This document provides an overview of pulmonary tuberculosis and its management. It discusses the etiology, risk factors, pathophysiology, signs and symptoms, diagnostic evaluation including tuberculin skin test and chest x-ray, classification, medical management including DOTS therapy, complications, nursing assessment and interventions. Key points covered are that tuberculosis is caused primarily by Mycobacterium tuberculosis and affects the lungs. Diagnosis involves history, physical exam, skin test and chest x-ray. Treatment is with a combination of antibiotics over a period of 6-9 months to prevent drug resistance. Nursing care focuses on education, monitoring for side effects and preventing transmission.

1. PULMONARY
TUBERCULOSIS AND
ITS MANAGEMENT

2. INTRODUCTION
• Tuberculosis (TB) is an infectious
disease that primarily affects the
lung parenchyma. It may also be
transmitted to other parts of the
body, including the meninges,
kidneys, bones, and lymph nodes.
The primary infectious agent,
Mycobacterium tuberculosis, is an
acid-fast aerobic rod that grows
slowly and is sensitive to heat and
ultraviolet light.
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3. • TB is a worldwide public health problem, and the
mortality and morbidity rates continue to rise.
• The estimated TB incidence in India is 27 Lakhs (2018).
• Affected population is mainly in the age group of 15-69
years and 2/3rd being males.
• HIV co-infection among TB was nearly fifty thousand
cases amounting to TB HIV coinfection rate of 3.4%.
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5. ETIOLOGY
•Mycobacterium tuberculosis
•Mycobacterium africanum
•Mycobacterium microti
•Mycobacterium Bovis
All cause tuberculosis (TB) and are
members of the tuberculosis species
complex but the main cause is
Mycobacterium tuberculosis.
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7. RISK FACTORS
•Close contact with someone who has active TB.
•Immunocompromised status
•Substance abuse
•Any person without adequate health care
•Pre-existing medical conditions
•Immigration from countries with a high prevalence of TB (south-eastern
Asia, Africa, Latin America, Caribbean)
•Institutionalization
•Living in overcrowded, substandard housing
•Being a health care worker performing high-risk activities: sputum
induction procedures, bronchoscopy, suctioning, coughing procedures,
caring for the immunosuppressed patient, etc.
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8. PATHOPHYSIOLOGY
Initial infection or primary infection
Entry of micro organism through droplet nuclei
Bacteria is transmitted to alveoli through airways
Deposition and multiplication of bacteria
Bacilli are also transported to other parts of the body through blood
stream
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9. Phagocytosis by neutrophils and macrophages
Accumulation of exudate in alveoli
Broncho pneumonia
New tissue masses of live and dead bacilli are surrounded by macrophages
which form a protective mass around granulomas
Granulomas then transforms to fibrous tissue mass and central portion of
which is called ghon tubercle
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10. The material (bacteria and macrophages) becomes necrotic forming cheesy
mass
Mass becomes calcified and becomes collagenous scar
Bacteria become dormant and no further progression of active disease
Active disease or re infection
Inadequate immune response
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11. Ghon tubercle ulcerates and releasing cheesy material into bronchi
Bacteria then become airborne resulting in further spread of infection
Ulcerated tubercle heals and becomes scar tissue
Infected lung become inflammed
Further devolopment of pneumonia and tubercle formation
Unless the process is arrested it spreads downwards to the hilum of lungs and
later extends to adjacent lobes
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14. CLASSIFICATION OF TB
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15. GENERAL SYMPTOMS
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20. PULMONARY SYMPTOMS
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24. •Both the systemic and pulmonary
symptoms are usually chronic and may
have been present for weeks to months.
The elderly usually presents with less
pronounced symptoms than do younger
patients.
•In patients with AIDS, extrapulmonary
disease is more prevalent and may occur
in up to 70% of cases.
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25. DIAGNOSTIC EVALUATION
•Complete history collection
•Physical examination
•Tuberculin skin test
•Chest x-ray
•Acid-fast bacillus smear
•Sputum culture
•QuantiFERON-TB Gold Test
•CBNAAT
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26. TUBERCULIN SKIN TEST
•Tubercle bacillus extract (tuberculin), purified protein
derivative (PPD), is injected into the intradermal layer
of the inner aspect of the forearm, approximately 4
inches below the elbow.
•Tuberculin syringe with a half-inch 26- or 27-gauge
needle is used. The needle, with the bevel facing up, is
inserted beneath the skin. Then 0.1 mL of PPD is
injected, creating an elevation in the skin, a wheal or
bleb.
•The test result is read 48 to 72 hours after injection.
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30. Interpretation of Results
The size of the induration determines the significance of the
reaction.
•A reaction of 0 to 4 mm is considered not significant.
•A reaction of 5 mm or greater may be significant in
individuals who are considered at risk.
•An induration of 10 mm or greater is usually considered
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 bacilli Calmette-Guerin (BCG) vaccine.
