MEDICAL SURGICAL NURSING

A SEMINAR
ON
TUBERCULOSIS

SUBMITTED TO:
MRS.SINDHU.C. PHILIP
ASSO. PROFESSOR
TMM COLLEGE OF NURSING
THIRUVALLA

SUBMITTED BY:
MISS. THANUJA ELEENA MATHEW
1ST YEAR MSC NURSING
TMM COLLEGE OF NURSING
THIRUVALLA

SUBMITTED ON:
22 -12-2017

1
INTRODUCTION
Tuberculosis [TB] as it’s commonly called is a contagious infection that usually attacks the lungs. It can also
spread to other parts of the body, like the brain and spine. Pulmonary tuberculosis is caused by the
Mycobacterium tuberculosis, a pathogen of tuberculosis, also written as m. tuberculosis or tubercle bacillus.
Person can get TB by breathing in air by droplets by cough or sneeze of an infected person. This is called
pulmonary TB.

DEFINITION
Pulmonary tuberculosis is marked by the formation of granuloma in infected lung tissues and by cell
meditated hyper sensitivity, that also cause inflammation and fibro cavitary destruction in the lung, produces
chronic respiratory symptoms, and reduce the quality of life.

INCIDENCE
In 2016, there were an estimated 10.4 million new TB cases worldwide, 10% of which were people living
with HIV. Seven countries accounted for 64% of the total burden, with India bearing the brunt, followed
by Indonesia, China, Philippines, Pakistan, Nigeria and South Africa. An estimated 1.7 million people
died from TB, including nearly 400 000 people who were co-infected with HIV. This is a drop by 4%
compared to 2015.
In 2015, 10.4 million people around the world became sick were 1.8 million TB related death worldwide.
The largest number of new TB cases accrued in Asia with 61% of new cases, followed by Africa, with 26%
new cases.

In 2016 an estimated 28 lakh cases occurred and 4.5 lakh people died due to TB.

Estimated burden of TB 2016

Estimates of TB burden (2015) Global India

Incidence of HIV/TB 11.7 lakh (1.17 million) 1.1 lakh (110,000)

Incidence of TB cases 104 lakhs (10.4 million) 28 lakhs (2.79 million)

MDR TB 4.8 lakh (480,000) 0.84 lakh (84,000)

Mortality of HIV/TB 3.9 lakh (390,000) 12,000

TB mortality 14 lakhs (1.4 million) 4.35 lakh (435,000)

RISK FACTORS

2
Anyone can get tuberculosis, but certain factors can increase your risk of the disease. These factors
include:

Weakened Immune System

A healthy immune system often successfully fights TB bacteria, but your body can't mount an effective
defence if your resistance is low. A number of diseases 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

 Veryyoung or advanced age

Travelling or Living in Certain Areas

 Africa

 Eastern Europe
 Asia

 Russia

 Latin America
 CaribbeanIslands
Poverty and Substance Abuse

 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.
 Substance abuse. IV drug use or alcohol abuse weakens your immune system and makes you more
vulnerable to tuberculosis.
 Tobaccouse. Using tobacco greatly increases the risk of getting TB and dying of it.
Working or Living Status

 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.

3
 Living or working in a residential care facility. People who live or work in prisons, immigration
centres 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 a refugee camp or shelter. Weakened by poor nutrition and ill health and living in crowded,
unsanitary conditions, refugees are at especially high risk of tuberculosis infection.

CAUSES
Tuberculosis is caused by a group of five closely related species, which form the mycobacterium tuberculosis
complex: m. tuberculosis, m. bovis, m. africanum, m. microti, and m. canettii.

TRANSMISSION
Through the air, just like a cold or the flu, when someone who’s sick coughs, sneezes, talks, laughs, or sings,
tiny droplets that contain the germs are released. If you breathe in these nasty germs, you get infected.
TB is contagious, but it’s not easy to catch. The germs grow slowly. You usually have to spend a lot of time
around a person who has it. That’s why it’s often spread among co-workers, friends, and family members.
Tuberculosis germs don’t thrive on surfaces. You can’t get the disease from shaking hands with someone who
has it, or by sharing their food or drink.

