A CASE PRESENTATION ABOUT

TUBERCULOSIS

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 Introduction

Tuberculosis is a common and often deadly infectious disease caused by mycobacteria,

mainly Mycobacterium tuberculosis. Tuberculosis usually attacks the lungs (as pulmonary TB)

but can also affect the central nervous system, the lymphatic system, the circulatory system, the

genitourinary system, the gastrointestinal system, bones, joints, and even the skin. Other

mycobacteria such as Mycobacterium bovis, Mycobacterium africanum, Mycobacterium canetti,

and Mycobacterium microti also cause tuberculosis, but these species are less common.

The typical symptoms of tuberculosis are a chronic cough with blood-tingedsputum,

fever, night sweats and weight loss. Infections of other organs cause a wide range of symptoms.

The diagnosis relies on radiology (commonly chest X-rays), a tuberculin skin test, blood tests, as

well as microscopic examination and microbiological culture of bodily fluids. Tuberculosis

treatment is difficult and requires long courses of multiple antibiotics. Contacts are also screened

and treated if necessary. Antibiotic resistance is a growing problem in (extensively) multi-drug-

resistant tuberculosis. Prevention relies on screening programs and vaccination, usually with

Bacillus Calmette-Guérin (BCG vaccine).

Tuberculosis is spread through the air, when people who have the disease cough, sneeze

or spit. One third of the world's current population had been infected with M. tuberculosis, and

new infections occur at a rate of one per second. However, most of these cases will not develop

the full-blown disease; asymptomatic, latent infection is most common.

TB remains one of the top 10 causes of death worldwide. Millions of people continue to fall sick

from TB each year. The Global TB Report 2019 provides a comprehensive and up-to-date

assessment of the TB epidemic, and progress in the response, at global, regional and country
levels. It features data on disease trends and the response to the epidemic in 202 countries and

territories. The Global Report includes trends in TB incidence and mortality, data on case

detection and treatment results for TB, multidrug-resistant TB (MDR-TB), TB/HIV, TB

prevention, universal health coverage as well as financing. It presents progress towards targets

set at the first-ever United Nations General Assembly high-level meeting on TB in 2018, that

brought together heads of state, as well as the targets of the WHO End TB Strategy and the

Sustainable Development Goals. The report also includes an overview of pipelines for new TB

diagnostics, drugs and vaccines. Additionally, it outlines a monitoring framework that features

data on SDG indicators that can be used to identify key influences on the TB epidemic at

national level and inform the multi-sectoral actions required to end the TB epidemic.

I. Definition of Terms

Extrapulmonary - situated or occurring outside the lungs

Infection - Invasion and multiplication of microorganisms such as bacteria, viruses, and

parasites that are not normally present within the body.

Kinyoun stain - is a procedure used to stain acid-fast species of the bacterial genera

Mycobacterium and Nocardia and the apicomplexan genus Cryptosporidium.

Latent tuberculosis - State of persistent immune response to stimulation by

Mycobacterium tuberculosis antigens without evidence of clinically manifested active TB.

Someone has latent TB if they are infected with the TB bacteria but do not have signs of

active TB disease and do not feel ill

Mantoux test – Also called Mendel–Mantoux test is a tool for screening for tuberculosis and for

tuberculosis diagnosis. It is one of the major tuberculin skin tests used around the world

Mycobacterium tuberculosis - Species of pathogenic bacteria in the family. Mycobactericidal

and the causative agent of tuberculosis.

Mycobacterium tuberculosis complex - is a genetically related group of Mycobacterium

species that can cause tuberculosis in humans or other animals.

Pulmonary – Related to the lungs

Silicosis - Lung fibrosis caused by the inhalation of dust containing silica.

Tuberculosis - an infectious bacterial disease characterized by the growth of nodules (tubercles)

in the tissues, especially the lungs.

Tubercles - a small nodular lesion in the lungs or other tissues.

Chest x-rays - This may be helpful in cases when the Acid-Fast Bacilli are not seen on sputum

examination. However, chest x-rays with findings suggestive of TB are not definitive proof that

the disease is really TB. There are other diseases that may mimic the appearance of TB on chest

x-rays. It also frequently difficult to judge if the lung disease is active or not by chest x-ray

Ziehl–Neelsen stain - is a type of Acid-fast stain, it is a bacteriological stain used to identify

acid-fast organisms, mainly Mycobacteria.

 II. Review of Related Literature

TB remains one of the top 10 causes of death worldwide. Millions of people continue to fall

sick from TB each year. The Global TB Report 2019 provides a comprehensive and up-to-date

assessment of the TB epidemic, and progress in the response, at global, regional and country

levels. It features data on disease trends and the response to the epidemic in 202 countries and

territories. The Global Report includes trends in TB incidence and mortality, data on case

detection and treatment results for TB, multidrug-resistant TB (MDR-TB), TB/HIV, TB

prevention, universal health coverage as well as financing. It presents progress towards targets

set at the first-ever United Nations General Assembly high-level meeting on TB in 2018, that

brought together heads of state, as well as the targets of the WHO End TB Strategy and the

Sustainable Development Goals.  The report also includes an overview of pipelines for new TB

diagnostics, drugs and vaccines. Additionally, it outlines a monitoring framework that features

data on SDG indicators that can be used to identify key influences on the TB epidemic at

national level and inform the multi-sectoral actions required to end the TB epidemic.

(WHO, 2019)

Tuberculosis is the infectious disease that causes the most deaths each year in the world.

Around 25% of the population is estimated to be infected with, Mycobacterium tuberculosis, the

bacteria that gives rise to the disease, and more than one and a half million people die each year

from this cause. A rigorous bibliometric analysis has been developed around tuberculosis

disease, and the most remarkable results are presented in this paper. It is observed that interest in

tuberculosis is growing, and the control of its spread has become one of the main health priorities

in the world, with the United States, the United Kingdom, and India, leading the research in this
area. On the other hand, it has been observed that there are two main health concerns around the

tuberculosis: drug-resistant tuberculosis and co-infection with HIV. Finally, conclusions are

offered, playing a frontline role in science policy decisions and research performance

evaluations. (Sciencedirect, J.A.Garrido-Cardenas, 2020)

Filamentous Temperature Sensitive Mutant Z (FtsZ), an important cell division protein in

bacteria, has been validated as a potential target for antibiotics development. Citric acid has been

found to inhibit the polymerization of Mycobacterium tuberculosis (MTB) FtsZ and several other

drugs have been predicted as potential inhibitors through a gene ontology-based drug

repurposing approach. An in-depth study on four of the predicted drugs; Fusidic acid (FusA), L-

tryptophan, Carbamic acid, and 2-(3-guanidinophenyl)-3-mercaptopropanoic acid, as potential

inhibitors of MTB-FtsZ polymerization was conducted using Citric acid as reference compound.

The applied in silico methods involve DFT calculations, molecular docking and molecular

dynamics simulations. DFT approach was applied to evaluate selectivity and stability properties

of the predicted drugs. Calculated parameters including non-linear optical properties, charge

distribution and electrostatic potential analyses enabled selectivity prediction of these potential

drugs. DFT-based descriptors revealed FusA as the most potent compound, even more reactive

than the referenced compound, Citric acid, which is also supported from the molecular docking

study. Parameters including MM/PBSA binding free energies, RMSD, RMSF, RoG and

hydrogen bond analysis also support FusA as the best potential MTB-FtsZ polymerization

inhibitor, that forms a stable complex with the protein and impose greatest level of rigidity to the

protein. (OlayinkaI.Akinpel, bMonsurat M.Lawal, aHezekiel M.Kumalo, 2020)

 This study reports the development of a new PCR-free device, using IS6110 gene as

biomarker, for Tuberculosis (TB) diagnosis. An arginine film (ARGFILM) was used to prepare

the biosensor platform. MT-probe was immobilized on this biosensor platform to identify IS6110

gene. This gene is an excellent biomarker for Mycobacterium tuberculosis (MT).