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31. •A reaction of 5 mm or greater is defined as positive
for patients who are HIV-positive or have HIV risk
factors and are of unknown HIV status, those who are
close contacts with an active case, and those who
have chest x-ray results consistent with tuberculosis.
•A nonsignificant (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.
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32. Chest X-Ray
The chest x-ray
may also appear
normal in a
patient with TB.
Findings
suggestive of TB
include upper
lobe infiltrations,
cavitary
infiltrates and
lymph node
involvement.
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34. QuantiFERON-TB Gold Test
The QuantiFERON-TB Gold (QFT-G) test is an enzyme-
linked immunosorbent assay (ELISA) that detects the
release of interferon-gamma by white blood cells when
the blood of a patient with TB is incubated with
peptides similar to those in M. tuberculosis. The results
of the QFT-G test are available in less than 24 hours and
are not affected by prior vaccination with BCG.
Additional rapid tests for TB include the QuantiFERON-
TB Gold in-tube test (QFT-GIT), the T-SPOT TB test (T-
spot), and the Xpert MTB/RIF, which was endorsed by
WHO.
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41. Medical Management
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42. DOTS (directly observed treatment, short-course)
It is the name given to the World Health Organization-recommended
tuberculosis control strategy that combines five components:
1. Government commitment (including both political will at all levels,
and establishing a centralized and prioritized system of TB
monitoring, recording and training)
2. Case detection by sputum smear microscopy
3. Standardized treatment regimen directly observed by a healthcare
worker or community health worker for at least the first two months
4. A regular drug supply
5.A standardized recording and reporting system that allows
assessment of treatment results.
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44. INH also may be used as a prophylactic (preventive) measure for those at
risk for significant disease, including:
• Household family members of patients with active disease.
• HIV-infected patients with a PPD test reaction of 5 mm of induration or
more.
• Patients with fibrotic lesions detected on a chest x-ray, suggestive of old
TB, and a PPD reaction of 5 mm of induration or more.
• Patients whose current PPD test results show a change from former test
results, suggesting recent exposure to TB and possible infection (also called
skin test converters).
• Drug (intravenous or injectable) users with PPD test results of 10 mm of
induration or more.
• Patients with high-risk comorbid conditions with a PPD result of 10 mm
of induration or more.
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45. Other candidates for preventive INH therapy are
those 35 years or younger with PPD test results of
10 mm of induration or more and one of the
following criteria:
• Foreign-born individuals from countries with a
high prevalence of TB
• High-risk, medically underserved populations
• Institutionalized patients
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46. Prophylactic INH treatment involves taking daily doses for 6
to 12 months. Liver enzyme, blood urea nitrogen, and
creatinine levels are monitored monthly. Sputum culture
results are monitored for acid-fast bacillus to evaluate the
effectiveness of treatment and the patient’s compliance with
therapy.
The objectives of TB therapy are:
•Cure the individual patient and minimize risk of death and
disability
•Reduce transmission of M. tuberculosis to other persons
•Prevent the development of drug resistance during therapy
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49. COMPLICATIONS
•Adverse side effects of medication therapy:
hepatitis, neurologic changes (deafness or
neuritis), skin rash, gastrointestinal upset
•Meningitis
•Spread of TB infection (miliary TB)
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52. NURSING ASSESSMENT
•Perform a complete history and physical examination.
•Assess for fever, anorexia, weight loss, night sweats,
fatigue, cough, and sputum production.
•Assess the lungs for consolidation by evaluating breath
sounds (diminished, bronchial sounds, crackles), fremitus,
and dullness on percussion. Enlarged, painful lymph nodes
may be palpated as well.
•Assess the patient’s living arrangements, perceptions and
understanding of TB and its treatment, and readiness to
learn.
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53. Nursing Diagnosis
1. Ineffective airway clearance related to copious tracheobronchial
secretions.
2. Imbalanced nutrition: less than body requirements related to
inability to ingest adequate nutrients.
3. Activity intolerance related to imbalance between oxygen supply
and demand.
4. Risk for impaired gas exchange related to decrease in effective lung
surface.
5. Risk for infection related to inadequate primary defenses and
lowered resistance.
6. Deficient knowledge about treatment regimen and preventive
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54. CDC Recommendations for Preventing
Transmission of Tuberculosis in Health
Care Settings
1. Early identification and treatment of persons with
active TB.
2. Prevention of spread of infectious droplet nuclei by
source control methods and by reduction of microbial
contamination of indoor air.
3. Surveillance for TB transmission.
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55. Patient education
1.Malnutrition
2.Side Effects of Medication Therapy
•Patients taking INH should avoid foods containing tyramine
and histamine (red wine, soy sauce, yeast extracts). Eating
these types of foods while taking INH may result in headache,
flushing, hypotension, light-headedness, palpitations, and
diaphoresis.
