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[Audio] Hello Everyone ! This presentation is about Tuberculosis. Let Us start our learning...

[Audio] Learning Objectives. At the end of this session the participant will be able to: Define TB cases State the four key features important to classifying TB cases. Categorize TB cases Describe the criteria and method for determining an infectious period. Evaluate the risk of transmission based on clinical content of disease and diagnostic tests. Able to identify the risk behaviors and risk factors..

[Audio] TB Classification. TB cases are also classified according to: Anatomical site of TB Disease Bacteriologic results (including drug resistance) History of previous TB treatment HIV status of the patient.

[Audio] Pulmonary Tuberculosis . Pulmonary Tuberculosis ( PTB): Refers to disease involving the lung parenchymaA patient with both pulmonary and extra-pulmonary TB constitutes a case of PTB Miliary TB is classified as PTB because there are lesions in the lungs..

[Audio] Extra-pulmonary Tuberculosis ( EPTB): Refers to TB disease of organs other than the lungs. Therefore the following constitute a case of EPTB: Tuberculous intrathoracic lymphadenopathy ( mediastinal and/or hilar) Tuberculous pleural effusion, without radiographic abnormalities in the lungs Extra thoracic TB.

[Audio] Tuberculosis also can be classified according to the anatomical part it affected. One is Pulmonary TB and the other is Extra Pulmonary TB; Pulmonary TB contains Primary disease and secondary Disease; and Extra Pulmonary TB includes Lymph node TB, Pleural TB, TB of upper airways, Skeletal TB, , Genitourinary TB, Miliary TB, Pericardial TB, Gastro Intestinal TB , Tuberculous Meningitis and some other less Common forms..

[Audio] Classification By CDC; Data from the history, physical examination, TB test, chest xray, and microbiologic studies are used to classify TB into one of five classes. Class 0. There is no exposure or no infection. So Negative reaction to TST or IGRA. Class 1. There is an exposure but no evidence of infection. History of exposure to M. tuberculosis •Negative reaction to TST or IGRA (given at least 8 to 10 weeks after exposure) Class 2. There is latent infection but no disease. Positive reaction to TST or IGRA •Negative bacteriological studies ( smear and cultures) •No bacteriological or radiographic evidence of active TB disease Class 3. There is a disease and is clinically active. Positive culture for M. tuberculosis OR •Positive reaction to TST or IGRA, plus clinical, bacteriological, or radiographic evidence of current active TB Class 4. There is a disease but not clinically active. •May have past medical history of TB disease •Abnormal but stable radiographic findings •Positive reaction to the TST or IGRA •Negative bacteriologic studies (smear and cultures) •No clinical or radiographic evidence of current active TB disease Class 5. There is a suspected disease but the diagnosis is pending. Signs and symptoms of active TB disease, but medical evaluation not complete.

[Audio] Difference between latent and Active Tuberculosis; In latent TB , The mycobacterium lives but does not grow in the body; and It doesnot make a person feel sick or symptoms; and also can't spread from person to person; and incase our immune power comes down or incase our nutritional status becomes very low or our body's physiological function is in stress, it may advance to TB disease. And on the other hand, we see the TB disease is active and grows in the body, also makes a person feel sick , and also it is communicable to person to person and can cause death if not treated. Treatment can stop TB disease from developing… incase of latent TB….. and on the other hand in the TB disease treatment can stop TB disease..

[Audio] When seeing the Incidences Tuberculosis is a worldwide public health problem that is closely associated with poverty, malnutrition, overcrowding, substandard housing, and inadequate health care. M. tuberculosis infects an estimated one-third of the world's population and remains the leading cause of death from infectious disease in the world. After exposure to M. tuberculosis, roughly 5% of infected people develop active TB within a year..

[Audio] As we all know and as we seeing our hospital also, we have many patients expatriates subjected to screening Comprehensive study on the prevalence of TB among expatriates applying for residence visas An Comprehensive study on the prevalence of TB among expatriates applying for residence visas( which is the first First study on this topic done in 2013) The results of the study indicate that the prevalence of active TB among adult expatriates subjected to screening (about 39 per 100,000) is around 14-fold higher than the estimated prevalence of TB in the UAE. The prevalence of active TB was even more among the new applicants ( 49.3 per 100,000) compared with 25.2 per 100,000 among renewals. New visa screening applicants were also more likely to be smear positive compared with renewals ..

