PULMONARY TUBERCULOSIS (PTB)

I. INTRODUCTION

Pulmonary Tuberculosis (PTB) or known as the White Plague during the 19 th century, has
inflicted the human race ever since. It is described as a chronic infectious disease caused by
an organism called Mycobacterium tuberculosis through droplet transmission, like coughing,
sneezing, or if the person inhales the infected droplet.

It can be considered as primary or secondary infection depending on recovery of the client

from the communicable infection. It is a reportable communicable disease and a repeated
exposure to it causes a person to acquire it.

According to a study conducted by Knechel, the progression of tuberculosis has several

stages.

1. Latent Tuberculosis – It is the stage of infection when the person who had been
exposed to the M. tuberculosis nuclei does not manifest signs and symptoms of the
disease and do not have the capacity to infect other people. The nuclei just persist in
the system in its necrotic form which could stay for a long time, not until that
immunosuppression or a certain factor triggers it to become its virulent form.
2. Primary Pulmonary Tuberculosis – Since the most immediate location of pathogenesis
of the organism is in the lungs, primary activation of disease in the pulmonary cavity is
considered. It is usually asymptomatic and only identified through significant diagnostic
examinations. Only the presence of lymphadenopathy is something that is indicative for
its infection.
3. Primary Progressive Tuberculosis – It is the stage of the disease process when it is
already considered as active. Clinical manifestations are evident and the client may
reveal positive in sputum examination for presence of the organism. Sometimes, he or
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she may manifest cough with purulent sputum and some pleuritic chest pains because
of inflammation in the parenchymal walls.
4. Extrapulmonary Tuberculosis – It is when tuberculosis extends its infection to other
parts of the aside from the pulmonary cavity. The most fatal location is the central
nervous system and its infection to the bloodstream. Other locations may include the
lymphatic system, the bones and joints and at times the genitourinary system.
Tuberculosis(TB) Pathophysiology

II. OTHER NAMES

The disease Tuberculosis (TB) has been known by many different names during the history
of TB. The various names include phthisis, scrofula, the Kings Touch, The White Plague and
the Captain of all these Men of Death.

III. CAUSES

Causes of acquiring tuberculosis include the following:

 Close contact. Having close contact with someone who has an active TB.
 Low immunity. Immunocompromised status like those with HIV, cancer, or
transplanted organs increases the risk of acquiring tuberculosis.
 Substance abuse. People who are IV/injection drug users and alcoholics have a
greater chance of acquiring tuberculosis.
 Inadequate health care. Any person without adequate health care like the
homeless, impoverished, and the minorities often develop active TB.
 Immigration. Immigration from countries with a high prevalence of TB could
affect the patient.
 Overcrowding. Living in an overcrowded, substandard housing increases the
spreading of the infection.

IV. RISK FACTORS

Anyone can get tuberculosis, but certain factors can increase your risk of the disease. These
factors include:

Weakened immune system

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A healthy immune system often successfully fights TB bacteria, but your body can't mount
an effective defense if your resistance is low. A number of diseases, conditions and
medications can weaken your immune system, including:

 HIV/AIDS

 Diabetes

 Severe kidney disease

 Certain cancers

 Cancer treatment, such as chemotherapy

 Drugs to prevent rejection of transplanted organs

 Some drugs used to treat rheumatoid arthritis, Crohn's disease and psoriasis

 Malnutrition

 Very young or advanced age

Traveling or living in certain areas

The risk of contracting tuberculosis is higher for people who live in or travel to areas that
have high rates of tuberculosis and drug-resistant tuberculosis, including:

 Africa
 Eastern Europe
 Asia
 Russia
 Latin America
 Caribbean Islands

Poverty and substance use

 Lack of medical care. If you receive a low or fixed income, live in a remote area, have
recently immigrated to the United States, or are homeless, you may lack access to the
medical care needed to diagnose and treat TB.

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 Substance use. Use of IV drugs or excessive alcohol weakens your immune system and
makes you more vulnerable to tuberculosis.

 Tobacco use. Using tobacco greatly increases the risk of getting TB and dying of it.

