to alveoli
Multiplication in alveoli
Transmission of bacilli to other areas of lung
and other parts of body(kidneys, bone,
meninges) 30
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31. Pathophysiology …
Initiation of inflammatory reaction
Accumulation of exudate in alveoli, causing
bronchopneumonia
Granulomas formation
31
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32. Pathophysiology …
Necrotic changes of granuloma, forming cheesy mass
and then become calcified and form collagenous scar
Transformation of granuloma into fibrous tissue mass(the
central portion of this is called ghon tubercle)
At this point, bacteria become dormant—no progression of
active TB
32
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33. Pathophysiology …
• In some cases, bacteria may remain active,
leading to disease
• In cases, where the bacteria are dormant
they may become reactivated after
exposure to infection
33
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34. PATHOPHYSIOLOGY
• The reactivation occurs through following
steps:
Ulceration of ghon tubercule
Cheesy material release into bronchi(making
bacteria airborne)
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35. Pathophysiology …
Ulcerated tubercle heals
and forms scar tissue
This causes Further
inflammation of infected
lungs
Causing further bronchopneumonia and
tubercle formation
35
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36. 7/24/2022 36

37. Contd….
PULMONARY SYMPTOMS
• Dyspnea
• Non resolving bronchopneumonia
• Chest tightness
• Non productive cough
• Mucopurulent sputum with hemoptpysis
• Chest pain
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38. Contd….
EXTRA PULMONARY SYMPTOMS
• Pain
• Inflammation
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39. DIAGNOSIS
• HISTORY TAKING
• PHYSICAL EXAMINATION
– Clubbing of the fingers or toes (in people with
advanced disease)
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40. Contd….
– Swollen or tender lymph nodes in the neck or
other areas
– Fluid around a lung (pleural effusion)
– Unusual breath sounds (crackles)
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41. Contd…
IF MILIARY TB;
• A physical exam may show:
– Swollen liver
– Swollen lymph nodes
– Swollen spleen
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42. Diagnosis
Chest radiography: bilateral
shadows, especially if these are
in lesions in upper lobes- TB
• Sputum examination (smear and
culture)
• Tuberculin skin test
42
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43. SPUTUM EXAMINATION
There are direct smear and culture:
– The presence of AFB on a sputum
smear may indicate disease but
does not confirm the diagnosis
–A culture is done to confirm the
diagnosis
43
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44. • Mantoux method---Injecting a
small amount of protein from
tuberculosis bacteria into intra-
dermal layer of inner aspect of
forearm approximately 4 inch
below the elbow.
44
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45. MANTOUX METHOD
• 0.1ml of purified protein derivative is injected
and the test result is read 48 to 72 hours after
injection.
• A reaction occurs when both induration and
erythema are present
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46. CONTD……
• A reaction of less than 5 mm is
considered negative , 5-9 mm is
considered positive (+)
• 10-19 mm is considered positive (++)
• More than 20 mm is considered positive
(+++)
• This indicates mycobacterium infection
46
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47. QUANTI-FERON-TB gold test
Interferon-gamma Blood test—ELISA test
• A sample blood is mixed with synthetic
proteins similar to those produced by the
tuberculosis bacteria.
47
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48. CONTD….
• If people are infected with tuberculosis
bacteria, their white blood cells produce
interferons-gama, in response to the synthetic
proteins.
White blood count and ESR
– The white blood count is usually normal.
–ESR is often elevated
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49. • Thoracocentesis (Pleural Fluid)
• Pleural biopsy
• The Xpert MTB/RIF assay is a new test that is
revolutionizing tuberculosis (TB) control by
contributing to the rapid diagnosis of TB disease
and drug resistance.
• The test simultaneously detects Mycobacterium
tuberculosis complex (MTBC) and resistance to
rifampin (RIF) in less than 2 hours.
49
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50. 50
Diagnosis of Pulmonary TB
Cough 3 weeks
AFB X 3
Broad-spectrum antibiotic 10-14 days
If symptoms persist, repeat AFB smears, X-ray
If consistent with TB
Anti-TB Treatment
If 1 positive,
X-ray and
evaluation
If 2/3 positive:
Anti-TB Rx
If negative:
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51. A. Medical management:
– For the patient suffering with TB, the medical
therapy is primary treatment.
– The treatment regimens should be continued for at
least 6 months to a total of 9 months.