PATHOPHYSIOLOGY

TYPES OF TUBERCULOSIS

4
Latent TB: the germs in the body and immune system stops them from spreading. That means it don’t have
any symptoms and not contagious. But the infection is still alive in the body and one day become active. at
high risk for re-activation for instance, if have HIV, the primary infection was in the last 2 years, chest X-ray
is abnormal, or immunocompromised with doctor will treat with antibiotics to lower the risk for developing
active TB.
Latent TB
Any introduction to TB must explain the difference between latent TB and TB disease
The bacteria that usually cause TB in humans, usually affect the lungs, but can affect other parts of the
body. If infected with the bacteria, won’t necessarily become sick, because it can have either latent TB or
TB disease. People with latent TB do not feel sick and do not have any symptoms.
Active TB disease: This means the germs multiply and can make sick. It can spread the disease to others.
Ninety percent of adult cases of active TB are from the reactivation of a latent TB infection.
Bovine TB is a disease caused by similar bacteria called Mycobacterium bovis (M. bovis). Bovine TB
mainly affects cattle but can also affect humans. Most of the information on this website refers to TB in
humans.
Just a few years ago it was believed that TB was an old disease, and that it was no longer a problem in
humans. But now because of such issues as drug resistance and HIV, it has become a major problem
again.

CLINICAL MANIFESTATION

 Coughing that lasts three or more weeks

 Coughing up blood
 Chest pain, or pain with breathing or coughing
 Unexplained weight loss
 Fatigue

 Fever

 Night sweats
 Chills

 Loss of appetite
 Mucoid or mucopurulent sputum
 Breathing difficulty
 Wheezing
 Clubbing of the fingers or toes.
 Enlarged or tender lymph nodes in the neck or other areas
 Fluid around lung
 Unusual breath sounds {cracked lungs}

DIAGNOSTIC EVALUATION

Tuberculin skin test

5
The TB skin test involves injecting a small amount of fluid (called tuberculin) into the skin in the lower
part of the arm. Then the person must return after 48 to 72 hours to have a trained health care worker look
at their arm. The health care worker will look for a raised hard area or swelling, and if there is one then
they will measure its size. They will not include any general area of redness.1

The TB skin test result depends on the size of the raised hard area or swelling. The larger the size of the
affected area the greater the likelihood that the person has been infected with TB bacteria at some time in
the past. But interpreting the TB skin test result, that is whether it is a positive result, may also involve
considering the lifestyle factors of the person being tested for TB.2 The TB skin test also cannot tell if the
person has latent TB or active TB disease.
Imaging tests

If you've had a positive skin test, your doctor is likely to order a chest X-ray or a CT scan. This may show
white spots in your lungs where your immune system has walled off TB bacteria, or it may reveal changes
in your lungs caused by active tuberculosis. CT scans provide more-detailed images than do X-rays.

Sputum tests

If your chest X-ray shows signs of tuberculosis, your doctor may take samples of your sputum — the
mucus that comes up when you cough. The samples are tested for TB bacteria.

Sputum samples can also be used to test for drug-resistant strains of TB. This helps your doctor choose
the medications that are most likely to work. These tests can take four to eight weeks to be completed.

Quanti FERON-TB gold test

Blood tests

Blood tests may be used to confirm or rule out latent or active tuberculosis. These tests use sophisticated
technology to measure your immune system's reaction to TB bacteria. Quanti FERON-TB Gold in-Tube
test and T-Spot.TB test are two examples of TB blood tests.