Where you work or live

 Health care work. Regular contact with people who are ill increases your chances of
exposure to TB bacteria. Wearing a mask and frequent hand-washing greatly reduce
your risk.

 Living or working in a residential care facility. People who live or work in prisons,

homeless shelters, psychiatric hospitals or nursing homes are all at a higher risk of
tuberculosis. That's because the risk of the disease is higher anywhere there is
overcrowding and poor ventilation.

 Living in or emigrating from a country where TB is common. People from a country

where TB is common may be at high risk of tuberculosis infection.

 Living with someone infected with TB. Living with someone who has TB increases
your risk.

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V. ANATOMY AND PHYSIOLOGY

Tuberculosis is an acute or chronic infection caused by Mycobacterium tuberculosis,

tuberculosis is characterized by pulmonary infiltrates, formation of granulomas with
caseation, fibrosis, and cavitation in the lungs. When the bacterium enters the lungs, it
starts to multiply and later compromises the immune system. The infection destroys
patients' lung tissue, causing them to cough up the bacteria, which then spread through the
air and can be inhaled by others.

When a person gets active TB disease, it means the bacteria are multiplying and attacking
the lung(s) or other parts of the body, such as the lymph nodes, bones, meninges, kidney,
brain, spine and even the skin. From the lungs, TB bacteria move through the blood or
lymphatic system to different parts of the body.

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VI. PATHOLOGY / PATHOPHYSIOLOGY

INITIAL INFECTION/PRIMARY INFECTION

BACTERIA IS TRANSMITTED TO ALVEOLI

THROUGH AIRWAYS

DEPOSITION AND MULTIPLICATION OF

BACTERIA

BACILLI ARE ALSO TRANSPORTED TO OTHER

PARTS OF THE BODY THROUGH BLOOD
STREAM AND LYMPH NODE INFLAMMATION

GHON TUBERCLE ULCERATES AND RELEASING

CHEESY MATERIAL INTO BRONCHI

BACTERIA THEN BECOME AIRBORNE

RESULTING IN FURTHER SPREAD OF
INFECTION

ULCERATED TUBERCLE HEALS AND BECOMES

SCAR TISSUE

INFECTED LUNG BECOME INFLAMED

FURTHER DEVELOPMENT OF PNEUMONIA

AND TUBERCLE FORMATION

UNLESS THE PROCESS IS ARRESTED IT

SPREADS DOWNWARDS TO THE HILUM OF
THE LUNGS AND LATER EXTENDS TO
ADJACENT LOBES

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VII. CLINICAL MANIFESTATION

After an incubation period of 4 to 8 weeks, TB is usually asymptomatic in primary infection.

 Nonspecific symptoms. Nonspecific symptoms may be produced such as fatigue,

weakness, anorexia, weight loss, night sweats, and low-grade fever, with fever
and night sweats as the typical hallmarks of tuberculosis.
 Cough. The patient may experience cough with mucopurulent sputum.
 Hemoptysis. Occasional hemoptysis or blood on the saliva is common in TB
patients.
 Chest pains. The patient may also complain of chest pain as a part of discomfort.

VIII. ASSESSMENT & DIAGNOSTIC METHODS

To diagnose tuberculosis, the following tests could be performed:

 Sputum culture: Positive for Mycobacterium tuberculosis in the active stage of

the disease.
 Ziehl-Neelsen (acid-fast stain applied to a smear of body fluid): Positive for acid-
fast bacilli (AFB).
 Skin tests (purified protein derivative [PPD] or Old tuberculin [OT] administered
by intradermal injection [Mantoux]): A positive reaction (area of induration 10
mm or greater, occurring 48–72 hr after intradermal injection of the antigen)
indicates past infection and the presence of antibodies but is not necessarily
indicative of active disease. Factors associated with a decreased response to
tuberculin include underlying viral or bacterial infection, malnutrition,
lymphadenopathy, overwhelming TB infection, insufficient antigen injection, and
conscious or unconscious bias. A significant reaction in a patient who is clinically
ill means that active TB cannot be dismissed as a diagnostic possibility. A
significant reaction in healthy persons usually signifies dormant TB or an infection
caused by a different mycobacterium.
 Enzyme-linked immunosorbent assay (ELISA)/Western blot: May reveal
presence of HIV.
 Chest x-ray: May show small, patchy infiltrations of early lesions in the upper-
lung field, calcium deposits of healed primary lesions, or fluid of an effusion.
Changes indicating more advanced TB may include cavitation, scar tissue/fibrotic
areas.
 CT or MRI scan: Determines degree of lung damage and may confirm a difficult
diagnosis.