[Audio] Causes and Risk factors for Acquiring tuberculosis includes : Close contact. Having close contact with someone who has an active TB. Low immunity. Immunocompromised status like those with HIV, cancer, or transplanted organs increases the risk of acquiring tuberculosis. Substance abuse. People who are IV/ injection drug users and alcoholics have a greater chance of acquiring tuberculosis. Inadequate health care. Any person without adequate health care like the homeless, impoverished, and the minorities often develop active TB. Immigration. Immigration from countries with a high prevalence of TB could affect the patient. Overcrowding. Living in an overcrowded, substandard housing increases the spreading of the infection. All these are the main risk factors.

[Audio] When coming to the Clinical Manifestations, After an incubation period of 4 to 8 weeks, TB is usually asymptomatic in primary infection. When it get progress.. The main symtoms are Cough that lasts three or more weeks, The patient may experience the cough with mucopurulent sputum; Chest pain, Loss of Appetite, Chills, Unintended weight loss, fatique, Night sweats, Fever or low grade fever, Hemoptysis that is coughing out blood with sputum.

[Audio] In this picture we can see the Clinical Manifestations- and infectious levels When the mycobacterium enters our body, it can be eliminated either by Inmate immune response if aperson is realy very healthy or it can be eliminated with acquired immune response that is the immunity that was acquired from vaccines… Here, we can see when the pathogen invades if the pathogen is not eliminated by any of these immunity, then the person is getting latent TB, that is the micro organism lives but neither communicable nor sympamatic, and the TST that is Tuberculin skin test and IGRA that is Interferon-Gamma Release Assays are positive but the patient's AFB smear is negative and culture and radiological significance may not be seen; When the immunity fails the disease advances to subclinical stage and then it progresses to Active TB...

[Audio] To prevent transmission of tuberculosis.. Need to make sure.. 1. Early identification and treatment of persons with active TB. 2. Prevention of spread of infectious droplet nuclei by source control methods and by reduction of microbial contamination of indoor air. 3. Maintain surveillance for TB infection among health care workers by routine, periodic tuberculin skin testing. And Eat healthy diet, Consider vaccination, maintain your body healthy, give up smoking, use mask, follow cough etiques, wash your hands after sneezing and coughing, stay away from coughing people and all….

[Audio] Complications If left untreated or mistreated, pulmonary tuberculosis may lead to: Respiratory failure. Respiratory failure is one of the most common complication of pulmonary tuberculosis. Pneumothorax. Pneumothorax becomes a complication when tuberculosis is not treated properly. Pneumonia. One of the most fatal complications of tuberculosis is pneumonia as it could cause infection all over the lungs..

[Audio] Assessment and Diagnostic Findings; There are two kinds of tests used to detect TB bacteria in the body: The TB skin test ( TST) and TB blood tests.. Here.. A positive TB skin test or TB blood test only tells that a person has been infected with TB bacteria. It does not tell whether the person has latent TB infection ( LTBI) or has progressed to TB disease..

[Audio] How to diagnose latent tuberculosis?! The main ways to diagnose LTBI are by Placing a tuberculin skin test ( TST) on the forearm By getting a TB blood test, In addition to obtaining a chest radiograph ( x-ray) if either one of these tests is positive. One-third of the world's population has LTBI. The TB germs are dormant (asleep) in the body..

Study on Diagnosis and Management of Latent Tuberculosis Infection in 2015 ( PUBMED).

Diagnosis for Latent Tuberculosis Infection: New Alternatives 2020 study.