Management
51
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52. • Ethambutol (E): Bacteriostatic for the tubercle
bacillus
• Isoniazid (H): Bacteriocidal against rapidly
developing cells
• Pyrazinamide (Z): Bacteriocidal effect against
dominant or semi dominant bacteria
• Rifampicin (R): Bacteriocidal against rapidly
developing cells and against semi dominant
bacteria
• Streptomycin: Bacteriocidal
First line drugs
52
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53. • These drugs are often used in special conditions like
resistance to first line therapy, extensively drug-
resistant tuberculosis (XDR-TB) or multidrug-resistant
tuberculosis (MDR-TB).
• There are six classes of second-line drugs (SLDs) used
for the treatment of TB.
Second line drugs
53
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54. CONTD……
1. Aminoglycosides: amikacin, kanamycin
2. Polypeptides: capreomycin, viomycin, enviomycin
3. Fluoroquinolones: ciprofloxacin, levofloxacin,
moxifloxacin
4. Thioamides: ethionamide, prothionamide
5. Cycloserine: closerin
6. Terizidone
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55. • There is now only one category of treatment
for TB patients needing first-line treatment.
• All TB patients whether bacteriologically
confirmed or clinically diagnosed will receive
Treatment Regimen (2HRZE/4HR).
• In patients who require TB re-treatment, drug
susceptibility testing should be conducted to
inform the choice of treatment regimen.
TREATMENT REGIMEN
55
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56. • New TB cases
- Adult and Childhood
- Bacteriological or clinically diagnosed
- Pulmonary or extra-pulmonary
• Intensive phase: 2HRZE
• Continuation phase: 4HR
Categories of treatment and their anti-
TB drug regimens
56
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57. • Complicated/Severe Extra-pulmonary cases
(CNS TB, TB Pericarditis, Musculoskeletal TB,
Miliary TB etc.)
• Intensive phase: 2HRZE
Categories of treatment and their
anti-TB drug regimens
57
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58. CONTD…..
• Continuation phase: 7-10 HRE
• If treatment is required beyond 12 months,
then refer to a higher level center for
treatment decisions.
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59. • WHO has recommended fixed dose
combination drug for treatment of TB.
• It consist of:
–Isoniazid + rifampicin + pyrazinamide +
ethambutol: 75 mg + 150 mg + 400 mg + 275
mg.
Fixed dose combination drug
59
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60. • Isoniazid: Peripheral neuropathy, Hepatitis,
Rash
• Rifampicin: Febrile reactions, Hepatitis, Rash,
Gastrointestinal disturbance
• Pyrazinamide: Hepatitis, Gastrointestinal
disturbance, Hyperuricaemia
• Streptomycin: Ototoxicity, Nephrotoxicity
• Ethambutol: Retrobulbar neuritis, Peripheral
neuropathy
Adverse Reaction Of First Line Drugs
60
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61. 7/24/2022 61

62. What is DOTS?
• D.O.T.S. stands for Directly observed
treatment short course.
• It is a comprehensive strategy endorsed by the
World Health Organization and International
Union Against Tuberculosis and Lung Diseases
(IUATLD) to detect and cure TB patients.
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63. DOTS
• DOTS means that the patient taking the
medicine should be observed by a nominated
person, and the taking of the medicine should
be recorded.
• This ensures that the patient takes the
medication regularly, which is essential for the
medicines to be effective – and to prevent the
bacteria from becoming resistant and
the drug from becoming ineffective.
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64. History of DOTS
• The technical strategy for DOTS was developed
by Karel Styblo of the International Union Against TB
& Lung Disease in the 1970s and 80s, primarily in
Tanzania, but also in Malawi, Nicaragua and
Mozambique.
• Styblo refined “a treatment system of checks and
balances that provided high cure rates at a cost
affordable for most developing countries.”
• This increased the proportion of people cured of TB
from 40% to nearly 80%.
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65. Contd….
• During the early 1990s, WHO determined that of
the nearly 700 different tasks involved in Styblo's
meticulous system, only 100 of them were
essential to run an effective TB control program.
• From this, WHO's relatively small TB unit at that
time, led by Arata Kochi, developed an even more
concise "Framework for TB Control" focusing on
five main elements and nine key operations.
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66. Contd….
• On March 19, 1997, at the Robert Koch
Institute in Berlin, Germany, WHO announced
that "DOTS was the biggest health
breakthrough of the decade."
7/24/2022 66

67. DOTS program in nepal
• DOTS policy was adopted by
GoN in 1995.
• DOTS strategy was piloted in
1996 in 4 centers (Kathmandu,
Parsa, Nawalparasi and Kailali).
• DOTS have successfully been
implemented throughout the
country since April 2001.
• A total of 4244
DOTS treatment centers are
providing TB treatment
service.
