PULMONARY TUBERCULOSIS

DEFINITION
Tuberculosis, MTB, or TB (short for tubercle bacillus) is a common, and in many cases lethal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis. Tuberculosis typically attacks the lungs, but can also affect other parts of the body. It is spread through the air when people who have an active TB infection cough, sneeze, or otherwise transmit respiratory fluids through the air. Most infections are asymptomatic and latent, but about one in ten latent infections eventually progresses to active disease which, if left untreated, kills more than 50% of those so infected. The classic symptoms of active TB infection are a chronic cough with bloodtinged sputum, fever, night sweats, and weight loss (the latter giving rise to the formerly prevalent term "consumption"). Infection of other organs causes a wide range of symptoms. Diagnosis of active TB relies on radiology (commonly chest X-rays), as well as microscopic examination and microbiological culture of body fluids. Diagnosis of latent TB relies on the tuberculin skin test (TST) and/or blood tests. Treatment is difficult and requires administration of multiple antibiotics over a long period of time. Social contacts are also screened and treated if necessary. Antibiotic resistance is a growing problem in multiple drug-resistant tuberculosis (MDR-TB) infections. Prevention relies on screening programs and vaccination with the bacillus CalmetteGurin vaccine.

STATISTIC
One third of the world's population is thought to have been infected with M. tuberculosis, with new infections occurring in about 1% of the population each year. In 2007, there were an estimated 13.7 million chronic active cases globally, while in 2010, there were an estimated 8.8 million new cases and 1.5 million associated deaths, mostly occurring in developing countries.[6] The absolute number of tuberculosis cases has been decreasing since 2006, and new cases have decreased since 2002. The distribution of tuberculosis is not uniform across the globe; about 80% of the population in many Asian and African countries test positive in tuberculin tests, while only 510% of the United States population tests positive. More people in the developing world contract tuberculosis because of compromised immunity, largely due to high rates of HIV infection and the corresponding development of AIDS.

RISK FACTORS
A number of factors make people more susceptible to TB infections. The most important risk factor globally is HIV; 13% of all TB cases are infected by the virus. This is a particular problem in sub-Saharan Africa, where rates of HIV are high. Tuberculosis is closely linked to both overcrowding and malnutrition, making it one of the principal diseases of poverty. Those at high risk thus include: people who inject illicit drugs, inhabitants and employees of locales where vulnerable people gather (e.g. prisons and homeless shelters), medically underprivileged and resource-poor communities, high-risk ethnic minorities, children in close contact with high-risk category patients, and health care providers serving these patients. Chronic lung disease is another significant risk factor with silicosis increasing the risk about 30-fold. Those who smoke cigarettes have nearly twice the risk of TB than nonsmokers. Other disease states can also increase the risk of developing tuberculosis, including alcoholism and diabetes mellitus (threefold increase). Certain medications, such as corticosteroids and infliximab (an antiTNF monoclonal antibody) are becoming increasingly important risk factors, especially in the developed world. There is also a genetic susceptibility, for which overall importance remains undefined.

PATHOPHYSIOLOGY
High Risks Factors: 1. Old/Age 2. Infants 3. Children 4. Low socioeconomic status 5. Drug Addicts 6. HIV positive 7. Severely Malnourished 8. Health Care workers Etiological Agent: Myobacterium tuberculosis Mode of transmission: Droplets Nuclei

Environmental Factors: 1. High risks communities 2. Low income communities 3. Health care facilities

Mode of Entry: Respiratory Tract Lungs Alveoli

Diagnostic Procedure: Medical History Physical Examination Chest Radiography Mantoux tuberculin skin test 5. Microbiological Smears and Culture 1. 2. 3. 4.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Signs and Symptoms: Fever Fatigue Anorexia Hemoptysis Productive Cough Night Sweats Pallor Chest Pain Dyspnea Anxiety Low Self-Esteem Elevated WBC

Death

Treatment: 1. Anti-TB drugs 2. Surgery

Cure

CLINICAL MANIFESTATION
Primary tuberculosis Primary tuberculosis (TB) was considered to be mainly a disease of childhood until the introduction of effective chemotherapy with isoniazid in the 1950s. Many studies since that time have shown an increased frequency in the acquisition of TB in adolescents and adults. Symptoms and signs The natural history of primary TB was well described in a prospective study of 517 new tuberculin converters living on the Faroe Islands off the coast of Norway from 1932 to 1946. The study included 331 adults and 186 children; all were followed for more than five years. The clinical manifestations of primary TB varied substantially in this population, and symptoms and signs referable to the lungs were present in approximately one-third of patients. Fever was the most common symptom, occurring in 70 percent of 232 patients in whom fever was not a condition for enrollment in the study. The fever onset was generally gradual and low grade but could be as high as 39C and lasted for an average of 14 to 21 days. Fever resolved in 98 percent of patients by 10 weeks. Fever was not usually accompanied by other symptoms, although approximately 25 percent of patients developed pleuritic or retrosternal pain. One-half of patients with pleuritic chest pain had evidence of a pleural effusion. Retrosternal and dull interscapular pain were ascribed to enlarged bronchial lymph nodes and sometimes worsened with swallowing. Rarer symptoms included fatigue, cough, arthralgias, and pharyngitis.)