Assessment and Diagnostic Findings. Assessment and Diagnostic Findings To diagnose tuberculosis, the following tests could be performed: Sputum culture: Positive for Mycobacterium tuberculosis in the active stage of the disease. Ziehl-Neelsen (acid-fast stain applied to a smear of body fluid): Positive for acid-fast bacilli (AFB). Skin tests (purified protein derivative [PPD] or Old tuberculin [OT] administered by intradermal injection [ Mantoux ]): A positive reaction (area of induration 10 mm or greater, occurring 48–72 hr after interdermal injection of the antigen) indicates past infection and the presence of antibodies but is not necessarily indicative of active disease. Factors associated with a decreased response to tuberculin include underlying viral or bacterial infection, malnutrition, lymphadenopathy, overwhelming TB infection, insufficient antigen injection, and conscious or unconscious bias. A significant reaction in a patient who is clinically ill means that active TB cannot be dismissed as a diagnostic possibility. A significant reaction in healthy persons usually signifies dormant TB or an infection caused by a different mycobacterium. The tuberculosis (TB) blood test, also called an Interferon Gamma Release Assay or IGRA, is a way to find out if you have TB germs in your body . The TB blood test can be done instead of a TB skin test (Mantoux)..

Assessment and Diagnostic Findings cont... Enzyme-linked immunosorbent assay (ELISA)/Western blot: May reveal presence of HIV . 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. CT or MRI scan: Determines degree of lung damage and may confirm a difficult diagnosis. Bronchoscopy : Shows inflammation and altered lung tissue. May also be performed to obtain sputum if patient is unable to produce an adequate specimen. Histologic or tissue cultures (including gastric washings; urine and cerebrospinal fluid [CSF]; skin biopsy ): Positive for Myco­bacterium tuberculosis and may indicate extrapulmonary involvement..

Assessment and Diagnostic Findings cont... Needle biopsy of lung tissue: Positive for granulomas of TB; presence of giant cells indicating necrosis. Electrolytes : May be abnormal depending on the location and severity of infection; e.g., hyponatremia caused by abnormal water retention may be found in extensive chronic pulmonary TB. ABGs : May be abnormal depending on location, severity, and residual damage to the lungs. Pulmonary function studies: Decreased vital capacity, increased dead space, increased ratio of residual air to total lung capacity, and decreased oxygen saturation are secondary to parenchymal infiltration/fibrosis, loss of lung tissue, and pleural disease (extensive chronic pulmonary TB)..

Medical Management. Pulmonary tuberculosis is treated primarily with antituberculosis agents for 6 to 12 months. First line treatment. First-line agents for the treatment of tuberculosis are isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide. Active TB. For most adults with active TB, the recommended dosing includes the administration of all four drugs daily for 2 months, followed by 4 months of INH and RIF. Latent TB. Latent TB is usually treated daily for 9 months..

Treatn•ent Regirnens for Latent TB Infection Drug(s) Isoniazid Isoniazid & Rifapentine Rifampin Duration 9 months months 6 months 3 4 rnonths Interval Daily Twice weekly Daily Twice weekly Once weekly Daily Minirnurn Doses 270 76 180 52 12 120 Note: Rifampin (RIF) and Pyrazinamide (PZA) should not be offered to persons with LTBI. RIF and PZA should continue to be administered in multidrug regimens for the treatment of persons with TB disease..

Medical Management cont... Treatment guidelines. Recommended treatment guidelines for newly diagnosed cases of pulmonary TB have two parts: an initial treatment phase and a continuation phase. Initial phase. The initial phase consists of a multiple-medication regimen of INH, rifampin, pyrazinamide, and ethambutol and lasts for 8 weeks. Continuation phase. The continuation phase of treatment include INH and rifampin or INH and rifapentine , and lasts for an additional 4 or 7 months. Prophylactic isoniazid. Prophylactic INH treatment involves taking daily doses for 6 to 12 months. DOT. Directly observed therapy may be selected, wherein an assigned caregiver directly observes the administration of the drug..

Pharmacologic Therapy. The first line antituberculosis medications include:• Isoniazid (INH). INH is a bactericidal agent that is used as prophylaxis for neuritis, and has side effects of peripheral neuritis, hepatic enzyme elevation, hepatitis , and hypersensitivity. Rifampin ( Rifadin ). Rifampin is a bactericidal agent that turns the urine and other body secretions into orange or red, and has common side effects of hepatitis, febrile reaction, purpura, nausea , and vomiting . Pyrazinamide. Pyrazinamide is a bactericidal agent which increases the uric acid in the blood and has common side effects of hyperuricemia, hepatotoxicity, skin rash, arthralgias , and GI distress. Ethambutol ( Myambutol ). Ethambutol is a bacteriostatic agent that should be used with caution with renal disease, and has common side effects of optic neuritis and skin rash..

