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Osano, Denise R.

Penaranda, Elisa C.

Reyes, Mary Louise Joanna F.

Salazar, Renmar John A.

Santander, Sheena L.

Silab, Ann Colleen T.

Tumaliuan, Santiboy N,

Viduya Lady Anne Rosette M.

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TUBERCULOSIS

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Pulmonary tuberculosis is an infectious disease caused by slow- growingbacteria that resembles a fungus, Mycobacterium tuberculosis, which isusually spread from person to person by droplet nuclei through the air. Thelung is the usual infection site but the disease can occur elsewhere in thebody. Typically, the bacteria from lesion (tubercle) in the alveoli. The lesionmay 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 directlyto adjacent tissue, through the blood stream, the lymphatic system, or thebronchi.

Most people who become infected do not develop clinical illness because thebodys immune system brings the infection under control. However, theincidence of tuberculosis (especially drug resistant varieties) is rising.Alcoholics, the homeless and patients infected with the humanimmunodeficiency virus (HIV) are especially at risk. Complications oftuberculosis include pneumonia, pleural effusion, and extra pulmonarydisease.

PTB

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Symptoms

The primary stage of TB usually doesn't cause symptoms. When symptoms ofpulmonary TB occur, they may include:

Cough (usually cough up mucus)

Coughing up blood

Excessive sweating, especially at night

Fatigue

Fever

Unintentional weight loss

Other symptoms that may occur with this disease:

Breathing difficulty

Chest pain

Wheezing

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Causes

Pulmonary tuberculosis (TB) is caused by the bacteria Mycobacterium tuberculosis (M.tuberculosis). You can get TB by breathing in air droplets from a cough or sneeze of aninfected person. This is called primary TB.

In the United States, most people will recover from primary TB infection withoutfurther evidence of the disease. The infection may stay asleep or inactive (dormant)for years. However, in some people it can reactivate.

Most people who develop symptoms of a TB infection first became infected in the

past. However, in some cases, the disease may become active within weeks after theprimary infection.

The following people are at higher risk for active TB:

Elderly

Infants People with weakened immune systems, for example due to AIDS, chemotherapy,

diabetes, or certain medications

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Risk factors

There are a number factors that make people more susceptible to TB infections.Worldwide the most important of these is HIV with co-infection present in about 13% ofcases. This is a particular problem in Sub-Saharan Africa where rates of HIV are high.

Tuberculosis is closely linked to both over crowding and malnutrition making it one ofthe principal diseases of poverty. Chronic lung disease is a risk factor with smokingmore than 20 cigarettes a day increasing the risk by two to four times and silicosisincreasing the risk about 30 fold. Other disease states that increase the risk ofdeveloping tuberculosis include alcoholism and diabetes mellitus (threefold increase).Certain medications such as corticosteroids and Infliximab (an anti-TNF monoclonalantibody) are becoming increasingly important risk factors, especially in the developedworld. There is also a genetic susceptibility for which overall importance is stillundefined.

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Mycobacterium

The main cause of TB is, Mycobacterium tuberculosis, a small aerobic non-motilebacillus or less commonly the closely related Mycobacterium bovis. The high lipidcontent of this pathogen accounts for many of its unique clinical characteristics. Itdivides every 16 to 20 hours, an extremely slow rate compared with other bacteria,which usually divide in less than an hour. Since MTB has a cell wall but lacks aphospholipid outer membrane, it is classified as a Gram-positive bacterium.However, if a Gram stain is performed, MTB either stains very weakly Gram-positiveor does not retain dye as a result of the high lipid and mycolic acid content of its cell

wall. MTB can withstand weak disinfectants and survive in a dry state for weeks. Innature, the bacterium can grow only within the cells of a host organism, but M.tuberculosis can be cultured in the laboratory.

Using histological stains on expectorate samples from phlegm (also called sputum),scientists can identify MTB under a regular microscope. Since MTB retains certainstains after being treated with acidic solution, it is classified as an acid-fast bacillus

(AFB).[The most common acid-fast staining technique, the Ziehl-Neelsen stain, dyesAFBs a bright red that stands out clearly against a blue background. Other ways tovisualize AFBs include an auramine-rhodamine stain and fluorescent microscopy.

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Diagnosis

Tuberculosis is diagnosed definitively by identifying the causative organism(Mycobacterium tuberculosis) in a clinical sample (for example, sputum or pus). Whenthis is not possible, a probablealthough sometimes inconclusive-diagnosis may be

made using imaging (X-rays or scans), a tuberculin skin test (Mantoux test), or a,Interferon Gamma Release Assay (IGRA).

The main problem with tuberculosis diagnosis is the difficulty in culturing this slow-growing organism in the laboratory (it may take 4 to 12 weeks for blood or sputumculture). A complete medical evaluation for TB must include a medical history, a physicalexamination, a chest X-ray, microbiological smears, and cultures. It may also include atuberculin skin test, a serological test. The interpretation of the tuberculin skin testdepends upon the person's risk factors for infection and progression to TB disease, suchas exposure to other cases of TB or immunosuppression.

New TB tests have been developed that are fast and accurate. These include polymerasechain reaction assays for the detection of bacterial DNA. One such molecular diagnosticstest gives results in 100 minutes and is currently being offered to 116 low- and middle-income countries at a discount with support from WHO and the Bill and Melinda Gates

foundation.

