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Pulmonary tuberculosis is an infectious disease caused by slow- growing bacteria that resembles a
fungus, Myobacterium tuberculosis, which is usually spread from person to person by droplet nuclei
through the air. The lung is the usual infection site but the disease can occur elsewhere in the body.
Typically, the bacteria from lesion (tubercle) in the alveoli. The lesion may heal, leaving scar tissue; may
continue as an active granuloma, heal, then reactivate or may progress to necrosis, liquefaction,
sloughing, and cavitation of lung tissue. The initial lesion may disseminate bacteria directly to adjacent
tissue, through the blood stream, the lymphatic system, or the bronchi.
Most people who become infected do not develop clinical illness because the body’s immune system
brings the infection under control. However, the incidence of tuberculosis (especially drug resistant
varieties) is rising. Alcoholics, the homeless and patients infected with the human immunodeficiency
virus (HIV) are especially at risk.



Respiration is defined in two ways. In common usage, respiration refers to the act of breathing, or
inhaling and exhaling. Biologically speaking, respiration strictly means the uptake of oxygen by an
organism, its use in the tissues, and the release of carbon dioxide. By either definition, respiration has two
main functions: to supply the cells of the body with the oxygen needed for metabolism and to remove
carbon dioxide formed as a waste product from metabolism. This lesson describes the components of the
upper respiratory tract.

The upper respiratory tract conducts air from outside the body to the

lower respiratory tract and helps protect the body from irritating substances. The upper
respiratory tract consists of the following structures:
The nasal cavity, the mouth, the pharynx, the epiglottis, the larynx, and the upper trachea. The esophagus
leads to the digestive tract.
One of the features of both the upper and lower respiratory tracts is the mucociliary apparatus that
protects the airways from irritating substances, and is composed of the ciliated cells and mucus-producing
glands in the nasal epithelium. The glands produce a layer of mucus that traps unwanted particles as they
are inhaled. These are swept toward the posterior pharynx, from where they are swallowed, spat out,
sneezed, or blown out.

Air passes through each of the structures of the upper respiratory tract on its way to the
lower respiratory tract. When a person at rest inhales, air enters via the nose and mouth. The nasal cavity
filters, warms, and humidifies air. The pharynx or throat is a tube like structure that connects the back of
the nasal cavity and mouth to the larynx, a passageway for air, and the esophagus, a passageway for food.
The pharynx serves as a common hallway for the respiratory and digestive tracts, allowing both air and
food to pass through before entering the appropriate passageways.
The pharynx contains a specialized flap-like structure called the epiglottis that lowers over the larynx to

prevent the inhalation of food and liquid into the lower respiratory tract.
The larynx, or voice box, is a unique structure that contains the vocal cords, which are essential for
human speech. Small and triangular in shape, the larynx extends from the epiglottis to the trachea. The
larynx helps control movement of the epiglottis. In addition, the larynx has specialized muscular folds
that close it off and also prevent food, foreign objects, and secretions such as saliva from entering the

lower respiratory tract.


The lower respiratory tract begins with the trachea, which is just below the larynx. The

trachea, or windpipe, is a hollow, flexible, but sturdy air tube that contains C-shaped

cartilage in its walls. The inner portion of the trachea is called the lumen.

The first branching point of the respiratory tree occurs at the lower end of the trachea,

which divides into two larger airways of the lower respiratory tract called the right
bronchus and left bronchus. The wall of each bronchus contains substantial amounts of cartilage that help
keep the airway open. Each bronchus enters a lung at a site called the hilum. The bronchi branch
sequentially into secondary bronchi and tertiary bronchi.
The tertiary bronchi branch into the bronchioles. The bronchioles branch several times until they arrive at
the terminal bronchioles, each of which subsequently branches into two or more respiratory bronchioles.
The respiratory bronchiole leads into alveolar ducts and alveoli. The alveoli are bubble-like, elastic, thin-
walled structures that are responsible for the lungs’ most vital function: the exchange of oxygen and
carbon dioxide.

Each structure of the lower respiratory tract, beginning with the trachea,
divides into smaller branches. This branching pattern occurs multiple times, creating multiple branches.

