Tuberculosis is present globally; mostly in developing countries. Several countries in Asia, Africa, Eastern Europe, and Latin and Central America continue to have an unacceptably high burden of tuberculosis.
With the improvement of living conditions and the introduction of effective treatment in the late 1940s, the number of clients in the United States reported having TB began to steadily decline. In 2011, 10,528 TB cases (a rate of 3.4 cases per 100,000 population) were reported in the United States, representing a 5.8% decline in the number of reported TB cases and a 6.4% decline in the case rate, compared with 2010.
Among racial and ethnic groups, the largest percentage of total cases was in Asians (30%), followed by Hispanics (29%) and non-His panics. The World Health Organization (WHO) reports a 22% drop in global TB mortality from 2000 through 2015. WHO also estimated that 2 billion people have latent TB and that globally, in 2009, the disease killed 1.7 million people.
Tuberculosis, a multisystemic disease with myriad presentations and manifestations, is the most common cause of infectious disease-related mortality worldwide. It is an ancient human disease caused by Mycobacterium tuberculosis which mainly affects the lungs, making the pulmonary disease the most common presentation. However, TB is a multisystemic disease with a protean presentation. The organ system most commonly affected includes the respiratory system, the gastrointestinal system, the lymphoreticular system, the skin, the central nervous system, the musculoskeletal system, the reproductive system, and the liver.
Multidrug-resistant TB is defined as resistance to isoniazid and rifampin, which are the 2 most effective first-line drugs for TB. A rare type of MDR-TB called extensively drug-resistant TB (XDR-TB), is resistant to isoniazid, rifampin, any fluoroquinolone, and at least one of 3 injectable second-line drugs. XDR-TB resistance to all anti-TB drugs tested has been reported in Italy, Iran, and India.
PTB
The principal mode of spread is through the inhalation of infected aerosolized droplets. Infection with M. tuberculosis results most commonly through the exposure of the lungs or mucous membranes to infected aerosols. Droplets in these aerosols are 1-5 μm in diameter; in a person with active pulmonary TB, a single cough can generate 3000 infective droplets, with as few as 10 bacilli needed to initiate infection. When inhaled, droplet nuclei are deposited within the terminal airspaces of the lung. The organisms grow for 2-12 weeks until they reach 1,000-10,000 in number, which is sufficient to elicit a cellular immune response that can be detected by a reaction to the tuberculin skin test.
When a person is infected with M. tuberculosis, the infection can take 1 of a variety of paths, most of which do not lead to actual TB. The infection may be cleared by the host immune system or suppressed into an inactive form called latent tuberculosis infection (LTBI), with resistant hosts controlling mycobacterium growth before the development of active disease. Clients with LTBI cannot spread TB.
85% of clients with TB present with pulmonary complaints. However, extrapulmonary TB can also occur as part of a primary or late, generalized infection. Initial lesions may heal and the infection becomes latent before symptomatic disease occurs. If the host is unable to arrest the initial infection, the client develops progressive, primary TB with tuberculosis pneumonia in the lower and middle lobes of the lung. Purulent exudates with large numbers of acid-fast bacilli can be found in sputum and tissue.
Infected persons living in crowded or closed environments pose a particular risk to noninfected persons. Approximately 20% of household contacts develop an infection. Populations at high risk for acquiring the infection also include hospital employees, inner-city residents, nursing home residents, and prisoners.
Nursing care planning for clients diagnosed with PTB should focus on adherence to the therapeutic regimen with no interruption until its conclusion. With regard to the enhancement of therapeutic adherence, the recommendations emphasize the role of nursing professionals in the elaboration of care plans that include not only help for diagnosis but also operationalization of directly observed therapy. The following are nursing diagnoses associated with the management of PTB.
- Risk for Infection
- Ineffective Airway Clearance
- Imbalanced Nutrition: Less than Body Requirements
Pulmonary Tuberculosis Nursing Care Plan
Below are sample nursing care plans for the problems identified above.
Risk for Infection
The risk of infection following TB exposure is primarily governed by exogenous factors and is determined by an intrinsic combination of the infectiousness of the source case, proximity to the contact, and social and behavioral risk factors including smoking, alcohol, and indoor air pollution. When a person is infected with M. tuberculosis, the infection can take one of a variety of paths. The infection may be cleared by the host immune system or suppressed into an inactive form called latent tuberculosis infection.