QuantiFERON-TB Gold (QFT) is a simple blood test that aids in the detection of Mycobacterium
tuberculosis, the bacteria which causes tuberculosis (TB). QFT is an interferon-gamma (IFN-γ) release
assay, commonly known as an IGRA, and is a modern alternative to the tuberculin skin test (TST, PPD or
Mantoux). Unlike the TST, QFT is a controlled laboratory test that requires only one patient visit and is
unaffected by previous Bacille Calmette-Guerin (BCG) vaccination.
QFT is highly specific and sensitive: a positive result is strongly predictive of true infection with M.
tuberculosis. However, like the TST and other IGRAs, QFT cannot distinguish between active
tuberculosis disease and latent tuberculosis infection, and is intended for use with risk assessment,
radiography, and other medical and diagnostic evaluations. Like any diagnostic aid, QFT cannot replace
clinical judgment.

MEDICAL MANAGEMENT

FIRST LINE DRUGS

6
The five basic or “first line” TB drugs are:2
 Isoniazid

 Rifampicin

 Pyrazinamide

 Ethambutol

 and Streptomycin
SECOND LINE DRUGS
Drug- Capreomycin
 Dosage- 15 – 30 mg/kg
 Prior assessment- before the treatment, monitor vestibular and measure blood urea nitrogen during
treatment.
 Note- Dosage may be reduced to two - three times per week after bacteriologic conversion. Safety and
effectiveness in children have not been established
Drug- Ethionamide
 Dosage- 15 - 20 mg/kg
 Prior assessment- Measure hepatic enzymes.
 Note- Start with low dosage and increase with improved tolerance. If used with PAS, it may cause
hypothyroid condition.
Drug- Para-aminosalicylic acid
 Dosage- 150 mg/kg
 Prior assessment- Measure hepatic enzymes and monitor volume status.
 Note- Start with low dosage and increase with improved tolerance. Cardiac patients must be monitored
for sodium load. Used with ethionamid, it may cause hypothyroid condition.
Drug- Cycloserine
 Dosage- 15 - 20 mg/kg
 Prior assessment- Assess mental status and serum drug levels.
 Note- Initially, low dosage should be given and can be increased with improved toleration.
Drug - Levofloxacin
 Dosage- 500 mg/day
 Prior assessment- Drug interactions in the patient.
 Note- Should not be used in children. After taking it, the patient may experience headache, restlessness,
dizziness and hypersensitivity.

TB treatment in India – New patients, previously treated, daily treatment

The Standards for TB care in India sets out the TB treatment that should be provided in India. It was
published in 2014 and details the TB treatment that should be provided for all patients with TB including
those in special categories, such as those with TB and HIV co-infection.
Subsequently the Technical & Operational Guidelines for Tuberculosis Control in India 2016 was
launched by the Health Minister. This document does not replace the Standards for TB Care in India.
However, it does update it as well as expand it. In particular it makes it clear that the Standards for TB
Care in India applies to all patients including those in the private sector.

7
Categories of Patients
There are two main ways to classify patients for TB treatment. The first is classifying them by the site of
their disease. The second is classifying patients by their history of TB treatment.

Classification of patients by the site of their disease

Classification by the site of TB disease basically divides patients in two categories. This is Pulmonary TB
which is TB in the lungs. There is also extra pulmonary TB which is TB involving any organ apart from
the lungs.

Classification of patients by their history of TB treatment

There are three categories of patient based on their history of TB treatment. These are:
a) New TB patients – these are TB patients who have never had treatment for TB or they have taken anti
TB drugs for less than one month
b) Previously treated patients – these are patients who have received one month or more of anti TB
drugs in the past.

Recurrent TB cases are patients who have previously been considered as successfully treated
(cured/treatment completed) and they have subsequently been micro biologically confirmed as a case of
TB.
Treatment after failure patients are those who have previously been treated for TB and their treatment
failed at the end of their most recent course of treatment.
Treatment after lost to follow-up is a TB patient who has previously received TB treatment for a month or
more and they were declared lost to follow up in their most recent course of treatment. They have also
subsequently been found to be a microbiologically confirmed TB case.
Other previously treated patients are patients who have previously been treated but whose outcome after
their most recent course of treatment is unknown or undocumented.
c) Transferred in – is a TB patient who is received for treatment in a TB unit, after being registered for
treatment in another TB unit.
A micro biologically confirmed TB case refers to a patient who is presumed to have TB and who has a
biological specimen positive for acid fast bacilli. It is also a patient positive for TB through a quality
assured Rapid Diagnostic Molecular test.

