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A.CAUSATIVE AGENT:
B. MODE OF TRANSMISSION:
B. INCUBATION PERIOD:
4-6 weeks to develop after the initial contact
C. INITIAL SYMPTOM:
Inflammation in Alveoli
Calcified Liquefaction
Cavity
E. PATTERNS OF INFECTION
1.Primary tuberculosis
F. CLINICAL FINDINGS
• Subjective
o Malaise
o Pleuritic pain
o Easily fatigued
• Objective
o Fever
o Night sweats
o Cough that progressively becomes worse.
o Hemoptysis
o Weight loss
o Chest x-ray examination to determine presence of active or
calcified lesions.
o Analysis of sputum and gastric contents for the presence of
acid-fast bacilli.
• OTHER SYMPTOMS
G. CLASSIFICATION OF TUBERCULOSIS
• CLASS 0
o No exposure; no infection
• CLASS 1
o Exposure; no evidence of infection
• CLASS 2
o Latent infection; no disease
• CLASS 3
o Disease; clinically active
• CLASS 4
o Disease; not clinically active
• CLASS 5
o Suspected disease; diagnosis pending
H. DIAGNOSIS
I. The Mantoux test
• Mantoux testing is not recommended for people who have had a past
Mantoux reaction of 15 mm or greater or in people who have had
previous Tuberculosis disease.
• PROCEDURE:
1. Provide patient education and locate the injection
site
o Collect necessary supplies and explain why
the Mantoux test is given and what is
involved in the procedure.
o Explain that 48 to 72 hours after the test is
administered, the patient must return to
have the in duration measured and
interpreted.
o Place the forearm palm side up on a firm,
well-lit surface and select an area of healthy
skin 5 to 10 centimeter below the elbow joint
which is free of muscle margins, heavy hair,
veins, sores, or scars .
o Only visibly dirty skin needs to be washed
with soap and water.
a)Stretch taut the selected area of skin between the thumb and forefinger.
b)Insert the needle slowly, bevel upwards, at an angle of 5 to 15 degrees
c)Advance the needle through the epidermis approximately 3mm so that the
entire bevel is covered and visible just under the skin.
d)Release the stretched skin and, holding the syringe in place on the
forearm, slowly inject the tuberculin solution.
e)If the needle is inserted correctly you should feel quite firm resistance as
the tuberculin enters the skin to form a tense, pale wheal 6 to 10 mm in
diameter.
5. Reading
• Inspect the site
• Palpate induration
• Mark induration
o The diameter of the induration is
measured across the forearm, from the
thumb side of the arm to the little finger
side.
o Use fingertip as a guide to mark lightly
with a fine dot at the widest edges of
induration across the forearm.
o If the margins of induration are irregular,
mark and measure the longest diameter
across the forearm.
• Measure induration
6. Interpretation
The Mantoux test does not measure immunity to Tuberculosis but the degree
of hypersensitivity to tuberculin. There is no correlation between the size of
induration and likelihood of current active Tuberculosis disease but the
reaction size is correlated with the future risk of developing Tuberculosis
disease.
The interpretation of the test result will depend on all relevant clinical
circumstances. In the absence of specific risk factors for Tuberculosis, an
induration of between 6 and 15mm is more likely to be due to previous BCG
vaccination or infection with environmental mycobacteria than to TB
infection. Where there is a higher probability of TB infection, such as recent
contact with an infectious case, a high occupational risk or residence in a
high prevalence country, then an induration of 6mm or greater is more likely
to be due to Tuberculosis.
• Mantoux conversion
This is defined as when the second of two Mantoux tests increases by 10mm
or greater over the first test. This is most useful in providing evidence of
infection in exposed contacts but does not apply if vaccination takes place in
the meantime. If a person is exposed to infectious TB who has a documented
Mantoux test result within the past 12 months, then only one test is
necessary to detect conversion. People who demonstrate Mantoux conversion
should be investigated for latent TB infection or active disease.
