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INTRODUCTION
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.
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
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 LUNGS
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
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
I. DIAGNOSTIC TEST
1. Sputum Culture
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
to:
1. Determine the clinical activity of TB, whether it is inactive(any control) or
active(ongoing)
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
person
• Recurrence
Leads to
Inhalation/exposure
of M. Tuberculosis
through
Airway to alveoli
causing
Inflammatory
reaction &
phagocytosis
causing
Accumulation of
exudates in the
Alveoli
Ghon Tubercle
(Bacteria &
Macrophages)
leads to
Necrosis (forming a
cheesy mass)
Calcification/Liquifica
tion
Tubercle Bacilli
Immunity develops
DIAGNOSIS (2-6 weeks after
infection)
• Sputum causing
Culture
• Tuberculin Bacteria become
Skin Test dormant
• Chest X-
ray
PULMONARY
TUBERCULOSIS
I. MEDICATIONS
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
Anti-TB drugs No. of tablets/vial per day No. of tablets per day
Intensive Phase Continuation Phase
(3 months) (5 months)
Isoniazid (H) 1 1 1
Rifampicin (R) 1 1 1
Pyrazinamide (Z) 2 2
Ethambutol (E) 2 2 2
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
ISONIAZID
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.
RIFAMPICIN
Action: it is a broad-spectrum bactericidal drug that kills the offending organism by inhibiting
protein synthesis.
Nursing Intervention:
PYRAZINAMIDE
Action: Unknown, but it is believed to work by inhibiting lipid & nucleic acid synthesis in the
mycobacteria.
Nursing Intervention:
• Always give pyrazinamide with other antituberculotics to prevent the development of resistant
organisms.
• 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.
ETHAMBUTOL
Adverse effects:
Nursing Intervention:
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
STREPTOMYCIN
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:
GI: Nausea, vomiting, anorexia, increased ALT, AST, bilirubin, hepatomegaly, hepatic necrosis,
splenomegaly
GU: oliguria, hematuria, renal damage, renal failure, nephrotoxicity
Nursing Intervention:
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
CUES:
Objective:
➢ Increased RR-32 bpm
➢ Decreased O2 Sat-90%
➢ (+) cyanosis
NURSING INTERVENTION:
Independent:
➢ 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.
Collaborative:
CUES:
Objective:
➢ Decreased O2 Sat=90%
➢ Nasal flaring
➢ Sputum characteristics (green, purulent, yellowish mucoid)
NURSING INTERVENTION:
Independent:
Priority no. 3:
by purulent sputum
CUES:
Objective:
➢ Night fever
➢ Chills
➢ Greenish sputum
NURSING INTERVENTION:
Independent:
➢ Instruct patient to cough/sneeze and expectorate into tissue and refrain from
spitting.
➢ Review necessity of infection control measures, e.g. temporary respiratory
isolation.
➢ 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.
Collaborative:
Priority no. 4:
NURSING DIAGNOSIS: Imbalanced Nutrition, less than body requirements related to frequent
cough as evidenced by lack of interest in food.
CUES:
Objective:
NURSING INTERVENTIONS:
Independent:
Collaborative:
Priority no. 5:
NURSING DIAGNOSIS: Activity intolerance related to imbalance between oxygen supply and
demand.
CUES:
Objective:
➢ (+) cyanosis
➢ Increased RR
➢ Decreased tolerance to activity
NURSING INTERVENTION:
Independent:
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.
IX. DISCHARGE PLAN AND HEALTH EDUCATION PLAN
DISCHARGE PLAN
Medications
Medications Dosage/Frequency Nursing Instructions
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
minutes.
Diet:
• Include a liberal amount of calcium in your diet to promote healing of tuberculin
lesions
Spiritual care:
• Encourage patient to have regular prayer time to promote relaxation and to meditate.
Materials Needed:
1. Pamphlets
2. Visual Aid
IX. PROGNOSIS
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
quickly.