ASSESSMENT
A physical examination is done to assess the patient's general health and find other factors which may affect the TB treatment plan. It cannot be used to confirm or rule out TB. However, certain findings are suggestive of TB. For example, blood in the sputum, significant weight loss and drenching night sweats may be due to TB. When you give your medical history, your doctor collects information about whether you are likely to have tuberculosis (TB), a bacterial infection. An active infection can spread to other people. A latent infection cannot spread to other people, but it can turn active and become contagious. Your doctor will ask whether you: Have symptoms of active TB, such as ongoing cough, fatigue, fever, or night sweats. Have been in any situations that may increase your risk of being infected with TB-causing bacteria, such as contact with a person who has active TB, recent travel to places where TB is common, or having a weakened immune system. Have had a tuberculin skin test (TB skin test, PPD test) before, and what the results were. Have human immunodeficiency virus (HIV) infection or have had an HIV test in the past 6 months. Are taking any medicines, both prescription and nonprescription. Your doctor will want a list of all of these medicines, including herbs and natural products. Have been diagnosed with TB in the past but were not treated. The physical exam looks for signs of TB. A doctor uses a stethoscope to listen to your breathing for sounds that indicate a problem in your lungs. The doctor also will look for signs of a TB infection in parts of the body other than your lungs (extrapulmonary TB). Why It Is Done A medical history and physical exam may be done to check for TB if you have: TB symptoms, such as ongoing cough, fatigue, fever, or night sweats. Close contact with a person infected with active TB disease. Spent time in a country where TB is common. Results Results from the physical exam may include:

Normal The sounds your lungs make while you breathe are normal. You do not have a cough or a fever. There are no signs of TB infection in parts of the body other than your lungs (extrapulmonary TB). Abnormal The sounds your lungs make while you breathe indicate a problem. You have a cough or a fever. You have signs of TB infection in parts of the body other than your lungs, such as swollen lymph nodes.

DIAGNOSTIC FINDINGS
During the physical exam, your doctor will check your lymph nodes for swelling and use a stethoscope to listen carefully to the sounds your lungs make when you breathe. The most commonly used diagnostic tool for tuberculosis is a simple skin test. A small amount of a substance called PPD tuberculin is injected just below the skin of your inside forearm. You should feel only a slight needle prick. Within 48 to 72 hours, a health care professional will check your arm for swelling at the injection site. A hard, raised red bump means you're likely to have TB infection. The size of the bump determines whether the test results are significant. Results can be wrong The TB skin test isn't perfect. Sometimes, it suggests that people have TB when they really don't. It can also indicate that people don't have TB when they really do. A false-positive test may happen if you've been vaccinated recently with the bacille Calmette-Guerin (BCG) vaccine. This tuberculosis vaccine is seldom used in the United States but is widely used in countries with high TB infection rates. False-negative results may occur in certain populations including children, older people and people with AIDS who sometimes don't respond to the TB skin test. A false-negative result can also occur in people who've recently been infected with TB, but whose immune systems haven't yet reacted to the bacteria.

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. These tests may be useful if you're at high risk of TB infection, but have a negative response to the skin test, or if you received the BCG vaccine. Because these tests are relatively new, many health departments don't have them. Chest X-ray If you've had a positive skin test, your doctor is likely to order a chest X-ray. 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. Sputum tests If your chest X-ray shows signs of tuberculosis, your doctor may take a samples of your sputum the mucus that comes up when you cough. The samples are tested for TB bacteria. These bacteria can also be tested to see if they are resistant to the effects of medications commonly used to treat tuberculosis. This helps your doctor choose the medications that are most likely to work. Alternative sampling In patients incapable of producing a sputum sample, common alternative sample sources for diagnosing pulmonary tuberculosis include gastric washings, laryngeal swab, bronchoscopy (with bronchoalveolar lavage, bronchial washings, and/or transbronchial biopsy), and fine needle aspiration (transtracheal or transbronchial). In some cases, a more invasive technique is necessary, including tissue biopsy during mediastinoscopy or thoracoscopy.

MEDICAL MANAGEMENT
First line All first-line anti-tuberculous drug names have a standard three-letter and a single-letter abbreviation: Ethambutol is EMB or E, isoniazid is INH or H, pyrazinamide is PZA or Z, rifampicin is RMP or R,

Streptomycin is no longer considered as a first line drug by ATS/IDSA/CDC because of high rates of resistance.