Nursing Diagnosis
- Risk for Infection
Risk Factors
- Inadequate primary defenses, decreased ciliary action, and stasis of secretions
- Lowered resistance, suppressed inflammatory process
- Environmental exposure
- Malnutrition
Evidenced by
- (Not applicable; the presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes
After implementation of nursing interventions, the client is expected to:
- Identify interventions to prevent or reduce the risk of spread of infection.
- Demonstrate techniques and initiate lifestyle changes to promote a safe environment.
Nursing Interventions
| Assessment
Monitor the client’s vital signs, especially the temperature. |
Rationale
Febrile reactions are indicators of the continuing presence of infection. |
| Auscultate the client’s lung sounds. | Clients with pulmonary TB have abnormal breath sounds, especially over the upper lobes or involved areas. Rales or bronchial breath signs may be noted, indicating lung consolidation. |
| Identify others at risk, such as household members, close associates, and friends. | Those exposed may require a course of drug therapy to prevent the development of infection. Approximately 20% of household contacts develop infection (positive tuberculin skin test). The population at high risk for acquiring the infection also includes hospital employees, inner-city residents, nursing home residents, and prisoners. |
| Identify individual risk factors for reactivation of tuberculosis. | Clients at risk for reactivation include clients who have lowered resistance associated with alcoholism, malnutrition, intestinal bypass surgery, use of immunosuppressant drugs, presence of diabetes mellitus or cancer, or postpartum. Knowledge about these factors helps the client alter lifestyle and avoid or reduce the incidence of exacerbation. |
| Perform screening for tuberculosis (Mantoux test or screening questionnaires for resource-poor settings. | The Mantoux reaction following the injection of a dose of PPD (purified protein derivative) is the traditional screening test for exposure to tuberculosis. Several screening questionnaires have been validated to enable healthcare workers working in remote and resource-poor environments to screen for tuberculosis. |
| Independent | |
| Review the pathology of the disease and potential spread of infection via airborne droplet. | This helps the client realize and accept the necessity of adhering to a medication regimen to prevent reactivation and complications. Understanding how the disease is passed and awareness of transmission possibilities help the client and significant others take steps to prevent infection of others. |
| Instruct the client to cough, sneeze, and expectorate into tissue and to refrain from spitting. | Review proper disposal of tissue and good handwashing techniques then ask the client to perform a return demonstration. These are behaviors necessary to prevent the spread of infection. |
| Review the necessity of infection control measures, such as temporary respiratory isolation. | This may help the client understand the need for protecting others while acknowledging the client’s sense of isolation and social stigma associated with communicable diseases. Note: AFB can pass through standard masks; therefore, particulate respirators are required. |
| Stress the importance of uninterrupted drug therapy. Evaluate the client’s potential for cooperation. | The contagious period may last only 2 to 3 days after initiation of drug regimen, but in the presence of cavitation or moderately advanced disease, the risk of spread of infection may continue up to 3 months. Compliance with multidrug regimens for prolonged periods is difficult; therefore, DOT should be considered. Directly observed treatment, short-course (DOTS) is the internationally recommended strategy to improve adherence, reduce the risk of acquired drug resistance and increase the possibility of cure. |
| Educate the client about the importance of follow-up and periodic reculturing of sputum for the duration of the therapy. | This aids in monitoring the effects of medications and the client’s response to therapy. Without adequate support, a significant proportion of clients with TB discontinue treatment before the end of the planned period or take medication irregularly. |
| Encourage selection and ingestion of well-balanced meals. Provide frequent small “snacks” in place of large meals as appropriate. | The presence of anorexia or preexisting malnutrition lowers resistance to infectious processes and impairs healing. Small snacks may enhance overall intake. |
| Dependent/Collaborative | |
| Administer anti-infective agents, as indicated. | The goals for the treatment of TB are to cure the individuals and to minimize transmission to other persons. It is essential that treatment be tailored and supervision is based on each client’s clinical and social circumstances. DOT may be the most effective way to maximize the completion of therapy. The primary drugs given are isoniazid, rifampin, pyrazinamide, and ethambutol. These four drugs should not be given in divided doses; all four drugs should be given together. Evidence shows this promotes the therapy’s effectiveness. |
| Administer BCG vaccine, as indicated. | The vaccination drive in developing countries has played a bigger role in decreasing the prevalence of this infection. The preventive effect of the BCG vaccination is controversial but many studies have identified vaccination as a very important tool in the fight against tuberculosis. |
| Monitor laboratory studies and sputum smear results. | A client who has three consecutive negative sputum smears over a 3- to 5-month period is adhering to the drug regimen and who is asymptomatic will be classified as a nontransmitter. |
| Collaborate with other healthcare professionals to provide psychological counseling and health education services. | Psychological counseling and health education services can reduce the level of non-adherence among TB clients, and are recommended in the case of routine treatment. This could be best achieved if these interventions are guided by behavioral theories and incorporated into routine anti-tuberculosis treatment strategies. |
| Notify the local health department. | Reporting if there is a case of TB is required by the law and should be reported within 1 week of diagnosis. this can be helpful in identifying contacts to reduce the spread of infection. The treatment course is long and usually handled in the community, with the public health nurse monitoring. |
Ineffective Airway Clearance
If the host is unable to arrest the initial infection, the client may develop a progressive, primary TB with tuberculous pneumonia in the lower and middle lobes of the lung. Purulent exudates with large numbers of acid-fast bacilli can be found in the sputum and tissue. subserosal granulomas may rupture into the pleural or pericardial spaces and create serous inflammation and effusions.