Nursing Management. Nursing Assessment The nurse may assess the following: Complete history. Past and present medical history is assessed as well as both of the parents’ histories. Physical examination. A TB patient loses weight dramatically and may show the loss in physical appearance..

Nursing Diagnosis. Based on the assessment data, the major nursing diagnoses for the patient include: Risk for infection related to inadequate primary defenses and lowered resistance. Ineffective airway clearance related to thick, viscous, or bloody secretions. Risk for impaired gas exchange related to decrease in effective lung surface. Activity intolerance related to imbalance between oxygen supply and demand. Imbalanced nutrition : less than body requirements related to inability to ingest adequate nutrients..

Nursing interventions for the patient include:. Promoting airway clearance. The nurse instructs the patient about correct positioning to facilitate drainage and to increase fluid intake to promote systemic hydration. Adherence to the treatment regimen. The nurse should teach the patient that TB is a communicable disease and taking medications is the most effective means of preventing transmission. Promoting activity and adequate nutrition. The nurse plans a progressive activity schedule that focuses on increasing activity tolerance and muscle strength and a nutritional plan that allows for small, frequent meals..

Nursing interventions contd... Preventing spreading of tuberculosis infection. The nurse carefully instructs the patient about important hygienic measures including mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and handwashing . Acid-fast bacillus isolation. Initiate AFB isolation immediately, including the use of a private room with negative pressure in relation to surrounding areas and a minimum of six air changes per hour. Disposal. Place a covered trash can nearby or tape a lined bag to the side of the bed to dispose of used tissues. Monitor adverse effects. Be alert for adverse effects of medications..

Discharge and Home Care Health Education. Before the discharge, the nurse should instruct the patient to: Disposal of secretions. Cough and sneeze into tissues and to dispose of all secretions in a separate trash can. Isolation. Wear a mask when going outside of the room. Activity and nutrition. Remind the patient to take a lot of rest and to eat balanced meals to aid recovery. Adverse effects. Advise the patient to watch out for adverse effects of medications and to report them to the physician immediately..

Documentation Guidelines. If You Didn't DOCUMENT YOU DIDN'T DO.

[Audio] Caloric intake. Individual cultural or religious restrictions and personal preferences. Plan of care. Plan of care. Teaching plan. Responses to interventions, teaching, and actions performed. Attainment or progress toward desired outcomes. Discharge needs..

References. 1. Lippincott Mannual of Nursing Practice, 8 th Edition,Sandra M.Nettina , Lipincot Williams & Willkins Publications , Page Numbers: 295-300. 2.Assessment and Management of Clinical Problems Medical surgical Nursing , 7 th Edition,Lewis , Keitkember , Dirkson , O’brien , Bucher Mosby Elsevier Publications , Page Numbers: 569-575..

References (Studies as EVIDENCE). 1. Prevalence of pulmonary tuberculosis among expatriates subjected to medical visa screening in Abu Dhabi, United Arab Emirates, Journal of Epidemiology and Global Health Volume 3, Issue 1 , March 2013, Pages 23-30 2. Diagnosis and Management of Latent Tuberculosis Infection Cold Spring Harb Perspect Med. 2015 Nov; 5(11): a017830. doi : 10.1101/cshperspect.a017830 PMCID: PMC4632867 PMID: 26054858 Laura Muñoz , 1,2 Helen R. Stagg , 2 and Ibrahim Abubakar 2 Author information Copyright and License information Disclaimer 3. Diagnosis for Latent Tuberculosis Infection: New Alternatives https://doi.org/10.3389/fimmu.2020.02006 ; This article is part of the Research Topic Advances in Immunotherapeutic Approaches to Tuberculosis Cl audia Carranza 1 , Si gifredo Pedraza-Sanchez 2 , Eleane de Oyarzabal-Mendez 1 and Ma rtha Torres 1,3*.

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