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 Bronchoscopy: Shows inflammation and altered lung tissue. May also be

performed to obtain sputum if patient is unable to produce an adequate
specimen.
 Histologic or tissue cultures (including gastric washings; urine and cerebrospinal
fluid [CSF]; skin biopsy): Positive for Mycobacterium tuberculosis and may
indicate extrapulmonary involvement.
 Needle biopsy of lung tissue: Positive for granulomas of TB; presence of giant
cells indicating necrosis.
 Electrolytes: May be abnormal depending on the location and severity of
infection; e.g., hyponatremia caused by abnormal water retention may be found
in extensive chronic pulmonary TB.
 ABGs: May be abnormal depending on location, severity, and residual damage to
the lungs.
 Pulmonary function studies: Decreased vital capacity, increased dead space,
increased ratio of residual air to total lung capacity, and decreased oxygen
saturation are secondary to parenchymal infiltration/fibrosis, loss of lung tissue,
and pleural disease (extensive chronic pulmonary TB).

IX. PREVENTION

To prevent transmission of tuberculosis, the following should be implemented.

 Identification and treatment. Early identification and treatment of persons with

active TB.
 Prevention. Prevention of spread of infectious droplet nuclei by source control
methods and by reduction of microbial contamination of indoor air.
 Surveillance. Maintain surveillance for TB infection among health care workers by
routine, periodic tuberculin skin testing

Tuberculosis Vaccine

Children in countries where TB is common often get the BCG vaccine. Doctors recommend it
only for children living with someone who has an active TB infection with a very drug-resistant
strain or who can’t take antibiotics.

X. COMPLICATIONS

If left untreated or mistreated, pulmonary tuberculosis may lead to:

 Joint damage
 Lung damage

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 Infection or damage of your bones, spinal cord, brain, or lymph nodes

 Liver or kidney problems
 Inflammation of the tissues around your heart
 Respiratory failure
 Pneumothorax
 Pneumonia

XI. MEDICAL MANAGEMENT

Pulmonary tuberculosis is treated primarily with anti-tuberculosis agents for 6 to 12 months.

 First line treatment. First-line agents for the treatment of tuberculosis are

isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide.
 Active TB. For most adults with active TB, the recommended dosing includes the
administration of all four drugs daily for 2 months, followed by 4 months of INH
and RIF.
 Latent TB. Latent TB is usually treated daily for 9 months.
 Treatment guidelines. Recommended treatment guidelines for newly diagnosed
cases of pulmonary TB have two parts: an initial treatment phase and a
continuation phase.
 Initial phase. The initial phase consists of a multiple-medication regimen of INH,
rifampin, pyrazinamide, and ethambutol and lasts for 8 weeks.
 Continuation phase. The continuation phase of treatment includes INH and
rifampin or INH and rifapentine, and lasts for an additional 4 or 7 months.
 Prophylactic isoniazid. Prophylactic INH treatment involves taking daily doses for
6 to 12 months.
 DOT. Directly observed therapy may be selected, wherein an assigned caregiver
directly observes the administration of the drug.

XII. PHARMACOLOGIC MANAGEMENT

The first line antituberculosis medications include:

 Isoniazid (INH). INH is a bactericidal agent that is used as prophylaxis for neuritis,

and has side effects of peripheral neuritis, hepatic enzyme elevation, hepatitis,
and hypersensitivity.
 Rifampin (Rifadin). Rifampin is a bactericidal agent that turns the urine and other
body secretions into orange or red, and has common side effects of hepatitis,
febrile reaction, purpura, nausea, and vomiting.