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68. • Pneumonectomy for lung abscess---a surgical
procedure to remove a lung.
• Thoracoplasty-- involves the surgical removal
(resection) of rib segments
• Lobectomy—Removal of lobe
Surgical management
68
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69. NURSING
MANAGEMENT
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70. ASSESSMENT
• Assess symptoms: fever, anorexia, weight
loss, night sweats, cough , sputum
production, fatigue
• Assess change in temperature, respiratory
rate, amount and color of secretions,
frequency and severity of cough
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71. –Evaluate breath sounds for consolidation.
–Assess patient’s for living arrangements.
–Review results of physical and laboratory
evaluations.
71
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72. ASSESSMENT
• During drug therapy, assess for liver
dysfunction.
– Question the patient about loss of appetite,
fatigue, joint pain, fever, tenderness in liver
region, clay-colored stools, and dark urine.
– Monitor for fever, right upper quadrant abdominal
tenderness, nausea, vomiting, rash, and persistent
paresthesia of hands and feet.
– Monitor results of periodic liver function studies.
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73. Nursing management..
• Nursing diagnosis
–Ineffective airway clearance related to
copious tracheo-bronchial secretions,
poor cough effort.
–Activity intolerance related to fatigue,
fever.
73
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74. CONTD…
–Imbalance nutrition less than body
requirements related to loss of
appetite.
–Deficient knowledge of preventive
health measures and treatment
regimen and self care.
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75. Contd....
–Risk for impaired gas exchange related to
destruction of alveolar-capillary membrane,
thick, viscous secretions or Bronchial edema.
–Infection, risk for [spread/reactivation] related
to inadequate primary defense, decreased
cilliary action/stasis of secretions or extension
of infection, lowered resistance or
malnutrition.
75
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76. Nursing management..
Nursing Interventions
• Promoting airway clearance
–Assess respiratory function noting breath
sounds, rate, rhythm, and depth and use of
accessory muscles.
–Note ability to expectorate mucus and cough
effectively; document character, amount of
sputum, presence of hemoptysis.
76
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77. Nursing management..
• Place patient in semi or high-Fowler’s position.
Assist patient with coughing and deep-
breathing exercises.
• Clear secretions from mouth and trachea;
suction as necessary.
• Maintain fluid intake of at least 2500 mL/day
unless contraindicated.
–Humidify inspired air and oxygen.
77
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78. Nursing management..
• Administer medications as indicated:
–Mucolytic agents: acetylcysteine (Mucomyst);
–Bronchodilators: oxtriphylline (Choledyl),
theophylline (Theo-Dur);
–Corticosteroids (prednisone).
• Be prepared for/assist with emergency
intubation.
78
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79. Nursing management..
• Promoting activity
–Plan a progressive activity schedule to
increase activity tolerance and muscle
strength
79
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80. Nursing management..
Maintaining adequate nutrition….
• Document patient’s nutritional status on
admission, noting skin turgor, current weight
and degree of weight loss, integrity of oral
mucosa, ability or inability to swallow, presence
of bowel tones, history of nausea and vomiting
or diarrhea.
• Ascertain patient’s usual dietary pattern.
Include in selection of food.
80
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81. Nursing management..
• Monitor I&O and weight periodically.
• Investigate anorexia and nausea and vomiting,
and note possible correlation to medications.
• Monitor frequency, volume, consistency of
stools.
• Encourage and provide for frequent rest period.
• Provide oral care before and after respiratory
treatments.
81
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82. Nursing management..
• Encourage small, frequent meals with foods
high in protein and carbohydrates.
• Encourage to bring foods from home and to
share meals with patient unless
contraindicated.
• Refer to dietitian for adjustments in dietary
composition.
• Consult with respiratory therapy to schedule
treatments 1–2 hr before or after meals.
82
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83. Nursing management..
• Monitor laboratory studies: BUN, serum
protein, and albumin.
• Administer antipyretics as appropriate.
83
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84. Nursing management..
Promoting the understanding of disease
process/prognosis and prevention.
–Assess patient’s ability to learn.
– Note level of fear, concern, fatigue,
participation level; best environment in
which patient can learn; how much content;
best media and language; who should be
included.
84
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85. Nursing management..
–Provide instruction and specific written
information for patient to refer to schedule for
medications and follow-up sputum testing for
documenting response to therapy.
• Encourage patient to verbalize fears and
concerns. Answer questions factually. Note
prolonged use of denial.
85
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86. Nursing management..
• Identify symptoms that should be reported to
healthcare provider: haemoptysis, chest pain,
fever, difficulty breathing, hearing loss,
vertigo.
