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PULMONARY

TUBERCULOSIS

REFERENCE

GOAL/OBJECTIVES
General
The general objective of this lecture is to broaden our knowledge about
the disease and develop skills on how to render the best possible care to a
patient suffering from Pulmonary Tuberculosis.

Specific
To be able to define Pulmonary Tuberculosis as well as on how it is
acquired, factors, signs and symptoms.
To apply and enhance our skills learned from this lecture to actual
handling and caring of a patient who suffered from Pulmonary
Tuberculosis.
To determine the possible nursing intervention that will be a great help in
patients prognosis.
To be able to give the appropriate health teaching and better
understanding of the disease to the patient, family and significant others.

TABLE OF CONTENTS

DISEASE DEFINITION
According to World Health organization (WHO) and Center for
Disease Control (CDC) they define Tuberculosis (TB) is caused by
bacteria (Mycobacterium tuberculosis) that most often affect the lungs.
Tuberculosis is curable and preventable. TB is spread from person to
person through the air. When people with lung TB cough, sneeze or spit,
they propel the TB germs into the air. A person needs to inhale only a few
of these germs to become infected. About onethird of the world's
population has latent TB, which means people have been infected by TB
bacteria but are not (yet) ill with the disease and cannot transmit the
disease. People infected with TB bacteria have a 10% lifetime risk of
falling ill with TB. However, persons with compromised immune systems,
such as people living with HIV, malnutrition or diabetes, or people who use
tobacco, have a much higher risk of falling ill.
As Department of Health (DOH) defines Tuberculosis as a disease
caused by a bacterium that is mainly acquired by inhalation of infectious
droplets containing viable tubercle bacilli. Infectious droplets can be
produced by coughing, sneezing, talking and singing. Coughing is
generally considered as the most efficient way of producing infectious
droplets. And as our institution San Lazaro Hospital (SLH), Tuberculosis
is a chronic bacterial infection and its characterized by formation of
granuloma in infected tissues and florid cell-mediated hypersensitivity.

DISEASE ETIOLOGY AND HISTORY


TUBERCULOSIS THROUGH THE AGES
Tuberculosis has a long history. People have been getting sick from
tuberculosis since we began walking upright! Over the years, different
cultures have understood tuberculosis differently what caused it, how to
cure it but the underlying effects of the disease are all described
similarly.
Ancient Egypt: We know that the
Egyptians suffered from tuberculosis 5500
years ago. Mummified remains dating to
3400 BCE have been found with tubercular
lesions and tomb drawings and sculptures
of hunchbacks suggest to many scholars
that some Egyptians suffered from Potts
disease. Medical papyri, such as the Ebers
papyrus, also describe treatment for lung
ailments that bear great similarity to tuberculosis.
Ancient India: Ancient Indian texts refers to
the treatment of consumption. The Rig-Veda,
written c. 1500 BCE, describes conditions that
suggest pulmonary tuberculosis. The AyurVeda, written in 700 BCE, states that, the
physician who wants great fame cures a man
attacked by consumption. The symptoms
and diagnosis of the disease were well
understood
by
this
point,
and
the
recommended treatments included improved diet and hygiene.
Ancient Greece:
The Hippocratic
Collection is compilation of sixty medical
books written over the course of several
hundred years. Though the number of
authors is unknown, it is speculated that
as many as twenty different authors
contributed to the works. The most
famous among these is believed to be
Hippocrates,
a
Greek
doctor
who
revolutionized medicine by disassociating disease with spiritual causes.
Written between the fifth century BCE and 200 CE, tuberculosis or
phthisis, as it was the called is referred to several times: Phthisis most
commonly occurs between the ages of eighteen and thirty-five years.
Aphorisms Section V, no. 9 ; In person with phthisis, if the sputa which
they cough up have a heavy smell when poured upon coals, and if the
hairs of the head fall off, the case will prove fatal. Aphorisms Section V,
no. 11.

Roman Empire: Roman doctors also dealt


with phthisis Galen, c 131 CE, listed signs
and symptoms of pulmonary phthisis to
include chest pain, cough, sputum, fever and
wasting. His suggested treatments included
rest,
increased
milk
consumption,
astringents, and the application of chest
plasters.

The Middle Ages and Early Modern


Europe: For centuries many people
believed that tuberculosis might be cured
by the touch of royalty. The practice of
having Kings and Queens touch the ill,
particularly those with scrofula (A form of
tuberculosis affecting the lymph nodes,
especially of the neck, that is most
common in children and is usually spread
by unpasteurized milk from infected cows) to cure them dates as far back
as 496 CE. It was believed that God gave the power of healing to the true
line of royalty. Edward I (1272-1307) reportedly touched 533 people in one
month, while Philip of Valois (1328-1340) touches 1500 in one ceremony.
Charles II, King of England from 1660-1685, is said to have touched nearly
100,000 subjects in an attempt to cure them. In 1772, as part of his
coronation ceremony, King Louis XV of France laid hands on over 2000
individuals inflicted with scrofula. The Practice of healing hands
continued into the eighteenth century in England and into the early
nineteenth century in France. Shakespeares Macbeth describes the Royal
Touch.
19th Century Europe and North America: During the 19th century
tuberculosis was commonly called the White Plague because of the pallor
of its victims. In the midst of the Romantic Movement in art and literature,
tuberculosis symbolized tragic beauty. In 1852 Henry David Thoreau
wrote: decay and disease are often beautiful, like the pearly tear of the
shellfish and the hectic glow of consumption. Those suffering from the
disease were idealized because of the intensity of emotion they could
experience and their heroism in the face of tragedy. So many artist were
afflicted with tuberculosis that the disease became associated with them.
After the peak of the Industrial Revolution the incidence of tuberculosis
increased, causing the Romantic view of the disease to face. Tuberculosis
continued to be a popular subject in literature, though. Thomas Manns
The Magic Mountain (1924) is considered by some to be the most
influential work of twentieth century German literature. In it the
protagonist visits his cousin in a Swiss sanatorium, only to come down