In this way, the lower respiratory tract resembles an “upside-down” tree that begins with

one trachea “trunk” and ends with more than 250 million alveoli “leaves”. Because of

this resemblance, the lower respiratory tract is often referred to as the respiratory tree.
In descending order, these generations of branches include:

• trachea
• right bronchus and left bronchus
• secondary bronchi
• tertiary bronchi
• bronchioles
• terminal bronchioles
• respiratory bronchioles
• alveoli
The thoracic cage, or ribs, and the diaphragm bound the thoracic cavity. There are two lungs that occupy
a significant portion of this cavity.
The diaphragm is a broad, dome-shaped muscle that separates the thoracic and abdominal cavities and
generates most of the work of breathing. The inter-costal muscles, located between the ribs, also aid in
respiration. The internal intercostal muscles lie close to the lungs and are covered by the external
intercostal muscles.
The lungs are cone-shaped organs that are soft, spongy and normally pink. The lungs cannot expand or
contract on their own, but their softness allows them to change shape in response to breathing. The lungs
rely on expansion and contraction of the thoracic cavity to actually generate inhalation and exhalation.
This process requires contraction of the diaphragm.
To facilitate the movements associated with respiration, each lung is enclosed by the pleura, a membrane
consisting of two layers, the parietal pleura and the visceral pleura.
The parietal pleura comprise the outer layer and are attached to the chest wall. The visceral pleura are
directly attached to the outer surface of each lung. The two pleural layers are separated by a normally tiny
space called the pleural cavity. A thin film of serous or watery fluid called pleural fluid lines and
lubricates the pleural cavity. This fluid prevents friction and holds the pleural surfaces together during
inhalation and exhalation.


1. Physical Assessment

Inspection: cough initially non-productive, later productive of purulent, yellow green

sputum, may be blood tinged. Dypnea, Orthopnea, fatigue, weakness.

Palpitation: skin moist at night from night sweats.

Percussion: resonant initially. Dull over any effusion.

Auscultation: normal or decrease vesicular breath sounds.

Adventitious sounds: crackles over upper lobes common, persist following full expiration
and cough.

2. Review of Systems
➢ Respiratory System
• Shortness of Breathing
• Tachypnea/Dyspnea on exertion
• Cough (productive/non-productive)
• Dullness to percussion & decreased fremitus
• Breath sound diminished/absent bilaterally or unilaterally tubular breath
sounds & / whispered Pectoriloquis over large lesion
• Crackles may be noted over apex of lung during quick inspiration after a
short cough
• Sputum: green/ purulent, yellowish mucoid or blood-tinged

➢ Musculoskeletal System
• Generalized weakness & fatigue
• Muscle wasting
• Pain & stiffness

➢ Gastrointestinal System
• Loss of appetite in digestion

➢ Integumentary System
• Poor skin turgor
• Dry/flaky skin

➢ Cardiovascular System
• Tachycardia
• Chest pain aggravated with current cough


1. Sputum Culture

A diagnosis of TB is suggested by the manifestations and a positive smear for acid-fast

bacillus. Sputum is obtained, smeared on a slide, and stained with a red dye. After the
slide has dried, it is treated with an acid alcohol to remove the stain. TB does not detain
with this procedure and remains red. The acid-fast bacillus test is not specific for TB
(other organisms are also acid-fast), but it is used as a quick method to determine whether
TB treatment and precautions should be started until more definitive testing can be

2. Tuberculin Skin Test

The tuberculin test result is the most commonly used reliable test of TB infection. A
small amount (0.1 mL) of purified protein derivative (PPD) is given intradermally in the
forearm. An area of indurations (not just redness) measuring 10 mm or greater in
diameter 48 to 72 hours after injection indicates exposure to and infection with TB.
Recent studies indicate that a reading after 72 hours rather than after just 48 hours is more
accurate. The incidence of false-negative readings is greater at 48 hours. A positive
reaction does not mean that active disease is present but indicates exposure to TB or the
presence of inactive (dormant) disease. A reaction of 5 mm or greater is considered
positive in people with HIV infection. A reduce skin reaction or a negative skin test does
not rule out TB disease or infection of the very old or anyone who is severely
immunocompromised. This condition is called anergy.