Another such test, which was approved by the FDA in 1996, is the amplifiedmycobacterium tuberculosis direct test (MTD, Gen-Probe). This test yields results in 2.5to 3.5 hours, and it is highly sensitive and specific when used to test smears positive foracid-fast bacilli (AFB).

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Transmission

When people with active pulmonary TB cough, sneeze, speak, sing, or spit, they expelinfectious aerosol droplets 0.5 to 5 m in diameter. A single sneeze can release up to40,000 droplets. Each one of these droplets may transmit the disease, since the

infectious dose of tuberculosis is very low and inhaling fewer than ten bacteria maycause an infection.

People with prolonged, frequent, or intense contact are at particularly high risk ofbecoming infected, with an estimated 22% infection rate. A person with active butuntreated tuberculosis can infect 1015 other people per year. Others at risk includepeople in areas where TB is common, people who inject illicit drugs, residents andemployees of high-risk congregate settings, medically under-served and low-incomepopulations, high-risk racial or ethnic minority populations, children exposed to adultsin high-risk categories, those who are immunocompromised by conditions such asHIV/AIDS, people who take immunosuppressant drugs, and health care workers servingthese high-risk clients.

Transmission can only occur from people with activenot latentTB. The probability oftransmission from one person to another depends upon the number of infectious

droplets expelled by a carrier, the effectiveness of ventilation, the duration of exposure,and the virulence of the M. tuberculosis strain. The chain of transmission can be brokenby isolating people with active disease and starting effective anti-tuberculous therapy.After two weeks of such treatment, people with non-resistant active TB generally ceaseto be contagious. If someone does become infected, then it will take three to fourweeks before the newly infected person can transmit the disease to others.

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Tuberculosis, sometimes called primary complex, is a disease that affects

people across the world. The World Health Organization (WHO) estimatesthat 100,000 children die of tuberculosis every year, and Kenyon College inOhio claims that the disease is responsible for more deaths in young peoplethat any other communicable disease in the world. Most child deaths causedby tuberculosis occur in low-income areas.

Cause

Tuberculosis is caused by infection from the bacteria Mycobacteriumtuberculosis. It is contracted by inhaling tuberculosis bacilli, the immatureform of Mycobacterium tuberculosis, in the air. Tuberculosis bacilli arespread through coughing, sneezing, breathing and talking. Once breathedin, tuberculosis bacilli can sit in the lungs for an extended period of time and

may not ever develop into full-blown tuberculosis, as the WHO estimatesthat only 10 percent of cases develop into the disease. Fewer bacteria sit inthe lungs of children infected with the disease, making them less infectious.

PRIMARY COMPLEX

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Symptoms

In the first stage of tuberculosis in a child, the bacteria infect the lungs. At thispoint, the bacteria may remain latent. In rare cases, the child's immune system may

be strong enough at this point to fight the infection,. Four or five months later, inthe next stage, the main symptoms of tuberculosis become apparent. These includepneumonia, liquid on the lungs, and collapse of the lungs. More apparent symptomsinclude weight loss and heavy coughing. There are no apparent symptoms in thefinal stage, but the bacteria are usually still present in the lungs and may causeanother infection.

Diagnosis

Tuberculosis is difficult to diagnose in children because a lot of the methods used todiagnose the disease, such as chest radiographs, have difficulty distinguishingtuberculosis in a child from other chest and lung infections, such as pneumonia.Testing the sputum coughed up by a child is the most reliable method of diagnosing

the disease, but this is complicated by the fact that most children cannot producethe amount of sputum needed for the test. Because of these factors, tuberculosis inchildren is often diagnosed by identifying the symptoms.

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Treatment

It takes a long time to kill the bacteria that lead to tuberculosis. For this reason, it isimportant to begin treatment as quickly as possible. The drug combinations used to

cure tuberculosis in adults are used in smaller doses for children and include drugssuch as ethambutol, isoniazid, pyrazinamide, rifampicin and streptomycin. Almost90 percent of the bacteria are killed within the first two weeks of treatment,according to Kenyon College. However, treatment must be continued for six monthsto kill the remaining 10 percent. If treatment is not continued then there is a highrisk of the re-infection.

Prevention

Because children are less infectious than adults, children usually pick up the diseasefrom infected adults. For this reason, early diagnosis and treatment of adults withtuberculosis who are in close contact with children is the best way to try to preventtuberculosis in those children. BCG immunization is a live virus vaccine developed to

combat tuberculosis, and the WHO is 2004 recommended that a single dose of BCGshould be given to all infants in countries with a high incidence of tuberculosis,except for infants who are confirmed as HIV-positive. In countries with low incidenceof tuberculosis, the WHO stated that BCG vaccinations could be limited to thoseinfants in high-risk groups: "In some low-burden populations, BCG vaccination hasbeen largely replaced by intensified case detection and supervised early treatment."

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Cells in the body require oxygen to survive.Vital functions of the body are carried out as

the body is continuously supplied with oxygen.Without the respiratory system exchange ofgases in the alveoli will not be made possibleand systemic distribution of oxygen will not bemade possible. The transportation of oxygen inthe different parts of the body is accomplished

by the blood of the cardiovascular system.However, it is the respiratory system thatcarries in oxygen to the body and transportsoxygen from the tissue cells to the blood. Thus,cardiovascular system and respiratory systemworks hand in hand with each other. A problem

in the cardiovascular system would affect theother and vice versa.