Electrochemical analyses were carried out using differential pulse voltammetry method (DPV)

by methylene blue (MB) reduction signal measurement before and after hybridization either

between probe and synthetic target or extracted DNA from clinical sputum samples. The

optimization study of MT-probe immobilization on modified-electrode surface showed that the

best probe concentration was 15 μM. The analytical analysis of hybridization assays was

performed using different concentrations of synthetic MT-target (15–500 nM). The linear

response was between 15 and 100 nM and the detection limit was 4.4 nM. The biosensor

performance was also investigated with extracted DNA from sputum samples (PCR-free). The

results showed that the biosensor was able to detect the MT from samples, exhibiting a high

sensitivity and satisfactory selectivity. Thus, these results allow for the possibility of developing

a portable detection device for effective diagnosis of TB patients. (Laboratório de

Imunopatologia Keizo Asami – LIKA/ UFPE, Av. Prof. Moraes Rego, 1235,CEP 506070-901,

Cidade Universitária, Recife, Pernambuco, Brazil, 2020)

The sensitivity of in vivo low-dose high-resolution micro-computed tomography imaging

enables monitoring the lung damage caused by tuberculosis. Here, we propose a radiological

score integrated in the experimental workflow that enables longitudinal monitoring for

prospective efficacy studies in drug development programs. The score is based on an automatic

measurement of total unaffected lung volume in vivo normalized for inter-subject comparison. It

was validated on well-characterized progression of chronic tuberculosis in Erdman and H37Rv

strains in C3HeB/FeJ-based models.. We demonstrated that a decrease in the score value

indicates increasing adverse effects and vice versa. The colony-forming units count confirmed

the variability in the host response suggested by the score values. The correlation between

changes in the mice's weight and the score is consistent with disease progression. The

classification of disease extent by k-means clustering of the score values provided the definition

of the lung damage severity according to the bacillus strain. The proposed score will reduce

sources of bias and improve the statistical robustness of studies by the attrition of non-infected

subjects or subjects with a weak immune response. Readily available quantifications allow for a

fast assessment of the therapeutic potential in drug-resistant tuberculosis strains.( Diseases of the

Developing World, Infectious Diseases-Centre for Excellence in Drug Discovery (ID CEDD),

GlaxoSmithKline, Madrid, Spain,2020)

III. Evidence Based Practice

Although a vaccine for TB was developed 100 years ago, one in three people across the

world are thought to be infected with the infectious disease. About 1.7 million die from the bug

each year worldwide and 7.3 million people were diagnosed and treated in 2018, up from the 6.3

million in 2016. Patients are forced to take a cocktail of strong antibiotics over 6 to 8 months,

often enduring unpleasant side effects with a 20% risk that the disease will return. But now The

University of Manchester team's discovery has been proven effective in guinea pigs at Rutgers

University in the United States. The team identified one Virulence Factor called MptpB as a

suitable target, which when blocked allows white blood cells to kill Mycobacterium Tuberculosis

in a more efficient way Professor Tabernero added: "The great thing about MptpB is that there's

nothing similar in humans -- so our compound which blocks it is not toxic to the human cells.
”Because the bacteria hasn't been threatened directly, it is less likely to develop resistance

against this new agent, and this will be a major advantage over current antibiotics, for which

bacteria had already become resistant. (University of Manchester, September 11, 2018)

Today, people who contract tuberculosis typically take a course of drugs for six to eight

months. However, the length of treatment means some patients don't stick with the therapy or

may develop adverse effects from drug toxicity. Some may develop resistance to the drugs,

requiring changes in the drug regimen that can lengthen the treatment to as long as two years.

Even worse, there is a high fatality rate among those with drug-resistant TB. In new research,

UCLA scientists have reported finding a way to significantly reduce the duration of treatment by

using an approach called "artificial intelligence-parabolic response surface." This data analysis

method identifies which drug combinations work synergistically -- that is, individual drugs

working together in a way that is more potent than the sum of their individual potencies. The

method, when used in cell culture and subsequently mouse models of TB, allowed researchers to

quickly identify three- or four-drug combinations among billions of possible combinations of

drugs and doses, that significantly cut the duration of TB therapy. These regimens are suitable

for treating both drug-sensitive TB and most cases of drug-resistant TB -- that is, they are

"universal" regimens -- and are up to five times faster than the currently available standard

treatment. In all, the researchers evaluated 15 drugs to identify the best four-drug combinations.

The two most potent regimens comprised clofazimine, bedaquiline, pyrazinamide, and either

amoxicillin/clavulanate or delamanid. Two of the drug regimens achieved a 100 percent cure

rate, without relapse, in mice in three weeks. Another regimen cured the mice in five weeks.

Both of the drug combinations included currently approved medications, Horwitz said.
 IV. Anatomy and Systems Involved

Respiratory System:

The respiratory system consists of the airways, the lungs, and the respiratory muscles that

mediate the movement of air into and out of the body. Within the alveolar system of the lungs,

molecules of oxygen and carbon dioxide are passively exchanged, by diffusion, between the

gaseous environment and the blood. Thus, the respiratory system facilitates oxygenation of the

blood with a concomitant removal of carbon dioxide and other gaseous metabolic wastes from

the circulation. The system also helps to maintain the acid-base balance of the body through the

efficient removal of carbon dioxide from the blood.

Upper Airways – Nasal Cavity:

The nasal cavity (or nasal fossa) is a large air-filled space above and behind the nose in

the middle of the face. The nasal cavity conditions the air to be received by the areas of the

respiratory tract and nose. Owing to the large surface area provided by the conchae, the air

passing through the nasal cavity is warmed or cooled to within 1 degree of body temperature. In

addition, the air is humidified, and dust and other particulate matter is removed by vibrissae,

short, thick hairs, present in the vestibule. The cilia of the respiratory epithelium move the

particulate matter towards the pharynx where it is swallowed.

Upper Airways – Pharynx:

The pharynx is the part of the neck and throat situated immediately posterior to the mouth

and nasal cavity, and cranial, or superior, to the esophagus, larynx, and trachea. It is part of the

digestive system and respiratory system of many organisms. Because both food and air pass
through the pharynx, a flap of connective tissue called the epiglottis closes over the trachea when

food is swallowed to prevent choking or aspiration. In humans the pharynx is important in

vocalization.

Upper Aiways – Larynx:

The larynx (plural larynges), colloquially known as the voice box, is an organ in the neck

of mammals involved in protection of the trachea and sound production. The larynx houses the

vocal folds, and is situated just below where the tract of the pharynx splits into the trachea and

the esophagus.

Sound is generated in the larynx, and that is where pitch and volume are manipulated.

The strength of expiration from the lungs also contributes to loudness, and is necessary for the

vocal folds to produce speech. During swallowing, the backward motion of the tongue forces the

epiglottis over the laryngeal opening to prevent swallowed material from entering the lungs; the

larynx is also pulled upwards to assist this process. Stimulation of the larynx by ingested matter

produces a strong cough reflex to protect the lungs.

Lower Airways –Trachea:

The trachea extends from the larynx to the level of the 7th thoracic vertebrae, where it

divides 2 main bronchi, which is called the carina. It is a flexible, muscular 12-cm long air

passage with c shaped cartilaginous rings. Along with other regions of the lower airways it is

lined pseudo stratified columnar epithelium that contains goblet cells and Celia. Because the

Celia beat upward, they tend to carry foreign particles and excessive mucus away from the lungs
to the pharynx. The trachea (windpipe) divides into two main bronchi the left and the right, at the

level of the sternal angle.

