b.

Assist
the
physician
in
counselling
and
initiating
treatment of TB patient
c. Open the NTP treatment card
d. Agree with TB patient the mode
of DOT including the treatment
partner
e. Supervise midwives to ensure
proper implementation of DOTS
f. Maintain
and
update
the
Presumptive TB Masterlist and
TB registerDirect sputum smear
microscopy
(DSSM)
is
fundamental to the detection of
infectious cases
g. and is recommended for case
finding
among
adults
and
children who can expectorate. It
is the primary
h. diagnostic method adopted by
the NTP among such individuals
because:
i. 1. It provides a definitive
diagnosis of active TB;
j. 2. the procedure is simple;
k. 3. it is economical; and,
l. 4. a microscopy center could be
put up even in remote areas.
m. Facilitate
requisition
and
distribution of anti-TB drugs,
laboratory supplies and forms
n. Maintain records on logistics
and ensure proper storage of
drugs.
i. Provide
continuous
health
education to all patients
j. Conduct training of health
workers
and
community
volunteers
k. Prepare, analyse and submit the
quarterly reports

Pamantasan ng Lungsod ng Pasig

Alkalde Jose St. Kapasigan, Pasig City
COLLEGE OF NURSING

Tuberculosis
Cusative agent:
tuberculosis.

Mycobacterium

MOT: It is transmitted from a TB

patient to another person through
coughing, sneezing and spitting.
*Lungs are commonly affected but it
could also affect other organs such as
the kidney, bones, liver and others.
*In 2010, TB was the 6th leading
cause of mortality with a rate of 26.3
deaths for every 100,000 population
and accounts for 5.1% of the total
deaths.1
The National TB Control Program
(NTP)
*The NTP is one of the public health
programs
being
managed
and
coordinated by the Infectious Disease
Office (IDO) of the National Center for
Disease
Prevention
and
Control
(NCDPC) of the Department of Health
(DOH).
*NTP has the mandate of developing
TB control policies, standards and
guidelines, formulating the national
strategic plan, managing program
logistics, providing leadership and
technical assistance to the lower
health offices / units, managing data
and monitoring and evaluating the
program.
Vision: TB-free Philippines
Goal: By 2016, reduce TB mortality
and prevalence by half compared to
1990 data

Role of the NURSE:

a. Manage
the
process
detecting
TB
cases
coordination with other staff

of
in

Case finding is the identification and

diagnosis
of
TB
cases
among
individuals with signs and symptoms

presumptive of tuberculosis. The

current approach to case finding
includes passive and intensified case
finding. The available tests utilized by
the program for diagnosing TB are:
direct sputum
smear microscopy,
TB
culture
and
drug
susceptibility test, tuberculin
skin test and
rapid
molecular
diagnostic
tests.
Direct sputum smear microscopy
(DSSM) is fundamental to the
detection of infectious cases
and is recommended for case finding
among adults and children who can
expectorate. It is the primary
diagnostic method adopted by the NTP
among such individuals because:
1. It provides a definitive diagnosis of
active TB;
2. the procedure is simple;
3. it is economical; and,
4. a microscopy center could be put up
even in remote areas.
*This is also used to: a) monitor
progress of patients with TB while they
are on antiTB treatment; and, b)
confirm cure at the end of treatment.
Chest X-ray is used to complement
bacteriologic testing in making a
diagnosis. However, it has
low
specificity
and
does
not
differentiate drug-susceptible from
drug-resistant disease.
TB Culture and drug susceptibility
test (DST) using solid (Ogawa or
Lowenstein Jensen) or liquid
media (MGIT) is a routine diagnostic
test for drug resistant TB cases under
the NTP. It is also used for TB
prevalence surveys, drug resistance
surveillance, research and other
special cases.
Tuberculin skin test (TST) is a basic
screening tool for TB infection among
children using purified