• Two-step-testing
In persons who may be liable to boosting in whom it is important to establish
a true baseline Mantoux response a second Mantoux test can be administered
one week after the first. Two-step-testing is not necessary for contacts of
infectious cases who will have already been re-sensitised if transmission has
occurred, or for anyone who has been Mantoux tested in the previous two
years.
• Mantoux reversion
This is defined as a reduction in Mantoux response following a previous test
and, while rare, is most common in elderly people and in those who had an
induration of 15mm or greater following a previous test.
• The Heaf test for Tuberculosis was first described in the Lancet on 28
July 1951.
• It consists of firing a circular pattern of six needles into the skin
through a film of prepared protein derivative (ppd).
• The site is inspected for reaction, usually seven days after the test.
• If the six puncture points have united to form a circle, or a more
severe reaction is noted, the test is considered to give a positive
indication of exposure to Tuberculosis.
• Patients who exhibit a negative reaction may be offered BCG
vaccination.
• Only available in United Kingdom.
• PROCEDURE:
1) Disposable Heads for the Heaf Test
The single use heads are to be used only with the Model 2000 handle and are
not suitable for use with the much older Mark 7 apparatus. Two types of head
are available which can be identified by both the description on the unit pack
and by the colour of the outer plastic moulding.
This head has six needles, which protrude 2mm when actuated. It is for
routine use in the Heaf method of multiple puncture tuberculin testing, for all
patients aged 2 years or over.
This head has six needles, which protrude 1 mm when actuated. It should be
used only for testing neonates and children of less than 2 years of age when
using the Heaf method of tuberculin testing.
One end of the pouch has been prepared to make opening easier. This is
identified on the printed side and has a chevron shaped seal visible from the
transparent side. With the printed side on a firm surface, the transparent side
of the pouch is peeled back from this end. This will leave the head exposed,
with the metal plate uppermost. The re-useable handle may now be used to
pick up the head by means of the circular magnet at the open end.
The handle should be held upright and the magnet brought into contact with
the metal plate on the head. The head will then attach itself to the magnet
and the apparatus is ready for use.
The front (volar aspect) of the forearm is the preferred area of skin for
testing. A site midway between wrist and elbow, or just above, should be
chosen to avoid visible veins or skin abnormalities.
If the skin requires cleansing, the area should be lightly prepared with
alcohol and allowed to dry completely by evaporation before applying the
test.
Purified protein derivative (PPD) specifically prepared for the Heaf method of
tuberculin testing (100,000 units/ml) is the only solution used. This should
be transferred from a newly opened ampoule to the skin by means of a
syringe (with the needle removed), bulb pipette, glass rod or loop. Enough
must be put on the skin site so that the whole end plate of the head will be
coated when applied to the skin. This may require up to 0. 1 ml of PPD and
can be confirmed by observing a complete rim of fluid around the end face,
when in contact with the skin.
The complete apparatus is placed on the PPD liquid, so that the plastic end
face is completely touching the skin and so that the apparatus is at right
angles to the skin.
The head may be gently moved a small amount to ensure an even coating.
To actuate the apparatus, the tester supports the forearm with one hand and,
with the other hand, presses down firmly, but steadily, on the handle,
keeping the whole apparatus at right angles to the skin. A click is heard as
the needles are released to penetrate the skin.
The PPD has now been introduced into the skin and six sites of needle entry
should be visible in the coated area.
5) Aftercare of the skin
Excess liquid can be wiped from the skin. No dressing is needed. The subject
should be instructed not to rub or scratch the area and to return in seven
days for reading the result.
The head should be separated carefully from the handle and immediately put
into a sharps disposal container.
The heads are for single use only and, after use, the needles remain
protruding from the end face. The tester should hold only the wide edge of
the head, to avoid self injury. Any head with protruding needles should be
discarded as it may have been used and it will not fire again.
7) Next test
The handle is now ready for a new head and the next test, following
instructions 2 to 6 again
The skin tones in the photographs have been selected to give the best visual
images. On darker skin tones, the reactions may be less visible and palpation
may be necessary to detect them.
