Tuberculosis

Tuberculosis is an acute or chronic infection caused by Mycobacterium tuberculosis.

TB is characterized by pulmonary infiltrates, formation of granulomas with caseation,
fibrosis, and cavitation. People living in crowded and poorly ventilated conditions and
who are immunocompromised are most likely to become infected. In the United
States, incidence is higher among the homeless, drug-addicted, and impoverished
populations, as well as among immigrants from or visitors to countries in which TB is
endemic. In addition, persons at highest risk include those who may have been
exposed to the bacillus in the past and those who are debilitated or have
lowered immunity because of chronic conditions such as AIDS, cancer, advanced age,
and malnutrition. When the immune system weakens, dormant TB organisms can
reactivate and multiply.

When this latent infection develops into active disease, it is known as reactivation TB,
which is often drug resistant. Multidrug-resistant tuberculosis (MDR-TB) is also on
the rise, especially in large cities, in those previously treated with antitubercular drugs,
or in those who failed to follow or complete a drug regimen. It can progress from
diagnosis to death in as little as 4–6 weeks. MDR tuberculosis can be primary or
secondary. Primary is caused by person-to-person transmission of a drug-resistant
organism; secondary is usually the result of nonadherence to therapy or inappropriate
treatment.

Nursing Care Plans

Here are five (5) nursing care plans (NCP) for pulmonary tuberculosis:

1. Risk for Infection

2. Ineffective Airway Clearance
3. Risk for Impaired Gas Exchange
4. Imbalanced Nutrition: Less Than Body Requirements
5. Deficient Knowledge
6. Other Possible Nursing Care Plans

Risk for Infection: At increased risk for being invaded by pathogenic organisms.
Nursing Diagnosis

 Infection, risk for [spread/reactivation]

Risk factors may include

 Inadequate primary defenses, decreased ciliary action/stasis of secretions

 Tissue destruction/extension of infection
 Lowered resistance/suppressed inflammatory process
 Malnutrition
 Environmental exposure
 Insufficient knowledge to avoid exposure to pathogens

Possibly evidenced by

 Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

 Identify interventions to prevent/reduce risk of spread of infection.

 Demonstrate techniques/initiate lifestyle changes to promote safe
environment.

Nursing Interventions Rationale

Review pathology of disease

Helps patient realize or accept necessity of
(active and inactive phases; dissemination of
adhering to medication regimen to prevent
infection through bronchi to adjacent tissues or
reactivation or complication. Understanding of
via bloodstream and/or lymphatic system) and
how the disease is passed and awareness of
potential spread of infection via airborne
transmission possibilities help patient and SO
droplet during coughing, sneezing, spitting,
take steps to prevent infection of others.
talking, laughing, singing.

Identify others at risk like household members,

Those exposed may require a course of drug
close associates and friends.
therapy to prevent spread or development of
Nursing Interventions Rationale

infection.

Instruct patient to cough or sneeze and

expectorate into tissue and to refrain from
Behaviors necessary to prevent spread of
spitting. Review proper disposal of tissue and
infection.
good hand washingtechniques. Encourage
return demonstration.

May help patient understand need for

protecting others while acknowledging
Review necessity of infection control
patient’s sense of isolation and social stigma
measures. Put in temporary respiratory
associated with communicable diseases. AFB
isolation if indicated.
can pass through standard masks; therefore,
particulate respirators are required.

Febrile reactions are indicators of continuing

Monitor temperature as indicated.
presence of infection.

Identify individual risk factors for reactivation

of tuberculosis: lowered resistance associated
Knowledge about these factors helps patient
with alcoholism, malnutrition, intestinal
alter lifestyle and avoid or reduce incidence of
bypass surgery, use of immunosuppressive
exacerbation.
drugs, corticosteroids, presence of diabetes
mellitus, cancer, postpartum.

Contagious period may last only 2–3 days after

initiation of chemotherapy, but in presence of
Stress importance of uninterrupted drug cavitation or moderately advanced disease, risk
therapy. Evaluate patient’s potential for of spread of infection may continue up to 3
cooperation. months. Compliance with multidrug regimens
for prolonged periods is difficult, so directly
observed therapy (DOT) should be considered.

