NORTHERN CHRISTIAN COLLEGE, INC

The Institution for Better Life

Laoag City

In partial fulfillment of the requirements in NCM 112

TUBERCULOSIS

GROUP 1

MEMBERS:
ADONAY, ELIJAH JIREH R.
AGNIR, JATHNIEL JOSH B.
AGONOY GLAIZA LEIGH R.
AGUB, MARNELIE
ALONZO, RIZZA
ARGEL, SHARIES MAE R.
BALLESTEROS, XERLAN GELLA T.
BANIAGA, DAICEEBEL R.
BENAVIDEZ, BEA T.
DOMINGO, ALOHA LEI
BSN-3B

October 13, 2023

 I. INTRODUCTION:

Tuberculosis, often referred to as TB, is a contagious bacterial infection that has

plagued humanity for centuries. It remains a significant global health concern, with millions of

new cases reported each year. Our group's concept map aims to provide a comprehensive

understanding of this infectious disease by breaking down its various aspects, from its origins

to the strategies employed for its diagnosis and management.

Tuberculosis is caused by the bacterium Mycobacterium tuberculosis and primarily

affects the lungs. However, it can also target other organs and systems within the body. The

disease is transmitted from person to person or animal-person through the inhalation of

respiratory droplets containing the bacteria, making it a significant public health issue. While

TB is preventable and curable, its continued existence and resurgence in some regions

underscore the importance of a thorough understanding of its various dimensions, including

predisposing factors, pathophysiology, clinical manifestations, diagnostic tests, medical

management, and nursing interventions. In the pages that follow, we will explore each of these

facets in detail to create a comprehensive concept map that helps shed light on this global health

challenge.
 II. MANIFESTATIONS:

• Chronic cough (>2 weeks) - Dry/Productive

• Low grade fever - remittent (appears late afternoon and fades out)
• Anorexia - inhibiting action of cytokines on the hypothalamus
• Weight loss
• Night sweats
• Progressive pulmonary involvement - increasing amounts of sputum
• Hemoptysis - aggressive disease
• Pleuritic type chest pain - extension of the infection to plural surfaces

III. PREDISPOSING FACTORS:

Medical factors

There are medical conditions that can increase your risk of developing tuberculosis.

• Immunosuppression

A weakened immune system makes it harder for your body to fight infection and more

likely that latent TB becomes active. It also makes it more likely to be infected with TB in the

first place.

The following conditions can impair a person's immune system:

• Age: The immune systems of the very young and the very old tend to be weak.

• Chemotherapy: These treatments fight cancer but also weaken your immune system.

• Corticosteroids: Anyone who takes oral steroids long-term, the equivalent of 15 mg

prednisolone for a month or longer, has a weakened immune system.

 • HIV/AIDS: The risk of developing TB is estimated to be at least 16 times greater for

people who also have HIV. As HIV disease worsens or progresses to AIDS, the risk for

TB increases further.

• Organ transplants: To prevent the body from rejecting a transplanted organ (heart,

kidney, or liver), people typically take life-long immunosuppressant medications.

Chronic Medical Conditions

The following conditions could increase your risk for TB infection:

• Celiac disease, Chronic hepatitis, Chronic obstructive lung disease (COPD), Cirrhosis,

Diabetes, Gastric bypass surgery, Head and neck cancer, Kidney disease, Silicosis

Some of these conditions impair the immune system or prevent adequate nutrient absorption.

If you have one of these conditions, take steps to decrease your possible TB exposure.

Lifestyle Factors

There are non-medical risk factors of TB that may be more within your control. Issues

like poverty, homelessness, and decreased access to health care can make managing some of

these factors challenging.

Diet and Nutrition

Poor nutrition plays a role in TB infection. Severe malnutrition weakens the immune

system and leads to weight loss. People who are underweight are twice as likely to be infected

than people with a higher BMI.

When it comes to specific nutrients, iron and vitamin D levels can have an impact:
 • High iron levels in the blood may promote the growth of mycobacteria, making people

more susceptible to TB.

• Vitamin D restricts the growth of mycobacteria, so a deficiency can increase your risk.

Vitamin D deficiency is a risk factor for tuberculosis.

Whenever possible, it is important to eat a nutrient-rich diet and maintain a healthy

weight. Socioeconomic situations often make it challenging to do that.

Living Conditions

TB can spread quickly when people are in crowded and poorly ventilated living and

working environments. Crowded conditions within a community or even within a household

increase that risk considerably. This is especially true when there is poor ventilation within a

building. Homeless shelters, in particular, can be overcrowded and are not always properly

maintained.