Lower Airways – Bronchi and Bronchioles:

A bronchus is a caliber of airway in the respiratory tract that conducts air into the lungs.

No gas exchange takes place in this part of the lungs. . The right main bronchus is wider, shorter,

and more vertical than the left main bronchus. The right main bronchus subdivides into three

segmental bronchi while the left main bronchus divides into two. The lobar bronchi divide into

tertiary bronchi. Each of the segmental bronchi supplies a broncho-pulmonary segment. A

broncho-pulmonary segment is a division of a lung that is separated from the rest of the lung by a

connective tissue septum.

Lower Airways – Lungs:

The trachea divides into the two main bronchi that enter the roots of the lungs. The

bronchi continue to divide within the lung, and after multiple divisions, give rise to bronchioles.

The bronchial tree continues branching until it reaches the level of terminal bronchioles, which

lead to alveolar sacks. Alveolar sacs are made up of clusters of alveoli, like individual grapes

within a bunch. The individual alveoli are tightly wrapped in blood vessels, and it is here that gas

exchange actually occurs. Deoxygenated blood from the heart is pumped through the pulmonary

artery to the lungs, where oxygen diffuses into blood and is exchanged for carbon dioxide in the

hemoglobin of the erythrocytes. The oxygen-rich blood returns to the heart via the pulmonary

veins to be pumped back into systemic circulation.

 Human lungs are located in two cavities on either side of the heart. Though similar in

appearance, the two are not identical. Both are separated into 22 lobes, with three lobes on the

right and two on the left. The lobes are further divided into lobules, hexagonal divisions of the

lungs that are the smallest subdivision visible to the naked eye. The connective tissue that divides

lobules is often blackened in smokers and city dwellers. The medial border of the right lung is

nearly vertical, while the left lung contains a cardiac notch. The cardiac notch is a concave

impression molded to accommodate the shape of the heart. Lungs are to a certain extent

'overbuilt' and have a tremendous reserve volume as compared to the oxygen exchange

requirements when at rest. This is the reason that individuals can smoke for years without having

a noticeable decrease in lung function while still or moving slowly; in situations like these only a

small portion of the lungs are actually perfused with blood for gas exchange. As oxygen

requirements increase due to exercise, a greater volume of the lungs is perfused, allowing the

body to match its CO2/O2 exchange requirements.

Lower Airways – Alveoli:

An alveolus is an anatomical structure that has the form of a hollow cavity. Mainly found

in the lung, the pulmonary alveoli are spherical outcroppings of the respiratory bronchioles and

are the primary sites of gas exchange with the blood. The lungs contain about 300 million

alveoli, representing a total surface area of approx. 70-90 square meters. Each alveolus is

wrapped in a fine mesh of capillaries covering about 70% of its area. The alveoli have radii of

about 0.05 mm but increase to around 0.1 mm during inhalation. The alveoli consist of an

epithelial layer and extracellular matrix surrounded by capillaries. In some alveolar walls there

are pores between alveoli. There are three major alveolar cell types in the alveolar wall.
• Type I cells, that form the structure of an alveolar wall

• Type II cells, that secretes surfactant to lower the surface tension of water and allows the

membrane to separate thereby increasing the capability to exchange gases. Surfactant is

continuously released by exocytosis. It forms an underlying aqueous protein-containing

hypophase and a 23 overlying phospholipids film composed primarily of dipalmitoyl

phosphatidylcholine.

• Macrophages, that destroy foreign material, such as bacteria.

Lower Airways – Diaphragm

The Diaphragm is a dome-shaped musculo-fibrous septum, which separates the thoracic from

the abdominal cavity, its convex upper surface forming the floor of the former, and it’s concave

under surface the roof of the latter. Its peripheral part consists of muscular fibers, which take

origin from the circumference of the thoracic outlet and converge to be inserted into a central

tendon. The diaphragm is crucial for breathing and respiration. During inhalation, the diaphragm

contracts, thus enlarging the thoracic cavity (the external intercostal muscles also participate in

this enlargement). This reduces intra-thoracic pressure: in other words, enlarging the cavity

creates suction that draws air into the lungs. When the diaphragm relaxes, air is exhaled by

elastic recoil of the lung and the tissues lining the thoracic cavity in conjunction with the

abdominal muscles, which act as an antagonist, paired with the diaphragm's contraction an

antagonist paired with the diaphragm's contraction.

 V. SIGNS & SYMPTOMS

A person with latent, or inactive tuberculosis, will have no symptoms. Though one can

still have a tuberculosis infection, but the bacteria in the body is not yet causing any harm.

Symptoms of active tuberculosis include:

• A persistent cough that lasts for more than 3 weeks

• Chest pain

• Breathlessness that gradually gets worse

• Coughing up blood or sputum

• Loss of appetite and unintentional weight loss

• Extreme weakness or fatigue

• Chills

• Fever

• Night sweats

Other symptoms may be experienced related to the function of other specific organs or

systems that are affected. It can affect the small glands that form part of the immune system (the

lymph nodes), the bones and joints, the digestive system, the bladder and reproductive system,

and the brain and nerves (the nervous system). Tuberculosis affecting other parts of the body is

more common in people who have a weakened immune system. These symptoms can include:

• Persistently swollen glands

• Abdominal pain

• Pain and loss of movement in an affected bone or joint

• Confusion

• Confusion
• A persistent headache

• Seizure fits

.
 PATHOPHYSIOLOGY

Predisposing factors Precipitating factors

Inhalation of air-borne nuclei containing tubercle bacill
 Close contact with someone who has
active TB specifically wife
 Immunocompromised status
(weak immune system)

Bacteria are transmitted through the airways to the bronchioles and alveoli

Deposition and multiplication in the apices of the lungs

Bacilli transported via the lymph system and bloodstream to other parts of the body

Inflammatory reaction Low-grade fever:

fever
37.9oC

Neutrophils and macrophages engulf

many bacteria
TB-specific lymphocytes lyse the
bacilli and normal tissue
 Productive cough
w/ greenish sputum
Production of exudates  Phlegm crackles on
R Lung
in the alveoli

Partial occlusion of the

bronchi or alveoli
 Interferes with the Dyspnea
diffusion of oxygen Shortness
and carbon dioxide of breath

Areas of the lungs are dyspne

inadequately ventilated a

Tachypnea
Decreased Oxygen-carrying 34CPM
capacity (Hypoxemia) dyspnea

Tissue hypoxia Pallor

Fatigue
Weakness
tachycardia
dizziness

Low grade
Development of active disease fever
after initial exposure and Night sweats
infection Anorexia
Weight loss

Ulceration of Ghon tubercle Hemoptysis

Release of cheesy material into Productive

the bronchi cough of more
than 2 weeks
Whitish
phlegm
Ghon tubercle heals forming
scar tissue
Parenchymal
lesions on
CXR
Inflammation of infected lungs

Spreading to the hilum of the Dyspnea

lungs and later extends to Easy fatigability
adjacent lobes
 Tuberculosis is caused by infection by an organism called Mycobacterium tuberculosis.

This organism most often (85%) presents as a lung infection due to its airborne transmission. It

causes granulomas to form in the alveolar sacs, which will create cavitation as immune cells

surround it. If the host’s immune system cannot fight it off, the inflammation and infection will

continue to spread, damaging more and more alveoli. The more damage to alveoli, the worse the

patient’s oxygenation and gas exchange will be.

Etiology

Tuberculosis is spread via airborne aerosolization of particles. If the host’s immune system is

strong enough to resist initial infection, the infection may lay dormant in the form of “Latent TB

Infection” for years until the host’s immune system is compromised.  Countries with

overcrowded populations or other crowded or closed environments (i.e. prisons, homeless

shelters) carry higher risks, as well as history of HIV, diabetes mellitus, substance abuse, cancer,

end stage renal disease, and smoking.