These second-line drugs may be required when

infection is resistant to or intolerant of primary
Review importance of follow-up and periodic drugs or may be used concurrently with
reculturing of sputum for the duration of primary anti tubercular drugs. MDR-TB
therapy. requires minimum of 18–24 mo therapy with at
least three drugs in the regimen known to be
effective against the specific infective organism
and which patient has not previously taken.
Nursing Interventions Rationale

Treatment is often extended to 24 mo in

patients with severe symptoms
or HIV infection.

Patient who has three consecutive negative

Encourage selection and ingestion of well-
sputum smears (takes 3–5 mo), is adhering to
balanced meals. Provide frequent small
drug regimen, and is asymptomatic will be
“snacks” in place of large meals as appropriate.
classified a non transmitter.

Monitors adverse effects of drug therapy

Liver function studies: AST/ALT.
including hepatitis.

Helpful in identifying contacts to reduce spread

of infection and is required by law. Treatment
Notify local health department. course is long and usually handled in the
community with public health nurse
monitoring.

Initial therapy of uncomplicated pulmonary

Administer anti-infective agents as disease usually includes four drugs, e.g., four
indicated: primary drugs or combination of primary and
secondary drugs.

INH is usually drug of choice for infected

 Primary drugs: isoniazid (INH), patient and those at risk for developing TB.
Short-course chemotherapy, including INH,
ethambutol (Myambutol), rifampin rifampin (for 6 mo), PZA, and ethambutol or
(RMP/Rifadin), rifampin with streptomycin, is given for at least 2 mo (or until
isoniazid (Rifamate), pyrazinamide sensitivities are known or until serial sputums
are clear) followed by 3 more months of
(PZA), streptomycin, rifapentine therapy with INH.Ethambutol should be given
(Priftin); if central nervous system (CNS) or
disseminated disease is present or if INH
resistance is suspected.
Extended therapy (up to 24 mo) is indicated for
 Second-line drugs: ethionamide reactivation cases, extrapulmonary reactivated
(Trecator-SC), para-aminosalicylate TB, or in the presence of other medical
(PAS), cycloserine (Seromycin), problems, such as diabetes mellitus or silicosis.
Prophylaxis with INH for 12 mo should be
capreomycin (Capastat). considered in HIV-positive patients with
positive PPD test.
Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory
tract to maintain a clear airway.

Nursing Diagnosis

 Airway Clearance, ineffective

May be related to

 Thick, viscous, or bloody secretions

 Fatigue, poor cough effort
 Tracheal/pharyngeal edema

Possibly evidenced by

 Abnormal respiratory rate, rhythm, depth

 Abnormal breath sounds (rhonchi, wheezes), stridor
 Dyspnea

Desired Outcomes

 Maintain patent airway.

 Expectorate secretions without assistance.
 Demonstrate behaviors to improve/maintain airway clearance.
 Participate in treatment regimen, within the level of ability/situation.
 Identify potential complications and initiate appropriate actions.

Nursing Interventions Rationale

Diminished breath sounds may reflect

Assess respiratory function noting breath atelectasis. Rhonchi, wheezes indicate
sounds, rate, rhythm, and depth, and use of accumulation of secretions and inability to
accessory muscles. clear airways that may lead to use of accessory
muscles and increased work of breathing
Nursing Interventions Rationale

Expectoration may be difficult when secretions

are very thick as a result of infection and/or
Note ability to expectorate mucus and cough inadequate hydration. Blood-tinged or frankly
effectively; document character, amount of bloody sputum results from tissue breakdown
sputum, presence of hemoptysis. (cavitation) in the lungs or from bronchial
ulceration and may require further evaluation
or intervention.

Positioning helps maximize lung expansion and

Place patient in semi or high-Fowler’s position. decreases respiratory effort. Maximal
Assist patient with coughing and deep- ventilation may open atelectatic areas and
breathing exercises. promote movement of secretions into larger
airways for expectoration.

Prevents obstruction and aspiration. Suctioning

Clear secretions from mouth and trachea;
may be necessary if patient is unable to
suction as necessary.
expectorate secretions.

Maintain fluid intake of at least 2500 mL/day High fluid intake helps thin secretions, making
unless contraindicated. them easier to expectorate.

Prevents drying of mucous membranes and

Humidify inspired air and oxygen
helps thin secretions.