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 Pyrazinamide. Pyrazinamide is a bactericidal agent which increases the uric acid

in the blood and has common side effects of hyperuricemia, hepatotoxicity, skin
rash, arthralgias, and GI distress.
 Ethambutol (Myambutol). Ethambutol is a bacteriostatic agent that should be
used with caution with renal disease, and has common side effects of optic
neuritis and skin rash.

XIII. SURGICAL MANAGEMENT

Surgical treatment for tuberculosis is called collapse therapies. The aim of these procedures
was to deprive the TB bacteria of oxygen.

The use of surgical resection, meaning the removal of part or all of the diseased tissue, in
this instance the lung, was used as a treatment for PTB. As techniques were improved
surgery became a widely used treatment for TB alongside the development of combination
drug treatment. Surgery usually entails eitherlobectomy, bilobectomy, pneumonectomy or
staged lobectomies for localized bilateral disease. Wedge or segmental resections are
usually avoided due to the increased risk of a bronchopleural fistula.

XIV. NURSING MANAGEMENT

Nursing management includes the following:

Nursing Assessment

The nurse may assess the following:

 Complete history. Past and present medical history is assessed as well as both of

the parents’ histories.
 Physical examination. A TB patient loses weight dramatically and may show the
loss in physical appearance.

Nursing Care Planning & Goals

The major goals for the patient include:

 Promote airway clearance.

 Adhere to treatment regimen.
 Promote activity and adequate nutrition.
 Prevent spread of tuberculosis infection.

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Nursing Interventions

Nursing interventions for the patient include:

 Promoting airway clearance. The nurse instructs the patient

about correct positioning to facilitate drainage and to increase fluid intake to
promote systemic hydration.
 Adherence to the treatment regimen. The nurse should teach the patient that TB
is a communicable disease and taking medications is the most effective means of
preventing transmission.
 Promoting activity and adequate nutrition. The nurse plans a progressive
activity schedule that focuses on increasing activity tolerance
and muscle strength and a nutritional plan that allows for small, frequent meals.
 Preventing spreading of tuberculosis infection. The nurse carefully instructs the
patient about important hygienic measures including mouth care, covering the
mouth and nose when coughing and sneezing, proper disposal of tissues,
and handwashing.
 Acid-fast bacillus isolation. Initiate AFB isolation immediately, including the use
of a private room with negative pressure in relation to surrounding areas and a
minimum of six air changes per hour.
 Disposal. Place a covered trash can nearby or tape a lined bag to the side of the
bed to dispose of used tissues.
 Monitor adverse effects. Be alert for adverse effects of medications.

Evaluation

Expected patient outcomes include:

 Promoted airway clearance.

 Adhered to treatment regimen.
 Promoted activity and adequate nutrition.

 Prevented spread of tuberculosis infection.

Discharge and Home Care Guidelines

Before the discharge, the nurse should instruct the patient to:

 Disposal of secretions. Cough and sneeze into tissues and to dispose of all

secretions in a separate trash can.
 Isolation. Wear a mask when going outside of the room.

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 Activity and nutrition. Remind the patient to take a lot of rest and to eat
balanced meals to aid recovery.
 Adverse effects. Advise the patient to watch out for adverse effects of
medications and to report them to the physician immediately.

Documentation Guidelines

The focus of documentation should include:

 Recent or current antibiotic therapy. Signs and symptoms of infectious process.

 Signs and symptoms of infectious process. Breath sounds, presence and character
of secretions, and use of accessory muscles for breathing.
 Breath sounds, presence and character of secretions, and use of accessory
muscles for breathing.
 Character of cough and sputum. Respiratory rate, pulse oximetry, oxygen
saturation, and vital signs.
 Respiratory rate, pulse oximetry, oxygen saturation, and vital signs. Level of
activity.
 Level of activity. Causative or precipitating factors.
 Causative or precipitating factors. Client reports of difficulty or change.
 Client reports of difficulty or change. Caloric intake.
 Caloric intake. Individual cultural or religious restrictions and personal
preferences.
 Individual cultural or religious restrictions and personal preferences. Plan of care.
 Plan of care. Teaching plan.
 Teaching plan. Responses to interventions, teaching, and actions performed.
 Responses to interventions, teaching, and actions performed. Attainment or
progress toward desired outcomes.
 Attainment or progress toward desired outcomes. Modifications to
 Modifications to plan of care. Discharge needs.
 Discharge needs.

