2. Introduction
It is caused the mycobacteria species which
are responsible for the disease and these are:
1. Mycobacterium tuberculosis which is a
major cause of infection
2
3. cont
2. Mycobacterium bovis which is endemic
in cattle.this type may spread to man by
drinking contaminated milk
3.Opportunistic Mycobacteria which are
rare.they may cause pulmonary or general
infection in the immunocomperomised
3
4. Spread of infection
TB is an airborne disease transmitted by
droplet nuclei, usually from the respiratory
tract of an infected person who exhales
them during coughing, talking, sneezing.
by the following methods:
1- direct droplet spread :
From person to person by inhalation of
airborne bacilli in to the atmosphere
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5. 2-indirect spread:
Via dishes ,clothing and other articles of
daily used laden with bacilli.
3- via ingested milk:
Ingested contaminated milk with M.
tuberculosis bovine causes intestinal
TB.
5
6. Pathology
The first infection with M. tuberculosis is
known as primary tuberculosis. It is usually
sub pleural, often in the mid to upper zones
(Ghon focus). Within an hour of reaching
the lung, tubercle bacilli reach the draining
lymph nodes at the hilum of the lung and a
few escape into the bloodstream.
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Granulomatous lesions consist of a central
area of necrotic material of a cheesy nature,
called caseation, surrounded by epithelioid
cells and Langhans' giant cells with multiple
nuclei, both cells being derived from the
macrophage.
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Lymphocytes are present and there is a
varying degree of fibrosis. Subsequently the
casemated areas heal completely and many
become calcified.
It is known that at least 20%of these
calcified primary lesions contain tubercle
bacilli, initially lying dormant but capable
of being activated by depression of the host
defense system.
9. cont
Reactivation leads to typical post primary
pulmonary tuberculosis with cavitation,
usually in the apex or upper zone of the
lung.
'Post-primary tuberculosis' refers to all
forms of tuberculosis that occur after the
first few weeks of the primary infection
when immunity to the mycobacterium has
developed.
10. Extra pulmonary TB occurs more
commonly in children and immune
compromised individuals and can involve
lymph nodes, bones, joints, pleural space,
pericardium, CNS, GU tissue, and the
peritoneum.
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11. Predisposing factors
1- Environmental factors
Poverty ,Overcrowding ,Unhygienic condition
2- Pathologic factors
DM ,Chronic lung disease ,Malnutrition ,Immune
compromised, HIV
3- Children younger than age 4
4- prolonged corticosteroid use in organ
transplanted patient
5- history of untreated or inadequately treated TB.
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12. Clinical Manifestations
Patient may be Asymptomatic or may have
insidious symptoms that may be ignored.
1. Constitutional symptoms
a. Fatigue, anorexia, weight loss, low-grade fever,
night sweats.
b. Some patients have acute febrile illness, chills,
and flu-like symptoms.
12
13. Clinical Manifestations
2. Pulmonary signs and symptoms
a. Cough progressing in frequency and
producing mucoid or mucopurulent sputum,
hemoptysis
b. Chest pain; dyspnea (suggest extensive
involvement)
3. Extrapulmonary TB:
pain, inflammation, and dysfunction in any of
the tissues infected. 13
14. Type of tuberculosis
Primary tuberculosis
Secondary tuberculosis
Miliary tuberculosis
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15. INVESTIGATION
Diagnosis of TB is based on history, examination
,chest X-ray finding and sputum examination .
1- chest x-ray
Define nodular or reticulonodular situated in one of
the upper lobes
Also shows the cavity in the lung .
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16. 2- Sputum for AFB (fast acid bacilli)smear:
Microscopic examination of 3 specimen of sputum collected
early morning and detection of acid-fast bacilli (AFB) in
stained smears.
A positive acid-fast test suggests an active infection.
The diagnosis is confirmed by a positive culture for
Mycobacterium tuberculosis.
3- Sputum culture
Isolated the M .bactirium TB on solid medium 4-8 weeks .
a positive culture for M. Tuberculosis confirms a diagnosis of
TB.
4-Plural fluid aspiration 16
17. 5- Mantoux test
In this test 0.1ml of standard purified
protein derivative (PPD)is injected
intradermal on the anterior surface of
forearm then the skin test site observe and
recorded after 48-72 hrs.
Negative test dos not rule out the diagnosis
of TB.
An induration (palpable, raised, hardened
area) of 10 mm or greater in diameter
indicates a positive skin test.
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An induration of 5 mm is considered a positive
test for immunocompromised clients.
A positive Mantoux test indicates that the client
has developed an immune response to TB.
It does not confirm that active disease is present.
Clients who have been treated for TB may retain
a positive reaction.
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Individuals who have latent TB may have a
positive Mantoux test and may receive
treatment to prevent development of an active
form of the disease.
Clients who have received a Bacillus Calmette-
Guerin (BCG) vaccine within the past10 years
may have a false-positive Mantoux test. These
clients will need a chest x-ray toevaluate the
presence of active TB infection. 19
22. Treatment for TB Disease
DOT .
6 Months regimen .
Longer regimen .( 9- 12) month .
