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Course: Medical Surgical Nursing

Topic: Pulmonary Tuberculosis

The Nurses International Community

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Module Goals

Learners will be able to

Describe the clinical manifestation of pulmonary tuberculosis.
Discuss the assessment and diagnostic findings of pulmonary tuberculosis.
Discuss the complications of pulmonary tuberculosis.
Describe the medical management of pulmonary tuberculosis.
Discuss the nursing management of pulmonary tuberculosis.

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Tuberculosis Incidence

Most common infections in the world.
Nearly 2 billion people (¼ of world population) infected.
10 million develop TB and 1.6 million die each year.
Leading cause of death due to infectious disease worldwide.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Transmission of TB

An organism called mycobacterium tuberculosis causes TB. TB spreads person to person through the air. The dots in the air represent droplet nuclei containing tubercle bacilli.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Pathogenesis of TB

When person inhales air containing droplet nuclei with M.tuberculosis, most often larger droplets become lodged in the upper respiratory tract and do not cause infection. Smaller droplets nuclei may reach the alveoli where infection begins when they multiply and enter lymph nodes and bloodstream.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

How is TB spread? Select one.

TB spreads person to person through blood
TB spreads persons to person through the air
TB spreads person to person through touch
All of the above

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Latent TB Infection (LTBI)

Tubercle bacilli are in body, but suppressed by immune system and under control.

LTBI is detected by tuberculin skin test (TST) or an interferon-gamma release assay (IGRA).

People with LTBI are not contagious.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Classification of TB

https://www.cdc.gov/tb/education/tbetn/default.htm

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LTBI vs TB Disease

https://www.cdc.gov/tb/education/tbetn/default.htm

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

A 30-year -old man visits the health department for a TB skin test that is required for him to start his job as a healthcare worker. He has a 18 mm positive reaction to the TB skin test. He has no symptoms of TB and a normal chest x-ray.

Should this be considered a case of TB? Why or why not?

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TB Control

Persons in enclosed spaces with people who are infected with TB are most likely to be exposed

Example public transportation, inside buildings, schools
Contacts may include friends, roommates or coworkers.

Best way to stop transmission is through isolation and giving standard TB treatment as soon as possible.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Drug-resistant TB

Caused by M. tuberculosis organisms that are resistant to drugs normally used to treat the disease.

Therefore these drugs no longer kill the bacteria.

https://www.cdc.gov/tb/education/tbetn/default.ht m

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Controlling TB

Targeted testing is a TB control strategy used to identify and treat persons.

At high risk for latent TB infection (LTBI)
At high risk for developing TB disease once infected with M. tuberculosis.

Identifying persons with LTBI important to prevent development of TB disease and spread to other people.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Target Testing High-Risk Groups

People who are at high risk of exposure or infection.
People who are at high risk for developing B disease if infected

Contact with known or suspected TB disease
Visiting areas with high prevalence of TB
Living or working in congregate settings (nursing homes, homeless shelters, prisons)
Healthcare workers who serve at risk patients
Infants, children, adolescents exposed to adults at high risk.

https://www.cdc.gov/t b/education/tbetn/default.htm

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Diagnosis of LTBI

Mantoux tuberculin skin test (TST).
Blood tests know as interferon-gamma release assays (IGRAs):

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

https://www.cdc.gov/tb/education/tbetn/default.htm

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Mantoux Tuberculin Skin Test

Transdermal injection of 0.1 ml of 5 tuberculin units of liquid tuberculin.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Mantoux Tuberculin Skin Test

Forearm should be examined within 48 to 72 hours by healthcare worker.
Reaction is an area of induration (swelling around injection site).
Induration is measured in millimeters.
Erythema (redness) is not measured.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Interpreting Tuberculin Skin Test

Induration of ≥ 5 mm is considered positive for high risk individuals

HIV
Recent contacts of people with infectious TB
Positive TB disease
Organ transplants
Other immunosuppressed patients

https://www.cdc.gov/tb/education/tbetn/default.htm

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Interpreting Tuberculin Skin Test

