Pulmonary Tuberculosis: Comprehensive Treatment Management Including Adherence Support, Side Effect Management, Drug Resistance Education, Contact Tracing and Occupational Health Planning
Your Role — Nurse
Respiratory Clinic
Your 38-year-old patient with pulmonary tuberculosis has been on standard quadruple therapy for 6 weeks but has missed appointments and doses due to side effects and misunderstanding about treatment duration. The patient currently feels well. They live with their partner and two children. They work as a chef in a busy restaurant kitchen. You are the TB specialist nurse providing comprehensive re-education on treatment adherence, side effect management, directly observed therapy, contact tracing, public health implications, and occupational health considerations.
- •Greet warmly and non-judgementally. Explore reasons for non-adherence: side effects (nausea, fatigue, orange urine), feeling better, misconceptions, practical barriers, stigma.
- •Validate the difficulty of TB treatment. Address each side effect: explain orange urine is harmless, manage nausea with food timing and antiemetics, check for visual changes from ethambutol.
- •Explain why strict adherence is critical: risk of drug resistance, treatment failure, prolonged infectiousness, need for second-line therapy (longer, more toxic, lower success rate).
- •Discuss DOT and family screening: arrange community nurse for DOT, blister pack, blood test monitoring for liver function. Explain family screening process for partner and children.
- •Discuss occupational health: fitness for work as a chef, infection control in the workplace, employer confidentiality, fit note requirements. Provide clear written adherence plan and follow-up schedule.
The Interlocutor
Played by the actor / assessor
You are 38 years old with pulmonary TB. You stopped taking your medication after 2 weeks because you felt better. The tablets made you nauseous and your urine turned orange. You work as a chef and live with your partner and 2 children.
- •Say the medication made you feel sick and tired. The orange urine frightened you.
- •Say you thought you were cured after 2 weeks — you felt completely better.
- •Ask whether you can pass TB to your children. You share a bedroom with your partner.
- •Say you are worried about your job — as a chef you cannot afford more time off work.
- •Say you understand the risks now. You will restart medication and agree to nurse visits.
Sample Role-play
Thank you for coming into the clinic today. How have you been feeling on the TB treatment?
Awful to be honest. Nauseous and exhausted all the time. And my urine turned this strange orange colour which really frightened me so I stopped taking the tablets.
I am sorry you have had those difficult side effects. Let me reassure you straight away about the orange urine — that is completely harmless. It is caused by one of your medicines called rifampicin and it simply means your body is processing the medication properly. The nausea and fatigue can be more challenging but there are definitely things we can do to help manage those symptoms effectively.
I also stopped because after a couple of weeks I started feeling completely better so I thought the TB must have gone.
I can see why you would think that and it is a very logical assumption. But TB bacteria are different from most other infections — they grow very slowly which is exactly why the treatment has to continue for a full six months. After just two weeks you have only managed to kill the weakest bacteria. The stronger more resilient ones are still alive in your lungs. If you stop early those remaining bacteria can become resistant to the standard medications.
I did not realise it could become resistant. That sounds very serious.
Most side effects improve as your body gets used to the medication over the first few weeks. Taking your tablets with a small amount of food can really help with the nausea and I can prescribe anti-nausea medication if needed. I will arrange a blister pack so you can clearly see your daily doses and a community nurse for directly observed therapy to support you through your treatment.
That would definitely help keep me on track.
I will also need to monitor your liver function with regular blood tests throughout your treatment. There is one important safety warning — one of your medications called ethambutol can occasionally affect your vision. If you notice any blurring or changes in how you see colours you must contact me immediately. We will also screen your household contacts as a precaution.
How long before I can return to work as a chef?
You can return to work after two weeks of effective treatment once we confirm you are no longer infectious. The occupational health team at your workplace can advise on any adjustments needed. I will provide a medical certificate and a letter for your employer explaining the situation.
Can TB come back after I finish treatment?
I will restart the medication and come for my appointments.
What if I get pregnant while on TB treatment?
TB treatment is safe to continue during pregnancy. If there is any chance you could be pregnant we would check and adjust your medication regimen accordingly. The most important thing is to complete the full course of treatment.
Do I need to tell my employer about my diagnosis?
You need to inform your employer for occupational health reasons but they are required by law to keep your medical information confidential. The occupational health team can advise on when it is safe for you to return to work which is typically after two weeks of effective treatment.
How will I know if the medication is working?
We will monitor your progress with regular sputum samples to check whether the TB bacteria are clearing. We also track your symptoms weight and general wellbeing. The fact that you felt better after two weeks shows the medication was working. If you complete the full six-month course the chance of TB returning is very low. The full duration is designed to kill all the bacteria including the slow-growing ones. This is why completing the course matters so much. I will see you next week for your first blood test to check your liver function.
Useful Phrases
Clinical Background
TB treatment adherence is a public health priority. Standard therapy: 2 months rifampicin + isoniazid + pyrazinamide + ethambutol (intensive phase), followed by 4 months rifampicin + isoniazid (continuation phase). Non-adherence is the leading cause of drug resistance (MDR-TB). DOT (directly observed therapy) is recommended. Common side effects include: orange secretions (rifampicin), peripheral neuropathy (isoniazid — give pyridoxine), hepatitis (monitor LFTs), optic neuritis (ethambutol — urgent if visual changes).
Common Mistakes to Avoid
- ✕Being confrontational about missed doses — a non-judgemental approach is more effective.
- ✕Not addressing the orange urine side effect — this causes unnecessary alarm if not explained in advance.
- ✕Underestimating the difficulty of side effects — dismissive attitudes reduce patient trust and adherence.