Administer medications as indicated:

 Mucolytic agents: acetylcysteine

Reduces the thickness and stickiness of
(Mucomyst); pulmonary secretions to facilitate clearance.

 Bronchodilators: oxtriphylline Increases lumen size of the tracheobronchial

(Choledyl), theophylline (Theo-Dur); tree, thus decreasing resistance to airflow and
improving oxygen delivery.
May be useful in presence of extensive
 Corticosteroids (prednisone). involvement with profound hypoxemia and
when inflammatory response is life-
threatening.
Intubation may be necessary in rare cases of
Be prepared for/assist with emergency
bronchogenic TB accompanied by laryngeal
intubation.
edema or acute pulmonary bleeding.
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Risk for Impaired Gas Exchange: At risk for excess or deficit in oxygenation and/or carbon
dioxide elimination at the alveolar-capillary membrane.

Nursing Diagnosis

 Gas Exchange, risk for impaired

Risk factors may include

 Decrease in effective lung surface, atelectasis

 Destruction of alveolar-capillary membrane
 Thick, viscous secretions
 Bronchial edema

Possibly evidenced by

 Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

 Report absence of/decreased dyspnea.

 Demonstrate improved ventilation and adequate oxygenation of tissues by
ABGs within acceptable ranges.
 Be free of symptoms of respiratory distress.

Nursing Interventions Rationale

Pulmonary TB can cause a wide range of

Assess for dyspnea (using 0–10 scale), effects in the lungs, ranging from a small patch
tachypnea, abnormal or diminished breath of bronchopneumonia to diffuse intense
sounds, increased respiratory effort, limited inflammation, caseous necrosis, pleural
chest wall expansion, and fatigue. effusion, and extensive fibrosis. Respiratory
effects can range from mild dyspnea to
profound respiratory distress. Use of a scale to
Nursing Interventions Rationale

evaluate dyspnea helps clarify degree of

difficulty and changes in condition.

Evaluate change in level of mentation. Note Accumulation of secretions and/or airway

cyanosis and/or change in skin color, including compromise can impair oxygenation of vital
mucous membranes and nail beds. organs and tissues.

Demonstrate and encourage pursed-lip Creates resistance against outflowing air to

breathing during exhalation, especially for prevent collapse or narrowing of the airways,
patients with fibrosis or parenchymal thereby helping distribute air throughout the
destruction. lungs and relieve or reduce shortness of breath.

Reducing oxygen consumption and demand

Promote bedrest or limit activity and assist
during periods of respiratory compromise may
with self-care activities as necessary.
reduce severity of symptoms.

Decreased oxygen content (PaO2) and/or

Monitor serial ABGs and pulse oximetry. saturation or increased PaCO2 indicate need for
intervention or change in therapeutic regimen.

Aids in correcting the hypoxemia that may

Provide supplemental oxygen as appropriate. occur secondary to decreased
ventilation/diminished alveolar lung surface.

Risk for Impaired Gas Exchange: At risk for excess or deficit in oxygenation and/or carbon
dioxide elimination at the alveolar-capillary membrane.

Nursing Diagnosis

 Gas Exchange, risk for impaired

Risk factors may include

 Decrease in effective lung surface, atelectasis

 Destruction of alveolar-capillary membrane
  Thick, viscous secretions
 Bronchial edema

Possibly evidenced by

 Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

 Report absence of/decreased dyspnea.

 Demonstrate improved ventilation and adequate oxygenation of tissues by
ABGs within acceptable ranges.
 Be free of symptoms of respiratory distress.

Nursing Interventions Rationale

Pulmonary TB can cause a wide range of

effects in the lungs, ranging from a small patch
of bronchopneumonia to diffuse intense
Assess for dyspnea (using 0–10 scale),
inflammation, caseous necrosis, pleural
tachypnea, abnormal or diminished breath
effusion, and extensive fibrosis. Respiratory
sounds, increased respiratory effort, limited
effects can range from mild dyspnea to
chest wall expansion, and fatigue.
profound respiratory distress. Use of a scale to
evaluate dyspnea helps clarify degree of
difficulty and changes in condition.

Evaluate change in level of mentation. Note Accumulation of secretions and/or airway

cyanosis and/or change in skin color, including compromise can impair oxygenation of vital
mucous membranes and nail beds. organs and tissues.

