Exclusively meant for health science students.

1. B. SC NURSING
MEDICAL-SURGICAL NURSING I
UNIT III - NURSING MANAGEMENT OF
PATIENTS WITH RESPIRATORY
PROBLEMS
PULMONARY TUBERCULOSIS
1

2. OVERVIEW
2
 The history of TB
 The basic microbiological
mycobacterium
 Definition of Tuberculosis
aspects of
 Magnitude of Tuberculosis & Mode of
transmission of TB
 The risk factors for TB
 Pathophysiology of Pulmonary TB
 Clinical manifestations of TB
 Diagnosis & Management of Tuberculosis

3. OBJECTIVES
GENERAL OBJECTIVE: at the end of the class,
the students will gain in depth knowledge
regarding pulmonary tuberculosis and will use
this knowledge in clinical areas with a right
attitude.
3

4. SPECIFIC OBJECTIVES
SPECIFIC OBJECTIVES:
• At the end of the class, students will be able to:
 Define tuberculosis
 State the etiology and the mode of transmission
of TB
 State the risk factors for TB
 Explain the Pathophysiology of PulmonaryTB
 Classify TB

5. SPECIFIC OBJECTIVES:
 Enlist the clinical manifestations of TB
 Enumerate the diagnostic investigations for TB
Explain in detail the medical management (drug
therapy) for TB
 Explain the nursing management of a patient
with Pulmonary TB including home
considerations and complications

6. DEFINITION OF TUBERCULOSIS
Tuberculosis is an infectious disease caused by
mycobacterium tuberculosis primarily affecting
lung parenchyma, any organ like bones, kidneys,
brain etc can also be affected.

8. • ETIOLOGY:
• TB is spread person to Person through the air
via droplet Nuclei
• M. Tuberculosis may Be expelled when an
infectious person:– Coughs, Sneezes ,
Speaks & Sings
• Transmission occurswhen another person
inhales droplet nuclei of infected person.

9. Factors that increase the risk of
acquiring the disease
 Homeless people , Residents of inner-city
neighbourhood
 People living in slums
 Those working or living in institutions (long term
care facilities, prisons, shelters, hospitals
 Poor access to health care
 People who live in close contact with
• someone with active TB
 Diabetes mellitus
 Immuno suppression from any etiology (HIV/AIDS,
cancer, long term corticosteroids)
 Alcoholism , IV drug abuse , Age less than % years
 Smoking , Low body weight .

10. TB PATHOGENESIS
Droplet nuclei containing tubercle bacilli are
inhaled, enter the lungs, and travel to small air
sacs (alveoli) .

11. TB PATHOGENESIS
bronchiole
blood vessel
tubercle
bacilli
alveoli
2
Tubercle bacilli multiply in alveoli, where infection
begins

12. TB PATHOGENESIS
A small number of tubercle bacilli
enter bloodstream and spread
throughout body.
brain
lung
kidney
bone
3

13. TB PATHOGENESIS
LTBI
special
immune
cells form a
barrier shell
(in this
example,
bacilli are
in the lungs)
4
• Within 2 to 8 weeks the immune system produces
special immune cells called macrophages that
surround the tubercle bacilli
• These cells form a barrier shell that keeps the
bacilli Contained and under control (LTBI)

14. TB PATHOGENESIS
TB DISEASE
Shell breaks
down and
tubercle
bacilli escape
and multiply
(in this
example, TB
disease
develops in
the lungs)
5
• If the immune system CANNOT keep tubercle
bacilli under control, bacilli begin to multiply
rapidly and cause TB disease
• This process can occur in different places in the
body.

16. STAGES OF TB:
E
LAL
AAA
EXPOSURE
LATENT
ACTIVE

17. 1.EXPOSURE:
•This happens when a person has been in contact
with or exposed to another person who has TB.
•The exposed person will have a negative skin test,a
normal chest xray,and no signs or symptoms of the
disease.
•2.LATENT TB:
•This happens when a person has TB bacteria in his
or her body,but does not have symptoms of the
disease.
• TB remains inactive throughout life in most people
who are infected.

18. •This person would have a positive skin test,but a
normal chest x ray
•ACTIVE TB:
•This describes the person who has signs and
symptoms of an active infection.The person would
have a positive skin test and a positive chest x ray

19. BASED ON SITE
•Pulmonary Tuberculosis-affects the lungs
•Pleural Tuberculosis-extrapulmonary TB[after
lymphatic involvement]
•Skeletal Tuberculosis-involvement of bones/joints
•Brain Tuberculosis-affects brain and spine
•Bladder and Kidney Tuberculosis
•Gastrointestinal Tract Tuberculosis-involves
peritoneum,stomach,intestinal tract,hepatobiliary
tree,pancreas

20. PATHOPHYSIOLOGY
Entry of organisms through droplet nuclei
Bacteria is transmitted to alveoli through airways
Deposition and multiplication of bacteria
Bacteria is transmited to other parts of the body parts
through blood stream
Accumulation of exudates in alveoli

21. Formation of dead bacilli as a mass around
granulomas[aggregation of macrophages]
Granulomas then transforms to fibrous tissue mass
called GHON tubercle-gray white inflammation with
consolidation emerges
Tissue becomes necrotic[cell death] and forming
cheesy mass
Mass becomes calcified[hardened] and scared
Progression of active disease

22. SYMPTOMS
•Coughing for three or more weeks.
•Coughing up blood or mucus.
•Chest pain, or pain with breathing or
coughing.
•Unintentional weight loss.
•Fatigue.
•Fever.
•Night sweats.
•Chills.