The US uses abbreviations and names that are not internationally recognised: rifampicin is called rifampin and abbreviated RIF; streptomycin is abbreviated STM. Drug regimens are similarly abbreviated in a standardised manner. The drugs are listed using their single letter abbreviations (in the order given above, which is roughly the order of introduction into clinical practice). A prefix denotes the number of months the treatment should be given for; a subscript denotes intermittent dosing (so 3 means three times a week) and no subscript means daily dosing. Most regimens have an initial highintensity phase, followed by a continuation phase (also called a consolidation phase or eradication phase): the high-intensity phase is given first, then the continuation phase, the two phases divided by a slash. So, 2HREZ/4HR3 means isoniazid, rifampicin, ethambutol, pyrazinamide daily for two months, followed by four months of isoniazid and rifampicin given three times a week. Second line The second line drugs are considered as the reserved therapy for tuberculosis treatment. These drugs are often used in special conditions. When situations like resistance to first line therapy, extensively drug-resistant tuberculosis (XDR-TB) or multidrug-resistant tuberculosis (MDR-TB) arise, the second-line drugs are implemented for the treatment of tuberculosis. There are six classes of second-line drugs (SLDs) used for the treatment of TB. A drug may be classed as second-line instead of first-line for one of three possible reasons: it may be less effective than the first-line drugs (e.g., p-aminosalicylic acid); or, it may have toxic side-effects (e.g., cycloserine); or it may be unavailable in many developing countries (e.g., fluoroquinolones): aminoglycosides: e.g., amikacin (AMK), kanamycin (KM); polypeptides: e.g., capreomycin, viomycin, enviomycin; Fluoroquinolones: e.g., ciprofloxacin (CIP), levofloxacin, moxifloxacin (MXF); thioamides: e.g. ethionamide, prothionamide cycloserine: e.g., closerin Terizidone: Third line Other drugs that may be useful, but are not on the WHO list of SLDs: rifabutin macrolides: e.g., clarithromycin (CLR); linezolid (LZD);

 thioacetazone (T); thioridazine; arginine; vitamin D; R207910. These drugs may be considered "third-line drugs" and are listed here either because they are not very effective (e.g., clarithromycin) or because their efficacy has not been proven (e.g., linezolid, R207910). Rifabutin is effective, but is not included on the WHO list because for most developing countries, it is impractically expensive.

NURSING MANAGEMENT
Nursing Diagnoses for Tuberculosis A nursing diagnosis is a statement that describes a patient's response to his medical problem which in this case is tuberculosis. Nursing diagnoses for tuberculosis are as follows: risk for infection related to pulmonary TB disease ineffective breathing pattern related to decreased lung volumes and pulmonary infection ineffective therapeutic regimen related to long term treatment and lack of motivation imbalanced nutrition; less than body requirements related to fatigue, poor appetite, and productive cough. Nursing Interventions for Risk for Infection The goal of care for this nursing diagnosis is to reduce the risk of spreading tuberculosis and making sure the patient's tuberculosis is effectively treated. The following nursing activities address these goals: Teach the patient about the infectious nature of tuberculosis and the need to prevent its spread. Place the patient in a negative pressure room and in a private room. All nurses and visitors entering the patient's room should wear an N-95 mask. Put a mask on the patient during transportation to other departments. Keep the door to the patient's room shut and place an isolation sign at a visible location near the door. Use standard precautions when providing direct care to the patient. This includes wearing gloves, gowns and effective hand washing. Teach patient how to avoid spreading the disease by sneezing or coughing into doubly ply tissue instead of their bare hands, washing their hands after this and disposing of the tissue into a closed plastic bag.

Teach the tuberculosis patient to stay in well ventilated areas and limit contact to other people while he or she is still able to spread the infection.

Nursing Interventions for Ineffective Breathing Pattern Patients with tuberculosis may need to work harder to breathe due to coughing, nervousness or a high fever. Ineffective breathing pattern involves breathing at a faster or slower rate, use of accessory muscles to breathe and fast heart rates amongst other things. Nursing interventions for this problem are as follows: Administer oxygen if ordered and as ordered by a physician. Give the TB patients fluids to loosen up secretions for easier expulsion from the lungs. Position the patient in a high fowlers position to reduce the work needed to breathe. Encourage and provide rest periods so the tuberculosis patient can have energy to breathe. Nursing Interventions to Improve Nutritional Status of TB Patients Proper nutrition is necessary for the body to heal and fight off infections. Nursing interventions to improve the nutritional status of TB patients includes explaining the importance of a nutritious diet, monitoring the patient's weight for improvement or maintenance, administering vitamin supplements as prescribed and providing small frequent meals. Nursing Interventions to Improve Compliance with Tuberculosis Drug Regimen It is important for tuberculosis patients to take their medications as prescribed. Failure to do this may result in drug resistant forms of tuberculosis. This would make the patients tuberculosis difficult to cure. To increase compliance with the drug regimen for tuberculosis which can be very long, the nurse does the following: teaches the patient about the importance of taking all prescribed medications because the bacteria that causes TB grows slowly and requires a long time to be eliminated. provide the TB patient with information about expected side effects of TB drugs so that they know when to seek a doctors care and when not to be alarmed. refer patients having a hard time sticking to their drug therapy for direct observation therapy, where someone will watch them take their medication as they should. If all the goals of care for nursing management of tuberculosis are met, the tuberculosis patient should be free of fever and able to breathe properly, practice good infection prevention strategies, maintain his or her body weight and take all medications as prescribed.