Animals and humans are also affected by other related bacteria in the Mycobacterium

tuberculosis complex, such as Mycobacterium bovis. The bacteria infect cows, buffalo, deer, and

elk, among others. It can be transmitted to humans through unpasteurized milk and cheeses. This

recognition of this led many governments to regulate dairy herds and the pasteurization of milk

in the early twentieth century.

Diagnostic Tests:

a. Chest X-Ray

Image: Tuberculosis Xray

This may be helpful in cases when the Acid-Fast Bacilli are not seen on sputum
examination. However, chest x-rays with findings suggestive of TB are not definitive proof
that the disease is really TB. There are other diseases that may mimic the appearance of TB
on chest x-rays. It also frequently difficult to judge if the lung disease is active or not by
chest x-ray. In active pulmonary TB, infiltrates or consolidations and/or cavities are often
seen in the upper lungs with or without mediastinal or hilar lymphadenopathy.

b. Sputum Culture and Smear

A sputum culture is a test to detect and identify bacteria or fungi that infect the

lungs or breathing passages. Normally, fresh morning sample is preferred for the
bacteriological examination of sputum. Sputum is dark green in the early stages of an
 infection and gradually lightens as the infection improves. It is the presence of an enzyme
called myeloperoxidase that gives the sputum its green color, during an infection. Some
infections may cause sputum to be yellow, gray, or rusty colored.

c. Mantoux Skin Test

The Mantoux tuberculin skin test (TST) is the standard method of determining

whether a person is infected with Mycobacterium tuberculosis. Reliable administration

and reading of the TST requires standardization of procedures, training, supervision, and

practice. The skin test reaction should be read between 48 and 72 hours after

administration. A patient who does not return within 72 hours will need to be rescheduled

for another skin test. The reaction should be measured in millimeters of the induration

(palpable, raised, hardened area or swelling). The reader should not measure erythema

(redness). The diameter of the indurated area should be measured across the forearm

(perpendicular to the long axis).

The tuberculin is placed intradermally and the skin is evaluated 48-72 hours later.

What we’re looking for is what’s called induration. That means it is raised and hard.

Some people, like myself, will have severe skin reactions and have very large red areas,

but since it isn’t raised, it’s considered negative. So how do we know what’s positive.

Well for anyone, if the area of induration (the raised hard part) is greater than 15 mm in

diameter, that’s considered positive. However, for those at higher risk, we have a lower

threshold. For those with higher risk, for example healthcare workers or people who’ve

traveled to high-risk countries, an induration greater than 10 mm is considered positive.

And for anyone who is immunosuppressed or with known exposure, anything over 5mm

is considered positive.
d. Quantiferon Gold –

A whole-blood test for use as an aid in diagnosing

Mycobacterium tuberculosis infection, including latent tuberculosis infection (LTBI)

and tuberculosis (TB) disease. Blood samples are mixed with antigens (substances that

can produce an immune response) and controls. It’s more accurate than the PPD skin test,

but it’s cost-prohibitive to do it for everyone, so the TB skin test is standard.

Drug Study
GENERIC BRAND GENERAL MECHANISM OF ROUTE OF INDICATIONS CONTRAINDICA ADVERSE NURSING
NAME NAME CLASSIFICAT ACTION DOSAGE TIONS REACTION RESPONSIBILITY
ION
Rifampicin Rifadin, Anti-infectives; Inhibits DNA-dependent Per Orem For the initial Hypersensitivity to any High doses of rifampicin May cause reddish-orange
Rimactane Antituberculotic RNA polymerase, thus 150mg/75mg/400m phase treatment ingredient in the (>600 mg) given once or discoloration of urine,
impairing RNA synthesis g/275mg product twice weekly have resulted saliva, tears, sweat and
(bactericidal). Rifampicin, a
of all forms of Jaundice or severe liver in a high incidence of sputum. Instruct the patient
semisynthetic antibiotic pulmonary and disease adverse reactions including: that this is to be expected
derivative of Rifamycin, extrapulmonary Acute gout the “flu-like” syndrome and not harmful.
suppresses bacterial RNA tuberculosis. Pre-existing optic (i.e., fever, chills,
synthesis by binding to the b neuritis from any cause sometimes with headache, Monitor patient’s visual
subunit of DNA-dependent dizziness, and bone pain); acuity, visual fields, and
RNA polymerase, thus hematopoietic reactions red-green discrimination
inhibiting the attachment of (i.e., leukopenia, regularly as reversible optic
the enzyme to DNA, thrombocytopenia, and neuritis may be caused by
blocking RNA transcription, acute hemolytic anemia); Ethambutol.
elongation, and subsequent cutaneous; gastrointestinal
translation to protein. It does and hepatic reactions; Instruct patients in proper
not inhibit the counterpart dyspnea, wheezing; shock; oral hygiene, including
mammalian enzyme. and acute renal failure. caution in the use of regular
Rifampicin has bactericidal Hepatic: Elevations in toothbrushes, dental floss,
action and potent sterilizing serum concentrations of and toothpicks. The
effect against both ALT, AST, bilirubin, and leukopenic and
intracellular and extracellular alkaline phosphatase, thrombocytopenic effects of
tubercle bacilli. Cross asymptomatic jaundice, and Rifampin may result in an
resistance has been shown hepatitis. Rarely, hepatitis increased incidence of
only with other rifamycin or shock-like syndrome certain microbial infections,
derivatives. with liver involvement and delayed healing, and
abnormal liver function test gingival bleeding. If
results. leukopenia or
Dermatologic: Rash, thrombocytopenia occurs,
pruritus, urticaria, dental work should be
acneiform eruptions, defined until blood counts
pemphigoid reaction, have returned to normal.
erythema multiforme Rifampin may cause a
including Stevens-Johnson hypersensitivity
syndrome, toxic epidermal reaction of sores in mouth
necrolysis, vasculitis, or tongue.
exfoliative dermatitis,
flushing, and rarely,
anaphylaxis.
GI: Heartburn, epigastric
distress, nausea, vomiting,
anorexia, abdominal
cramps, flatulence,
diarrhea, sore mouth and
tongue, pseudomembranous
colitis, and pancreatic
insufficiency.

Musculoskeletal: Ataxia,
muscular weakness,
myopathy, and pain in
muscles, joints and
extremities.

Hematologic: Eosinophilia,
leukopenia, purpura,
hemolytic anemia,
decreased hemoglobin
concentrations, hemolysis,
thrombocytopenia,
disseminated intravascular
dissemination, and
agranulocytosis.

Renal: Increased BUN and

serum uric acid
concentrations,
hemoglobinuria, light chain
proteinuria, hematuria,
renal insufficiency,
interstitial nephritis, acute
tubular necrosis, and acute
renal failure.
 Endocrine: Precipitation of
adrenocortical insufficiency
and menstrual disturbances.

Ophthalmologic: Visual
disturbances and exudative
conjunctivitis.

Others: Fever, edema of

face and extremities,
dyspnea, wheezing,
hypotension, and shock.

