Tuberculosis (TB) is an infectious disease caused by the bacteria Mycobacterium tuberculosis that mainly affects the lungs but may affect other organs. TB is an airborne disease spread through tiny droplets released into the air via coughs and sneezes.
TB can be cured and prevented but continues to be a global health crisis, especially for poorer countries. Persons most likely to contract TB disease include those who are immunocompromised, have HIV/AIDS, are malnourished, and are very young or very old.
There are three stages of TB infection:
- Exposure. When someone comes into contact with another person who has the disease. The exposed person may not show symptoms or have a positive TB test.
- Latent infection. TB can lay dormant in the body, sometimes never progressing to active TB. A TB skin or blood test will be positive.
- Active infection. The person begins to show symptoms of TB infection.
Symptoms of tuberculosis include:
- Chronic cough
- Bloody sputum
- Chest pain with breathing or coughing
- Weight loss
- Fatigue
- Night sweats
If a person is suspected to have TB, various tests can be conducted to confirm. A TB skin test, also known as the Mantoux tuberculin skin test, is the easiest way to detect the presence of bacteria. TB disease can be confirmed through a chest x-ray or sputum testing.
Nursing Process
As with all infectious diseases, preventing their spread is one of the top priorities. Tuberculosis is a contagious disease so healthcare professionals play a huge role in keeping the infection contained by making sure that all necessary precautions are applied, like wearing masks, sanitation practices, and proper hygiene.
The treatment of TB heavily relies on adherence to a months-long treatment regimen. Nurses are key in making sure that the medications are administered as prescribed and that patients are educated on adherence, side effects, and follow-up appointments.
Nursing Care Plans Related to Tuberculosis
Risk for Infection
Tuberculosis is caused by bacteria that spreads throughout the body, usually in the lungs, which may hinder the immune system’s optimal function.
Nursing Diagnosis: Risk for Infection
Related to:
- Poor primary defenses
- Malnutrition
- Exposure to environmental pathogens
- Suppressed immune system
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will verbalize the importance of reducing the risk of infection.
- Patient will demonstrate proper handling of items in the environment and proper sanitation.
- Patient will verbalize understanding of the importance of a proper diet and nutrition plan.
Assessment:
1. Assess the patient’s level of understanding of the disease.
An understanding of the disease process and how it is transmitted will demonstrate the patient’s ability to follow treatment plans.
2. Identify close contacts or household members.
Those in close proximity to the patient can also get sick. Similarly, they can also expose the patient to other pathogens.
3. Assess the patient’s lifestyle.
Individual risk factors, like smoking, drinking, and drug abuse, can increase the risk of acquiring TB and other infectious diseases.
4. Evaluate the patient’s willingness to cooperate.
Strict compliance with a multidrug regimen is crucial to the treatment of TB.
Interventions:
1. Place on airborne precautions.
While inpatient, airborne precautions are required and the patient must be placed in a negative-pressure isolation room. Educate the patient on proper hygiene protocols, like wearing masks and regular handwashing to help avoid the spread of the bacteria to others.
2. Educate on the medication regimen.
Treatment for TB may take 6 months to be cured. Educate the patient that their medication must be taken exactly as prescribed to kill the bacteria.
3. Reiterate the importance of follow-ups and regular retesting of sputum.
Monitoring the progression or regression of the disease is important to ensure the effectiveness of treatments.
4. Monitor symptoms.
Fever, tachycardia, and changes in sputum production are common symptoms of infection.
5. Encourage a well-balanced diet.
TB may cause a loss of appetite and weight loss. Teach patients to eat small frequent snacks if they cannot tolerate larger meals. A nutritious diet will help in preventing malnutrition.
6. Check liver function studies (ALT/AST).
Since the treatment plan includes a months-long multi-drug regimen, the liver may be affected.
7. Report to the appropriate health authorities.
TB is a reportable disease. In most states, healthcare workers are required to report cases and potentially exposed persons to the local health department within 24 hours.
Ineffective Airway Clearance
TB destroys lung tissue and leads to inflammation and a productive cough. The patient may experience an inability to clear secretions or obstructions from their respiratory tract.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Secretions that may be thick, bloody, or viscous
- Fatigue leading to weaker coughing
- Inflammation of the airway
As evidenced by:
- Irregular breathing (abnormal respiratory rate, rhythm, depth)
- Abnormal breath sounds
- Dyspnea
- Tightness in the chest
- Productive, chronic cough
Expected outcomes:
- Patient will display a patent airway as evidenced by unlabored breathing and clear breath sounds.