Anatomy and Physiology

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Nose

The nose is the only external part of the respiratory system and is the part where the airpasses through. During inhalation and exhalation, air enters the nose by passing throughthe external nares or nostrils. Nasal cavity is found inside the nose and is divided by a nasalseptum. The receptors for the sense of smell, olfactory receptors are found in the mucosa

of the slit-like superior part of the nasal cavity which is located beneath the ethmoid bone.Respiratory mucosa lines the rest of the nasal cavity and rests on a rich network of thin-walled veins that warms the air passing by.

Pharynx

The pharynx is a 13 cm long muscular tube that is commonly called the throat. Thismuscular passageway serves as a common food and air pathway. This structure is

continuous with the nasal cavity anteriorly via the internal nares.Parts of pharynx:

Nasopharynx the superior portion of the pharynx. The pharyngotympanic tubes thatdrain the middle ear open in this area. This is the main reason why children who have otitismedia may follow a sore throat or other types of pharyngeal infections since the twomucosae of these regions are continuous.

Oropharynx middle part

Laryngopharynx part of pharynx that enters the larynx.

When food enters the oral cavity, it travels to the oropharynx and laryngopharynx.However, instead of entering the larynx, the food is directed into the esophagus and not tothe larynx.

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Tonsils clusters of lymphatic tissues found in the pharynx.

Types of Tonsils:

Palatine tonsils tonsils found at the end of the soft palate.

Pharyngeal tonsils lymphatic tissues located high in the nasopharynx. This is alsocalled adenoid.

Lingual tonsils located at the base of the tongue.

Larynx

The larynx is the one that routes the air and food into their proper channels. Alsotermed as the voice box, it plays an important role in speech. This structure islocated inferior to the pharynx and is formed by:

Eight rigid hyaline cartilages

Spoon-shaped flap of elastic cartilage, which is called the epiglottis.

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Epiglottis this is a flap of tissue that serves as a guardian of the airways as itprotects the superior portion of the larynx. The epiglottis does not restrict passageof air into the lower respiratory passages when a person is not swallowing. However,when a person swallows food, the epiglottis tips and forms a lid or blocks theopening of the larynx so that food will not be directed to the lower respiratorypassages. The food will be then routed to the esophagus and in cases where it entersthe larynx, a cough reflex is triggered to expel the substance and prevent it fromcontinuing into the lungs. This protective reflex does not work when a person isunconscious that is why it is not allowed to offer or administer fluids to an

unconscious client.Vocal folds a pair of folds which is also called the true vocal cords that vibratewhen air is expelled.

Glottis the slit-like passageway between the vocal folds.

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Trachea

Also called the windpipe, the trachea is about 10 to 12 cm long or about 4 incheasand travels dwon from the larynx to the fifth thoracic vertebra. This structure is

reinforced with C-shaped rings of hyaline cartilage and these rings are veryimportant for the following purposes:

The open parts of the rings abut the esophagus that allows the structure to expandanteriorly when a person swallows a large size of food.

The solid portions of the C-rings are supporting the walls of the trachea to keep it

patent or open even though pressure changes during breathing.

The trachea is lined with ciliated mucosa that primarily serves for this purpose: Topropel mucus loaded with dust particles and other debris away from the lungstowards the throat where it can either be swallowed or spat out.

Main Bronchi

The main bronchi, both the right and the left, are both formed by trachealdivisions. There is a slight difference between the right and left main bronchi. Theright one is wider, shorter and straighter than the left. This is the most commonsite for an inhaled foreign object to become lodged. When air reaches the bronchi,it is already warmed, cleansed of most impurities and well humidified.

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Lungs

The lungs are fairly large organs that occupy the most of the thoracic cavity. Themost central part of the thoracic cavity, the mediastinum, is not occupied by thelungs as this area houses the heart.

Apex the narrow superior portion of each lung and is located just below the clavicle

Base the resting area of the lung. This is a broad lung area that rests on thediaphragm.

Divisions of the Lungs

The lungs are divided into lobes by the presence of fissures. The left lung has twolobes while the right lung has three.

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Pleural Layers

Visceral pleura also termed as the pulmonary pleura and covers each surface ofthe lings.

Parietal pleura covers the walls of the thoracic cavity.

Pleural fluid a slippery serous secretion that allows the lungs to slide along overthe thorax wall during breathing movements and causes the two pleural layers tocling together.

Bronchioles smallest air-conducting passageways.

Bronchial tree or respiratory tree a network formed due to the branching andrebranching of the respiratory passageways within the lungs.

Alveoli air sacs. This is the only area where exchange of gases takes place. Millionsof clustered alveoli resembles bunches of grapes and these structures make up the

bulk of the lungs.

Respiratory Zone this part includes the respiratory bronchioles, alveolar ducts,alveolar sacs, alveoli.

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Physiology of Respiration

The respiratory primarily supplies oxygen to the body and disposes of carbondioxide through exhalation. Four events chronologically occur, for respiration to

take place.Pulmonary ventilation this process is commonly termed as breathing. Withpulmonary ventilation, air must move out into and out of the lungs so that thealveoli of the lungs are continuously drained and filled with air.

External respiration this is the exchange of gases or the loading of oxygen and the

unloading of carbon dioxide between the pulmonary blood and alveoli.