2. 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. Chest X-ray is also used
1. Determine the clinical activity of TB, whether it is inactive(any control) or
2. To determine the size of the lesion:
• Minimal-very small
• Moderately advance-lesion is less 4 cm
• Far advance-lesion is greater than 4 cm



• Age • Occupation
• Immunosup • Repeated
pression close
• Systemic contact with
Infection infected
• Recurrence

Leads to

of M. Tuberculosis

Airway to alveoli


reaction &

Accumulation of
exudates in the

Ghon Tubercle
(Bacteria &
leads to
Necrosis (forming a
cheesy mass)


Tubercle Bacilli
Immunity develops
DIAGNOSIS (2-6 weeks after
• Sputum causing
• Tuberculin Bacteria become
Skin Test dormant
• Chest X-

With Medical Without Medical

Intervention Leads to
• Early Reactivation of the
detection/diagno Tubercle Bacilli (due to
sis repeated exposure to
infected individual,
No recurrence Ghon Tubercle Ulcerates
MEDICATION Cheesy material into
bronchi (bacterial
• Isoniazid become airborne)
• Rifampicin
• Pyrazinamide
• Ethambutol Inflammation of
• Streptomycin lungs


Treatment Regimen for Categories I:

Anti-TB Drugs No. of tablets per day No. of tablets per day
Intensive Phase Continuation Phase
(2 months) (4 months)

Isonaizid (H) 1 1

Rifampicin (R) 1 1

Pyrazinamide (Z) 2

Ethambutol (E) 2

Treatment Regimen for Category II:

Anti-TB drugs No. of tablets/vial per day No. of tablets per day
Intensive Phase Continuation Phase
(3 months) (5 months)

First 2 months 3rd month

Isoniazid (H) 1 1 1

Rifampicin (R) 1 1 1

Pyrazinamide (Z) 2 2

Ethambutol (E) 2 2 2

Streptomycin (S) 1 vial/day

Treatment Regimen for Category III:

Anti-TB drugs No. of tablets per day No. of tablets per day
Intensive Phase Continuation Phase
(2 months) (2 months)

Isoniazid (H) 1 1

Rifampicin (R) 1 1

Pyrazinamide (Z) 2

Treatment Regimen for Category IV:

Type of TB pt: Chronic (still smear-positive after supervised re-treatment)

Treatment Regimen: Refers to specialized facility or DOTS Plus Center. Refer to Povincial/City NTP


Action: bactericidal drug that kills the mycobacterium by disrupting cell-wall synthesis and
essential cellular function. INH is metabolized in the liver then process called acetylation, w/c requires a
certain enzymatic pathway to break down to drug. However, some people have a genetic deficiency of the
liver enzymes needed for this to occur. Such people are called slow acetylators. When INH is taken by
slow acetylators, the INH accumulates because these is not enough of the enzymes to break down the
INH. Therefore, the dosages of INH may need to be adjusted downward in these patients.

Adverse Effects: Peripheral neuritis, hepatotoxicity, optic neuritis & visual disturbances,
hyperglycemia, red-orange-brown discoloration of bodily secretions (e.g. urine, sweats, tears, sputum)

Nursing Interventions: Instruct pt. to take drug exactly as prescribed; warn against stopping drug
without prescriber’s consent. Advise pt. to avoid alcoholic beverages while taking drugs.


Action: it is a broad-spectrum bactericidal drug that kills the offending organism by inhibiting
protein synthesis.

Adverse Effects: hepatitis, hematologic disorders, Neutropenia, red-orange-brown discoloration

of urine, feces saliva, sputum, sweat, tears, skin.