protein derivative (PPD) tuberculin

solution
to
trigger
a
delayed
hypersensitivity reaction among those
previously infected. Also known as the
PPD test or Mantoux test, it is one of
the criteria in determining disease
activity among children.
Rapid molecular diagnostic tests
endorsed by the WHO will be utilized
by the NTP. Currently,
WHO-endorsed available diagnostic
tests in the country are Xpert MTB/RIF
and Line-Probe Assay (LPA) for first
line drugs. Xpert MTB/RIF assay is a
rapid test that detects Mycobacterium
tuberculosis and rifampicin resistance.
Presumptive TB any person
whether adult or child with signs
and/or symptoms suggestive of
TB whether pulmonary or extrapulmonary, or those with chest x-ray
findings suggestive of
active TB.
Presumptive Drug Resistant-TB
(DRTB) Any person (whether adult
or child) who belongs to
any of the DR-TB high-risk groups,
such as: re-treatment cases, new TB
cases that are contacts ofconfirmed
DR-TB cases or non-converter of
Category 1, and people living with HIV
with signs and symptoms of TB.

Identification of Presumptive TB
1.For patients 15 years old and
above, a presumptive TB has any
of the following:
i. Cough of at least 2 weeks duration
with
or
without
the
following
symptoms:
Significant and unintentional weight
loss,
Fever,
Bloody sputum (hemoptysis),
Chest/back pains not referable to
any musculoskeletal disorders,
Easy fatigability or malaise,
Night sweats, and
Shortness of breath or difficulty of
breathing;
ii. Unexplained Cough of any duration
in: 1) a close contact of a known
active TB case; 2) high-risk clinical
groups (HIV/AIDS, diabetes, end-stage
renal disease, cancer, connective
tissue diseases, autoimmune diseases,
silicosis, patients who underwent
gastrectomy
or
solid
organ
transplantation
and
patients
on
prolonged systemic steroids); and, 3)
high risk populations (elderly, urban
poor, inmates and other congregate
settings)
2. For patients below 15 years old,
a presumptive PTB has any of the
following:
i. at least three (3) of the following
clinical criteria:
Coughing/wheezing of 2 weeks or
more, especially if unexplained;
Unexplained fever of 2 weeks or
more after common causes such as

malaria or pneumonia have been

excluded;
Loss of weight/ failure to gain
weight/ weight faltering/ loss of
appetite;
Failure to respond to 2 weeks of
appropriate antibiotic therapy for
lower respiratory tract infection;
Failure to regain previous state of
health 2 weeks after a viral infectionor
exanthema (e.g., measles); and,
Fatigue, reduced playfulness, or
lethargy (child has lost his/her normal
energy)
ii. ANY one of the above signs and
symptoms (clinical criteria) in a child
who is a close contact of a known
active TB case.
3. Chest x-ray findings suggestive
of PTB, with or without symptoms,
regardless of age.
4. Presumptive extra-pulmonary
TB may have any of the following:
Gibbus, especially of recent onset
(resulting from vertebral TB);

Non-painful
enlarged
cervical
lymphadenopathy with or without
fistula formation;
Neck stiffness (or nuchal rigidity)
and/or drowsiness suggestive of
meningitis that is not responding to
antibiotic treatment, with a sub-acute
onset or raised intracranial pressure;
Pleural effusion;
Pericardial effusion;
Distended abdomen (i.e., big liver
and spleen) with ascites;
Non-painful enlarged joint; and
Signs of tuberculin hypersensitivity
(e.g.
phlyctenular
conjunctivitis,
erythema nodosum).
_______________________________________
Sputum Collection. Demonstrate
how to produce quality sputum. Mucus
from the nose and throat, and saliva
from
the mouth are NOT good specimens.
Advise the patient to:
a. Clean mouth by thoroughly rinsing
with water. Food particles or other

solid particulates may inhibit the test

for Xpert MTB/RIF.
b. Breathe deeply, hold breath for a
second or two, and then exhale slowly.
Repeat the entire sequence two (2)
more times.
c. Cough strongly after inhaling deeply
for the third time and try to bring up
sputum from deep within the lungs.
d. Expectorate the sputum into a
container with a well fitted cap.
e. Collect at least 1 teaspoonful (510ml) for DSSM. For Xpert MTB/RIF,
sputum sample should not be less
than one (1) ml.
f. Examine the specimen to see that it
is not just saliva. Repeat the process if
necessary.

clavulanate, linezolid, carbapenems,

thioacetazone, then clarithromycin.
*Rifampicin: taken before meals,
causes red urine urine WOF s/s
hepatitis. Monitor liver and kidney
function.
*Isoniazide:
causes
peripheral
neuritis, given with Vit.B6 (pyridoxine).
Taken with food
*Pyrazinamide:
cause
hyperurucemia
*Ethambutol:
causes
optic
neuritis/blurring of vision
*Streptomycin: cause tinnitus, loss
of hearing
balance, damage to 8th cranial nerve
Note: After 2-4 weeks of treatment,
patient is no longer contagious

Meningococcemia
Causative
agent:
meningitidis,
also
meningococcus.