Respiratory gas transport this is the process where the oxygen and carbon dioxideis transported to the and from the lungs and tissue cells of the body through thebloodstream.

Internal respiration in internal respiration the exchange of gases is taking place

between the blood and tissue cells

h h lHi h Ri k F t

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PathophysiologyHigh Risk Factors:1. Old age2. Infants3. Children4. Low economic

status5. Drug Addicts6. Severely

malnourished7. Healthcare

Workers

Environmental Factors:1. High risk

communities2. Low income

communities

3. Healthcare facilities

Etiological Agent1. Mycobacterium

Tuberculosis

Mode of Transmission1. Droplets Nuclei

MODE OF ENTRYRespiratory Tract

Lungs

Diagnostic Procedures1. Medical History 4. Mantoux Tuberculin2. Physical Examination 5. Microbiological

3. Chest Radiography Smears and cultures

Next

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Signs and Symptoms1. Fever2. Fatigue3. Anorexia4. Hemoptysis5. Productive Cough6. Night Sweats7. Pallor8. Chest pain9. Dyspnea

10. Anxiety11. Low self esteem12. Elevated WBC

Treatment1. Anti-TB Drugs2. Surgery

Death

Cure

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Name: Michael Angelo Villapando

Civil Status: Single

Location: Brgy. Mabato, Los Banos,Laguna.

Date of Birth: November 12, 1985

Age: 27 year old

Religion: Roman Catholic

Diagnosis:

(+) PTB

Physical Assessment:

Fatigue.

Dyspnea.

V/S taken

as follows:

T: 37.8

P: 105

R: 24

BP: 130/90

Patients Profile

Chief Complaint: Hindi ako makatulog dahil sa ubo ko at masakit ang katawan ko asverbalized by the patient.

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NURSING CARE PLANS

Assessment Diagnosis Planning

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Assessment Diagnosis Planning

Subjective:

Hindi ako

makatulog

dahil sa ubo

ko asverbalized by

the patient.

Objective:

Fatigue.

Dyspnea.

V/S taken

as follows:

T: 37.8

P: 105

R: 24

BP: 130/90

Activity intolerance

related to exhaustion associated

with interruption

in usual sleep pattern

because of discomfort,Excessive coughing and

dyspnea.

After 4 hours of nursing

interventions , the patient

Will demonstrate

A measurable increase in

tolerance in activity withabsence of dyspnea and

Excessive fatigue.

Intervention Rationale Evaluation

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Intervention Rationale Evaluation

Independent:

Evaluate patients

response to activity.

Provide a quiet

Environment and limit

visitors during acute phase.

Elevate head and

Encourage frequent position changes, deep

breathing and effective

coughing.

Encourage adequate rest

balanced with moderate

activity.

Promote

Adequate Nutritional

intake

These measures

promotes maximal

inspiration, enhance

expectoration of secretions

to

Improve ventilation.

Facilitates healing

process and enhances

Natural Resistance.

Fluids especially

warm liquids aid in

Mobilization and

Expectoration of

secretions.

Aids in reduction of

bronchospasm and

Mobilization of secretions.

After 4 hours of

nursing

Interventions ,

the patient

was able to

demonstrate

A measurable

increase in

tolerance in

activity with

absence of

dyspnea and

Excessive

fatigue.

Intervention

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Intervention

Force fluids to at least 3000 ml per day and offer warm, rather than cold fluids.

Collaborative:

Administer

medications as prescribe:

mucolytics or expectorants.

Assessment Diagnosis Planning

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Assessment Diagnosis Planning

Subjective:

Ang sakit ng aking

katawan as verbalized by

the patient

Objective:

Fatigue.

Dyspnea

T: 37.8

P: 105

R: 24

BP: 130/90

Activity intolerance related to

general malaise secondary to DM

Short Term GoalAfter 4 hours of giving

effective nursing

interventions, the patient will

be able to cope with fatigueas evidenced by verbalized

feelings of comfort and

increase activity participation

Long Term Goal

Within 3 days of giving

nursing interventions, the

patient will be able to

demonstrate an increase

inactivity tolerance as

evidenced by doing simple

ADL

Intervention Rationale Evaluation

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Intervention Rationale Evaluation

Independent:

Assessed patients ability to

perform tasks/noting

reports of weakness, fatigue

and difficulty accomplishingtask

Recommended quiet

atmosphere; bed

rest if indicated stress-need

to monitor and limit visitors,

phone call sand repeated

unplanned interruptions

Elevated head of bed as

tolerated.

Provided/recommended

assistance with activities

/ ambulation as necessary,

allowing pt. to do as much

as possible

Assisted pt. to prioritize

ADLs/desired activities.

Influence of choice

of interventions assistance

Enhance rest to lower bodys

oxygen requirements, andreduces strain on the heart and

lungs

Enhances lung expansion to

maximize oxygenation for cellular

uptake.

Although help maybe necessary,

self esteem is enhanced when pt.

does things for self.

promotes adequate rest energy

level , and alleviates strain on the

cardiac and respiratory systems

After 4 hours of giving

effective nursing

interventions, the patient was

able to cope with fatigue as

evidenced by verbalization offeelings of comfort and

participating in passive ROM

Within 3 days of giving

nursing intervention, the

patient was not able to do

simple ADLs

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TREATMENTS

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Treatment

The goal of treatment is to cure the infection with drugs that fight the TB bacteria.Treatment of active pulmonary TB will always involve a combination of many drugs(usually four drugs). All of the drugs are continued until lab tests show which medicines

work best.