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ASSESSMENT
Patient DIAGNOSIS
Name: Galay, Jester Pesigan PLANNING NURSINGINTERVENTION
CARE PLAN RATIONALE EVALUATION
Diagnosis: Pulmonary Tuberculosis
Ineffective
Age: 21 y/o Gender: Male airway Short Term Goal: 1.) Assess 1.) Provides a basis for At the end of the shift,
clearance related respiratory rate. evaluating adequacy of the client was able to
Subjective: to poor cough During my 6 hrs nursing ventilation. display patency of
effort possibly intervention, the client will 2.) Noted chest airway as manifested by:
“Nahihirapan po evidence by be able to; movement; use of 2.) Use of accessory
akong huminga” as abnormal breath accessory muscles muscles of respiration may  Client’s
verbalized by the sounds and  Sustain respiratory during respiration. occur in response to respiratory rate
patient. dyspnea. rate within normal ineffective ventilation. is within normal
range = 12-20 cpm 3.) Auscultate range: RR = 19
 Display decreasing breath sounds: 3.) Crackles indicate bpm
amount of secretion noted areas with accumulation of secretions  Secretions
Objective:  Allay restlessness presence of and inability to clear decreased
adventitious breath airways.  Client’s
- Abnormal Breath Long Term Goal: sounds. restlessness was
Sounds: Wet 4.) Expectorations may be alleviated and
Crackles During the client’s stay at 4.) Documented different when secretions remained calm.
the hospital he will be able respiratory are very thick.
- Dyspnea; use of to maintain patent airway secretions;
accessory muscle as evidenced by: character and 5.) Positioning helps
for respiration, amount of sputum. maximize lung expansion
elevated shoulders  Normal Respiration
as evidenced by 5.) Maintained 6.) To maintain adequate
- Restless absence of dyspnea patient on airway patency
and adventitious moderate high back
-Vital Signs: rest.
breath sounds (wet
crackles)
BP = 80/60 6.) Check for
 Normal Breathing
T = 36.5 C obstructions:
Pattern: RR = 12-20
RR = 26 cpm accumulation of
cpm
PR = 75 bpm

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 Absence of
Bronchial Secretions secretions.
 Allay restlessness
7.) Take medication
as prescribed by the
physician.

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DRUG NAME DOSAGES MECHANISM INDICATIONS ADVERSE EFFECT CONTRAINDICATION NURSING

OF ACTION CONSIDERATION
Generic Name: Dosage: Inhibits Indications: CNS: psychosis, seizure Contraindications: Perform mycobacterial
mycobacterial First-line Hypersensitivity, acute studies and susceptibility
Isoniazid 300 cell wall therapy of EENT: visual disturbances liver disease, previous tests prior to and
mg/day synthesis and active hepatitis from isoniazid periodically during
Brand Name: interferes with tuberculosis, in GI: drug-induced therapy to detect possible
metabolism. combination hepatitis, nausea, resistance. If isoniazid
Route:
with other vomiting over dosage occurs,
INH, Isotamine,
Bacteriostatic, agents. treatment with pyridoxine
Nydrazid Oral
bactericidal Prevention of NEURO: peripheral is instituted.
action. Bacterial tuberculosis in neuropathy
Drug Class: action against patients
susceptible exposed to MISC: fever
Antibacterial, organisms active disease.
Antituberculars

DRUG NAME DOSAGES MECHANISM INDICATIONS ADVERSE EFFECT CONTRAINDICATION NURSING

OF ACTION CONSIDERATION
Generic Name: Adults: Inhibits DNA- First-line CNS: Hypersensitivity to Assessment & Drug
dependent therapy of headache, drowsiness, rifampin; obstructive Effects
Rifampin/ 600 mg RNA polymeras active fatigue, dizziness, biliary disease;
Rifampicin PO or IV e, thus tuberculosis, in inability to concentrate, meningococcal disease; -Lab tests: Periodic liver
daily in 1 impairing RNA combination mental confusion, intermittent rifampin function tests are advised.
synthesis with other generalized numbness, therapy; lactation. Safe Closely monitor patients
Brand Name: single
(bactericidal) agents. muscle weakness, visual use during pregnancy with hepatic disease.
dose 1 disturbances. (category C) or in
hour