*Among the first group (the oral firstline

drugs)
high-dose
isoniazid,
pyrazinamide, and ethambutol are
thought of as an adjunct for the
treatment
of
MDR
and
XDR
tuberculosis. The second group is the
fluoroquinolones, of which the first
choice is high-dose levofloxacin. The
third group are the injectable drugs,
which should be used in the following
order: capreomycin, kanamycin, then
amikacin. The fourth group are called
the second-line drugs and should be
used
in
the
following
order:
thioamides,
cycloserine,
then
aminosalicylic acid. The fifth group
includes drugs that are not very
effective or for which there are sparse
clinical data. Drugs in group five
should be used in the following order:
clofazimine,
amoxicillin
with

Neisseria
called

MOT: Neisseria meningitidis bacteria

are spread through the exchange of
respiratory and throat secretions like
spit (e.g., by living in close quarters,
kissing). Fortunately, these bacteria
are not as contagious as germs that
cause the common cold or the flu. The
bacteria are not spread by casual
contact or by simply breathing the air
where a person with meningococcal
disease has been.
Incubation- 2-10 days
*Bacteria enter the bloodstream and
multiply, damaging the walls of the
blood vessels and causing bleeding
into the skin and organs.
Symptoms may include:
Fatigue
Vomiting
Cold hands and feet
Cold chills

Severe aches or pain in the muscles,

joints, chest or abdomen (belly)
Rapid breathing
Diarrhea
In the later stages, a dark purple rash

Dengue Hemorrhagic fever

Diagnostic Tests: Lumbar puncture,

cultures of blood, urine, nose and
throat secretions.

Causative agent:
DENV-1 to 4
genus flavivirus
MOT: Ades aegypti, Aedes albopictus

Prophylaxis:

Incubation
Period:
Probably 6 days to 1 week

Rifampicin

Adults: 600 mg twice daily for two

days

Children: 10 mg/kg twice daily for

two days

Neonates: 5 mg/kg twice daily for

two days

For pregnant women or contraindication to

rifampicin
Ceftriaxone

< 12yo: 125mg IM once only

> 12yo: 250 mg IM once only

Reconstitute 1 g vial with 3.2 ml

lignocaine 1% (250 mg/ml)

OR
Ciprofloxacin

>12yo: 500 mg oral as single dose

Treatment: Penicillin, ceftriaxone,

vancomycin, chloramphenicol.
Nursing Considerations:
1. Give IV antibiotics as ordered.
2. Maintain a patent airway.
3. Monitor GCS

Uncertain.

Manifestations:
First
4
days:
Febrile/Invasive Stage - starts abruptly
as fever - abdominal pain - headache vomiting - conjunctival infection
epistaxis,
4th

7th
days:
Toxic/Hemorrhagic Stage - decrease in
temperature - severe abdominal pain GIT bleeding - unstable BP (narrowed
pulse pressure) - shock - death may
occur
7th

10th
days:
Recovery/Convalescent
Stage
appetite regained
Classification (WHO): Grade I: a. flulike symptoms b. Hermans sign c. (+)
tourniquet sign
Grade II: a. manifestations of Grade I
plus spontaneous bleeding b. e.g.
petechiae, ecchymosis purpura, gum
bleeding, hematemesis, melena
Grade III: a. manifestations of Grade II
plus beginning of circulatory failure b.
hypotension, tachycardia, tachypnea
Grade IV: a. manifestations of Grade III
plus shock (Dengue Shock Syndome)
Diagnostic Test: Torniquet test
(Rumpel Leads Test / capillary fragility
test) PRESUMPTIVE; positive when 20
or more oetechiae per 2.5 cm square
or 1 inch square are observed Platelet
count CONFIRMATORY; (Normal is
150 - 400 x 103 / mL)
Treatment:
Supportive
and
symptomatic Paracetamol for fever
Analgesic for pain Rapid replacement
of body fluids most important
treatment ORESOL Blood tansfusion
Diet: low-fat, low-fiber, non-irritating,