GENERI BRAND GENERAL MECHANISM OF ROUTE OF INDICATIONS CONTRAINDICA ADVERSE NURSING

C NAME NAME CLASSIFIC ACTION DOSAGE TIONS REACTION RESPONSIBILITY
ATION
Isoniazid Hydrazine Anti-infectives; Isoniazid is a prodrug and must Adult: Daily Primary Treatment Hypersensitivity to any •CNS: peripheral • Use cautiously in
Antituberculoti be activated by bacterial regimen: 300 mg of Pulmonary and ingredient in the neuropathy, seizures, toxic elderly patients and in
c daily. Extrapulmonary TB product. encephalopathy, memory those with chronic non-
catalase.[1] It is activated by
Intermittent impairment, toxic isoniazidrelated liver
catalase-peroxidase enzyme
multiple-drug psychosis. disease, and seizure
KatG to form isonicotinic acyl
regimen: 10 EENT: optic neuritis and disorders (especially
anion or radical. These forms
mg/kg 3 atrophy. those taking
will then react with a NADH
times/wk or 15 GI: nausea, vomiting, phenytoin). Also use
 mg/kg twice/wk. epigastric distress. cautiously in patients
radical or anion to form
Child: Daily Hematologic: with severe renal
isonicotinic acyl-NADH
regimen: 5 agranulocytosis, hemolytic impairment or chronic
complex. This complex will bind
mg/kg daily. anemia, aplastic anemia, alcoholism.
tightly to ketoenoylreductase
Max dose: 300 eosinophilia, Always give isoniazid with
known as InhA and prevents
mg daily. thrombocytopenia, other antituberculotics to
access of the natural enoyl-
Intermittent sideroblastic anemia. prevent development of
AcpM substrate. This
multiple-drug Hepatic: hepatitis, resistant organisms.
mechanism inhibits the synthesis
regimen: 20-30 jaundice, bilirubinemia.
of mycolic acid in the
mg/kg (max 900 Metabolic: hyperglycemia, Isoniazid pharmacokinetics
mycobacterial cell wall.
mg) twice/wk. metabolic acidosis, may vary among
Isoniazid reaches therapeutic hypocalcemia, patients because drug
concentrations in serum, hypophosphatemia. is metabolized in the
cerebrospinal fluid (CSF), and Skin: irritation at I.M. liver by genetically
within caseous granulomas. injection site. controlled acetylation.
Isoniazid is metabolized in the Other: rheumatic and Fast acetylators
liver via acetylation. There are lupuslike syndromes, metabolize drug up to
two forms of the enzyme hypersensitivity reactions, five times as fast as
responsible for acetylation, so pyridoxine deficiency, slow acetylators. About
that some patients metabolize the gynecomastia 50% of blacks and
drug quicker than others. Hence, whites are slow
the half-life is bimodal with acetylators; more than
peaks at 1 hour and 3 hours in 80% of Chinese,
the US population. The Japanese, and Inuits
metabolites are excreted in the are fast acetylators.
urine. Doses do not usually have
to be adjusted in case of renal
failure. Peripheral neuropathy is
more common in
patients who are slow
acetylators or who are
malnourished,
alcoholic, or diabetic.

Isoniazid alters results of

urine glucose tests that
use cupric sulfate
method such as
Benedict’s reagent or
 Diastix.

Monitor hepatic function

closely for changes.
Elevated liver function
study results occur in
about 15% of patients;
most abnormalities are
mild and transient, but
some may persist
throughout treatment.

Severe and sometimes fatal

hepatitis may develop,
even after many
months of treatment.
Risk increases with
age. Monitor liver
studies closely.

Give pyridoxine, as
ordered, to prevent
peripheral neuropathy,
especially in malnourished
patients.
Nursing Diagnosis
 Risk for Infection: At increased risk for being invaded by pathogenic
organisms.

Risk factors may include

 Inadequate primary defenses, decreased ciliary action/stasis of

secretions
 Tissue destruction/extension of infection
 Lowered resistance/suppressed inflammatory process
 Malnutrition
 Environmental exposure
 Insufficient knowledge to avoid exposure to pathogens

Desired Outcomes

 Identify interventions to prevent/reduce risk of spread of

infection.
 Demonstrate techniques/initiate lifestyle changes to promote safe
environment.

Nursing Interventions Rationale

Review pathology of disease (active and inactive

phases; dissemination of infection Helps patient realize or accept necessity of adhering
through bronchi to adjacent tissues or via to medication regimen to prevent reactivation or
bloodstream and/or lymphatic system) and complication. Understanding of how the disease is
potential spread of infection via airborne droplet passed and awareness of transmission possibilities help
during coughing, sneezing, spitting, talking, patient and SO take steps to prevent infection of others.
laughing, singing.
 Nursing Interventions Rationale

Identify others at risk like household members, Those exposed may require a course of drug therapy to
close associates and friends. prevent spread or development of infection.

Instruct patient to cough or sneeze and expectorate

into tissue and to refrain from spitting. Review
proper disposal of tissue and good hand Behaviors necessary to prevent spread of infection.
washing techniques. Encourage return
demonstration.

May help patient understand need for protecting others

while acknowledging patient’s sense of isolation and
Review necessity of infection control measures. Put
social stigma associated with communicable
in temporary respiratory isolation if indicated.
diseases. AFB can pass through standard masks;
therefore, particulate respirators are required.

Febrile reactions are indicators of continuing presence of

Monitor temperature as indicated.
infection.

Identify individual risk factors for reactivation of

tuberculosis: lowered resistance associated with
Knowledge about these factors helps patient alter
alcoholism, malnutrition, intestinal bypass surgery,
lifestyle and avoid or reduce incidence of exacerbation.
use of immunosuppressive drugs, corticosteroids,
presence of diabetes mellitus, cancer, postpartum.

Contagious period may last only 2–3 days after initiation

of chemotherapy, but in presence of cavitation or
Stress importance of uninterrupted drug therapy. moderately advanced disease, risk of spread of infection
Evaluate patient’s potential for cooperation. may continue up to 3 months. Compliance with
multidrug regimens for prolonged periods is difficult, so
directly observed therapy (DOT) should be considered.

Review importance of follow-up and periodic These second-line drugs may be required when infection
reculturing of sputum for the duration of therapy. is resistant to or intolerant of primary drugs or may be
used concurrently with primary anti tubercular
drugs. MDR-TB requires minimum of 18–24 mo therapy
with at least three drugs in the regimen known to be
effective against the specific infective organism and
which patient has not previously taken. Treatment is
often extended to 24 mo in patients with severe
 Nursing Interventions Rationale

symptoms or HIV infection.

Encourage selection and ingestion of well-balanced Patient who has three consecutive negative sputum
meals. Provide frequent small “snacks” in place of smears (takes 3–5 mo), is adhering to drug regimen, and
large meals as appropriate. is asymptomatic will be classified a non transmitter.

Monitors adverse effects of drug therapy

Liver function studies: AST/ALT.
including hepatitis.

Helpful in identifying contacts to reduce spread of

infection and is required by law. Treatment course is
Notify local health department.
long and usually handled in the community with public
health nurse monitoring.

Initial therapy of uncomplicated pulmonary disease

Administer anti-infective agents as indicated: usually includes four drugs, e.g., four primary drugs or
combination of primary and secondary drugs.

INH is usually drug of choice for infected patient and

those at risk for developing TB. Short-
 Primary drugs: isoniazid (INH),
course chemotherapy, including INH, rifampin (for 6
ethambutol (Myambutol), rifampin
mo), PZA, and ethambutol or streptomycin, is given for
(RMP/Rifadin), rifampin with isoniazid
at least 2 mo (or until sensitivities are known or until
(Rifamate), pyrazinamide
serial sputums are clear) followed by 3 more months of
(PZA), streptomycin, rifapentine
therapy with INH.Ethambutol should be given if
(Priftin);
central nervous system (CNS) or disseminated disease is
present or if INH resistance is suspected.
Extended therapy (up to 24 mo) is indicated for
 Second-line drugs: ethionamide reactivation cases, extrapulmonary reactivated TB, or in
(Trecator-SC), para-aminosalicylate the presence of other medical problems, such as diabetes
(PAS), cycloserine (Seromycin), mellitus or silicosis. Prophylaxis with INH for 12 mo
capreomycin (Capastat). should be considered in HIV-positive patients with
positive PPD test.