23. DIAGNOSTIC INVESTIGATIONS
44
•History & Physical Examination
•Tuberculin Skin Test
•Chest X-ray
•Bacteriologic studies
•Sputum culture

24. TUBERCULIN SKIN TEST (TST)
 Tuberculin skin test (TST) (Mantoux test) using purified
protein derivative (PPD) is the standard method to
screen people for mycobacterium tuberculosis
 0.1 ml of PPD is injected intra dermally on the dorsal
surface of the forearm
 Patient’s arm is inspected 24 to 48 hours after injection
of PPD
 Inspect the area of induration or swelling around the
injection site; ignore the erythema or redness.

25.  When assessing induration,
* Diameter of the indurated area[swollen is measured
across the forearm and recorded in millimeter
* Erythema, or redness, is not measured.
 The presence of erythema does not indicate that a
person has TB infection
 Confirmation is done by induration time.

27. CHEST X-RAY
 Chest x-ray findings suggestive of TB include,
Upper lobe infiltrates
Cavitary infiltrates
Lymph node involvement

28. BACTERIOLOGIC EXAMINATION OF AFB
SMEARS
Classification
of Smear
Smear Result
Infectiousness of
Patient
4+ Strongly positive
Probably highly
infectious
3+ Strongly positive
Probably very
infectious
2+ Moderately positive Probably infectious
1+ Moderately positive Probably infectious
Actual number of
AFB seen (no plus
sign)
Weakly positive Probably infectious
No AFB seen Negative
May not be
infectious

29. MEDICAL MANAGEMENT OF TB
1.FIRST LINE ANTI-TB DRUGS
•Streptomycin 15mg/kg
•Isoniazid 5mg/kg
•Rifampicin 10mg/kg
•Pyrazinamide 15-30mg/kg
•Ethambutol 15-25mg/kg
•2.SECOND LINE MEDICATIONS:
•Capreomycin 12-15mg/kg
•Ethionamide 15mg/kg
•Paraaminosalycilate sodium 200-300mg/kg

30. •Cycloserine 15mg/kg
•Vitamin b usually administered with isoniazid
•3.THIRD LINE DRUGS
•Rifabutin
•Macrolides
•Thioacetazone
•Arginine
•Vitamin d
•Thioridazine

31. MULTIPLE DRUG THERAPY
•Taking several antibiotics at a time is called as
multiple drug therapy.Most of the medicines are given
as pills.
•Antibiotics such as rifampicin,ethambutol,isoniazid
are used initially.
•DOTS THERAPY-DIRECT OBSERVATIONAL
TREATMENT SHORTCOURSE:
•DOT means that a trained health care worker or
other designated individual[excluding a family
member]provides a prescribed TB drugs and watches
the patient swallow every dose.

32. •DOTS involved treatment with a four drug
regimen.These were
isoniazid,rifampicin,pyrazinamide and ethambutol for
6-9 months.
•This treatment help prevent TB from spreading to
others
•DOT decreases the chances of treatment failure
and relapse.
•A nurse or supervised outreach worker from the
patients country public health department normally
provides DOT.

33. – Receive a medical work up
– Receive appropriate drug therapy
– Receive nutritious diet
– Receive appropriate teaching
Airborne isolation:
– Refers to isolation of patients infected with
organisms spread by the airborne route
NURSING INTERVENTIONS

34. EDUCATE PATIENTS ON RESPIRATORY
HYGIENE
• T
o cover mouth & nose with paper tissues every
time they Cough, sneeze or produce sputum
thrown into paper bag and
the thrash, burned or flushed
• Tissues should be
disposed of with
down the toilet
• Emphasize careful hand washing after handling
sputum & Soiled tissues

35. • Not to spit sputum anywhere other than the into
the designated container
• If patients need to be out of the
pressure room, they must wear
negative
standard
isolation mask to prevent exposure to others
• Minimize prolonged visitation to other parts of
the hospital

36. HOME CARE CONSIDERATIONS
79
• T
each patients how to minimize exposure to close contacts &
household members.
• Teach respiratory hygiene.
• Homes should be well ventilated.
• While still infective, patient should sleep alone, spend as much
time as possible
Outdoors, minimize time in congregate settings & public
transportation.
• T
each patient on the importance of taking well balanced diet
(especially protein rich diet).

37. • T
each patient about the side effects of the drugs; if side
effects occur, to notify immediately.
• Teach patients the importance of cessation of smoking.
• Strategies to promote adherence: teaching & counseling,
reminder system, incentives & reward, DOTS.

38. COMPLICATIONS OF TB
• Miliary tuberculosis – widespread dissemination of
mycobacterium tuberculosis
• Acute bronchopneumonia – when large amounts of
tubercle bacilli are
lymph nodes
• Bronchiectasis
discharged into the lungs of

39. • Broncholithiasis[calcified material settles in
bronchial lumen]
• Fibrothorax[acc.of dense fib.tissue in pleural cavity]
• Carcinoma
• TB can infect organs throughout the body:
TB meningitis
TB spine (pott’s disease)
Abdominal TB
Kidneys
Adrenal glands

40. • Ineffective airway clearance related increased secretions
and fatigue
• Ineffective breathing pattern related to decreased lung
capacity
• Non-compliance related to lack of knowledge of disease,
lack of motivation, long term nature of treatment, & lack
of resources
• Knowledge deficit regarding disease process, nature of
treatment & home care related to lack of information and
unfamiliarity.
NURSING DIAGNOSIS

41. REFERENCES
 Lewis & Dirksen, (2015) textbook of medical –
2nd
surgical nursing, south Asian edition,
Elsevier publication.(Pg no: 610 - 627)
 WWW. Emedicine.Com

42. THANK YOU