Classification based on drug resistance

Patients can also be classified according to their drug resistance.
There is separately more about drug resistant TB in India.

Treatment for new TB patients

8
All new TB patients in India should receive an internationally accepted first line treatment regimen (a
regimen is the prescribed course of treatment, in this case the TB drugs) for new patients. The initial
intensive phase should consist of eight weeks of the drugs Isoniazid (H), Rifampicin (R), Pyrazinamide
(Z) and Ethambutol (E). The continuation phase should consist of the three drugs Isoniazid, Rifampicin
and Ethambutol given for another sixteen weeks. This is alternatively written as 2HREZ/4 – 6HRE. There
will be no need for any extension of the continuation phase.

All patients should receive their daily TB drugs under direct observation (DOTS). Under DOTS (Directly
Observed Therapy Short Term) the patient has to take the TB medication in front of a DOTS agent. The
DOTS agent is usually a volunteer from the patient’s community, and may be a family member. DOTS do
not say which drugs should be taken. DOTS apply when any TB drugs are taken with the patient being
observed by a DOTS volunteer.
Fixed dose combinations
Fixed dose combinations are desirable as they simplify drug procurement and logistics and the delivery of
DOTS. They may also increase adherence. Individually worked out drug dosing should be reserved for
patients with toxicities or contraindications to one or more components of the FDC. Fixed dose
combinations of four drugs (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol), three drugs (Isoniazid,
Rifampicin and Ethambutol) and two drugs (Isoniazid and Rifampicin) should be available. A fixed dose
combination is when two or more drugs are combined together in a single pill or tablet.

Previously treated patients

With previously treated patients, MDR-TB or R resistance must firstly be ruled out by a quality assured
test. Then if the TB patient is a previously treated patient as defined above, they should then receive the
retreatment regime containing first line drugs in a similar way to new TB patients. The main difference is
the addition of streptomycin to the intensive phase.
It is not usual to add one TB drug to a failing regimen as this can encourage the development of
resistance. But it may be considered that this is still sensible guidance as MDR-TB and rifampicin
resistance will have already been excluded.
However, the effect on the patients could still be considerable. Streptomycin has to be painfully injected,
and its common side effects include a loss of hearing. Difficulties arise when testing for second line
drugs is not available.

COMPLICATIONS

 Spinal pain. Back pain and stiffness are common complications of tuberculosis.
 Joint damage. Tuberculous arthritis usually affects the hips and knees.
 Swelling of the membranes that cover your brain (meningitis). This can cause a lasting or
intermittent headache that occurs for weeks. Mental changes also are possible.
 Liver or kidneyproblems. Your liver and kidneys help filter waste and impurities from your
bloodstream. These functions become impaired if the liver or kidneys are affected by tuberculosis.

9
Heart disorders. Rarely, tuberculosis can infect the tissues that surround your heart, causing inflammation
and fluid collections that may interfere with your heart's ability to pump effectively. This condition, called
cardiac tamponade, can be fatal.