• Emphasize the importance of maintaining
high-protein and carbohydrate diet and
adequate fluid intake
86
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87. Nursing management..
• Explain medication dosage, frequency of
administration, expected action, and the
reason for long treatment period.
• Review potential interactions with other
drugs and substances.
• Review potential side effects of treatment
(dryness of mouth, constipation, visual
disturbances, headache, orthostatic
hypertension) and problem-solve solutions.
87
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88. Nursing management..
• Stress need to abstain from alcohol while on
INH.
• Refer for eye examination after starting and
then monthly while taking ethambutol
• Evaluate job-related risk factors, working in
foundry or rock quarry, sandblasting.
• Encourage abstaining from smoking.
88
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89. Nursing management..
• Review how TB is transmitted (primarily by
inhalation of airborne organisms, but may
also spread through stools or urine if
infection is present in these systems) and
hazards of reactivation.
• Refer to public health agency.
89
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90. Nursing management..
• Improving gas exchange
–Assess for dyspnea (using 0–10 scale),
tachypnea, abnormal or diminished breath
sounds, increased respiratory effort, limited
chest wall expansion, and fatigue.
–Note cyanosis and/or change in skin color,
including mucous membranes and nail beds.
90
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91. Nursing management..
–Demonstrate and encourage pursed-lip
breathing during exhalation, especially for
patients with fibrosis or parenchymal
destruction.
–Promote bed rest or limit activity and assist
with self-care activities as necessary.
–Monitor serial ABGs and pulse oximetry.
–provide supplemental oxygen as appropriate.
91
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92. Nursing management..
• Decreasing infection
–Review pathology of disease
(active and inactive phases; dissemination of
infection through bronchi to adjacent tissues
or via bloodstream and/or lymphatic system)
and potential spread of infection via airborne
droplet during coughing, sneezing, spitting,
talking, laughing, singing.
–Identify others at risk like household members,
close associates and friends.
92
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93. Nursing management..
• Instruct patient to cough or sneeze and
expectorate into tissue and to refrain from
spitting.
• Review proper disposal of tissue and good hand
washing techniques. Encourage return
demonstration.
• Review necessity of infection control measures.
93
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94. CONTD….
• Put in temporary respiratory isolation if
indicated.
• Monitor temperature as indicated.
• Identify individual risk factors for reactivation
of tuberculosis: lowered resistance associated
with alcoholism, malnutrition, use of
immunosuppressive drugs, corticosteroids,
presence of diabetes mellitus, cancer,
postpartum.
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95. Nursing management..
• Stress importance of uninterrupted drug
therapy.
• Review importance of follow-up and periodic
reculturing of sputum for the duration of
therapy.
• Encourage selection and ingestion of well-
balanced meals. Provide frequent small “snacks”
in place of large meals as appropriate.
95
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96. Nursing management..
• Administer anti-infective agents as indicated:
– Primary drugs: isoniazid (INH), ethambutol
(Myambutol), rifampin (RMP/Rifadin), rifampin
with isoniazid (Rifamate), pyrazinamide (PZA),
streptomycin , rifapentine (Priftin);
– Second-line drugs: ethionamide (Trecator-SC),
para-aminosalicylate (PAS), cycloserine
(Seromycin), capreomycin (Capastat).
96
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97. Nursing management..
• Expected outcome
–Maintain patent airway.
–Expectorate secretions without assistance.
–Demonstrate progressive weight gain and be
free of signs of malnutrition.
97
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98. CONTD….
–Verbalize understanding of disease
process/prognosis and prevention.
–Report absence of/decreased dyspnea.
–Demonstrate improved ventilation and
adequate oxygenation of tissues by ABGs
within acceptable ranges.
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99. COMPLICATIONS
• Bones: Spinal pain and joint destruction may
result from TB that infects your bones(TB
spine or potss spine)
• Brain(meningitis)
• Heart(cardiac tamponade)
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100. CONTD….
• Pleural effusion
• Tb pneumonia
• Serious reactions to drug therapy(hepato
toxicity;hypersentivity)
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101. 7/24/2022 101

102. REFERENCES
• Mandal G.N, Textbook of medical surgical nursing
(adult nursing) published by Makalu publication
house, 3rd edition.
• Brunner and siddarth, Textbook of Medical-
Surgical Nursing, 13th edition.
• https://dohs.gov.np/centers/national-
tuberculosis-center/ on 2021/ 07/23 at 11 am
• https://www.slideshare.net/krishnameera999/pu
lmonary-tuberculosis-ppt on 2021/07/23 at 11
am.
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103. 103
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