Grade 0 Reaction
Grade 2 Reaction
Grade 3 Reaction
The handle should not require servicing in normal use and does not require
sterilisation.
After use, the handle should be wiped with a soft clean cloth or tissue, before
being replaced in the container provided. If there is any debris attached to
the magnet, pull the shield around the magnet back and remove the debris.
Note: the screw at the centre of the magnet should be clearly visible. If it is
not, one of the disks from the back of a disposable head may have detached
and become attached to the magnet. This disk must be removed, as it will
reduce the effectiveness of the magnet.
To remove stubborn stains, the handle may be wiped with a solvent cleaner
or washed with detergent. If using a water based cleaner, dry the magnet
immediately to avoid corrosion. Ensure that the handle is completely dry
before replacing it in the container.
The test is read by measuring the size of the largest papule. A negative
result is the presence of no papules.
Tuberculosis Symptomatic
(Cough for 2 weeks or more)
3 sputum collection
If at least 1 smear
If all smear negative
positive If symptoms
persist, collect
another 3 sputum
specimens and
Classify smear – Request for Chest x- refer to medical
positive Tuberculosis ray officer
• X-rays are valuable to detect old lessions or new ones they are large
enough to be seen.
• Cavities maybe present with far advanced disease.
• Inflammation that accompanies a new infection may also be apparent.
TUBERCULOUS
INFECTION:
Suspected because of:
Unresolved Pneumonia
Persistent Cough
Unexplained Fever
Contact
Positive
not significant
Tuberculin Skin Diagnosis
Test unlikely
Significan
t
Risk negativ
Chest x-ray
e
Factor
Positive
Positive Positive
Diagnosis
Asymptomat Confirme
d Diagnosis
ic infection Probable
Prophylaxis Treatment
I. NURSING DIAGNOSIS: KNOWLEDGE DEFICIT
CONCERNING THE DISEASE, TREATMENT AND
PROGNOSIS.
As-recently as the 1960s, people with TB were often confined for treatment
for months or years in sanatoriums.
J. MEDICAL INTEVENTIONS
• Assessment
1. Detailed history related to exposure, travel, or BCG inoculation.
2. Fatigue, anorexia, low-grade fever, and night sweats.
3. Sputum for color, amount, and consistency.
• Analysis/Implementation
•Ineffective Airway Clearance
•Ineffective Breathing Pattern
•Impaired Gas Exchange
•Pain
•Ineffective Individual Coping
•Ineffective Family Coping
•Altered Health Maintenance
•Noncompliance
•Sleep Pattern Disturbances
•Deficient Knowledge
•Ineffective Therapeutic Regimen Management
•Activity Intolerance
•Imbalanced Nutrition Less Than Body Requirements
•Risk for Infection
•Fatigue
• Planning/Implementation
1.Teach client to provide for scheduled rest periods.
2.Teach which foods to include in the diet and which are nutritious between
meal supplements.
3.Teach the importance of adhering, without variation, to the drug program
that has been established.
4.Teach the proper techniques to prevent spread of infection.
• Complications:
1. Tuberculosis empyema
2. Brorichopleural fistula
3. Potts Disease
4. Meningitis
5. Homaturia
6. Tuberculous osteomyelitis
7. Pericarditis
8. Bronchiectasis
9. Pneumonia
10. Headache
11. Diarrhea
L. EXTRAPULMONARY TUBERCULOSIS (XPTB)
• MYCOBACTERIUM TUBERCULOSIS
• Difficult to detect
• High among Caucasians
• ASSESSMENT:
a)Weight loss
b)Fatigue
c)Malaise
d)Fever
e)Sweats
• MILIARY TUBERCULOSIS
• Disseminated in a widespread pattern throughout the body may affect
any age group.
• Common in people aged 50 and older and in very young children with
unstable or undeveloped immune systems.
• ASSESSMENT:
a)Anorexia
b)Weakness
c) Fatigue
d)Weight loss
e)Fever
f) Chills
g)Sweats
h)Headache
i) Abdominal pain