- Patient will demonstrate effective clearing of secretions without assistance.
- Patient will demonstrate and verbalize understanding of behaviors to improve or maintain airway clearance as instructed.
Assessment:
1. Monitor breathing patterns, respiratory rate, rhythm, depth, and sounds.
Diminished breath sounds may indicate a collapse of the lungs. Abnormal breath sounds such as wheezing may be caused by an accumulation of secretions and the inability to clear the airways. Labored breathing, tachypnea, or accessory muscle use signals ineffective breathing.
2. Assess the ability to cough effectively to expel mucus from the airways.
Note any signs of blood in the mucus (hemoptysis). Getting rid of mucus from the patient’s airways on their own may be difficult due to the infection causing the secretions to be thick, and because of inflammation. The presence of blood in the mucus may be the result of tissue breakdown in the lungs or ulceration, which may require further intervention.
Interventions:
1. Place the patient in Fowler’s position.
Semi or high-Fowler’s position can increase the lung capacity, therefore allowing the patient to breathe more effectively.
2. Instruct on the use of respiratory devices.
An incentive spirometer expands the lungs and encourages deep breathing. A flutter valve can mobilize secretions.
3. Suction when necessary.
If the patient is unable to expectorate secretions, suctioning may be necessary. Clearing the airways helps in preventing obstruction and aspiration.
4. Administer oxygen if necessary.
Oxygen may be needed if a patient is having extreme dyspnea. Oxygen saturation levels that fall below 95 may require the assistance of oxygen delivered by nasal cannula or oxygen masks.
5. Advise the patient to increase their fluid intake unless advised otherwise.
Proper hydration helps in thinning secretions, making expectoration easier.
Risk for Impaired Gas Exchange
Tuberculosis is an infectious disease that affects the lungs and results in poor lung compliance due to changes in the lung tissue. Impaired gas exchange may occur due to a decline in the lungs’ functional capacity.
Nursing Diagnosis: Risk for Impaired Gas Exchange
Related to:
- Thick, viscous secretions
- Bronchial edema
- Destruction of the alveolar-capillary membrane
- Atelectasis
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will verbalize improvement in breathing or the absence of dyspnea.
- Patient will display comfortable breathing as evidenced by a regular respiratory rhythm and depth.
- Patient will have improved arterial blood gasses and demonstrate adequate ventilation and oxygenation of the tissues.
Assessment:
1. Monitor breathing patterns, taking note of any signs of distress.
Respiratory effects caused by TB can range from mild dyspnea to severe respiratory distress. Accessory muscle use, tachypnea, or nasal flaring can signal distress.
2. Assess skin color in the extremities, mucous membranes, and nail beds.
Cyanosis or a change in skin color and poor capillary refill can occur when oxygenation in the tissues and vital organs is insufficient due to poor perfusion.
3. Monitor ABGs and oxygen saturation.
Decreased oxygen saturation or increased PaCO2 indicates the need for further intervention.
Interventions:
1. Demonstrate and encourage pursed-lip breathing during exhalation.
This helps in distributing air throughout the lungs by creating resistance against outflowing air to prevent collapse or narrowing of the airways, ultimately relieving shortness of breath.
2. Encourage adequate rest and limit activities.
Promote a calm and restful environment. Reduce oxygen consumption and demand by promoting plenty of rest.
3. Provide supplemental oxygen.
Choose the lowest concentration that is indicated by the situation and manifested symptoms. Supplemental oxygen can worsen hypoxemia that may occur due to decreased ventilation from a high concentration of oxygen.
4. Consider supportive medications.
A corticosteroid inhaler or oral prednisone may assist with dyspnea and chronic coughing.
Imbalanced Nutrition: Less Than Body Requirements
Tuberculosis may cause sudden weight loss which can be attributed to several factors including reduced food intake due to loss of appetite.
Nursing Diagnosis: Imbalanced Nutrition
Related to:
- Fatigue
- Dyspnea; Frequent coughing
- Disease process
- Financial or socioeconomic factors
As evidenced by:
- Aversion to eating
- Expressed lack of interest in food
- Body weight 20% or more under ideal
- Muscle wasting
- Imbalanced electrolytes
Expected outcomes:
- Patient will demonstrate progressive weight gain toward their individual goal.
- Patient will display normalization of nutritional laboratory values.
- Patient will verbalize an improvement in appetite.
Assessment:
1. Assess the patient’s nutritional status upon admission.
Documenting current weight, degree of weight loss, history of nausea or diarrhea, and other factors that contribute to weight loss will help in determining causative factors, which will aid in implementing interventions.