Nursing Diagnosis
 Ineffective Airway Clearance: Inability to clear secretions or
obstructions from the respiratory tract to maintain a clear airway.

May be related to
  Thick, viscous, or bloody secretions
 Fatigue, poor cough effort
 Tracheal/pharyngeal edema
Possibly evidenced by

 Abnormal respiratory rate, rhythm, depth

 Abnormal breath sounds (rhonchi, wheezes), stridor
 Dyspnea
Desired Outcomes

 Maintain patent airway.

 Expectorate secretions without assistance.
 Demonstrate behaviors to improve/maintain airway clearance.
 Participate in treatment regimen, within the level of ability/situation.
 Identify potential complications and initiate appropriate actions.

Nursing Interventions Rationale

Diminished breath sounds may reflect

Assess respiratory atelectasis. Rhonchi, wheezes indicate
function noting breath sounds, rate, accumulation of secretions and inability to
rhythm, and depth, and use of accessory clear airways that may lead to use of
muscles. accessory muscles and increased work of
breathing

Note ability to expectorate mucus and Expectoration may be difficult when

cough effectively; document character, secretions are very thick as a result of
amount of sputum, presence of infection and/or inadequate
hemoptysis. hydration. Blood-tinged or frankly bloody
sputum results from tissue breakdown
(cavitation) in the lungs or from bronchial
ulceration and may require further
 Nursing Interventions Rationale

evaluation or intervention.

Positioning helps maximize lung expansion

Place patient in semi or high-Fowler’s and decreases respiratory effort. Maximal
position. Assist patient with coughing ventilation may open atelectatic areas and
and deep-breathing exercises. promote movement of secretions into larger
airways for expectoration.

Prevents obstruction and aspiration.

Clear secretions from mouth and
Suctioning may be necessary if patient is
trachea; suction as necessary.
unable to expectorate secretions.

Maintain fluid intake of at least 2500 High fluid intake helps thin secretions,
mL/day unless contraindicated. making them easier to expectorate.

Prevents drying of mucous membranes and

Humidify inspired air and oxygen
helps thin secretions.

Administer medications as indicated:

 Mucolytic agents: acetylcystein Reduces the thickness and stickiness of

e (Mucomyst); pulmonary secretions to facilitate clearance.
 Bronchodilators: oxtriphylline Increases lumen size of the tracheobronchial
(Choledyl), theophylline (Theo- tree, thus decreasing resistance to airflow
Dur); and improving oxygen delivery.
May be useful in presence of extensive
involvement with profound hypoxemia and
 Corticosteroids (prednisone).
when inflammatory response is life-
threatening.
Intubation may be necessary in rare cases of
Be prepared for/assist with emergency
bronchogenic TB accompanied by laryngeal
intubation.
edema or acute pulmonary bleeding.
Nursing Diagnosis:
 Risk for  Impaired Gas Exchange: At risk for excess or deficit in
oxygenation and/or carbondioxide elimination at the alveolar-capillary
membrane.

Risk factors may include

 Decrease in effective lung surface, atelectasis

 Destruction of alveolar-capillary membrane
 Thick, viscous secretions
 Bronchial edema

Desired Outcomes

 Report absence of/decreased dyspnea.

 Demonstrate improved ventilation and adequate oxygenation of
tissues by ABGs within acceptable ranges.
 Be free of symptoms of respiratory distress.

Nursing Interventions Rationale

Assess for dyspnea (using 0–10 scale), Pulmonary TB can cause a wide range of
tachypnea, abnormal or diminished effects in the lungs, ranging from a small
breath sounds, increased respiratory patch of bronchopneumonia to diffuse
effort, limited chest wall expansion, and intense inflammation, caseous necrosis,
fatigue. pleural effusion, and extensive fibrosis.
Respiratory effects can range from mild
dyspnea to profound respiratory
distress. Use of a scale to evaluate
dyspnea helps clarify degree of difficulty
 Nursing Interventions Rationale

and changes in condition.

Evaluate change in level of mentation. Accumulation of

Note cyanosis and/or change in skin secretions and/or airway compromise
color, including mucous membranes can impair oxygenation of vital organs
and nail beds. and tissues.

Creates resistance against outflowing air

Demonstrate and encourage pursed-lip
to prevent collapse or narrowing of the
breathing during exhalation, especially
airways, thereby helping distribute air
for patients with fibrosis or parenchymal
throughout the lungs and relieve or
destruction.
reduce shortness of breath.

Reducing oxygen consumption and

Promote bedrest or limit activity and
demand during periods of respiratory
assist with self-care activities as
compromise may reduce severity of
necessary.
symptoms.

Decreased oxygen content (PaO2) and/or

saturation or increased PaCO2 indicate
Monitor serial ABGs and pulse oximetry.
need for intervention or change in
therapeutic regimen.

Aids in correcting the hypoxemia that

Provide supplemental oxygen as may occur secondary to decreased
appropriate. ventilation/diminished alveolar lung
surface.
Nursing Diagnosis

 Imbalanced Nutrition: Less Than Body Requirements: Intake of

nutrients insufficient to meet metabolic needs.

May be related to

 Fatigue
 Frequent cough/sputum production; dyspnea
 Anorexia
 Insufficient financial resources
Possibly evidenced by

 Weight 10%–20% below ideal for frame and height

 Reported lack of interest in food, altered taste sensation
 Poor muscle tone
Desired Outcomes

 Demonstrate progressive weight gain toward goal with

normalization of laboratory values and be free of signs of
malnutrition.
 Initiate behaviors/lifestyle changes to regain and/or to maintain
appropriate weight.
Nursing Interventions Rationale

Document patient’s nutritional status on Useful in defining degree or extent of

admission, noting skin turgor, current problem and appropriate choice of
weight and degree of weight loss, interventions.
integrity of oral mucosa, ability or
inability to swallow, presence of bowel
tones, history of nausea and vomiting
 Nursing Interventions Rationale

or diarrhea.

Helpful in identifying specific needs and

Ascertain patient’s usual dietary pattern.
strengths. Consideration of individual
Include in selection of food.
preferences may improve dietary intake.

Useful in measuring effectiveness of

Monitor I&O and weight periodically.
nutritional and fluid support.

Investigate anorexia and nausea and

May affect dietary choices and identify
vomiting, and note possible correlation
areas for problem solving to enhance
to medications. Monitor frequency,
intake and utilization of nutrients.
volume, consistency of stools.

Helps conserve energy, especially when

Encourage and provide for frequent rest
metabolic requirements are increased
periods.
by fever.

Reduces bad taste left from sputum or

Provide oral care before and after medications used for respiratory
respiratory treatments. treatments that can stimulate the
vomiting center.

Maximizes nutrient intake without

Encourage small, frequent meals with undue fatigue/energy expenditure from
foods high in protein and carbohydrates. eating large meals, and reduces gastric
irritation.

Encourage SO to bring foods from home Creates a more normal social

and to share meals with patient unless environment during mealtime, and helps
contraindicated. meet personal, cultural preferences.
 Nursing Interventions Rationale

Provides assistance in planning a diet

with nutrients adequate to meet
Refer to dietitian for adjustments in
patient’s metabolic requirements,
dietary composition.
dietary preferences, and financial
resources post discharge.

May help reduce the incidence of nausea

Consult with respiratory therapy to
and vomiting associated with
schedule treatments 1–2 hr before or
medications or the effects of respiratory
after meals.
treatments on a full stomach.

Low values reflect malnutrition and

Monitor laboratory studies: BUN, serum
indicate need for intervention and
protein, and prealbumin, albumin.
change in therapeutic regimen.

Fever increases metabolic needs and

Administer antipyretics as appropriate.
therefore calorie consumption.