noncarbonated. Noodle soup may be

given. ADCF (Avoid Dark-Colored
Foods) ALERT! No Aspirin
Prevention: 4 oclock habit
Chemically treated mosquito net Larva
eating fish Environmental sanitation
Antimosquito
soap
Neem
tree
(eucalyptus)
Eliminate vector
Avoid too many hanging
clothes inside the house
Residual spraying with
insecticide
Daytime fumigation
Use of mosquito repellants
Wear long sleeves, pants,
and socks
For the control of H-fever,
knowledge of the natural history of the
disease is important.
Environmental control is
the
most
appropriate
primary
prevention approach and control of
Hfever.

Malaria
Causative
agent:
Plasmodium
Parasites: Vivax Falciparum (most
fatal; most common in the Philippines)
Ovale Malariae, recent species: P.
knowlesi
MOT: Bite of infected anopheles
mosquito Night time biting High-flying
Rural areas Clear running water
Assessment Findings: Cold Stage:
severe, recurrent chills (30 minutes to
2 hours)
Hot Stage: fever (4-6 hours)
Wet Stage: Profuse sweating Episodes
of chills, fevers, and profuse sweating
are associated with rupture of the red
blood cells. - intermittent chills and
sweating - anemia / pallor - teacolored
urine
malaise
hepatomegaly
splenomegaly
abdominal pain and enlargement easy fatigability
Treatment and Management:

Early diagnosis identification of a

patient with malaria as soon as he is
seen
through
clinical
and/or
microscopic method
Clinical method based on signs and
symptoms of the patient and the
history of his having visited a malariaendemic area
Microscopic method based on the
examination of the blood smear of
patient through microscope (done by
the
medical
technologist)
QBC/quantitative Buffy Coat fastest
Malarial Smear best time to get the
specimen is at height of fever because
the microorganisms are very active
and easily identified
Chemoprophylaxis: Only chloroquine
should be given (taken at weekly
intervals starting from 1-2 weeks
before entering the endemic area). In
pregnant
women,
it
is
given
throughout the duration of pregnancy.
Treatment: Blood Schizonticides drugs acting on sexual blood stages of
the parasites which are responsible for
clinical manifestations
1. QUININE oldest drug used to treat
malaria; from the bark of Cinchona
tree; ALERT: Cinchonism quinine
toxicity
2. CHLOROQUINE
3. PRIMAQUINE sometimes can also
be given as chemoprophylaxis
4.
FANSIDAR

combination
of
pyrimethamine and sulfadoxine
Prevention:
*Insecticide treatment of mosquito
net *House Spraying (night time
fumigation) *On Stream Seeding
construction of bio-ponds for fish
propagation
(2-4
fishes/m2
for
immediate impact; 200-400/ha. for a
delayed effect) *On Stream Clearing
cutting of vegetation overhanging
along stream banks *Avoid outdoor
night activities (9pm 3am) *Wearing
of clothing that covers arms and legs
in
the
evening
*Use
mosquito
repellents *Zooprophylaxis typing of
domestic animals like the carabao,
cow, etc near human dwellings to

deviate mosquito bites from man to

these animals Intensive IEC campaign
NURSING CARE: 1. TSB (Hot Stage)
2. Keep patent warm (Cold Stage) 3.
Change wet clothing (Wet Stage) 4.
Encourage fluid

Pain and swelling in the large

joints (such as knees)
Shooting
pains
that
may
interfere with sleep
Heart palpitations and dizziness
due to changes in heartbeat
Late disseminated stage (months to
years post-tick bite)

Lyme Disease

Causative agent: bacterium, Borrelia

burgdorferi
MOT: spread through the bite of
infected ticks. The blacklegged tick (or
deer tick, Ixodes scapularis) spreads
the disease in the northeastern, midAtlantic, and north-central United
States, and the western blacklegged
tick (Ixodes pacificus) spreads the
disease on the Pacific Coast.