Nursing Intervention:

• Use cautiously in patients with liver disease

• Give 1 hour before or 2 hours after meals for optimal absorption; however, if GI irritation
occurs, patient may take rifampin with meals.
• Monitor hepatic function, hematopoietic studies, and serum uric acid levels. Drug’s systemic
effects may cause asymptomatic elevation of liver function test results and serum uric acid
• Watch for and report to prescriber signs and symptoms of hepatic impairment
• Drug may cause hemorrhage in neonates of rifampin- treated mother


Action: Unknown, but it is believed to work by inhibiting lipid & nucleic acid synthesis in the

Adverse effects: hepatotoxicity, hyperuricemia

Nursing Intervention:

• Always give pyrazinamide with other antituberculotics to prevent the development of resistant
• Doses that exceed 35 mg/kg may cause liver damage
• Monitor liver function studies; assess patient for jaundice and liver tenderness or enlargement
before and frequently during therapy.

Patient Teaching

• Inform patient that he must take drug together with other antituberculotics
• Tell patient to report adverse reactions promptly, especially fever, malaise, and loss of appetite,
nausea, vomiting, dark urine, yellow skin or eye discoloration, and pain or swelling of the joints.
• Stress importance of compliance with drug therapy. If daily therapy poses a problem, tell patient
to ask prescriber about twice-weekly dosing.


Action: Inhibits RNA synthesis, decreases tubercle bacilli replication

Adverse effects:

CNS: headache, confusion, fever, malaise, dizziness, disorientation, hallucinations

EENT: blind vision, optic neuritis, photophobia, decreased visual acuity

GI: abdominal distress, anorexia, nausea, vomiting

Integumentary: Dermatitis, pruritis, toxic epidermal necrolysis,

Metabolism: Elevated uric acid, acute gout, liver function impairment

Musckuloskeletal: Thrombocytopenia, joint pain, bloody sputum, anaphylaxis

Nursing Intervention:

• Monitor liver function studies

• Assess patients mental status often: affect, mood, behavioral changes; psychosis may occur with
hallucinations, confusion
• Assess patients hepatic status: decreased appetite, jaundice, dark urine, fatigue
• Assess patients for visual disturbance that may indicate optic neuritis: blurred vision, change in
color perception; may lead to blindness

Health teaching:

• Advise patient that compliance with dosage schedule and duration is necessary to eradicate
disease; to keep scheduled appointments including ophthalmic appointments or relapse may occur
• Caution patient to report weakness, fatigue, loss of appetite, nausea, vomiting, yellowing of skin
or eyes, tingling/numbness of hands/feet, weight gain, or decrease urine output
• Instruct patient to report any visual changes; rash; hot, swollen, painful joints; numbness or
tingling of extremities to physician
• Caution patient to inform prescriber if pregnancy is suspected


Action: Interferes with protein synthesis in bacterial cell by binding to ribosomal submit, causing
inaccurate peptide sequence to form in protein chain, resulting in bacterial death.

Adverse effects:

CNS: confusion, dizziness, depression, numbness tremors, seizures, muscle twitching,


Cerebrovascular: hypotension, myocarditis, palpitations

EENT: ototoxicity, tinnitus, deafness, visual disturbances

GI: Nausea, vomiting, anorexia, increased ALT, AST, bilirubin, hepatomegaly, hepatic necrosis,
GU: oliguria, hematuria, renal damage, renal failure, nephrotoxicity

Hematologic: Agranulocytosis, thrombocytopenia, leucopenia, eosinophilia, anemia

Integumentary: Rash, burning, urticaria, dermatitis, alopecia

Nursing Intervention:

• Assess patient for previous sensitivity reaction

• Assess patient for signs and symptoms of infection including characteristics of sputum, urine,
• Obtain baseline information before and during treatment
• Assess for allergic reactions: rash, urticaria, pruritus, chills, fever, joint pain
• Identify urine output; if decreasing, notify prescriber( may indicate nephrotoxicity); also
increased BUN
• Monitor for bleeding: ecchymosis, bleeding gums, hematuria, and stool guaiac daily if on long-
term therapy.
• Assess for overgrowth of infection: perineal itching, fever, malaise, redness, pain, swelling,
drainage, rash, diarrhea, change in cough, sputum.