•The nurse informs the patient that rifampin may discolor
contact lenses, so the patient may want to wear eyeglasses
during treatment.
3.Multidrug Resistance
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58. RESEARCH ARTICLES
Nutritional status of tuberculosis patients, a comparative cross-
sectional study
Berhanu Elfu Feleke, Teferi Elfu Feleke & Fantahun Biadglegne
conducted a comparative cross-sectional study in Ethiopia in 2019.
A total of 5045 study participants were included. The prevalence
of underweight patients was 57.17% and 88.52% of TB patients
were anemic. The nutritional status of TB patients was determined
by site of infection, gender of the patient, residence, intestinal
parasite infection, problematic alcohol use. It concluded that high
proportions of TB patients were malnourished. TB patients were
highly susceptible to malnutrition and even a very distal reason for
malnutrition in the community became a proximal cause for TB
patients.
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59. The Prevalence and Demographic Risk Factors for Latent Tuberculosis
Infection (LTBI) Among Healthcare Workers in Semarang, Indonesia.
Meira Erawati and Megah Andriany conducted a cross-sectional study
involving 195 healthcare workers from 34 primary health centers from
August to October 2019 to determine the prevalence and demographic
risk factors for latent tuberculosis infection (LTBI) among healthcare
workers in Semarang, Indonesia. The prevalence of LTBI among
healthcare workers in this study was 23.6%. Comorbidities were the
only risk factor for LTBI identified among other risk factors. Other
demographic factors such as age, gender, smoking habits, and length of
work were not significant risk factors for LTBI. It concluded that
healthcare workers suffering from comorbidity have a high risk for
tuberculosis infection, and should not work in areas where they would
be exposed to patients with tuberculosis. Healthcare workers need to
apply occupational safety standards during contact with TB patients or
specimens to minimize the disease transmission.
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60. SUMMARY AND CONCLUSION
• As discussed throughout the presentation, learning about
pulmonary tuberculosis and its management will help nurses to
care for patients with pulmonary tuberculosis.
• Nurses can do assessment of patients with pulmonary
tuberculosis, observe the sign and symptoms, provide the
necessary nursing care and support the patient psychologically.
• Nurses can also counsel the patients and their family for
various options available in treatment for pulmonary
tuberculosis.
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61. REFERENCES
1.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical
Surgical Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 1. Pg. no.
586-591.
2.Joyce M. Black, Jane Hokanson Hawks. Medical Surgical Nursing Clinical
Management of Positive Outcomes.2015. New Delhi. Reed Elsevier India Private
Limited. Volume II. Pg. No.1604-1609.
3.Lewis. Medical Surgical Nursing Assessment and Management of clinical
problems.2015. New Delhi. Elsevier. 2nd Edition. Volume I. Pg. no. 553-559.
4.INDIA TB REPORT 2019. Available from
https://tbcindia.gov.in/WriteReadData/India%20TB%20Report%202019.pdf [cited 4
April 2020]
5.Feleke, B.E., Feleke, T.E. & Biadglegne, F. Nutritional status of tuberculosis
patients, a comparative cross-sectional study. BMC Pulm Med 19, 182 (2019).
https://doi.org/10.1186/s12890-019-0953-0.
6.PubMed. The Prevalence and Demographic Risk Factors for Latent Tuberculosis
Infection (LTBI) Among Healthcare Workers in Semarang, Indonesia. J Multidiscip
Healthc. 2020; 13: 197–206. doi: 10.2147/JMDH.S241972
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63. 1.A 55-year old male patient is admitted with an active tuberculosis
infection. The nurse will place the patient in ___________________
precautions and will always wear _____________________ when
providing patient care?
A. Droplet, respirator
B. Airborne, respirator
C. Contact and airborne, surgical mask
D. Droplet, surgical mask
Ans- A
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64. 2.A patient has a positive PPD skin test that shows an 8 mm induration. As the
nurse you know that:
A. The patient will need to immediately be placed in droplet precautions and
started on a medication regime.
B. The patient will need a chest x-ray and sputum culture to confirm the test
results before treatment is provided.
C. The patient will need a test to differentiate between a latent tuberculosis
infection versus an active tuberculosis infection.
D. The patient will need to repeat the skin test in 48-72 hours to confirm the
results.
Ans- B
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65. 3. A patient has a PPD skin test (Mantoux test). As the nurse you tell
the patient to report back to the office in _________ so the results
can be interpreted?
A. 24-48 hours
B. 12-24 hours
C. 48-72 hours
D. 24-72 hours
Ans- C
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66. 4.You note your patient’s sweat and urine is red-orange colored. You
reassure the patient and educate him that which medication below
is causing this finding?
A. Ethambutol
B. Streptomycin
C. Isoniazid
D. Rifampin
Ans- D
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67. ASSIGNMENT
Write down 3 nursing care plans
of patient with pulmonary
tuberculosis.
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