Induration of ≥ 10 mm is considered positive for

People who have visited where TB is common.
People who abuse drugs.
People living and working in high-risk congregate settings.
People with chronic medical conditions.
Children younger than 5 years of age.
Infants, children, or adolescents exposed to high risk adults.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Interpreting Tuberculin Skin Test

Induration of ≥ 15 mm is considered positive for

People who have no known risk factors for TB

https://www.cdc.gov/tb/education/tbetn/default.htm

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Mantoux Tuberculin Skin Test

False-Positive Reaction

Factors that may cause people to have a positive reaction even if they do not have TB infection.

Infection with nontuberculous mycobacteria
BCG vaccination
Administration of incorrect antigen
Incorrect measurement or interpretation of TST reaction.

Any person with TB symptoms should be evaluated regardless of skin test measurement.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Diagnosis of LTBI

IGRAs (interferon-gamma release assays) uses a blood sample. It is the preferred method of testing if

person is less likely to return for TST reading and interpretation (example homeless or drug users).
person who has received BCG vaccine.
person who are likely to be infected with M. tuberculosis and are at low to intermediate risk of progression to TB.

TST is the preferred method of test for children younger than 5 years

https://www.cdc.gov/tb/education/tbetn/default.htm

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BCG Vaccine

People who have been vaccinated with BCG may have a false-positive TST reaction.
However, there is no reliable way to distinguish a positive TST reaction caused by BCG vaccination from a reaction caused by tru TB infection
Individuals should always be further evaluated if they have a positive TST reaction.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

The nurse is screening a homeless person for TB.

What is the preferred method of screening for this client?

Why?

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Medical Management of LTBI

Targeted testing should be used to identify and treat people who are:

at high risk for exposure or infection with M. tuberculosis
at high risk for developing TB disease.

People in these groups should receive high priority for treatment if they have a positive skin test or interferon-gamma release assay (IGRA).

https://www.cdc.gov/tb/education/tbetn/default.htm

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Patient Medical Evaluation

Exclude presence of TB disease.
Determine whether patient has ever been treated for TB infection or TB disease.
Identify any medical conditions that might complicate therapy.
Build rapport with patient.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Treatment Regimens

Isoniazid for 9 months.
Isoniazid for 6 months.
Isoniazid and rifapentine for 12 months once-weekly doses.
Rifampin for 4 months.

https://www.cdc.gov/tb/education/tbetn/default.htm

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LTBI Treatment Regimens

Isoniazid (INH) daily for 9 months is very effective in preventing the development of TB.

INH may also be given for 6 months

Cost effective and patients may find it easier to adhere but not effective if given for less than 6 months.
Not recommended for people living with HIV, individuals with previous TB disease and children.

https://www.cdc.gov/tb/education/tbetn/default.htm

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LTBI Treatment Regimens

Isoniazid and rifapentine (12-dose Regimen)

Combination of INH and rifapentine given in 12 once a week doses.

Recommended for persons who

Are 12 years of age or older
were recently exposed to infectious TB
Have a TST or IGRA conversion from negative to positive
Have a chest x-ray findings of previous TB disease.

https://www.cdc.gov/tb/education/tbetn/default.htm

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LTBI Treatment Regimens

Isoniazid and rifapentine regimen is not recommended for

Children younger than 2 years of age.
People with HIv/AIDS who are taking ART regimens.
People presumed to be infected with isoniazid or rifampin resistant M. tuberculosis.
Pregnant women or women planning to get pregnant during 12 week regimen.

https://www.cdc.gov/tb/education/tbetn/default.htm

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

Which statement is true about the purpose of LTBI treatment?

It is given to people who have LTBI to prevent them from testing positive on future test for TB infection
It is given to people who have LTBI to prevent them from developing TB disease
It is given to people who have TB disease to prevent the disease from getting worse
It is give to people who have TB disease to prevent them from becoming infectious

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Diagnosis of TB Disease

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Chest X-Ray

Note abnormalities in apical and

posterior segments of the upper

lobe or in the superior segments

of the lower lobe.