Patient who not take the drugs correctly, the
germs that are still alive may become resistant
to those drugs.
isolation is not important unless children at risk
Rest is also of no use
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23. First line drugs
6 months duration using:
Initial stage for
2monhts(ethambutol/streptomycin+isoniaside+r
efampicin+pyrzinamide)
Continuation stage for 4months( isoniazide
+refampicin)
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24. cont
9 mnths duration:
Initial stage for
2monhts(Ethambutol/Streptomycin+Isoniaside+
Refampicin)
Continuation stage for 7months( Isoniazide
+Refampicin)
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The long term regimens are expensive used
in developing countries. These take
12mnths and are either Streptomycine
1g/IM+Isoniazide
15mg/kg+Pyridoxine10mg twice weekly or
Isoniazide 300mg+ Thiacetazone150mg
daily.
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26. Coticosteroids may be used to supress cell
mediated reactions induced by bacilli but
may also promote arapid dissemination of
infection unless given with effective
antituberculous drugs
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27. Second-line drugs
Include the following drugs :
Sodium aminosalicylate
,Ethionamide,Capreomycin,
Cycloserine,Clarithromycin, Azithromycin,
Ciprofloxacin, Ofloxacin, kanamycin,
Amikacin, Aoxifloxacin and Rifabutin.
27
28. Complications of TB
1. Pleural effusion
2. TB pneumonia
3. Other organ involvement with TB
4. Serious reactions to drug therapy
28
29. prevention
Improvement of socio-economic status
Case finding and treatment
Vaccination with BCG (Bacille Calmette-
Guerin).
Chemoprophylaxis
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30. Patient-Centered Care
Prevent infection transmission.
Wear an N95 or HEPA respirator when caring for clients who
are hospitalized with TB.
Place the client in a negative airflow room, and implement
airborne precautions.
Use barrier protection when the risk of hand or clothing
contamination exists.
Have the client wear an N95 or HEPA respirator if
transportation to another department is necessary. The client
should be transported using the shortest and least busy route.
Teach the client to cough and expectorate sputum into tissues
that are disposed of by the client into provided sacks.
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Administer medications as prescribed.
Promote adequate nutrition.
Encourage fluid intake and a well-balanced
diet for adequate caloric intake.
Encourage foods that are rich in protein,
iron, and vitamin C.
Provide emotional support.
32. Medications
■ Isoniazid, commonly referred to as INH, is bactericidal and
inhibits growth of mycobacteria by preventing synthesis of
mycolic acid in the cell wall.
■■ Nursing Considerations
This medication should be taken on an empty stomach.
Monitor for hepatotoxicity and neurotoxicity, such as
tingling of the hands and feet.
Vitamin B6 (pyridoxine) is used to prevent neurotoxicity
from isoniazid.
Client Education
Advise the client not to drink alcohol while taking isoniazid
because it may increase the risk for hepatotoxicity.
33. Medications
Rifampin, commonly referred to as RIF, is a bacteriostatic
and bactericidal antibiotic that inhibits DNA-dependent
RNA polymerase activity in susceptible cells.
■■ Nursing Considerations
Observe for hepatotoxicity.
■■ Client Education
Inform the client that urine and other secretions will be
orange.
Advise the client to report yellowing of the skin, pain or
swelling of joints, loss of appetite, or malaise immediately.
Inform the client this medication may interfere with the
efficacy of oral contraceptives.
34. Medications
Pyrazinamide
Pyrazinamide, commonly referred to as PZA, is a
bacteriostatic and bactericidal, and its exact mechanism of
action is unknown.
Nursing Considerations
Observe for hepatotoxicity.
Client Education
Instruct the client to drink a glass of water with each dose
and increase fluids during the day.
Advise the client to report yellowing of the skin, pain or
swelling of joints, loss of appetite, or malaise immediately.
Advise the client to avoid using alcohol while taking
pyrazinamide.
35. Medications
Ethambutol (Myambutol)
■■ Ethambutol, commonly referred to as EMB, is a
bacteriostatic and works by suppressing RNA synthesis,
subsequently inhibiting protein synthesis.
Nursing Considerations
Obtain baseline visual acuity tests.
Determine color discrimination ability.
This medication should not be given to children younger
than 13 years of age.
Client Education
Instruct the client to report changes in vision immediately.
36. Medications
Streptomycin sulfate (Streptomycin)
Streptomycin sulfate is an aminoglycoside antibiotic. It
potentiates the efficacy of macrophages during phagocytosis.
Nursing Considerations
Due to its high level of toxicity, this medication should be used
only in clients who have multidrug-resistant TB (MDR-TB).
It can cause ototoxicity, so monitor hearing function and
tolerance often.
Report significant changes in urine output and renal function
studies.
Client Education
Advise the client to drink at least 2 to 3 L of fluid daily.
Advise the client to notify the provider if hearing declines.
37. Client Education
Provide the client and family education because TB is
often treated in the home setting.
Exposed family members should be tested for TB.
Educate the client and family to continue medication
therapy for its full duration of 6 to 12 months.
Emphasize that failure to take the medications may lead
to a resistant strain of TB.
Instruct the client to continue with follow-up care for 1
full year.
Inform the client that sputum samples are needed every
2 to 4 wks to monitor therapy effectiveness. Clients are
not considered infectious after 3 –ve sputum cultures.
38. Encourage proper hand hygiene.
Instruct the client to cover mouth and nose
when coughing or sneezing.
Inform the client that contaminated tissues
should be disposed of in plastic bags.
Advise clients who have active TB to wear
an N95 or HEPA respirator when in public
places.
