Pulmonary tuberculosis/Ghons complex

 Tuberculosis is a chronic inflammation caused by Mycobacterium tuberculosis (tubercle bacillus, Koch

bacillus) - human type or bovine type.
 The most affected organ by tuberculosis is the lung.
 Pulmonary tuberculosis is classified in primary and secondary.

Primary tuberculosis
The Ghon complex is the lesion of primary pulmonary tuberculosis and it results from Koch bacillus
(Mycobacterium tuberculosis).

It contains three elements (Figure 1) :

 The Ghon focus is a small nodular lesion (aprox. 1 cm), white-yellowish, with central caseous necrosis,
encapsulated, located in the middle third of the lung (the lower part of the upper lobe or upper part of the
lower lobe).
 Lymphadenitis (inflammation of the lymph nodes) is caused by the lymphatic dissemination of Koch
bacillus into the hilar lymph nodes which appear enlarged, firm, yellowish-white, with or without central
caseous necrosis.
 Lymphangitis (inflammation of the walls of the lymphatic vessels) only radiologically visible, presents as
a discrete linear opacity & miliary nodules in "string of pearls" aligned along the lymphatic vessel. It
represents the tuberculous inflammation of the lymphatics linking the Ghon focus and the hilar lymph
nodes.

Primary pulmonary tuberculosis will heal by fibrosis & calcification. Otherwise, it evolves into progressive
primary tuberculosis, which includes the following :

 Primary caseous pneumonia occurs by the local extension of the Ghon focus to an entire lobe or
segment, the affected area gaining a consolidated appearance, yellow-gray, with low consistency. It can
have a severe evolution with liquefaction and drainage of the central necrosis through the airways..
 Tuberculous bronchopneumonia occurs due to local spread of the disease, from the primary
tuberculous complex to the entire lung parenchyma, especially at the base of the lung. Therefore, it results
patchy circumscribed foci with a diameter of 0.5-1 cm
 Miliary tuberculosis appears due to hematogenous dissemination of Koch bacilli, local (lung) or distant
(most common kidneys, liver, spleen, meninges). It presents as multiple small nodular lesions (2-3 mm),
well-defined, yellowish, millet seeds like, spread over the entire surface of the affected organ (miliary
tubercles).
 The Papanicolaou test (Pap smear)

 The Papanicolaou test (Pap smear) is a widely known cystologic test for early detection of cervical
cancer.
 This can also be used to detect cancerous cells of the breast, lung, stomach, and renal system.
 A physician or specifically trained nurse scrapes secretions from the patient’s cervic and spreads them on a
slide, which is sent to the laboratory for cystologic analysis.
 The American Cancer Society recommends a Pap test every 3 years for women between ages 20 and 40 who
aren’t in a high-risk category and who have had negative results from three previous Pap tests.
 Yearly tests (or tests at physician-recommended intervals) are advised for women older than age 40, for
those in a high risk category, and for those who had a positive test previously.
 If a Pap test is positive or suggest malignancy, cervical biopsy can confirm the diagnosis.

Purpose of Pap Smear

 To detect malignant cells.

 To detect inflammatory changes in tissue.
 To assess response to chemotherapy and radiation therapy.
 To detect viral, fungal, and occasionally, parasitic invasions.

Pap Smear Procedure

Patient Preparation

1. Instruct the patient to avoid intercourse for 24 hours, douching for 48 hours, and vaginal creams or
medication for 1 week.
2. Just before the test, instruct the patient to empty her bladder.
3. During the procedure, she might experience a slight discomfort but no pain from the speculum;
however, she may feel some pain when the cervix is scraped.
4. Explain the procedure takes only 5 to 10 minutes to perform.
5. Instruct the patient to disrobe from the waist down and to drape herself.
6. Ask her to lie on the examining table and to place her heels in the stirrups.
7. Tell her to slide her buttocks to the edge of the table.

Implementation

1. The patient is assisted into the lithotomy position with her feet in the stirrups.
2. An unlubricated speculum is inserted into the vagina.
3. The cervix is located.
4. Secretions from the cervix and material from the endocervical canal are collected with an
endocervical brush and wooden spatula.
5. Specimens are spread on slides and immediately immersed in fixative or sprayed with a fixative.
6. Specimens are appropriately labeled with date of last menses, collection site, and method.
7. If vaginal or vulval lesions are present, scrapings taken directly from the lesion are preferred.
8. The slides are preserved immediately.

Nursing Interventions
1. Help the patient up and ask her to dress when the examination is completed.
2. Supply the patient with a sanitary napkin if cervical bleeding occurs.
3. Tell the patient when to return for her next Pap test.
Interpretation

Normal Results
 No malignant cells or abnormalities are present.

Abnormal Results

Cells with relatively large nuclei, only small amounts of cytoplasm, abnormal nuclear chromatin patterns, and marked
variation in size, shape, and staining properties, with prominent nucleoli, suggest malignancy.

Atypical but nonmalignant cells suggest a benign abnormality.

 Atypical cells may suggest dysplasia.

Interfering Factors

 Douching within 24 hours of testing.

 Excessive use of lubricating jelly on the slide.
 Collection of specimen during menstruation
 Delay in fixing the specimens
 Consistency of specimen too thin or too thick.

Precautions
 Preserve the slides immediately after the specimen is collected.
 Preserve the ThinPrep solution by immediately placing the lid back on the container, as exposure to air or
light can cause distortion of cells.