Nursing Diagnosis
 Deficient Knowledge: Absence or deficiency of cognitive information
related to specific topic.

May be related to

 Lack of exposure to/misinterpretation of information

 Cognitive limitations
 Inaccurate/incomplete information presented
Possibly evidenced by
  Request for information
 Expressed misconceptions about health status
 Lack of or inaccurate follow-through of instructions/behaviors
 Expressing or exhibiting feelings of being overwhelmed
Desired Outcomes

 Verbalize understanding of disease process/prognosis and

prevention.
 Initiate behaviors/lifestyle changes to improve general well-being
and reduce risk of reactivation of TB.
 Identify symptoms requiring evaluation/intervention.
 Describe a plan for receiving adequate follow-up care.
 Verbalize understanding of therapeutic regimen and rationale for
actions.
Nursing Interventions Rationale

Assess patient’s ability to learn.

Note level of fear, concern, fatigue,
Learning depends on emotional and
participation level; best environment in
physical readiness and is achieved at an
which patient can learn; how much
individual pace.
content; best media and language; who
should be included.

Provide instruction and specific written

Written information relieves patient of
information for patient to refer to
the burden of having to remember large
schedule for medications and follow-up
amounts of information. Repetition
sputum testing for documenting
strengthens learning.
response to therapy.

Encourage patient and SO to verbalize Provides opportunity to correct

fears and concerns. Answer questions misconceptions and alleviate anxiety.
factually. Note prolonged use of denial. Inadequate finances or prolonged denial
 Nursing Interventions Rationale

may affect coping and managing the

tasks necessary to regain health.

Identify symptoms that should be

May indicate progression or reactivation
reported to healthcare provider:
of disease or side effects of medications,
hemoptysis, chest pain, fever, difficulty
requiring further evaluation.
breathing, hearing loss, vertigo.

Emphasize the importance of

Meeting metabolic needs helps minimize
maintaining high-protein and
fatigue and promote recovery. Fluids aid
carbohydrate diet and adequate fluid
in liquefying or expectorating secretions.
intake.

Enhances cooperation with therapeutic

Explain medication dosage, frequency of regimen and may prevent patient from
administration, expected action, and the discontinuing medication before cure is
reason for long treatment period. truly affected. Directly observed therapy
Review potential interactions with other (DOT) is the treatment of choice when
drugs and substances. patient is unable or unwilling to take
medications as prescribed.

Review potential side effects of

treatment (dryness of May prevent or reduce discomfort
mouth, constipation, visual disturbances, associated with therapy and enhance
headache, orthostatic hypertension) and cooperation with regimen.
problem-solve solutions.

Combination of INH and alcohol has

Stress need to abstain from alcohol
been linked with increased incidence
while on INH.
of hepatitis.

Refer for eye examination after starting Major side effect is reduced visual acuity;
and then monthly while taking initial sign may be decreased ability to
 Nursing Interventions Rationale

ethambutol. perceive green.

Excessive exposure to silicone dust

Evaluate job-related risk factors, working enhances risk of silicosis, which may
in foundry or rock quarry, sandblasting. negatively affect respiratory function
and cause bronchitis.

Although smoking does not stimulate

recurrence of TB, it does increase the
Encourage abstaining from smoking.
likelihood of respiratory dysfunction or
bronchitis.

Knowledge may reduce risk of

transmission/reactivation. Complications
associated with reactivation include
Review how TB is transmitted (primarily cavitation, abscess formation,
by inhalation of airborne organisms, but destructive emphysema,
may also spread through stools spontaneous pneumothorax, diffuse
or urine if infection is present in these interstitial fibrosis, serous effusion,
systems) and hazards of reactivation. empyema, bronchiectasis, hemoptysis,
GI ulceration, bronchopleural fistula,
tuberculous laryngitis, and miliary
spread.
Nursing Priorities

1. Promote Sufficient Gas Exchange

2. Ensure adequate airway clearance

3. Optimize energy levels

Therapeutic Management

 Place in an airborne isolation room

 Skin test should be measured in size

 Wear N95 mask and appropriate PPE

 Adherence to medication schedule

 Administer supplemental oxygen as appropriate

 Promote appropriate nutrition

 Begin discharge teaching early as long-term follow up is crucial

Nursing Interventions

1. Screen patient for symptoms and risk factors

RATIONALE

Screening for possible TB can help to identify patients who are at risk sooner rather than

later. Containing the infection is a priority. As soon as you suspect TB Infection, place

the patient in airborne isolation.

2. Place and Read TB skin test (PPD) (Intradermal Injection)

RATIONALE

Evaluate 48-72 hours after placement for signs of redness and induration. The size of the

induration determines if the test is positive:

 Anyone > 15 mm
  High Risk > 10 mm

 Immunocompromised > 5 mm

3. Collect Sputum Cultures

RATIONALE

Ensure the sample is entirely sputum, not saliva. You can use nasotracheal suction if

necessary. Collaborate with your Respiratory Therapist to obtain this culture if needed.

4. Place the patient in Airborne Isolation and adhere to these precautions strictly

RATIONALE

TB is spread via invisible airborne particles. The longer you are exposed to these

particles, the more likely you are to develop a TB infection. Protect yourself and other

patients.

5. Monitor respiratory status and lung sounds

RATIONALE

Patients may report shortness of breath and have a persistent cough. Evaluate their

respiratory effort and listen to their lungs. Coarse rhonchi or wheezing may indicate they

need a breathing treatment like a bronchodilator.

6. Monitor oxygenation (SpO2 and PaO2) and intervene as appropriate

RATIONALE

Because the alveoli are affected, the patient’s oxygenation and gas exchange will be

affected. Monitor ABGs and SpO2 closely. If the patient cannot oxygenate and ventilate

on their own, they may require mechanical ventilation or other supplemental oxygen

support.

7. Administer Anti-Tuberculosis Drugs as ordered:

  Rifampin

 Isoniazide

 Pyrazinamide

 Ethambutol

RATIONALE

RIPE therapy is the most common and most effective drug therapy against TB infections.

In some cases, patients are resistant to isoniazid or have Multi-Drug Resistant TB. In

these cases, other drugs may be given.

8. Educate patient on importance of completing ENTIRE course of treatment

RATIONALE

This treatment can be 6-12 months long. Although they’ll feel better and no longer be

contagious after about 3 weeks, they need to continue the full course. If they do not, they

risk their TB lying dormant and resurfacing later OR they risk developing Multi-Drug

Resistant TB.

9. Educate patient to eat small, frequent meals

RATIONALE

Patients may be fatigued, short of breath, and have a loss of appetite. Eater smaller, more

frequent meals may be more appealing and take less energy – but will allow them to still

get the nutrition their body needs to heal.

10. Cluster care and educate patient on clustering of activities

RATIONALE

This helps to conserve energy and minimize fatigue. This can also help provide extended

rest periods if the patient is short of breath.