The most commonly used drugs include:

Isoniazid

Rifampin

Pyrazinamide

Ethambutol

Other drugs that may be used to treat TB include:

Amikacin

Ethionamide

Moxifloxacin

Para-aminosalicylic acid

Streptomycin

Y d t t k diff t ill t diff t ti f th d f 6 th

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You may need to take many different pills at different times of the day for 6 months orlonger. It is very important that you take the pills the way your health care providerinstructed.

When people do not take their TB medications as recommended, the infectionbecomes much more difficult to treat. The TB bacteria may become resistant to

treatment, and sometimes, the drugs no longer help treat the infection.

When there is a concern that a patient may not take all the medication as directed, ahealth care provider may need to watch the person take the prescribed drugs. This iscalled directly observed therapy. In this case, drugs may be given 2 or 3 times perweek, as prescribed by a doctor.

You may need to be admitted to a hospital for 2 - 4 weeks to avoid spreading thedisease to others until you are no longer contagious.

Vaccines

The only currently available vaccine as of 2011 is Bacillus Calmette-Gurin (BCG)which while effective against disseminated disease in childhood confers inconsistent

protection against pulmonary disease. World wide it is the most widely used vaccinewith more than 90% of children vaccinated. However the immunity that it inducesdecreases after about ten years. As tuberculosis is uncommon in most of the Canada,the United Kingdom, and the United States it is not administered except to people athigh risk. Part of the reason against the use of vaccine is that it makes the tuberculinskin test falsely positive and thus of no use in screening.A number of new vaccines arein development

C C C C

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Category I Category II Category III Category IV

New sputum smear-positiveSeriously ill sputumsmear-negativeSeriously ill extra-pulmonaryNew SputumPositive/NegativeHIV Positive

Sputum smear-positive RelapseSputum smear-positive FailureSputum smear-positive Treatmentafter defaultSputum smearnegative

Others/Chronic

New sputum smear-negative, notseriously illNew extra-pulmonary, notseriously ill

Chronic ( Still Smear-positive aftersupervised re-treatment )

2H3R3Z3E3 + 4H3R3 2H3R3Z3E3S3 + 1H3R3Z3E3 +5H3R3E3

2H3R3Z3 + 4H3R3 Refers to specializedfacility or DOTS PlusCenterRefers toprovincial/City NTPcoordinator

2 months Intensivephase + 4 monthscontinuation phaseFour drugs at Thrice-

weekly Schedule

3 months Intensivephase + 5 monthscontinuation phaseFive drugs at Thrice-

weekly Schedule

2 months Intensivephase + 4 monthscontinuation phaseTwo drugs at Thrice-

weekly Schedule

How does it work?

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How does it work?

The BCG vaccine contains a live but weakened form of Mycobacterium bovis, whichis the bacterium that causes tuberculosis (TB). (The vaccine is known as BCGbecause a strain of the bacterium known as Bacillus Calmette-Guerin is used). Thevaccine is used to prevent tuberculosis, and works by stimulating the body's immuneresponse to the bacteria, without actually causing the disease.

When the body is exposed to foreign organisms, such as bacteria and viruses, theimmune system produces antibodies against them. Antibodies help the bodyrecognize and kill the foreign organisms. The antibodies remain in the body to helpprotect the body against future infections with the same organism. This is known as

active immunity.

The immune system produces different antibodies for each foreign organism itencounters. This establishes a pool of antibodies that helps protect the body fromvarious different diseases.

Vaccines contain extracts or inactivated forms of bacteria or viruses that causedisease. These altered forms of the organisms stimulate the immune system toproduce antibodies against them, but don't actually cause disease themselves. Theantibodies produced remain in the body so that if the organism is encounterednaturally, the immune system can recognise it and attack it. This prevents it fromcausing disease.

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Each bacteria or virus stimulates the immune system to produce a specific type ofantibody, and this means that different vaccines are needed to prevent differentdiseases.

The BCG vaccine stimulates the immune system to produce antibodies againstMycobacterium tuberculosis bacteria. This provides immunity against tuberculosis.The vaccine is given as one dose by injection into the skin of the upper arm. Thelength of time that the immunity lasts is not known, but revaccination is notrecommended.

The vaccine is no longer given to all children as part of the schools vaccination

programme. Instead there is now an improved programme of targeted vaccinationfor those individuals who are at greatest risk of contracting the disease. The mainrisk groups are infants under one year of age living in areas where the incidence ofTB is 40 cases per 100,000 people or higher, infants under one year of age whoseparents or grandparents were born in a country with an incidence of TB of 40 casesper 100,000 people or higher, and new immigrants from countries with a highincidence of TB who have not already been vaccinated.

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Children who would previously have been vaccinated through the schools programwill now be screened for risk factors for TB and only given the vaccine if they are atrisk. Other high risk groups who are recommended vaccination are: contacts ofpeople carrying tuberculosis; health care workers; veterinary and other workers who

handle animals susceptible to tuberculosis; staff working in prisons, in residentialhomes and in hostels for refugees and the homeless; and people intending to stayfor more than one month in countries with a high incidence of tuberculosis.