with symptoms of tuberculosis himself and


remain at the sanatorium for seven years.

PTB Cases and Deaths


San Lazaro Hospital, 2010-2015
2,750

2,500

2,250

2,000

1,750

1,500

2
1,250

1,000

750
500

250

2010

2011

2012
Cases

2013
Deaths

CFR (%)

INCIDENCE/PREVALENCE RATE

2014

2015

INCUBATION PERIOD AND PERIOD OF


COMMUNICABILITY

DISEASE
TYPES/CLASSIFICATION/STAGES/PHASE
S OF ILLNESS
DISEASE TYPE:
PULMONARY TUBERCULOSIS
Representing approximately 75% of all tuberculosis cases, pulmonary TB
is the most common form of the disease. Although the body forms a
tubercle around the invading bacteria, they can continue to replicate
inside, causing the tubercle to grow. As it gets larger, it may invade
different parts of the lung, affecting the ability to breathe or entering
blood supply lines. Eventually the tubercle may grow so large that it
bursts, spreading the bacteria that were inside.

EXTRA-PULMONARY TUBERCULOSIS
Adrenal Glands
When tuberculosis attacks the adrenal glands they become ineffective at
producing hormones, such as cortisol causing adrenal insufficiency.
Symptoms include weakness, muscle fatigue, weight loss, nausea and
vomiting. Today TB accounts for 20% of the cases of adrenal insufficiency
in developed countries.

Lymph Nodes
When the lymph nodes are infected, in the neck or elsewhere in the body,
they swell. Other symptoms may include fever and sweating. E.g. Scrofula

Central Nervous System


When the meninges, the membranes that surround the central nervous
system (i.e spinal cord, brain) are infected they become inflamed which
can affect brain and motor function. Fever and headache are the most
common signs and symptoms. This tubercular infection is usually fatal and
affects children more frequently that adults. E.g. Tuberculous meningitis.

Genito-Urinary
Tuberculosis of the genito-urinary system can manifest in a variety of
symptoms depending on the location of the infection and its severity.
Infection can produce fibrosis which in turn can cause ureter stricture and
other blockages. It can also cause infertility, genital ulcers and kidney
malfunction.

Cutaneous

When tuberculosis affects the skin it presents as lesions and growths that
can persist for years and often leave scarring. e.g Lupus Vulgaris

Gastrointestinal
Whether caused by the ingestion of tainted food products, or by
swallowing infected sputum from the lungs, TB in the digestive tract
produces ulcer-like lesions. Signs and symptoms include abdominal pain,
diarrhea and blood in the stool.

Osteo-Articular
When TB affects the joints or the spine, it causes a softening of the bones.
As the bones soften, they can compress in the spine this may cause a
hunchback while in the joints this can present with arthritis like symptoms.
e.g Potts disease.

Cardiac
If the tuberculous bacteria spread to the heart, they most commonly
affect the pericardium, the sac that contains the heart and part of the
major blood vessels. The presence and growth of the tubercles can cause
fibrosis and a hardening of the pericardium which can restrict the action of
the heart. e.g Tuberculous pericarditis

Miliary
Miliary tuberculosis refers to a tuberculosis infection that has spread to
multiple locations in the body through the blood stream or lymph system.
It is characterized by the presence of multiple, small seed-like collections
of bacilli, rather than larger granulomas.

SIGNS AND SYMPTOMS AND PHYSICAL


EXAMINATION

PATHOGENESIS

DIAGNOSTIC/CONFIRMATORY/LABS AND
PARAMETERS FOR ADMINISTRATION
Parameters For Admission
Any known PTB case with any of the following:
1. Massive hemoptysis
2. Severe dyspnea
3. Chest X-ray findings of:
- Pleural effusion obliterating more than of lung field
- Pneumothorax
- Atelectasis
- Pneumonia

MEDICAL (include major drugs and


vaccination)
AND
NURSING
MANAGEMENT
(Disease
specific,
include 3 prioritized NCP)

M.E.T.H.O.D.S
APPROACH
discharge parameters)

(include

Criteria For Discharge:


1. Patient is without episode of hemoptysis for at least 48
hours
2. No episodes of difficulty of breathing for at least 48 hours
3. Afebrile for three (3) days
4. Completed three (3) days sputum examination with AFB
and chest x-ray result
5. No complications were noted after three (3) days postextubation for cases that underwent CTT

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