Key Areas of Responsibility Core and Competency Indicators
A. Safe and Quality Core and Competency 1:  Explain to the patient
Nursing Care Demonstrate knowledge based in his /her health status
on the health /illness status or / condition.
individuals  Explain all the
rationale of all the
intervention done such
as administering
medications and other
procedures.
Core and Competency 2: Respecting their beliefs and
Provides sound decision culture of the patient
making in the care of especially in refusing medical
individuals considering their treatment.
beliefs and values
Core and Competency 3:  Vital signs checked
Promotes safety and comfort and recorded every 4
and privacy of clients hours
 Bed making done; side
rails up
 Assisted in getting up
to bed and when going
to comfort rooms
 Provided with calm,
clean and restful
environment

Core and Competency 4:

Sets priorities in Nursing Care Nursing Care Plan was done
based on client’s needs
Core and Competency 5:  Vital signs rechecked
Ensure continuity of care and recorded every
after 4 hours
 Intravenous Fluid
regulate well
 Medications still
monitoring
 Bed side care done;
side rails up
Core and Competency 6: We administer medications
Administer medications and the following 10 RIghts in
other health therapeutics Medication Administration
Core and Competency 7:
Utilizes the nursing process as
frame-work for nursing Assessment done by
7.1 Performs interviewing him/her
 comprehensive and systematic
nursing assessment

7.2 Formulates a plan of Nursing care plan was done

care in collaboration with with interventions
clients and other members of independently, dependently
the health team and collaboratively.
7.3 Implements planned  Asked permission as
nursing care to achieve to assigned student nurse
achieved identified outcomes for the shift
 Gives rationale every
interventions done
7.4 Evaluates progress Objectives were set and within
toward expected outcomes the span of nursing care goal
was evaluated if met or unmet.
B. Management of Core and Competency 1:  Administer
Resources and Organizes work load to medications on time
Environment facilitate client care  Procedures carried out
and done
Core and Competency 2:  Use available
Utilizes financial resources to resources as possible
support client care  Observe 3 R’s (reuse,
recycle, reduce)
Core and Competency 3:  Ensuring equipment’s
Establishes mechanism to and paraphernalias
ensure proper functioning of clean and functioning
equipment orderly
 Provide safety
measures; side rails up
 Hand washing done
before and after
procedures
 Disinfection of
equipment’s and
paraphernalias before
and after procedures
 Waste segregated
properly and
accordingly
Core and Competency 4:  Observed proper
Maintains a safe environment disposal of wastes and
follow the hospital
protocols
C. Health Education Core and Competency 1:  Set priorities
Assess the learning needs of accordingly
the client’s/partner’s assessment done
Core and competency 2:  Provided conductive
Develops health education learning during
plan based on assessed and walking hours at
anticipated needs bedside
Core and Competency 3:  Provide proper
Develops learning materials instructions
for Health Education accordingly to patients
condition
Core and Competency 4:  Health teaching
Implements the health (exercise, proper
education plan hygiene regularly, eat
nutritious food, and
drink a lot of water)
Core and Competency 5:  Documents data,
Evaluates the outcome of interventions and
health education outcome of care
D. Legal Responsibility Core and Competency 1:
Adheres to practices in  Ensured signed the
accordance with the nursing consent and documents
law and other relevant data are available
legislation including contracts
and informed consent
Core and Competency 2:  Nursing care and
Adheres to organizational intervention done and
policies and procedures, local follow the hospital
and national protocols
Core and Competency 3:  Charting done and
Documents care rendered to documented all
clients essential data
accordingly
E. Ethico-moral and Core and Competency 1:  Maintained
Responsibility Respects the rights of confidentiality and
individuals/groups privacy
Core and Competency 2:  Perform function
Accepts responsibility and accordingly to our
accountability for own scope as a student
decision and actions nurse
Core and Competency 3:  Ethical considerations
Adheres to the national and rendered, asked
international codes of ethics permission whenever
for nurse procedure is done
F. Personal and Core and Competency 1:  Accepted advices,
Professional Identifies own learning needs correction and advice
Development from the clinical
instructions

Core and Competency 2:  Applies learned

Pursues continuing education information for the
improvement of care
such as attended
seminars and class
discussions
Core and Competency 3:  PNSA OFFICER
Gets involved in professional  ROTARACT
organizational and civic OFFICER
activities
Core and Competency 4:  Dresses appropriately
Projects a professional image wearing prescribed
of the nurse uniforms
 Demonstrates good
manner and right
conduct at all times to
equally
Core and Competency 5:  Listens to suggestions
Possesses positive attitudes and recommendations
toward change and criticisms given by supervising
Clinical Instructor and
Nurses on Duty
Core and Competency 6:  Performed functions
Perform functions according according to standards
to professional standards as a student nurse
G. Quality Improvement Core and Competency 1:  Informed and notify
Gathered the data for quality physicians in regards
improvement to patient conditions
Core and Competency 2:  Endorsement of
Participate in nursing audits patients assignment
and rounds  NOD and student
Rounds
Core and Competency 3:  Documents the data
Identifies and report variances and report it and notify
the physicians to the
appropriate persons for
any discrepancies
Core and Competency 4:  Provided preventive
Recommends solution to measures; side rails up
 identified problems

H. Research Core and Competency 1:  Required and complied

Gathered the data using journal readings and
different methodologies case analysis related to
our concept
Core and Competency 2:  Initiates a research
Analyzes and interprets data study to identify
gathered researchable problems
 Assessment using
NAT
 Interview
Core and Competency 3:  Identifies researchable
Recommends action for problems related to
implementations immediate care of
patient
Core and Competency 4:  Maintained patients
Disseminated results of privacy and
research findings confidentiality of the
information gathered
Core and Competency 5:  Utilized findings of
Applies research findings in research studies in the
nursing practice immediate care of the
patient with alteration
in perception and
coordination
I. Records Management Core and Competency 1:  Copied and interpreted
Maintains accurate and patients record and
updated documentations of latest doctor order and
client care laboratory test
 Charting is accurate
and avoided errors
 Plotted accurately
patient’s vital signs
and I & O
Core and Competency 2:  Recorded patient
Records outcome of client response to the nursing
care intervention being
rendered.
Core and Competency 3:  Maintained patient’s
Observes legal imperatives In privacy and
record keeping confidentiality
J. Communication Core and Competency 1:  Asked patient name,
Establishes rapport with introduced self and ask
client’s, significant other and related questions
members of the health team pertaining to the
 condition and life of
the patient
Core and Competency 2:  Interprets and validates
Identifies verbal and non- client’s body language
verbal cues and facial expressions

HEALTH EDUCATION

Health Teaching
 Teach the patient to do proper hygiene regularly
 Find ways to make your life less stressful.

 Make sure that your family, friends, and the people you work with are tested.
 Avoid close contact with others until your healthcare provider says it is OK.
 Keep your hands clean. Be sure to wash them every time you use them to cover your
mouth when you cough.
 When you cough or sneeze, take steps to prevent the spread of TB:
o Cover your mouth and nose with a tissue.
o Put your used tissue in a closed bag and throw it away.
o If you don't have a tissue, cough or sneeze into your upper sleeve or elbow, not
your hands.
o Wash your hands often with soap and warm water for 20 seconds. If soap and
water are not available, use an alcohol-based hand gel.
Outpatient Orders
 Follow your provider's instructions for follow-up appointments.
 Keep appointments for any routine testing you may need.
 Encourage to meet regularly the physical therapies.

Diet
 General diet

Spirituality:
 Advise the patient to ask a assistance when doing their religious rituals.

DISCHARGE PLAN
Medication
 Take your medicine exactly as directed. Continue taking it even if you start to feel better.
You will take medicine for at least 6 months and maybe longer. Not taking your medicine
for the full course may lead you to get sick again. It also increases the chance of drug-
resistant TB. Drug-resistant TB means that one or more of the usual medicines for TB
don’t work.
 If you are taking birth control pills, use an additional backup method of birth control.
Some TB medicines may interfere with the pill’s effectiveness.
  Check with your healthcare provider before taking any over-the-counter medicines.

Environment
 Sleep in a room alone and with good air flow (ventilation).
 Limit your activity to avoid feeling tired. Plan frequent rest periods.
Treatment
 Cover your mouth and nose with a tissue.
 Put your used tissue in a closed bag and throw it away.
 If you don't have a tissue, cough or sneeze into your upper sleeve or elbow, not your
hands.
 Wash your hands often with soap and warm water for 20 seconds. If soap and water are
not available, use an alcohol-based hand gel.