PREVENTION
 Stay home. Don't go to work or school or sleep in a room with other people during the first few weeks
of treatment for active tuberculosis.
 Ventilate the room. Tuberculosis germs spread more easily in small closed spaces where air doesn't
move. If it's not too cold outdoors, open the windows and use a fan to blow indoor air outside.
 Cover your mouth. Use a tissue to cover your mouth anytime you laugh, sneeze or cough. Put the dirty
tissue in a bag, seal it and throw it away.
 Wear a mask. Wearing a surgical mask when infected during the first three weeks of treatment may
help lessen the risk of transmission.
 Finish entire course of medication
 This is the most important step that can take to protect from tuberculosis. When stop treatment early or
skip doses, TB bacteria have a chance to develop mutations that allow them to survive the most potent
TB drugs. The resulting drug-resistant strains are much more deadly and difficult to treat.
 Vaccinations
 In countries where tuberculosis is more common, infants often are vaccinated with bacillus Calmette-
Guerin (BCG) vaccine because it can prevent severe tuberculosis in children. The BCG vaccine isn't
recommended for general use in the United States because it isn't very effective in adults. Dozens of
new TB vaccines are in various stages of development and testing.
CONCLUSION
I conclude that tuberculosis infection and disease remain common in populations characterized by poor
housing conditions, drug use, and HIV infection. Linking a major medical provider with community-based
organizations is an effective means to provide highly targeted screening services to a population at serious
risk for disease acquisition and transmission.

NURSING DIAGNOSIS

↣ Risk for impaired gas exchange related to destruction of alveolar-capillary membrane.

↣ ineffective airway clearance related to thick, viscous, or bloody secretions.
↣ imbalanced nutrition less than body requirements related to fatigue.
↣ deficient knowledge related to lack of exposure to/misinterpretation of information.
↣ activity intolerance may be related to imbalanced between oxygen supply and demand, possibly
evidenced by reports of fatigue, weakness, and exertional dyspnoea.
↣ Risk for ineffective therapeutic regimen management risk factors may include complexity of therapeutic
regimen, economic difficulties, family patterns of healthcare, perceived seriousness, side effects of
therapy.

10
BIBLIOGRAPHY
 BRUNNER AND SUDDARTH, “TEXT BOOK OF MEDICAL AND SURGICAL NURSING”,
12TH EDITION, WOLTER KLUWER INDIA PRIVATE LIMITED, PAGE NUMBER:567-572.
 LEWIS, HEITKEMPER DIRKSEN, “MEDICAL SURGICAL NURSING” 6TH EDITION,
MOSBY PUBLICATIONS, PAGE NO: 601-607
 S.M. MOGOTLANE ET.AL “JUTAS MANUAL OF NURSING MEDICAL SURGICAL
NURSING PART 2: THE SYSTEMS”, VOLUME 4 JUTA PUBLICATIONS, PAGE NO: 13-24-29
 IGNATIVUS, WORKMAN “MEDICAL AND SURGICAL NURSING” 7TH EDITION,
ELSEVIER PUBLICATIONS, PAGE NO: 653-658
 ANSARI AND KAUR “A TEXT BOOK OF MEDICAL AND SURGICAL NURSING- 1ST,”
PEEVEE PUBLICATIONS, PAGE NO: 374-385
 BONITA BOYLES” MEDICAL SURGICAL NURSING CLINICAL COMPANION”
PUBLISHED BY CAROLINA ACADEMIC PRESS. PAGE NO:845-848.
 SWEARINGENS, “MANUAL OF MEDICAL SURGICAL NURSING” 7TH EDITION, ELSIVER
AND MOSBY PUBLICATIONS, PAGE NO:80-83
 LINTON, “INTRODUCTION TO MEDICAL SURGICAL NURSING” 4TH EDITION, ELSIVER
PUBLICATIONS, PAGE NO:562-566.
 USHA RAVINDRAN “TEXT BOOK OF MEDICAL SURGICAL” JAYPEE PUBLICATIONS
PAGE NO: 62-65.
 LYNDA JUALL CARPENITO {2004} “NURSING CARE PLANS AND DOCUMENTATION”
4TH EDITION PUBLISHED BY LIPPINCOTT WILLIAMS AND WILKINS, PAGE NO: 566-568.
NET REFERENCES

 www.tbfacts.org
 Careertrend.com
 En.wikipedia.org
 Slideshare.net/medical surgical nursing
 www.webmed.org

JOURNEL REFERENCE

 www.nejm.org
 Www.ncbi.nlm.nih.gov.org
 https://scholar.google.co.in
 http://www.nursingworld.org
 http://journals.lww.com

11