Nursing Diagnosis
- Ineffective Airway Clearance
Related Factors
- Thick, viscous, or bloody secretions
- Fatigue
- Poor cough effort
- Tracheal or pharyngeal edema
Evidenced by
- Abnormal respiratory rate, rhythm, depth
- Abnormal breath sounds- rhonchi, wheezes, stridor
- Dyspnea
Desired Outcomes
After implementation of nursing interventions, the client is expected to:
- Maintain patent airway.
- Expectorate secretions without assistance.
- Demonstrate behaviors to improve or maintain airway clearance.
- Participate in the treatment regimen, within the level of ability and situation.
- Identify potential complications and initiate appropriate actions.
Nursing Interventions
| Assessment
Assess the client’s respiratory function, such as breath sounds, rate, rhythm, depth, and use of accessory muscles. |
Rationale
Diminished breath sounds may reflect atelectasis. Rhonchi and wheezes indicate accumulation of secretions and inability to clear airways, which may lead to the use of accessory muscles and increased work of breathing. |
| Auscultate the client’s lung sounds. | Clients with pulmonary TB have abnormal breath sounds, especially over the upper lobes or involved areas. Rales or bronchial breath signs may be noted, indicating lung consolidation. |
| Note the client’s ability to expectorate and cough effectively; document the character and amount of sputum and presence of hemoptysis. | Expectoration may be difficult when secretions are very thick as a result of infection or inadequate hydration. Blood-tinged or frankly bloody sputum results from tissue breakdown in the lungs and may require further evaluation and intervention. |
| Independent | |
| Place the client in a semi- or high-Fowler’s position. Assist the client with coughing and deep-breathing exercises. | Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation may open atelectatic areas and promote the movement of secretions into larger airways for expectoration. |
| Clear the secretions from the mouth and trachea; suction as necessary. | This prevents obstruction and aspiration. Suctioning may be necessary if the client is unable to expectorate secretions. |
| Educate the client to maintain fluid intake of at least 2,500 ml/day unless contraindicated. | High fluid intake helps thin secretions, making them easier to expectorate. |
| Perform chest physiotherapy and postural drainage to loosen secretions if not contraindicated. | To enhance the clearance of secretions, chest wall clapping or percussion was added to postural drainage.
Mechanical percussion increases intra-thoracic pressure. The physiological rationale for the use of postural drainage to assist in the clearance of secretions is based on the use of gravity to assist with the mucociliary action. |
| Dependent/Collaborative | |
| Administer humidified oxygen. | Humidified oxygen prevents the drying of mucous membranes and helps thin secretions. To avoid condensation, the mixture of oxygen and air passes through a humidifier to a heated inspiratory circuit. It can improve client comfort and tolerance, especially when used with a high-flow nasal cannula. |
| Administer medications as indicated, such as mucolytic agents, bronchodilators, and corticosteroids. | Mucolytic agents reduce the thickness and stickiness of pulmonary secretions to facilitate clearance. Bronchodilators increase the lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery. Corticosteroids may be useful in the presence of extensive involvement with profound hypoxemia and when the inflammatory response is life-threatening. |
| Prepare to assist with emergency intubation. | Intubation may be necessary in rare cases of bronchogenic TB accompanied by laryngeal edema or acute pulmonary bleeding. |
Imbalanced Nutrition: Less than Body Requirements
An estimated 2.3 million TB cases were attributed to malnutrition according to the WHO, which is above those attributed to HIV (0.81 million) and DM (0.36 million). Macro- and micronutrients are essential to the enhanced immune response against various pathogens, including M. TB. TB clients frequently exhibit weight loss, or they are malnourished owing to suboptimal protein intake, muscle catabolism induced by inflammation, during infection, and gastrointestinal symptoms induced by acute-phase proteins.