Health teaching:

• Teach patient to report sore throat, bruising, bleeding, joint pain, may indicate blood
dyscrasias(rare); ringing, roaring in the ears
• Advice patient to contact prescriber if vaginal itching, loose foul-smelling stools, and furry
tongue occur; may indicate super infections


Priority no. 1:

NURSING DIAGNOSIS: Ineffective Airway Clearance related to fatigue, poor cough effort
as evidenced by abnormal breath sounds (rhonchi, wheezes), stridor
➢ Increased RR-32 bpm
➢ Decreased O2 Sat-90%
➢ (+) cyanosis



➢ Assess respiratory function (breath sounds, rate, rhythm & depth and use of
accessory muscles)
➢ Note ability to expectorate mucus effectively, document character amount of
sputum, presence of hemoptysis.
➢ Maintain fluid intake to at least 2500ml/day unless contraindicated.
➢ Place patient in semi-fowler’s position. Assist patient with coughing and deep
breathing exercises.


➢ Humidify inspired air/O2

➢ Administer meds: Mucolytic agents, bronchodilators.
Priority no.2:

NURSING DIAGNOSIS: Impaired Gas Exchange related to thick, viscous secretions



➢ Decreased O2 Sat=90%
➢ Nasal flaring
➢ Sputum characteristics (green, purulent, yellowish mucoid)



➢ Assess for dyspnea (using 0-10 scale), tachypnea, abnormal/diminished breath

sounds, increased respiratory effect.
➢ Note cyanosis and/or change in skin color, including mucous membranes.
➢ Encourage pursed-lip breathing during exhalation.
➢ Promote bed rest/ limit activity and assist with self-care activities as necessary.

Priority no. 3:

NURSING DIAGNOSIS: Reactivation of infection related to lowered resistance as evidenced

by purulent sputum



➢ Night fever
➢ Chills
➢ Greenish sputum



➢ Instruct patient to cough/sneeze and expectorate into tissue and refrain from
➢ Review necessity of infection control measures, e.g. temporary respiratory
➢ Monitor temperature as indicated.
➢ Identify others at risk, e.g. household members, close associates/friends
➢ Encourage selection/ingestion of well-balanced meals. Provide frequent small
“snacks” in place of large meals as appropriate.


➢ Administer anti-infective agents:(RIPES)

Priority no. 4:

NURSING DIAGNOSIS: Imbalanced Nutrition, less than body requirements related to frequent
cough as evidenced by lack of interest in food.



➢ Poor muscle tone

➢ Lack of interest in food



➢ Ascertain patient’s usual dietary pattern, likes/dislikes.

➢ Monitor I & O and weight periodically.
➢ Encourage small, frequent meals with foods high in protein and carbohydrates.
➢ Provide oral care before and after respiratory treatment.


➢ Refer to dietitian for adjustments in dietary composition.

➢ Monitor laboratory studies, e.g, BUN, serum protein and prealbumin.
➢ Administer antipyretics as appropriate.

Priority no. 5:

NURSING DIAGNOSIS: Activity intolerance related to imbalance between oxygen supply and



➢ (+) cyanosis
➢ Increased RR
➢ Decreased tolerance to activity



➢ Evaluate patient’s response to activity. Note report of dyspnea, increased

weakness or fatigue, and changes in vital signs during and after activities.
➢ Provide a quiet environment and limit visitors during acute phase as indicated.
Encourage use of stress management and diversional activities.
➢ Explain importance of treatment plan and necessity for balancing activities.


Pulmonary TB is treated primarily with chemotherapeutic agents (antituberculosis agents) for

6 to 12 months. A prolonged treatment duration is necessary to ensure eradication of the
organisms and to prevent relapse. A worldwide concern and challenge in TB therapy in the
continuing and increasing resistance of M. Tuberculosis to TB medications. Several types of
drug resistance must be considered when planning effective therapy:
• Primary drug resistance: resistance to one of the first-line antituberculosis agents in a
person who has not had previous treatment.
• Secondary or acquired drug resistance: resistance to one or more antituberculosis
agents in a patient undergoing therapy
• Multidrug resistance: resistance to two agents, isoniazid (INH) and rifampin. The
populations at highest risk for multidrug resistance are those who are HIV-positive,
institutionalized or homeless.

