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Pulmonary tuberculosis (PTB) is a chronic respiratory disease common among

crowded and poorly ventilated areas.

An acute or chronic infection caused by Mycobacterium tuberculosis,

tuberculosis is characterized by pulmonary infiltrates, formation of
granulomas with caseation, fibrosis, and cavitation.
Tuberculosis is an infectious disease that primarily affects the lung
It also may be transmitted to other parts of the body, including the
meninges, kidneys, bones, and lymph nodes.
The primary infectious agent, M. tuberculosis, is an acid-fast aerobic
rod that grows slowly and is sensitive to heat and ultraviolet light.

Tuberculosis is a highly infectious, airborne disease.

Inhalation. Tuberculosis begins when a susceptible person inhales

mycobacteria and becomes infected.
Transmission. The bacteria are transmitted through the airways to the
alveoli, and are also transported via lymph system and bloodstream to
other parts of the body.
Defense. The bodys immune system responds by initiating an
inflammatory reaction and phagocytes engulf many of the bacteria, and
TB-specific lymphocytes lyse the bacilli and normal tissue.
Protection. Granulomas new tissue masses of live and dead bacilli, ate
surrounded by macrophages, which form a protective wall.
Ghons tubercle. They are then transformed to a fibrous tissue mass, the
central portion of which is called a Ghon tubercle.
Scarring. The bacteria and macrophages turns into a cheesy mass that
may become calcified and form a collagenous scar.
Dormancy. At this point, the bacteria become dormant, and there is no
further progression of active disease.
Activation. After initial exposure and infection, active disease may
develop because of a compromised or inadequate immune system
Pathophysiology and Schematic Diagram for Pulmonary Tuberculosis

Data from the history, physical examination, TB test, chest xray, and microbiologic
studies are used to classify TB into one of five classes.

Class 0. There is no exposure or no infection.

Class 1. There is an exposure but no evidence of infection.
Class 2. There is latent infection but no disease.
Class 3. There is a disease and is clinically active.
Class 4. There is a disease but not clinically active.
Class 5. There is a suspected disease but the diagnosis is pending.

Statistics and Incidences

Tuberculosis is a worldwide public health problem that is closely associated with
poverty, malnutrition, overcrowding, substandard housing, and inadequate health
M. tuberculosis infects an estimated one-third of the worlds population
and remains the leading cause of death from infectious disease in the
According to the WHO, an estimated 1.6 million deaths resulted from TB
in 2005.
In the United States, almost 15,000 cases of TB are reported annually to
the CDC.
After exposure to M. tuberculosis, roughly 5% of infected people develop
active TB within a year.

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.

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

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
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

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

Respiratory failure. Respiratory failure is one of the most common

complication of pulmonary tuberculosis.
Pneumothorax. Pneumothorax becomes a complication when
tuberculosis is not treated properly.
Pneumonia. One of the most fatal complications of tuberculosis
is pneumonia as it could cause infection all over the lungs.

Assessment and Diagnostic Findings

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 4872 hr after
interdermal 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.
Bronchoscopy: Shows inflammation and altered lung tissue. May also be
performed to obtain sputum if patient is unable to produce an adequate
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).

Medical Management
Pulmonary tuberculosis is treated primarily with antituberculosis agents for 6 to 12

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 include INH
and rifampin or INH and rifapentine, and lasts for an additional 4 or 7
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.

Pharmacologic Therapy
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.
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.

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 Diagnosis
Based on the assessment data, the major nursing diagnoses for the patient include:

Risk for infection related to inadequate primary defenses and lowered

Ineffective airway clearance related to thick, viscous, or bloody
Risk for impaired gas exchange related to decrease in effective lung
Activity intolerance related to imbalance between oxygen supply and
Imbalanced nutrition: less than body requirements related to
inability to ingest adequate nutrients.

Nursing Care Planning & Goals

Main Article: 5 Pulmonary Tuberculosis Nursing Care Plans
The major goals for the patient include:

Promote airway clearance.

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

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 mouthand 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.

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.
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

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
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
Individual cultural or religious restrictions and personal preferences.Plan of
Plan of care.Teaching plan.
Teaching plan.Responses to interventions, teaching, and actions
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.