PULMONARY TUBERCULOSIS and Nursing Management Lecture

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PULMONARY TUBERCULOSIS
- Pulmonary tuberculosis – is bacterial infectious disease caused by Mycobacterium tuberculosis. (gram positive, rod-shaped, acid-fast and aerobic).
- Can live in dark for months as spores, destroyed by sunlight, heat and ultraviolet light and pasteurization.
- Affects 1/3 of world’s population.
- Leading cause of death from infectious diseases and people with HIV.
- Predisposing factors : inadequate health care, malnutrition, overcrowding and poor housing.
- Extrapulmonary Tuberculosis : TB develops in other organs – kidney, genitourinary tract, joints, subarachnoid space.
- Miliary TB : TB spreads all over the body.
Pathophysiology  Of Pulmonary Tuberculosis
3 stages.
- Primary TB or stage of early infection


Tubercle bacilli on inhalation implant on bronchioles or alveoli thru’ bronchial system
host no resistance to infection)
Phagocytes (neutrophils and macrophages) engulf bacilli
Bacilli multiply and spread  to lymph nodes, blood and distant organs.
In 2 weeks epithelial cells merge with macrophages forming granuloma (Ghon tubercle)
Lymphocytes surround Ghon tubercle
Central portion undergoes necrosis
Has a cheesy appearance
Liquefies and sloughs into connecting bronchus forming a cavity
(May enter tracheobronchial system – airborne transmission)
Healing by resolution, fibrosis and calcification
Scar formation around tubercle (Ghon complex)

Latent period :


Infection enters latent period – persists for many years without producing clinical symptoms. (clients with diabetes, HIV, chemotherapy or long term steroids.)

Secondary Tuberculosis : reactivation of initial infection .

Acute local inflammation and necrosis.
Ulceration of infected lung tissue
Tubercles cluster together, surrounded by inflammation.
Exudate fills surrounding alveoli
Development of bronchopneumonia.
TB tissue becomes caseous and ulcerates into the bronchus.
Cavities form
Ulceration heal with scar tissue around cavities.
Pleurae thicken and retract.

Signs and Symptoms of Pulmonary Tuberculosis
- Insidious onset.
- Early symptoms :(vague and can be overlooked)
- Fatigue, anorexia, weight loss, non-productive cough.
- Low grade fever esp. late afternoon, night sweats.
- Productive cough – mucopurulent and blood – streaked.
Later stages :
    Marked weakness, muscle wasting, hemoptysis (expectoration of blood or bloody sputum), dyspnea, chest pain,

Screening test : Tuberculin test (Mantoux test)
0.1 ml of PPD is injected intradermally into the dorsal aspect of the forearm.
Test read within 48-72 hours. Assess for erythema and induration. Diameter of induration (> 10mm)determines infection, read in millimeteres.
Positive reaction indicates client :
Has developed an immune response to bacillus.
Does not indicate active TB or current infection.
Body tissues are sensitive to tuberculin.
Needs further evaluation.

Diagnostic tests
3 consecutive early morning sputum sent for (AFB)acid-fast bacillus smear and culture.
Chest Xray
Fiberoptic bronchoscopy, gastric lavage, gastric aspiration.
Medical and surgical management
Medical Management for Pulmonary Tuberculosis
2 factors making drug therapy less than ideal


- Drug toxicity.
- Tendency of tubercle bacilli to develop drug resistance.

 

Combined therapy ( 6 or more months)
- Decreases drug resistance.
- Increases tuberculostatic action of the drugs
- Lessens toxic drug reactions
- Drugs – Isoniazide (INH), Rifampin (RMP), Pyrazinamide(PZA), Ethambutol(EMB), Streptomycin(SM).

Surgical Management :
- Disease is located in one segment of the lung
- segmental resection – (removal of a lobe segment)
- Wedge resection – removal of a wedge of the diseased tissue.
- If diseased area is larger
Lobectomy – removal of a lobe of the lung.
- If lung severely diseased
Pneumonectomy – removal of an entire lung.

- Isoniazide – numbness, tingling, burning in extremities. (pyridoxine (vit. B6) to prevent this effect.
- Rifampin – changes color of saliva tears, urine.
- Streptomycin – affects hearing balance.
- Ethambutol – affects vision and color perception.
- Isoniazide daily for 6-12 months is used to prevent active TB.

Recommended for persons:
- Living with or closely associated with newly diagnosed person with TB
- Positive skin reactions but normal chest radiographs.
- Positive skin test with chronic disease (DM), on steroids, post gastrectomy.
- Positive skin reactions in spite of history of negative reactions.
Nursing Process of Pulmonary Tubercolosis
Nursing assessment :
- Breath sounds, breathing pattern and respiratory status.
- Pain or discomfort while breathing.
- Sputum – color, viscosity, amount, signs of blood.
- Fatigue, weakness, anorexia, weight loss, night sweats,
- Low grade fever.
- Cough chest pain
- Ineffective airway clearance r/t pain with coughing , inability to cough, abnormal respirations.
- Assess cough, sputum ( color, consistency, amt, presence of blood)
- Encourage fluids (3-4lday)
- Humidify inspired air.
- DBCE 2hourly
- Semi-fowler’s position
- Postural drainage.
- Pain r/t chest expansion secondary to lung infection/inflammation.
- Assess pain level.
- Evaluate effectiveness of pain relief measures.
- Administer analgesics as ordered.
- Instruct use of splinting techniques.
Activity intolerance r/t general weakness, respiratory difficulty, fever, severity of illness.
- Encourage rest periods.
- Prioritize necessary tasks.
- Assist with activities as needed.
- Keep equipments close by.
- Encourage active ROM exercises 3 times a day.
Potential for side effects of medication therapy
- Take medications 1hr before or 2 hrs after meals – food interferes with medication absorbtion.
- Clients on INH avoid aged cheese, tuna, red wine, soy sauce, yeast extracts (tyramine and histamine foods)
- Clients on rifampin
- may need to readjust their dosages of betablockers, oral -anticoagulants as rifampin increases their metabolism.
- Wear eye glasses not contact lenses.
- Monitor LFT, RFT (BUN, Cr), skin rash, hearing loss, neuritis.
- Clients on rifampin and INH avoid alcohol – liver toxicity.
- Clients on ethambutol use caution while driving.
- Risk for infection.
- Knowledge regarding treatment regimen, disease condition, side-effe3cts of drugs.
- Ineffective therapeutic regimen management.

Discharge considerations for Pulmonary Tubercolosis
- Cover mouth when coughing, sneezing.
- Use disposable tissues to contain respiratory secretions
- Regular screening for high risk people.
- Prophylactic measures for those in close contact.
- Action , dose, timing, side effects of all medications.
- Report side-effects.
- Emphasize importance of long term therapy.
- Importance of \good ventilation, well balanced nutritious diet.
- Adequate rest.
- Avoid exposure to infection.
- Fluid intake 3-4 l/day.
- Avoid alcohol.
- Stop smoking and avoid exposure to secondary smoke.

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