A skin test may be performed before the vaccine is given to check that you don'talready have antibodies to the tuberculosis bacteria, either from a previousvaccination or from previous exposure to the disease. This test uses tuberculin PPDand is called the Mantoux test. For more information see the tuberculin PPDfactsheet.

For children up to six years of age, the Mantoux test is not required before thevaccine is given, providing that the child has not lived or stayed for more than onemonth in a country with an annual TB incidence of 40 per 100,000 people or greater

and they have not had contact with a person with known tuberculosis. All otherpeople should have the Mantoux test before vaccination.

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DRUG STUDY

G i B d Cl ifi ti I di ti C t I di ti Ad ff t

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Generic name Brand name Classification Indication Contra-Indication Adverse effect

Rifampicin Rifadin,

Rimactane,

Rofact

Antituberculotic Treatment of

pulmonary TB in

conjunction at least

one other effective

antituberculotic.

Contraindicated with

allergy to any rifamycin,

acute hepatic disease,

lactation.

CNS: Headache,

drowsiness,

fatigue, dizziness.

Dermatologic:

Rash.

GI: Heartburn,

epigastric distress.

GU:

Hemoglobinuria,

hematuria, acute

renal failure.

Hematologic:Eosinophilia,

thrombocytopenia,

transient

leukopenia.

Other: Pain in

extremities, flulike

symptoms.

Generic name Brand name Classification Indication Contra-Indication Adverse effect

TB ll f i U i l i h

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Isoniazid Isotamine Antituberculotic

TB, all forms in

which organisms are

susceptible.

Use cautiously with

renal impairment,

lactation, pregnancy.

Dermatologic:

Rashes,

photosensitivity.

GI: Hepatotoxicity,

nausea, vimitting,diarrhea, anorexia.

Hematologic:

Sideroblastic

anemia,

thrombocytopenia,

adverse effect on

clotting,mechanism or

vascular integrity.

Other: Acute gout.

Generic name Brand name Classification Indication Contra-Indication Adverse effect

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Pyrazinamide Tebrazid Antituberculotic

Initial treatment of

active TB in adults

and children when

combined with

otherantituberculotics.

Treatment of active

TB after treatment

failure with primary

drugs.

Treatment of drug-

resistant TB as part

of an individualized

regimen.

Contraindicated with

allergy to pyrazinamide,

acute hepatic disease,

lactation, acute gout.

Use cautiously with

diabetes mellitus, acute

intermittent, porpjyria,

pregnancy.

Dermatologic:

Rashes,

photosensitivity.

GI: Hepatotoxicity,

nausea, vimitting,diarrhea, anorexia.

Hematologic:

Sideroblastic

anemia,

thrombocytopenia,

adverse effect on

clotting,mechanism or

vascular integrity.

Other: Acute gout.

GenericName

Brand Name Classification Indications Contraindications

Adverse effect

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Name indications

Ethambutol Myambutol Anti-tuberculotic

Treatment ofpulmonary TB inconjunction with atleast one other

tuberculotic.

Contraindicatedwith allergy toethambutol; opticneuritis. Use

cautiously withimpairer renalfunction, lactation,pregnancy, visualproblems.

CNS: Opticneuritis(loss ofvisual activity),fever, malaise,

headache,dizziness.GI: Anorexia,nausea, vomiting.Hypersensitivity:Allergic reactions.Other: Toxicepidermalnecrolysis,thrombocytopenia, joint pain,acute gout.

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LAB TESTS AND DIAGNOSTIC PROCEDURE

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How Do You Evaluate Persons Suspected of Having TB Disease?A complete medical evaluation for TB includes the following:

1. Medical HistoryClinicians should ask about the patients history of TB exposure, infection, ordisease. It is also important to consider demographic factors (e.g., country oforigin, age, ethnic or racial group, occupation) that may increase the patients riskfor exposure to TB or to drug-resistant TB. Also, clinicians should determinewhether the patient has medical conditions, especially HIV infection, that increases

the risk of latent TB infection progressing to TB disease.

2. Physical ExaminationA physical exam can provide valuable information about the patients overall

condition and other factors that may affect how TB is treated, such as HIV infectionor other illnesses.

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3. Test for TB InfectionThe Mantoux tuberculin skin test (TST) or the TB blood test can be used to test for M.tuberculosis infection. Additional tests are required to confirm TB disease. The

Mantoux tuberculin skin test is performed by injecting a small amount of fluid calledtuberculin into the skin in the lower part of the arm. The test is read within 48 to 72hours by a trained health care worker, who looks for a reaction (induration) on thearm.

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Testing for TB Infection

Mantoux tuberculin skin testThe TB skin test (Mantoux tuberculin skin test) is performed by injecting a smallamount of fluid (called tuberculin) into the skin in the lower part of the arm. A persongiven the tuberculin skin test must return within 48 to 72 hours to have a trainedhealth care worker look for a reaction on the arm.

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4. Chest RadiographA posterior-anterior chest radiograph is used to detect chest abnormalities. Lesionsmay appear anywhere in the lungs and may differ in size, shape, density, and

cavitation. These abnormalities may suggest TB, but cannot be used to definitivelydiagnose TB. However, a chest radiograph may be used to rule out the possibility ofpulmonary TB in a person who has had a positive reaction to a TST or TB blood testand no symptoms of disease.