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children <5 y is not

Rifadin, Rimactane before or Dermatologic: Rash, established. -Check prothrombin time
2 hours pruritus, urticaria, daily or as necessary to
after flushing, establish and maintain
meals. reddish discoloration required anticoagulant
Drug Class: of body fluids tears, activity when patient is
saliva, urine, sweat, also receiving an
Route:
sputum. anticoagulant.
Antibacterial, Oral GI: heartburn, distress,
Antituberculars
anorexia, vomiting gas, Patient & Family
cramps, diaarhea, Education
hepatitis, pancreatitis.
-Do not interrupt
GU: hemoglobinuria, prescribed dosage
hematuria, renal regimen. Hepatorenal
insufficiency, acute reaction with flu-like
renal failure, menstrual syndrome has occurred
disturbances. when therapy has been
Hematologic: eosinophilia resumed following
, thrombocytopenia, interruption.
transient
leucopenia, hemolytic ane -Be aware that drug may
mia, decreasedHgb, impart a harmless red-
hemolysis orange color to urine,
feces, sputum, sweat, and
tears. Soft contact lenses
may be permanently
stained.

-Report onset of jaundice,

hypersensitivity reactions,
and persistence of GI
adverse effects to

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physician.

-Use or add barrier

contraceptive if using
hormonal contraception.
Concomitant use of
rifampin and oral
contraceptives leads to
decreased effectiveness
of the contraceptive and
to menstrual disturbances
(spotting, breakthrough
bleeding).

-Keep drug out of reach of

children.

-Do not breast feed while

taking this drug.

DRUG NAME DOSAGES MECHANISM INDICATIONS ADVERSE EFFECT CONTRAINDICATION NURSING

OF ACTION CONSIDERATION
Generic Name: Dosage: Bacteriostatic o Pyrazinamide is Dermatologic: Rashes, Pyrazinamide is Assessment:
r bactericidal indicated for photosensitivity contraindicated in
Pyrazinamide 15 to 30 against the initial Gastro Intestinal: persons: with severe History:
mg/kg mycobacterium treatment of Hepatotoxicity, nausea, hepatic damage; who Allergy to
Brand Name: tuberculosis active vomiting, diarrhea, have shown pyrazinamide, acute
Route: tubercuIosis in anorexia hypersensitivity to it; hepatic disease, gout,
adults and Hematologic: Sideroblasti with acute gout. diabetes mellitus, acute
Tebrazid
children when c anemia, intermittent porphyria,
combined with thrombocytopenia, pregnancy.

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other adverse effects on

Drug Class: Oral antitubercu- clotting mechanism or Physical:
lous agents. vascular integrity Skin color, lesions, joint
Antituberculotic Frequency Other: status, TB, liver
: evaluation, LFTs, serum
and urine uric acid levels,
TID blood and urine glucose,
CBC.

Intervention:
 Administer only i
n conjunction
with other
antituberculotics.
  Administer once a
day.
  Discontinue drug 
if patient shows sign
of liver damage

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REFERENCES:

https://www.rnpedia.com/nursing-notes/communicable-diseases-notes/tuberculosis-tb/

https://www.mayoclinic.org/diseases-conditions/tuberculosis/symptoms-causes/syc-20351250

https://www.lung.org/lung-health-diseases/lung-disease-lookup/tuberculosis/learn-about-tuberculosis

https://medicalguidelines.msf.org/viewport/TUB/latest/15-1-initial-assessment-20322834.html

https://www.webmd.com/lung/understanding-tuberculosis-basics

https://nurseslabs.com/pulmonary-tuberculosis/#medical_management

https://www.sciencedirect.com/science/article/abs/pii/S0039610916326998

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