Adult Medical-Surgical Nursing

1. Adult Medical-Surgical Nursing Respiratory Module: Tuberculosis

2. Tuberculosis (TB):Description • Tuberculosis is a chronic infectious disease primarily of the lungs (but may spread elsewhere through blood/ lymph) • Caused by Mycobacterium Tuberculosis, an acid-fast bacillus • Spread by droplet infection: very infectious in close communities

3. Tuberculosis: Epidemiology/ Incidence • TB is the leading cause of death from infectious disease world-wide • Associated with poverty, malnutrition, overcrowding, poor health care, HIV • A historical decline of TB occurred in C20 in some areas with ↑ housing, sanitation nutrition (↑ immunity) and later antibiotics • Now increased incidence, associated with migration, HIV, multi-drug resistance

4. Tuberculosis: Pathophysiology • TB bacilli are inhaled and start to multiply in the alveoli • Inflammatory/ immune response occurs (2-10 weeks post-exposure): • Exudate accumulates in the alveoli (bronchopneumonia) →

5. Tuberculosis: Pathophysiology • Disease progression leads to formation of granulomas in the alveoli (live and dead bacilli surrounded by macrophages) → • Granulomas fibrose surrounding a necrotic centre: “Ghon Tubercles” → • Calcification = dormant state (no longer active disease)

6. Tuberculosis: Reinfection • If while TB is dormant patient immunity becomes low: • Reinfection/ re-activation occurs from the dormant state → • Active disease • The Ghon Tubercles ulcerate, releasing the cheesy material with live bacilli into the bronchi • Bacilli are airborne and spread the disease

7. Tuberculosis: Progression of the disease • TB is a chronic respiratory disease with: • Slow progression in the lung • Long remission periods • Untreated disease spreads to other organs via the blood and lymph (kidneys, bone, brain) • Prolonged intensive treatment required to eradicate the bacilli • Health/ immune response affects progress

8. Tuberculosis: Clinical Manifestations • Insidious onset • Low grade fever • Cough: • Non-productive, mucopurulent or haemoptysis - “rusty” • Night sweats • Fatigue • Weight loss

9. Tuberculosis: Diagnosis • Chest Xray (AP/ lateral) • Sputum for Acid-Fast Bacilli (AFB) • Mantoux (PPD) tuberculin skin test: wheel/flare reaction read at 48-72 hours (if immunosuppressed may be no reaction) • QuantiFERON-TB Gold Test: enzyme-linked immunosorbent assay (ELISA) blood test to detect interferon-gamma released from white blood cells in TB

10. Tuberculosis: Diagnosis • To monitor spread of disease outside the lungs: • Skeletal Xray • Early morning urine samples for AFB

11. Tuberculosis: Management • Notification to the Ministry of Health • Immediate follow-up and screening of all contacts (given prophylactic treatment) • If active TB, respiratory isolation until remission (usually non-infectious after 2-3 weeks of continuous therapy) • Intensive antibiotic therapy over 6-12 months to prevent relapse

12. Tuberculosis: Antibiotic Therapy • Anti-TB antibiotic drugs are: • Rifampicin • Pyrazinamide • Isoniazid (INH) • Streptomycin • Ethambutol

13. Tuberculosis: Antibiotic Treatment Regime • Atleast 4 drugs used intensively for the first 8 weeks • If sputum culture is sensitive to the drugs: • Treatment with 3 drugs for further 8 weeks (stop Streptomycin or Ethambucil) • Isoniazid (INH) and Rifampicin therapy for further 4-8 months (total 8-12 months) • Vitamin B6 taken with INH to avoid neuropathy

14. Tuberculosis:Nursing Considerations • Follow-up screening of all contacts • Patient and family education: • The importance of strict adherence to medication (* if not taken regularly resistance develops*) • Avoidance of spread of disease (isolation): health education • Importance of good nutrition, hygiene, adequate housing in improving immunity

15. Tuberculosis: Follow-up/Monitoring Progress • Monitor progress through: • Vital signs (spiking temperature) • Night sweats • Weight (gain/ loss) • Regular chest Xrays • Sputum samples • Monitor for drug side-effects