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A chest x ray is a painless, noninvasive test that creates pictures of the structuresinside your chest, such as your heart, lungs, and blood vessels. "Noninvasive" meansthat no surgery is done and no instruments are inserted into your body.

This test is done to find the cause of symptoms such as shortness of breath, chestpain, chronic cough (a cough that lasts a long time), and fever.

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5.TB blood testsTB blood tests (also called interferon-gamma release assays or IGRAs) measurehow the immune system reacts to the bacteria that cause TB. If your health care

provider or local health department offers TB blood tests, only one visit is requiredto draw blood for the test. The QuantiFERON-TB Gold In-Tube test (GFT-GIT)and T-SPOT.TB test are two Foods and Drug Administration approved TB bloodtests. Test results are generally available in 24-48 hours.

Interferon-Gamma Release Assays (IGRAs) - Blood Tests for TB Infection

Interferon-Gamma Release Assays (IGRAs) are whole-blood tests that can aid indiagnosing Mycobacterium tuberculosis infection. They do not help differentiatelatent tuberculosis infection (LTBI) from tuberculosis disease. Two IGRAs that havebeen approved by the U.S. Food and Drug Administration (FDA) are commerciallyavailable in the U.S:

QuantiFERON-TB Gold In-Tube test (QFT-GIT);T-SPOT.TB test (T-Spot)

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6. Diagnostic Microbiology

The presence of acid-fast-bacilli (AFB) on a sputum smear or other specimen oftenindicates TB disease. Acid-fast microscopy is easy and quick, but it does not confirm

a diagnosis of TB because some acid-fast-bacilli are not M. tuberculosis. Therefore,a culture is done on all initial samples to confirm the diagnosis. (However, a positiveculture is not always necessary to begin or continue treatment for TB.) A positiveculture for M. tuberculosis confirms the diagnosis of TB disease. Cultureexaminations should be completed on all specimens, regardless of AFB smearresults. Laboratories should report positive results on smears and cultures within 24

hours by telephone or fax to the primary health care provider and to the state orlocal TB control program, as required by law.

A sputum sample is obtained by coughing deeply and expelling the material thatcomes from the lungs into a sterile cup. The sample is taken to a laboratory andplaced in a medium under conditions that allow the organisms to grow. A positive

culture may identify disease-producing organisms that may help diagnosebronchitis, tuberculosis, a lung abscess, or pneumonia.

How to collect a sputum sampleYour doctor or nurse will give you a special plastic cup for collecting your sputum. Follow these steps carefully:

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g y p p p g y p p y

1. The cup is very clean. Dont open it until you are ready to use it.

2.As soon as you wake up in the morning (before you eat or drink anything), brush your teeth and rinse your mouth with water. Do not use

mouthwash.

3.If possible, go outside or open a window before collecting the sputum sample. This helps protect other people from TB germs when you

cough.

4.Take a very deep breath and hold the air for 5 seconds. Slowly breathe out. Take another deep breath and cough hard until some sputum

comes up into your mouth.

5.Spit the sputum into the plastic cup.

6.

Keep doing this until the sputum reaches the 5 ml line (or more) on the plastic cup. This is about 1 teaspoon of sputum.

7. Screw the cap on the cup tightly so it doesnt leak.

8. Wash and dry the outside of the cup.

9. Write on the cup the date you collected the sputum.

10.Put the cup into the box or bag the nurse gave you.

11.Give the cup to your clinic or nurse. You can store the cup in the refrigerator overnight if necessary. Do not put it in the freezer or leave it at

room temperature.

Bi

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7.Biopsy

There are several different types of biopsies.

A needle (percutaneous) biopsy removes tissue using a hollow tube called a syringe.

A needle is passed several times through the tissue being examined. The surgeonuses the needle to remove the tissue sample. Needle biopsies are often done usingx-rays (usually CT scan or ultrasound), which guide the surgeon to the right area.

An open biopsy is a surgical procedure that uses local or general anesthesia. Thismeans you are relaxed (sedated) or asleep and pain-free during the procedure. Theprocedure is done in a hospital operating room. The surgeon makes a cut into theaffected area, and the tissue is removed.

Closed biopsy uses a much smaller surgical cut than open biopsy. A small cut ismade so that a camera-like instrument can be inserted. This instrument helps guidethe surgeon to the right place to take the sample.

8 B h

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8. Bronchoscopy

A bronchoscope is a device used to see the inside of the lungs. It can be flexible orrigid. Usually, a flexible bronchoscope is used. The flexible bronchoscope is a tubeless than 1/2 inch wide and about 2 feet long.

The scope is passed through your mouth or nose, through your windpipe (trachea),and then into your lungs. Going through the nose is a good way to look at theupper airways. The mouth method allows the doctor to use a larger bronchoscope.

A rigid bronchoscope requires general anesthesia. You will be asleep.

If a flexible bronchoscope is used, you will be awake. The doctor will spray anumbing drug (anesthetic) in your mouth and throat. This will cause coughing atfirst, which will stop as the anesthetic begins to work. When the area feels thick, itis numb enough. You may get medications through a vein (intravenously) to helpyou relax.

If the bronchoscopy is done through the nose, numbing jelly will be placed into onenostril.

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Once you are numb, the tube will be inserted into the lungs. The doctor may sendsaline solution through the tube. This washes the lungs and allows the doctor tocollect samples of lung cells, fluids, and other materials inside the air sacs. This partof the procedure is called a lavage.