Substance Abuse

Substance abuse is prevalent among people infected with TB. Smoking cigarettes

increases your risk as much as two-fold. Illicit drug use, whether injection or non-injection,

and drinking 40 grams or more of alcohol per day also increase the odds of TB transmission.
IV. PATHOPHYSIOLOGY

The sources of this infection are persons with pulmonary tuberculosis or cows with

mycobacterium bovis infection. Therefore, after inhalation of mycobacterium-infected aerosol

or ingestion of Mycobacterium bovis-infected milk and/or other dairy products through the

trachea, the bacteria will eventually reach the alveoli of the lungs. So, when the mycobacterium

reaches the alveoli, the macrophages will eventually detect the presence of pathogens, wherein

the alveolar macrophages are the immune system in the alveoli. After the macrophages detected

the pathogens, it will undergo the process of phagocytosis, wherein a cell will bind to the

mycobacterium to engulf on the surface. When the cell encapsulates the mycobacterium

tuberculosis, it is termed as phagosome, and to eradicate the pathogen, the macrophages have

lysosome with hydrolytic enzymes and under normal immune response. The lysosome fuses

with phagosome to form phago-lysosome, in which the pathogen is dissolved with acids and

finally gets eliminated. But in the case of tuberculosis, the phagosome and lysosome do not

fuse together or fusion is inhibited and the mycobacterium tuberculosis is remained and

protected inside the macrophages without being detected by the immune system. So, ultimately

the bacteria will replicate inside the macrophages and primary infection will occur. Three

weeks after the primary infection, the cell mediated immunity kicks in, and immune cells

surround the site of infection and form granuloma. The granuloma is being formed to surround

the infection site to prevent the mycobacterium from exiting the macrophages. In a significant

proportion of cases, the immune response effectively controls the infection. This phase is called

the Latent Tuberculosis. In this phase, the mycobacterium is still present within the granulomas

but are not actively multiplying. Thus, the patient won’t be experiencing any symptoms.

However, if the immune system cannot control the bacteria, active tuberculosis would occur

resulting to the multiplication of the bacteria. After that, it’s either the pathogens will enter and
will damage the lung tissue, wherein it is called pulmonary tuberculosis. Therefore, the person

will experience night sweats, fever, persistent cough, weight loss and fatigue. On the other

hand, we also have the extrapulmonary tuberculosis, in which the pathogens will spread

through the blood stream/lymphatic system. In here, the patient might experience/have CNS

tuberculosis, skeletal tuberculosis, lymphatic tuberculosis, and many more. Nonetheless, in the

Latent TB, reactivation to active TB might occur when the immune system is compromised,

often due to conditions like HIV infection, malnutrition, and immunosuppressive medications.

V. MEDICAL MANAGEMENT

Pulmonary TB is primarily treated for 6 to 12 months with anti-tuberculosis medications:

• Pharmacological management
• First line antitubercular medications
• Streptomycin 15mg/kg/day
• Isoniazid or INH (Nydrazid) 5 mg/kg (300 mg/max/day
• Rifampicin 10mg/kg/day
• Pyrazinamide 15-30 mg/kg/day
• Ethambutol (Myambutol) 12-25 mg/kg daily weeks and continuing for up to 4 to 7
months

Second line medications

• Capreomycin 12 – 15 mg/kg
• Ethionamide 15mg/kg
• Para-aminosalycilate sodium 200 -300 mg/kg
• Cycloserine 15 mg/kg
• Vitamin b (pyridoxine) ususally administered with INH

Third line drugs

• Other drugs that may be useful, but are not on the WHO list of SLDs:
• Rifabutin
• Macrolides,clarithromycin (CLR)
• Linezolid (LZD)
• Thioacetazone
• Thioridazine
• Arginine
DOTS
• DOTS (directly observed treatment, short – course) is the name given to the World
Health Organization recommended tuberculosis control strategy that combines five
components:
1. Government commitment (including both political will at all levels, and
establishing a centralized and prioritized system of TB monitoring, recording
and training).
2. Case detection by sputum smear microscopy
3. Standardized treatment regimen driectly observed by a healthcare worker or
community health worker for at least the first two months.
4. A regular drug supply
5. A standardized recording and reporting system allows assessment of treatment
results

• DOTS is especially critical for patients with drug resistant TB, HIV – infected patients
and those on intermittent treatment regimens. (2 or 4 months weekly)

Multiple-drug therapy
• Means taking several different antitubercular drugs at the same time
• The standard treatment is to take isoniazid, rifampin, ethambutol, and pyrazinamide for
2 months. Treatment is then continued for at least 4 months with fewer medicines.
VI. NURSING MANAGEMENT:

The nursing management of Tuberculosis involves various aspects, including prevention,

screening, diagnosis, treatment, and monitoring. Nurses play a critical role in the management
of TB, as they are often the first healthcare professionals to come into contact with patients
with suspected or confirmed TB.

I. Prevention of TB involves identifying and addressing risk factor such as close

contact with a person with active TB, immunosuppression, and poor living
conditions.
✓ Nurses can educate patients about ways to prevent TB, such as
maintaining good personal hygiene, improving ventilation in living
spaces, and getting vaccinated against TB if available.
II. Screening for TB involves identifying individuals at increased risk for TB
infection or disease and conducting tests to detect TB.
✓ Nurses can perform a thorough assessment of patients to identify risk
factors and recommend screening tests such as the Mantoux skin test
or the interferon-gamma release assay (IGRA).
III. Diagnosis of TB involves identifying the presence of Microbial tuberculosis in the
patient’s body.
 ✓ Nurses can assist with collecting and processing specimens for
laboratory testing, such as sputum samples or other body fluids.
IV. Treatment of TB involves a combination of medications, typically taken for
several months.
✓ Nurses can educate patients about the importance of adhering to the
medication regimen, monitor for adverse effects, and provide support
to help patients complete the full course of treatment.
V. Monitoring of TB involves regular follow-up to ensure that patients are
responding to treatment and to detect any potential complications.
✓ Nurses can monitor patients’ symptoms, provide ongoing education
and support, and collaborate with other healthcare professionals to
ensure coordinated care.
Nursing Assessment:

i. Medical history
Nurses should ask the patient about their symptoms, such as coughing, chest pain, fever, night
sweats, and weight loss. They should also ask about their medical history, including any past
TB infections or treatments, and their exposure to TB.

