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 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.
In this article:
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 Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to tuberculosis.
Review of Health History
1. Note the patient’s general symptoms.
Symptoms of tuberculosis include:
- Chronic cough
- Bloody sputum (hemoptysis)
- Chest pain with breathing or coughing
- Weight loss
- Fatigue
- Fever
- Night sweats
2. Identify the patient’s risk factors.
The following factors increase the risk of TB:
- Age: under 5 years old or 65 years old and above
- Compromised immune system (HIV, diabetes, organ transplant, medications that suppress the immune system, etc.)
- Positive purified protein derivative (PPD) test history
- Previous TB treatment history
- Exposure to TB
- Travel to or from a region where tuberculosis is prevalent
- Living or working with those at risk for TB, such as homeless shelters, hospitals, correctional facilities, and nursing homes
- Injection drug use
3. Determine the patient’s possible exposure.
A person who has a latent TB infection cannot infect others with the illness. Following 2 to 3 weeks of treatment, an individual with active TB is unlikely to spread the disease. Active TB disease spreads through the following:
- Coughing
- Sneezing
- Talking
- Singing
- Laughing
4. Review the medical history.
Patients with latent TB infection have no symptoms because the causative agent is dormant. The bacteria is still present in the body and can later become active. Some individuals can live a lifetime with a latent TB infection that never becomes active and progresses. TB may become active if the immune system declines and fails to prevent the bacteria from reproducing.
Physical Assessment
1. Identify the classic clinical characteristics of TB.
The following are classic clinical signs of active pulmonary TB:
- Cough
- Significant weight loss
- Loss of appetite
- Fever
- Night sweats
- Expectoration of bloody sputum (hemoptysis)
- Chest discomfort
- Fatigue
2. Perform a cephalocaudal assessment.
TB may affect other areas of the body other than the lungs. Check for the presence of the following symptoms:
- Tuberculous meningitis:
- Intermittent or persistent headache for 2 to 3 weeks
- Subtle changes in mental status
- Changes in levels of consciousness
- Mild fever
- Skeletal TB:
- Back pain
- Stiffness
- Paralysis in the lower extremities
- Unilateral tuberculous arthritis (ankle, elbow, wrist, and shoulder)
- Genitourinary TB:
- Flank pain
- Painful urination (dysuria)
- Frequent urination
- Males: pain in the scrotum and inflammation of the prostate, testicles, or epididymis
- Females: mimics pain that is misdiagnosed as pelvic inflammatory disease
- Gastrointestinal TB:
- Persistent mouth or anal ulcers
- Difficulty swallowing (dysphagia)
- Abdominal pain mimicking peptic ulcer disease
- Malabsorption
- Pain, diarrhea, or blood in the stool (hematochezia)
3. Auscultate the lungs.
Those who have pulmonary TB may display the following during a lung assessment:
- Abnormal breath sounds over the upper lobes or affected areas
- Rales heard upon auscultation
4. Note the signs of extrapulmonary TB.
Depending on the tissues affected, extrapulmonary TB symptoms can include the following:
- Confusion
- Neurologic impairment
- Inflamed choroid of the eye (chorioretinitis)
- Swollen lymph nodes
- Cutaneous lesions
5. Anticipate that immunocompromised and elderly patients can be asymptomatic.
In high-risk patients, especially those who are immunocompromised or elderly, classic symptoms are commonly absent.
Diagnostic Procedures
1. Encourage the patient to undergo screening tests.
Screening tests detect patients with active or latent TB:
- Mantoux tuberculin skin test is the primary screening test after receiving a dose of PPD (purified protein derivative). The findings reveal the patient’s overall exposure risk.
- Interferon release assays (IGRA, Quantiferon Assays) are a more accurate and sensitive tuberculosis screening test than the Mantoux test.
2. Assist the patient with a chest x-ray.
In all cases where a screening test is positive, a chest x-ray is recommended to rule out or confirm the presence of current illness.
3. Obtain sputum samples.
Acid-fast bacilli (AFB) smear and culture is performed on sputum from the patient. AFB culture has the highest specificity for TB, though a negative smear result does not rule out current TB infection.
4. Take a blood sample for HIV serology.
HIV serology is recommended for all TB patients with unknown HIV status: People with HIV have a higher risk of developing TB.
5. Obtain blood cultures.
Blood cultures can establish active TB, but only if specialized systems are used that can detect the specific bacilli.
6. Consider a new generation of diagnostic tools for detecting TB.
A new generation of tuberculosis diagnostic tools includes nuclear amplification and gene-based tests. These tests allow for identifying the bacteria or bacteria particles utilizing DNA-based molecular techniques. Examples are DR-MTB and Genexpert.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with tuberculosis.
Assist TB Treatment
1. Initiate antibiotic therapy.
Antibiotics are used to treat tuberculosis. The patient will likely be prescribed a combination of the following medications for empiric treatment:
- Isoniazid
- Rifampin
- Pyrazinamide
- Ethambutol
- Streptomycin
Patients must continue antibiotic treatment until they demonstrate three consecutive negative sputum smears.