Arthritis
caused
by
Lyme
disease manifests differently
than other causes of arthritis
and must be distinguished from
arthralgias
(pain,
but
not
swelling, in joints).

These include shooting pains,

numbness or tingling in the
hands or feet, and problems
with short-term memory.

Assessment
Findings:
Early
localized stage (3-30 days post-tick
bite)
Red, expanding rash called
erythema migrans (EM)--- can
reach up to 12 inches (30 cm)
across. Parts of the rash may
clear as it enlarges, resulting in
a bull's-eye appearance.
Rash usually feels warm to the
touch but is rarely itchy or
painful.
Fatigue, chills, fever, headache,
muscle and joint aches, and
swollen lymph nodes
small bump or redness at the
site of a tick bite that goes
away in 1-2 days, like a
mosquito bite.
Early disseminated stage (days to
weeks post-tick bite)

Additional EM lesions in other

areas of the body
Facial or Bell's palsy (loss of
muscle tone on one or both
sides of the face)
Severe headaches and neck
stiffness due to meningitis
(inflammation of the spinal
cord)

Lingering symptoms after treatment

(post-treatment
Lyme
disease
syndrome)
Lyme disease have symptoms that last
months to years after treatment with
antibiotics5. These symptoms can
include muscle and joint pains,
cognitive defects, sleep disturbance,
or fatigue.
Treatment: doxycycline, amoxicillin,
or cefuroxime axetil. Patients with
certain neurological or cardiac forms
of illness may require intravenous
treatment
with
drugs
such
as
ceftriaxone or penicillin.
Prevention: Tick repellant with N,NDiethyl-meta-toluamide
(DEET)
or
permethrin

Parrot Fever
Psittacosis
Causative agent: gram-negative
intracellular parasite Chlamydia
psittaci
MOT: Psittacine birds like parrots,
cockatiels, macaws, also pigeons and
turkeys may harbor the parasite in
their blood, feathers, tissue, nasal

secretions, liver, spleen, and feces.

Airborne transmission.
Assessment Findings: Incubation- 4
to 15 days.
Chills, low grade fever for 7- 10 days
In humans, fever, chills, headache,
muscle aches, and a dry cough.
Pneumonia is often evident on chest xray.
Complications:
Endocarditis, hepatitis, and neurologic
complications may occasionally occur.
Severe pneumonia requiring intensivecare support may also occur. Fatal
cases have been reported.
Diagnostic Tests:
Blood culture,
ELISA, Complement fixations
Treatment: Tetracycline, doxycycline,
erythromycin, and chloramphenicol
can be used

Bubonic Plaque
Causative agent: bacterium, Yersinia
pestis.
MOT:
flea
bites,
droplets,
contaminated fluid or tissues.
Assessment Findings:
Incubation
period- 2 to 8 days.
Malaise, fever, pain, swelling and
tenderness lymph nodes. Lymph node
damaged
(axillary
and
inguinal)
produces
painful,
inflamed,
supporative bubboes. Hemorrhagic
areas become necrotic in the skin and
appear dark (black death).

Pneumonic plague: Patients develop

fever, headache, weakness, and a
rapidly developing pneumonia with
shortness of breath, chest pain, cough,
and sometimes bloody or watery
mucous. Pneumonic plague may
develop from inhaling infectious
droplets
or
may
develop
from
untreated bubonic or septicemic
plague after the bacteria spread to the
lungs. The pneumonia may cause
respiratory
failure
and
shock.
Pneumonic plague is the most serious
form of the disease and is the only
form of plague that can be spread
from person to person (by infectious
droplets)
Septicemic plague: Patients develop
fever, chills, extreme weakness,
abdominal pain, shock, and possibly
bleeding into the skin and other
organs. Skin and other tissues may
turn black and die, especially on
fingers, toes, and the nose. Septicemic
plague can occur as the first symptom
of plague, or may develop from
untreated bubonic plague. This form
results from bites of infected fleas or
from handling an infected animal.
Diagnostic test: Blood culture, CSF,
CXR
Treatment:
streptomycin.
Chloramphenicol for meningeal type.
Prophylaxis: Doxycycline