The increasing prevalence of drug resistance points out the need to begin TB treatment with
four or more medications, to ensure completion of therapy, and to develop and evaluate new
anti-TB medications.


Medications Dosage/Frequency Nursing Instructions

Category I • (Isoniazid) Instruct

pt. to take drug
Isonaizid (H) 1 tab/day exactly as
Rifampicin (R) 1 tab/day prescribed; warn
against stopping
Category II drug without
prescriber’s consent.
Isonaizid (H) 1 tab/day Advise pt. to avoid
Rifampicin (R) 1 tab/day alcoholic beverages
Ethambutol (E) 2 tab/day while taking drugs.
• (Rifampicin)
Category III Give 1 hour
before or 2
Isonaizid (H) 1 tab/day hours after
Rifampicin (R) 1 tab/day meals for
however, if GI
irritation occurs,
patient may take
rifampin with
• (Ethambutol)
Advise patient that
Category IV compliance with
dosage schedule and
duration is necessary
to eradicate disease;
to keep scheduled
appointments or
relapse may occur
• Refer to specialized
facility or DOTS
Plus Center. Refer to
Povincial/City NTP
• Deep breathing exercise every morning for at least 5-10 minutes.

Health Teachings:
• Cover mouth and nose with double-ply tissue when coughing/sneezing. Do not
sneeze into bare hand.
• Wash hands after coughing/sneezing
• Encourage the patient to eat a nutritious diet
• Encourage the patient to have deep breathing exercise every morning for at least 5-10

OPD visits/Referrals: Report to clinic/ physician at specified intervals for bacteriologic

(smear) examination of sputum to monitor therapeutic response and patient compliance

• Include a liberal amount of calcium in your diet to promote healing of tuberculin

• If a patient suffers from hemorrhages, high iron supplementation is necessary.

• The diet should provide as much retinol as possible (as conversion of beta-carotene to
retinol in the intestinal mucosa is adversely affected) by giving milk, milk products,
eggs and meat.
• Tuberculosis being an infectious disease results in increased urinary loss of ascorbic
acid. As ascorbic acid helps in healing, additional amounts of ascorbic acid is
therefore recommended in the diet in the form of guava, orange, lemon and sprouted
• Avoid high fat foods, as it results in diarrhea and gastric upset.
• Fresh fruit diet is also recommended for the first three days.
• Avoid refined foods such as sugar, refined flour, canned and tinned foods, pies,
pudding and refined cereals.
• Abstain from caffeinated beverages, in addition to pickles, sauces and condiments.
• Juice of pineapple helps to dissolve the mucus and thus helps in recovery.
• Orange juice with honey and salt exhibits saline action and prevents the entry of
germs, thereby protecting from secondary infection.

Spiritual care:
• Encourage patient to have regular prayer time to promote relaxation and to meditate.


1. To help patient understand more regarding the disease
2. To educate patient on how to minimize the spread such disease
3. To help the patient in preventing complications

Materials Needed:
1. Pamphlets
2. Visual Aid

General Health Teachings Specific Health Teachings

Educating the client • Educate the patient to control

propagation of secretion while
• Cover mouth and nose with double-
ply tissue when coughing/sneezing.
Do not sneeze into bare hand.
Nutrition • Wash hands after coughing/sneezing
• Encourage the patient to eat a
Reinforcement nutritious diet
• Secure a booklet that facilitate
understanding tuberculosis to give
insight into and knowledge of the
• Review side effects of the drug
therapy with the patient
• Review possible complications with
the patient and family; hemorrhage,
Exercise pleurisy, symptoms of recurrence
(persistent cough, fever or
• Encourage the patient to have deep
breathing exercise every morning for
at least 5-10 minutes.

Ref: Manual of nursing practice 4th edition by Lippincott


Symptom may improve 2 to 3 weeks. A chest x-ray will not show this improvement until
later. The outlook is excellent if pulmonary TB is diagnosed early and treatment is begun