Sometimes, tiny brushes, needles, or forceps may be passed through thebronchoscope and used to take tissue samples (biopsies) from your lungs. Thepieces of lung material that are removed are small. The doctor can also place astent in the airway or view the lungs with ultrasound during a bronchoscopy.

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9.Thoracic CT

Thoracic CT (computer tomography) is an imaging method that uses x-rays tocreate cross-sectional pictures of the chest and upper abdomen.

You will be asked to lie on a narrow table that slides into the center of the scanner.Once you are inside the scanner, the machine's x-ray beam rotates around you.(Modern "spiral" scanners can perform the exam in one continuous motion.)

Small detectors inside the scanner measure the amount of x-rays that make itthrough the part of the body being studied. A computer takes this information anduses it to create several individual images, called slices. These images can be

stored, viewed on a monitor, or printed on film. Three-dimensional models oforgans can be created by stacking the individual slices together.

You must be still during the exam, because movement causes blurred images. Youmay be told to hold your breath for short periods of time.

Generally, complete scans take only a few minutes. The newest multidetector

scanners can image your entire body, head to toe, in less than 30 seconds.

Certain CT exams require a special dye, called contrast, to be delivered into thebody before the test starts. Contrast can highlight specific areas inside the body,which creates a clearer image. If your doctor requests a CT scan with contrast, youwill be given it intravenously (by IV) through a vein in your arm or hand.

Th t i

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10.Thoracentesis

Thoracentesis is a procedure to remove fluid from the space between the lining ofthe outside of the lungs (pleura) and the wall of the chest.

A small area of skin on your back is cleaned. Numbing medicine (local anesthetic) isinjected in this area.

A needle is placed through the skin and muscles of the chest wall into the spacearound the lungs, called the pleural space. Fluid is collected and may be sent to alaboratory for testing (pleural fluid analysis).

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DISCHARGE PLANNING

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Medications You must complete your treatment until you are cured of TB, even if you do not feelsick. It is very important that you take your TB medicines exactly as your caregiver tellsyou. If you skip or stop your pills, TB germs will not be killed. You will always have TB

germs in your body unless you correctly take all your medicines. Your caregiver must report all TB cases to the health department. This helps protectothers from getting TB. It also helps you get the care you need to cure your TB.

Environment If your patient has family, give them any instructions and information needed for thecare of your patient. This might include information on medications the patient needsto take, any other treatments, diet and follow-up visits. Before your patient leaves,make sure he and his family understand instructions for his care. Before you release your patient, assess how your patient is breathing. PTB can causebreathing difficulties, and it is important to make sure that your patient can breatheunassisted. Make sure that before your patient has left the hospital, he has taken all requiredmedications. If your patient is still contagious, he cannot leave the hospital until the

disease is contained and no longer poses a risk to others. Give your patient and his family a copy of his discharge plan. Provide the family withany other information that might be beneficial for your patient's care at home. Ensure that your patient understands that he will need a follow -up visit after he isreleased from the hospital. This is necessary to ensure that your patient is coping wellafter being released from the hospital.

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Treatments

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Treatments You must have regular follow-up to make sure the medicine is working. It is veryimportant that you keep all your appointments. Tell your caregiver if you do not feelwell or you do not feel the medicines are working. You may have any of the followingat your follow-up visits: Your weight, temperature, and lungs will be checked. A chest x-ray may be done to see how your lungs are healing. You may be asked for a sputum (phlegm) sample. It will be tested to see if you arecoughing up any TB germs and whether the pills are working.

Health Knowledge of Disease Discuss with the patient and his family what can be managed at home and whatwill need outside help. Make a note of these areas of need on the discharge careplan. Show the patient each medication she will take at home. Ensure sheunderstands what it is for and how to take it. Make any referrals before the patientis discharged. Make a note of each referral and contact details for the patient's

reference at home. Explain to the patient what she should do should she become illor need further help at home. Address potential problems that are specific to thepatient's condition.

Outpatient/Inpatient Referrals

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Outpatient/Inpatient Referrals Patient assessed for potential barriers that could interfere with treatment (i.e., access tocare, unstable housing, language barriers, cultural beliefs, substance abuse, and/or medical conditions) Will be discharged to a verified address Will NOT be discharged to a congregate setting (i.e., shelter, nursing home, etc.) unlesson anti-TB treatment regimen for at least 2 weeks, clinically improving, and demonstrate sputumAFB smear and culture conversion Will NOT have significant contact with or live with immunosuppressed persons If there are any immunosuppressed persons and/or children < 5 years of age in thehome, a plan for

evaluation by next business day for window period prophylaxis or LTBI must be in place.

Diet Before starting any diet, consult your dietitian or doctor. Once you begin regular TBtreatment, eat fruits such as apples, grapes, melons, oranges, pears, peaches orpineapples in five-hour intervals for three or four days. Drink unsweetened cold or hotlemon water or plain water.

Calcium will play a major role in improving your condition, so after a few days, add milk(preferably fat-free or low-fat, or equivalent milk products) to each meal. Aside from fruit, include potassium-rich vegetables in your diet. If you follow a 2,000calorie diet, eat 2 cups of fruit and 2 cups of vegetable daily.vary your vegetables fromall five subgroups (dark green, legumes, orange, starchy vegetables, and othervegetables).

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THATS ALL THANKYOU~~

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