2. Note food tolerance or aversions.
Consideration of individual preferences may improve dietary intake.
3. Assess financial or social barriers.
Malnutrition can be a risk factor for tuberculosis. Assess for a predisposition for poor nutrition due to a lack of food availability or access.
Interventions:
1. Monitor intake and output and weigh regularly.
Documenting the % of meals consumed along with progress in gaining weight will help determine the effectiveness of nutritional support and interventions.
2. Encourage adequate rest and sleep periods.
Conserving energy will help in slowing metabolic processes, especially when the patient is febrile.
3. Encourage small, frequent meals high in fats and protein.
Smaller meals require less effort than forcing larger ones, ultimately leading to maximized nutritional intake.
4. Refer to a dietician if necessary.
Dieticians will provide accurate adjustments in dietary composition, and in planning a diet with adequate nutrients to meet metabolic requirements, dietary preferences, and financial constraints.
5. Monitor BUN, serum protein, iron, and albumin.
Abnormal values indicate malnutrition and may point to a need for further intervention or a change in the therapeutic regimen.
6. Manage side effects of medications.
Nausea, vomiting, GI upset, and anorexia are common side effects of TB medications. Administer closer to bedtime if possible to minimize upset. Antiemetics may be required to allow for adequate food intake.
Deficient Knowledge
A lack of knowledge about tuberculosis results in a delay in seeking treatment, underutilization of services, poor understanding of the required regimen, and further transmission of the disease.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Misinterpretation of information
- Unfamiliarity with information resources
- Lack of interest in learning
- Lack of exposure
As evidenced by:
- Request for information
- Statement of misconception
- Inaccurate follow-through of instructions
- Poor adherence to the treatment plan
- Development of complications
- Spread of disease
Expected outcomes:
- Patient will participate in the learning process by asking questions and seeking more information.
- Patient will verbalize an understanding of their treatment plan by verbalizing their medication regimen and follow-up appointments.
- Patient will initiate necessary lifestyle changes to prevent transmitting the disease to others.
Assessment:
1. Determine the patient’s knowledge level.
Inquire what the patient already knows about TB to fill in knowledge gaps without assuming what education they require.
2. Determine the patient’s ability to learn.
Several factors such as physical, emotional, and mental capabilities may affect the patient’s ability to absorb information.
3. Identify support persons or significant others requiring information.
Involving the patient’s significant others in the teaching and treatment plans is an opportunity to reiterate education and establish a solid support system.
Interventions:
1. Provide written instructions and an after-visit summary.
Provide written details including medication schedules, laboratory testing requirements, and follow-up appointment dates to help relieve any burden of remembering specific details in large amounts.
3. Encourage questions and clarifications.
Correcting misunderstandings with the patient and their family will help in preventing misconceptions. Encourage questions to develop trust and ensure thorough comprehension.
4. Explain medication dosages and possible adverse effects.
Antibiotic treatment for TB is long; 6 months at the least. Reiterate the importance of not stopping treatment as the bacteria may become resistant, causing multidrug-resistant TB (MDR TB). Serious side effects include liver toxicity, ototoxicity, skin reactions, and more. Explain to contact their doctor if side effects become bothersome.
5. Review how TB is transmitted and reactivation.
Knowledge of how an illness is transmitted to other persons will help in preventing the further spread of the disease. Reactivation can occur in patients with weak immune systems and chronic conditions such as HIV, diabetes, or cancer.
References
- Tuberculosis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/tuberculosis/symptoms-causes/syc-20351250. Accessed Nov. 18, 2022
- Tuberculosis. MedlinePlus. https://medlineplus.gov/tuberculosis.html. Accessed Nov. 18, 2022
- TB bacterium may suppress immune system to spread disease. Medical News Today. https://www.medicalnewstoday.com/articles/317745#TB-bacterium-suppresses-more-than-one-pathway. Accessed Nov. 19, 2022
- Six minute walk test in people with tuberculosis sequelae. S Sivaranjini, P Vanamail, Jane Eason. National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/20957072/. Accessed Nov. 20, 2022
- Nutrition & TB – Malnutrition, under nutrition, assessment. TBFacts.Org. https://tbfacts.org/nutrition-tb/. Accessed Nov. 21, 2022
- Doenges, M. E., Moorhouse, M. F. (1993). Nurses’s Pocket Guide: Nursing Diagnoses with Interventions (4th Ed.). F.A. Davis Company.