ii. Physical examination

Nurses should perform a physical examination to assess the patient’s respiratory status. This
includes auscultation of the lungs for abnormal sounds, such as crackles or wheezes, and
palpation of the chest for tenderness or swelling.

iii. Diagnostic tests

Nurses may order diagnostic tests, such as a chest X-ray or sputum culture, to confirm the
diagnosis of TB. They may also order a tuberculin skin test (TST) or interferon-gamma release
assay (IGRA) to screen for latent TB infection.

iv. Risk assessment

Nurses should assess the patient’s risk factors for TB, such as being immunocompromised,
living in overcrowded or poorly ventilated environments, or having close contact with someone
who has TB.

v. Psychosocial assessment
Nurses should also assess the patient’s psychosocial status, including their mental health,
support system, and ability to adhere to treatment.

vi. Infection control assessment

Nurses should assess the patient’s ability to comply with infection control measures, such as
wearing a mask, covering their mouth and nose when coughing or sneezing, and avoiding close
contact with others.
 VI. DIAGNOSTIC TEST

Diagnosing tuberculosis (TB) typically involves a combination of clinical evaluation, medical

history, and various diagnostic tests. The choice of diagnostic test may depend on the patient's
symptoms, risk factors, and local healthcare resources.

SPUTUM EXAMINATION is a diagnostic procedure that involves the analysis of mucus and
other material coughed up from the lower respiratory tract (lungs and bronchial tubes). It is
primarily used to diagnose respiratory infections, including tuberculosis, pneumonia, and
chronic obstructive pulmonary disease (COPD).

Specimen: Phlegm

Collection of Sputum: A patient is asked to produce a sputum sample by hands on the waist
breath 3x (deep) coughing deeply and collect, usually in the morning, to obtain the most
representative sample.

Handling and Transport: The collected sputum should be collected in a sterile container and
handled with care to prevent contamination. Proper labeling and transportation are essential to
ensure accurate testing.

Microscopic Examination: The sputum sample is examined under a microscope to check for
the presence of bacteria, fungi, or abnormal cells. In the case of tuberculosis, acid-fast staining
is used to identify Mycobacterium tuberculosis, the bacteria causing TB.

Cultural Examination: The sputum is cultured in a special medium to encourage the growth
of bacteria, allowing for the identification of specific pathogens. This helps determine the type
of infection and its sensitivity to antibiotics.

Drug Susceptibility Testing: In the case of TB, a drug susceptibility test is conducted to
determine which antibiotics are effective against the tuberculosis bacteria and which are not.

Results Interpretation: Healthcare professionals interpret the results of sputum examination

to make a diagnosis. Positive results may indicate the presence of an infectious agent, while
negative results do not rule out infection entirely.

Sputum examination is a valuable tool in diagnosing respiratory infections and monitoring

treatment progress. It helps healthcare providers select appropriate treatments, especially for
diseases like tuberculosis, where accurate diagnosis is crucial for effective management and
prevention of disease spread.

Other diagnostic tests include:

Tuberculin Skin Test (TST) or Mantoux Test:

 • A small amount of purified protein derivative (PPD) derived from the Mycobacterium
tuberculosis bacterium is injected under the skin.
• A positive result shows a delayed-type hypersensitivity reaction at the injection site. It
does not confirm active TB but indicates exposure to the TB bacteria.

Interferon-Gamma Release Assays (IGRAs):

• Blood tests, such as the QuantiFERON-TB Gold In-Tube and T-SPOT.TB, measure the
release of interferon-gamma by T-cells in response to TB antigens.
• These tests are more specific than the TST and are used to detect latent TB infection.

Sputum Culture:

• The "gold standard" for TB diagnosis is the isolation and identification of

Mycobacterium tuberculosis in a culture of the patient's sputum or other body fluids.
• It is more sensitive than smear microscopy and allows for drug susceptibility testing.

It's important to note that the choice of diagnostic tests can vary depending on the
clinical presentation, the availability of resources, and the specific goals of diagnosis. In
many cases, a combination of tests may be used to confirm or rule out active tuberculosis
and to assess drug susceptibility for effective treatment.

VII. COMPLICATIONS
• Bones. Spinal pain and joint destruction may result from TB that infects your bone s
(TB spine or pots spine)
• Brain. (Meningitis)
• Liver or kidneys
• Heart (cardiac tamponade)
• Pleural effusion
• TB pneumonia
• Serious reactions to drug therapy (hepato toxicity; hypertensitivity)