2. Emphasize the need for strict treatment adherence.
These medications must be taken consistently for 4-6 months to work. It is risky to stop taking the drugs too soon or without consulting a doctor, as this may lead to drug-resistant TB.
3. Boost lung expansion.
Lung expansion and secretion mobility can be increased through pursed-lip and deep breathing, coughing, and aerobic exercises. Offer an incentive spirometer to aid in lung expansion.
4. Suction when needed.
Suctioning may be required if the patient can’t expectorate secretions. The prevention of airway blockage and aspiration is aided by clearing the airways.
5. Place the patient in an upright position.
The patient can breathe more effectively in a semi- or high-Fowler’s position, which allows the lungs to expand.
6. Mobilize secretions.
A flutter valve and fluids can mobilize secretions. Unless otherwise instructed, advise the patient to drink plenty of fluids to thin secretions, facilitating expectoration.
7. Conserve energy.
Induce a calm and relaxing atmosphere. Encourage rest to lower the demand for oxygen consumption.
8. Administer medications as ordered.
Provide supportive medications as prescribed. These may include pain medication, oxygen, inhaled or oral steroids, and mucolytics, which may help relieve discomfort with breathing and persistent coughing.
Control Transmission
1. Encourage vaccinations.
The Bacillus Calmette-Guerin (BCG) TB vaccine is used in some nations (not the United States). Children in countries with high TB prevalence are typically given the vaccination to protect against meningitis and miliary tuberculosis, a severe form of TB. The vaccine reduces the accuracy of TB skin testing.
2. Get screening tests when exposed.
Encourage individuals who were exposed to patients with TB to undergo screening tests.
3. Educate the patient about cough and sneeze etiquette.
Teach the patient to cover their mouth and nose when coughing or sneezing. While sneezing or coughing, turn the face away and use the fold of the elbow. Discard used paper tissues appropriately.
4. Maintain proper sanitation.
The risk of contracting TB infection and illness increases with malnutrition, congestion, poor air circulation, and poor sanitation. Educate the patient and family members on hand hygiene.
5. Implement airborne precautions.
TB is transferred from one person to another through the air. When a patient with TB coughs, speaks, laughs, sings, or sneezes, the air is contaminated with TB germs. Anyone near a person who has TB disease runs the risk of inhaling TB germs into their lungs. Instruct the patient to wear a surgical mask during transportation for tests within the hospital or after discharge when traveling to medical appointments.
6. Isolate the patient.
Negative pressure rooms should be used to isolate people who may have TB. When properly ventilated, the negative pressure prevents aerosol within the room from escaping to the rest of the facility.
7. Wear the appropriate PPE.
Healthcare workers must don the recommended personal protective equipment (PPE), such an an N95 respirator that has been fit-tested and certified by NIOSH.
8. Alert the health department.
Reports of latent or active TB must be reported to local health departments.
9. Monitor for signs of infection in caregivers and visitors.
Those who live with a patient with active TB are at high risk for contracting the disease and may also require treatment. Stress the need to keep people who are immunocompromised, children, and pregnant visitors away from close contact with the patient.
10. Encourage small meals and snacks.
Patients with TB often experience weight loss from the disease and require tailored diets that support muscle growth and meet nutritional deficits. Collaborate with a dietician as needed.
11. Educate on treatment side effects.
GI side effects (such as anorexia, nausea, and vomiting) are common side effects of TB medications. The patient must understand not to discontinue TB treatment unless advised by their provider.
12. Remind the patient about their follow-up schedule.
Most latent TB infections require 3-4 months of treatment. Four, six, or nine months of treatment are necessary for active TB illness. The patient will require frequent monitoring of their sputum for treatment success and drug toxicity monitoring through blood work to assess liver enzymes, CBC count, and creatine.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for tuberculosis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for tuberculosis.
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.
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.
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. Nursing interventions are 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.
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. Nursing interventions are 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.
References
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- Centers for Disease Control and Prevention. (2022, August 17). Fact sheets | General | Tuberculosis: General information | TB | CDC. Retrieved May 2023, from https://www.cdc.gov/tb/publications/factsheets/general/tb.htm
- Cleveland Clinic. (2022, May 24). Tuberculosis: Causes, symptoms, diagnosis & treatment. Retrieved May 2023, from https://my.clevelandclinic.org/health/diseases/11301-tuberculosis
- Doenges, M. E., Moorhouse, M. F. (1993). Nurses’s Pocket Guide: Nursing Diagnoses with Interventions (4th Ed.). F.A. Davis Company.
- Herchline, T. E. (2022, March 4). Tuberculosis (TB): Practice essentials, background, pathophysiology. Medscape. Retrieved May 2023, from https://emedicine.medscape.com/article/230802-overview
- Mayo Clinic. (2021, April 3). Tuberculosis – Symptoms and causes. Retrieved May 2023, from https://www.mayoclinic.org/diseases-conditions/tuberculosis/symptoms-causes/syc-20351250
- Nutrition & TB – Malnutrition, under nutrition, assessment. TBFacts.Org. https://tbfacts.org/nutrition-tb/. Accessed Nov. 21, 2022
- 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
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