Nursing Diagnosis
- Imbalanced Nutrition: Less than Body Requirements
Related Factors
- Fatigue
- Frequent cough and sputum production
- Dyspnea
- Anorexia
- Insufficient financial resources
Evidenced by
- Weight 10% to 20% below ideal for frame and height
- Reported lack of interest in food, altered taste sensation
- Poor muscle tone
Desired Outcomes
After implementation of nursing interventions, the client is expected to:
- Demonstrate progressive weight gain toward the goal with normalization of laboratory values
- Be free of signs of malnutrition
- Initiate behaviors or lifestyle changes to regain and to maintain appropriate weight gain.
Nursing Interventions
| Assessment
Assess and document the client’s nutritional status, noting skin turgor, current weight and degree of weight loss, the integrity of oral mucosa, ability to swallow, presence of bowel tones, and history of nausea, vomiting, or diarrhea. |
Rationale
These assessment findings are useful in defining the extent of the problem and appropriate choice of interventions. |
| Assess the client’s usual dietary pattern and likes and dislikes. | This helps identify specific needs or strengths. Consideration of individual preferences may improve dietary intake. |
| Monitor intake and output and weigh periodically. | This is useful in measuring the effectiveness of nutritional and fluid support. Malnutrition refers to a condition that includes wasting (low weight-to-height ratio), body mass index (BMI, kg/m²) <18.5 in adults, and micronutrient deficiencies. |
| Monitor frequency, volume, and consistency of stools. Investigate the occurrence of anorexia, nausea, and vomiting. | the presence of anorexia, nausea, and vomiting may affect the dietary choices of the client and can identify areas for problem-solving to enhance the intake of nutrients. |
| Independent | |
| Encourage and provide for frequent rest periods. | Providing rest periods helps the client conserve energy, especially when metabolic requirements are increased by fever. |
| Provide oral care before and after respiratory treatments. | Oral care reduces bad taste left from sputum or medications used for respiratory treatments that can stimulate the vomiting center. |
| Encourage small, frequent meals with foods high in protein and carbohydrates. | These foods maximize nutrient intake without undue energy expenditure from eating large meals. |
| Provide micronutrient supplementation. | Micronutrients such as vitamin D and A and zinc are essential elements in the diet, which are needed for multiple physiological processes, such as energy production, immune responses, and other functions. |
| Encourage the SO to bring foods from home and to share meals with the client unless contraindicated. | Sharing a meal with the client creates a more normal social environment during mealtime and helps meet personal and cultural preferences. |
| Schedule treatments with the respiratory therapist 1 to 2 hours before or after meals. | Respiratory therapy done 1 to 2 hours before or after meals may help reduce the incidence of nausea and vomiting associated with medications or the effects of respiratory treatments on a full stomach. |
| Dependent/Collaborative | |
| Refer the client to a dietitian for adjustments in dietary composition. | A dietitian assists in planning a diet with nutrients adequate to meet the client’s metabolic requirements, dietary preferences, and financial resources post-discharge. |
| Monitor laboratory studies, such as blood urea nitrogen, serum protein, and prealbumin and albumin. | Low values reflect malnutrition and indicate the need for change in the therapeutic regimen. |
Tuberculosis Nursing Care Plan Sample
Nursing Diagnosis: Ineffective Airway Clearance related to presence of bronchial infection and secretion.