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Examination of Clinical Specimens

Sputum, urine or cerebrospinal fluid examined and cultured fo M. tuberculosis.

Tested for drug susceptibility.

Core Curriculum on Tuberculosis: What the Clinician Should Know (cdc.gov)

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Diagnosis of TB

Acid-fast bacilli (AFB) smear: Microscopic examination of sputum to identify the presence of Mycobacterium tuberculosis.

Chest X-ray: Imaging study that may reveal infiltrates, cavitation, or fibrotic changes in the lungs.

WHO, 2019

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Treatment

Antitubercular therapy: Mainstay of treatment for pulmonary tuberculosis, involving a combination of medications.

Directly Observed Therapy (DOT): A strategy in which healthcare providers or designated individuals ensure that patients adhere to their medication regimen.

WHO, 2019

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Treatment of Active TB

4-month rifapentine-moxifloxacin TB Treatment Regimen

high-dose daily rifapentine (rPt) with
moxifloxacin (MOX)
isoniazid (INH)
pyrazinamide (PZA)

WHO, 2019

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Treatment of Active TB

6-month TB Treatment Regimen consists of

Rifampin
Isoniazid
Pyrazinamide
Ethambutol

9 month TB Treatment for high risk populations

WHO, 2019

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

Which drugs are recommended for the intensive phase of treatment for TB disease? (Select all correct).

Isoniazid (INH)
Rifapentine (RPT)
Rifampin (RIF)
Pyrazinamide (PZA)
E. Ethambutol (EMB)

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Nursing Care of TB Patient

Promote airway clearance- instruct client about positioning to facilitate drainage of fluid.
Ensure adherence to the treatment regimen.
Encourage activity and adequate nutritional intake.
Prevent spread of TB infection.
Initiate acid-fast bacillus isolation- private room with negative pressure.
Disposal of contaminated tissues in covered trash can.
Monitor for adverse drug reactions.

Nurselabs.com/pulmonarytuberculosis/

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Red Flags

Persons with increase risk of LTBI disease progression such as those with HIV infection and diabetes mellitus.

Drug resistance due to not being treated with the right TB drugs or patient did not properly follow the prescribed treatment regimen.

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Applying Purnell’s Model for Cultural Competence

Marcela, female aged 34, comes to the TB clinic for initial testing. She has recently migrated from a country which has a high incidence of tuberculosis. She worked as a registered nurse in her prior country. She now hopes to begin working as a health aide in a local nursing home.

Which of Purnell’s 12 Domains may relate to Marcela?
What cultural concerns may exist for Marcela?
What questions would the nurse ask?

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Marcela has several characteristics which identify her as potentially high risk for TB. She has lived in an area with a high incidence of TB, providing health care there. She is seeking work now in a workplace that (as a congregate setting) may also be high risk. The results of this initial testing could have implications for both her own health status and her employment situation. View Purnell’s Model, Domain: workforce Issues here (LINK TO SLIDE DECK- Domains ONE, slide “Workforce Issues”). The nurse would understand that there are cultural issues related to this testing (and its results). The nurse would ask questions such as: “Is your employment an important part of your life?” “What type of work will you be doing?” “How is this the same or different from the work that you have done in the past?” “Do you consider yourself a loyal worker?” “ Can you make independent decisions in this new position?” Marcela will need to consider how this work may affect her health and how much control she will have over her own health decisions in this new role.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References

Centers of Disease Control and Prevention (2022). Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention. Retrieved from https://www.cdc.gov/tb/education/tbetn/default.htm

Nurselabs (2023). Pulmonary Tuberculosis- Nursing Care Management. Retrieved from Nurselabs.com

World Health Organization. (2019). Guidelines for treatment of drug-susceptible tuberculosis and patient care. Retrieved from https://www.who.int/publications/i/item/9789241550530

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