PULMONARY TUBERCULOSIS

PULMONARY TUBERCULOSIS for nursing students( Pcl, BNS)

1. 7/24/2022 1

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

3. CONTENTS INTRODUCTION DEFINITION CLASSIFICATION OF TB TYPES INCIDENCE RISK FACTOR 7/24/2022 3

4. Contd…. 7. PATHOPHYSIOLOGY 8. SIGN AND SYMPTOMS 9. DIAGNOSIS 10. TREATMENT/ MANAGEMENT 11. NURSING MANAGEMENT 12. COMPLICATIONS 7/24/2022 4

5. PULMONARY TUBERCULOSIS 7/24/2022 5

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. 7/24/2022 6

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. 7/24/2022 7

8. MYCOBACTERIUM TUBERCULOSIS 7/24/2022 8

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. 7/24/2022 9

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. 7/24/2022 10

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. 7/24/2022 11

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. 7/24/2022 12

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 ). 7/24/2022 13

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) 7/24/2022 14

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. 7/24/2022 15

16. Classification based on Drug Resistance Primary drug resistance: resistance to one of the first line ATT agents in a person, who has not had previous treatment. Secondary or acquired drug resistance: resistance to one or more antituberculosis agents in a patient undergoing treatments. 7/24/2022 16

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. 7/24/2022 17

18. TYPES Pulmonary Tuberculosis Avian Tuberculosis( microbacterium avium ;of birds) Bovine Tuberculosis(mycobacterium bovis ;of cattle) Miliary Tuberculosis / disseminated tuberculosis 7/24/2022 18

19. PULMONARY TB 7/24/2022 19

20. MILIARY TB 7/24/2022 20

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. 7/24/2022 21

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%. 7/24/2022 22

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 7/24/2022 23

24. Transmission and Risk factors 7/24/2022 24

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. 7/24/2022 25

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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 7/24/2022 27

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. 7/24/2022 28

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…) 7/24/2022 29

30. PATHOPHYSIOLOGY 30 7/24/2022

31. Pathophysiology … 31 7/24/2022

32. Pathophysiology … 32 7/24/2022

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 7/24/2022

34. PATHOPHYSIOLOGY The reactivation occurs through following steps: Ulceration of ghon tubercule Cheesy material release into bronchi(making bacteria airborne) 7/24/2022 34

35. Pathophysiology … 35 7/24/2022

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37. Contd…. PULMONARY SYMPTOMS Dyspnea Non resolving bronchopneumonia Chest tightness Non productive cough Mucopurulent sputum with hemoptpysis Chest pain 7/24/2022 37

38. Contd…. EXTRA PULMONARY SYMPTOMS Pain Inflammation 7/24/2022 38

39. DIAGNOSIS HISTORY TAKING PHYSICAL EXAMINATION Clubbing of the fingers or toes (in people with advanced disease) 7/24/2022 39

40. Contd…. Swollen or tender lymph nodes in the neck or other areas Fluid around a lung (pleural effusion) Unusual breath sounds (crackles) 7/24/2022 40

41. Contd… IF MILIARY TB; A physical exam may show: Swollen liver Swollen lymph nodes Swollen spleen 7/24/2022 41

42. Diagnosis Chest radiography: bilateral shadows, especially if these are in l esions in upper lobes- TB Sputum examination (smear and culture) Tuberculin skin test 42 7/24/2022

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 7/24/2022

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 7/24/2022

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 7/24/2022 45

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 7/24/2022

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 7/24/2022

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 7/24/2022 48

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 7/24/2022

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 : 7/24/2022

51. 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 7/24/2022

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 7/24/2022

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 7/24/2022

54. CONTD…… Aminoglycosides : amikacin , kanamycin   Polypeptides: capreomycin , viomycin , enviomycin Fluoroquinolones : ciprofloxacin, levofloxacin , moxifloxacin   Thioamides : ethionamide ,  prothionamide Cycloserine: closerin Terizidone 7/24/2022 54

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 7/24/2022

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 7/24/2022

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 7/24/2022

58. CONTD….. Continuation phase: 7-10 HRE If treatment is required beyond 12 months, then refer to a higher level center for treatment decisions. 7/24/2022 58

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 7/24/2022

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 7/24/2022

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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. 7/24/2022 62

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. 7/24/2022 63

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%. 7/24/2022 64

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. 7/24/2022 65

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. 7/24/2022 67

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 7/24/2022

69. NURSING MANAGEMENT 7/24/2022 69

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 7/24/2022 70

71. Evaluate breath sounds for consolidation. Assess patient’s for living arrangements. Review results of physical and laboratory evaluations. 71 7/24/2022

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. 7/24/2022 72

73. Nursing management.. Nursing diagnosis Ineffective airway clearance related to copious tracheo -bronchial secretions, poor cough effort. Activity intolerance related to fatigue, fever. 73 7/24/2022

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. 7/24/2022 74

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 7/24/2022

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 7/24/2022

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 7/24/2022

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 7/24/2022

79. Nursing management.. Promoting activity Plan a progressive activity schedule to increase activity tolerance and muscle strength 79 7/24/2022

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 7/24/2022

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 7/24/2022

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 7/24/2022

83. Nursing management.. Monitor laboratory studies: BUN, serum protein, and albumin. Administer antipyretics as appropriate. 83 7/24/2022

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 7/24/2022

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 7/24/2022

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 7/24/2022

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 7/24/2022

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 7/24/2022

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 7/24/2022

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 7/24/2022

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 7/24/2022

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 7/24/2022

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 7/24/2022

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. 7/24/2022 94

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 7/24/2022

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 7/24/2022

97. Nursing management.. Expected outcome Maintain patent airway. Expectorate secretions without assistance. Demonstrate progressive weight gain and be free of signs of malnutrition. 97 7/24/2022

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. 7/24/2022 98

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) 7/24/2022 99

100. CONTD…. Pleural effusion Tb pneumonia Serious reactions to drug therapy(hepato toxicity;hypersentivity) 7/24/2022 100

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102. REFERENCES Mandal G.N, Textbook of medical surgical nursing (adult nursing) published by Makalu publication house, 3 rd edition. Brunner and siddarth , Textbook of Medical-Surgical Nursing, 13 th edition. https://dohs.gov.np/centers/national-tuberculosis-center/ on 2021/ 07/23 at 11 am https://www.slideshare.net/krishnameera999/pulmonary-tuberculosis-ppt on 2021/07/23 at 11 am. 7/24/2022 102

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