| Assessment | Nursing Diagnosis | Inference | Outcome | Nursing Interventions | Rationale | Evaluation |
|---|---|---|---|---|---|---|
| Subjective: “I had this recurrent cough for almost a month now and it seems that I am having difficulty in breathing at times...) - verbatim of client. Objective: RR= 23 breaths/ min PR= 95 beats/min T= 37.5 degree Celsius Easy fatigability Productive cough Chills at night Loss of appetite as claimed Chest X- ray and sputum examination revealed positive for pulmonary tuberculosis | Ineffective Airway Clearance related to presence of bronchial infection and secretion | Cough is the most common symptom of pulmonary tuberculosis. It may produce yellowish or greenish-colored sputum, especially during the day. Eventually, the sputum may be streaked with blood. Furthermore, a person with PTB may experience fatigue and loss of energy. It may affect his or her ability to expectorate secretions, too. Aside from that, difficulty of breathing signifies that there may be an accumulation of secretion in the bronchial cavity of the lungs. | After 8 hours of nursing care, client will be able to readily expectorate secretions and will have absence or decrease in episodes of dyspnea. | 1. Maintain infection control through the use of mask and performance of hand washing before and after contact with client. 2. Place client in high fowler’s position and encourage reposition every two hours. 3. Maintain room or environment free from any sorts of allergen 4. Teach and encourage deep breathing and coughing exercises. 5. Emphasize to increase fluid intake depending on individual tolerability or as indicated. 6. Instruct to take warm liquids instead of cold ones. 7. Provide postural drainage and percussion. 8. Monitor breathing patterns and breath sounds. 9. Educate client and family about disease condition and the need for compliance with the therapeutic regimen. | 1. PTB is transmitted via droplet inhalation so proper precaution should be performed to avoid transmission to other clients. 2. Elevating the head of the bed and turning client every two hours help in decreasing the pressure placed on the diaphragm. 3. Allergen may trigger more accumulation of secretion due to respiratory response. 4. These exercises hasten the expulsion of sputum and aids in maintaining airway patency. 5. Fluids help loosen secretion in the lungs. 6. Warm fluids help in loosening the secretions while cold. 7. Through the aid of gravity and percussion secretions are readily expelled. 8. It provides baseline data for future comparison in the evaluation of disease condition. 9. PTB can be transmitted through droplet inhalation and 6 months compliance to medication is needed in order to be treated with it. | After 8 hours of nursing care, the goal is partially met as evidenced by client’s participation to breathing and coughing exercises and ability to expectorate sputum upon evaluation; still there are episodes of dyspnea as claimed by the client. |
References
- Adigun, R., & Singh, R. (2022, January 5). Tuberculosis – StatPearls. NCBI. Retrieved March 1, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK441916/
- Demelo-Rodriguez, P., Samperio, M. O., Tocora, D. G. G., Ballesteros, J. C. C., & Lillo, J. A. A. (2015). High-flow Nasal Cannula Oxygen Therapy: Preliminary Study in Hospitalized Patients. Letters to the Editor, 51(12), 656-665.
- Herchline, T. E., & Stuart, M. (2020, June 4). Tuberculosis (TB): Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved March 1, 2022, from https://emedicine.medscape.com/article/230802-overview#a1
- McIlwaine, M. (2006). Physiotherapy and airway clearance techniques and devices. Pediatric Respiratory Review, 7s, S220-S222. 10.1016/j.prrv.2006.04.197
- Muller, A.M., Osorio, C.S., Silva, D.R., Sbruzzi, G., & de Tarso Roth Dalcin, P. (2018, July 1). Interventions to improve adherence to tuberculosis treatment: systematic review and meta-analysis. The International Journal of Tuberculosis and Lung Disease, 22(10), 731-740. https://doi.org/10.5588/ijtld.17.0596
- Murr, A. C., Doenges, M. E., & Moorhouse, M. F. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
- Narasimhan, P., Wood, J., MacIntyre, C. R., & Mathai, D. (2013, February 12). Risk Factors for Tuberculosis. NCBI. Retrieved March 2, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583136
- Tellez-Navarrete, N. A., Ramon-Luing, L. A., Muñoz-Torrico, M., Osuna-Padilla, I. A., & Chavez-Galan, L. (2020, July 27). Malnutrition and tuberculosis: the gap between basic research and clinical trials. The Journal of Infection in Developing Countries, 15(3), 310-319. doi:10.3855/jidc.12821
- Zago, P. T. N., Maffacciolli, R., Mattioni, F. C., Dalla-Nora, C. R., & Rocha, C. M. F. (2021). Nursing actions promoting adherence to tuberculosis treatment: scoping review. Journal of School of Nursing University of Sao Paulo, 55. https://doi.org/10.1590/1980-220X-REEUSP-2020-0300