Demonstrate and encourage pursed-lip Creates resistance against outflowing air to

breathing during exhalation, especially for prevent collapse or narrowing of the airways,
patients with fibrosis or parenchymal thereby helping distribute air throughout the
destruction. lungs and relieve or reduce shortness of breath.
Nursing Interventions Rationale

Reducing oxygen consumption and demand

Promote bedrest or limit activity and assist
during periods of respiratory compromise may
with self-care activities as necessary.
reduce severity of symptoms.

Decreased oxygen content (PaO2) and/or

Monitor serial ABGs and pulse oximetry. saturation or increased PaCO2 indicate need for
intervention or change in therapeutic regimen.

Aids in correcting the hypoxemia that may

Provide supplemental oxygen as appropriate. occur secondary to decreased
ventilation/diminished alveolar lung surface.

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet
metabolic needs.

Nursing Diagnosis

 Nutrition: imbalanced, less than body requirements

May be related to

 Fatigue
 Frequent cough/sputum production; dyspnea
 Anorexia
 Insufficient financial resources

Possibly evidenced by

 Weight 10%–20% below ideal for frame and height

 Reported lack of interest in food, altered taste sensation
 Poor muscle tone

Desired Outcomes
  Demonstrate progressive weight gain toward goal with normalization of
laboratory values and be free of signs of malnutrition.
 Initiate behaviors/lifestyle changes to regain and/or to maintain appropriate
weight.

Nursing Interventions Rationale

Document patient’s nutritional status on

admission, noting skin turgor, current weight
and degree of weight loss, integrity of oral Useful in defining degree or extent of problem
mucosa, ability or inability to swallow, and appropriate choice of interventions.
presence of bowel tones, history of nausea and
vomiting or diarrhea.

Helpful in identifying specific needs and

Ascertain patient’s usual dietary pattern.
strengths. Consideration of individual
Include in selection of food.
preferences may improve dietary intake.

Useful in measuring effectiveness of nutritional

Monitor I&O and weight periodically.
and fluid support.

Investigate anorexia and nausea and vomiting,

May affect dietary choices and identify areas
and note possible correlation to medications.
for problem solving to enhance intake and
Monitor frequency, volume, consistency of
utilization of nutrients.
stools.

Encourage and provide for frequent rest Helps conserve energy, especially when
periods. metabolic requirements are increased by fever.

Reduces bad taste left from sputum or

Provide oral care before and after respiratory
medications used for respiratory treatments that
treatments.
can stimulate the vomiting center.

Maximizes nutrient intake without undue

Encourage small, frequent meals with foods
fatigue/energy expenditure from eating large
high in protein and carbohydrates.
meals, and reduces gastric irritation.

Encourage SO to bring foods from home and to Creates a more normal social environment
Nursing Interventions Rationale

share meals with patient unless contraindicated. during mealtime, and helps meet personal,
cultural preferences.

Provides assistance in planning a diet with

Refer to dietitian for adjustments in dietary nutrients adequate to meet patient’s metabolic
composition. requirements, dietary preferences, and financial
resources post discharge.

May help reduce the incidence of nausea and

Consult with respiratory therapy to schedule vomiting associated with medications or the
treatments 1–2 hr before or after meals. effects of respiratory treatments on a full
stomach.

Low values reflect malnutrition and indicate

Monitor laboratory studies: BUN, serum
need for intervention and change in therapeutic
protein, and prealbumin, albumin.
regimen.

Fever increases metabolic needs and therefore

Administer antipyretics as appropriate.
calorie consumption.

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to

 Lack of exposure to/misinterpretation of information

 Cognitive limitations
 Inaccurate/incomplete information presented

Possibly evidenced by

 Request for information

 Expressed misconceptions about health status
 Lack of or inaccurate follow-through of instructions/behaviors
 Expressing or exhibiting feelings of being overwhelmed

Desired Outcomes
  Verbalize understanding of disease process/prognosis and prevention.
 Initiate behaviors/lifestyle changes to improve general well-being and
reduce risk of reactivation of TB.
 Identify symptoms requiring evaluation/intervention.
 Describe a plan for receiving adequate follow-up care.
 Verbalize understanding of therapeutic regimen and rationale for actions.

Nursing Interventions Rationale

Assess patient’s ability to learn. Note level

of fear, concern, fatigue, participation level;
Learning depends on emotional and physical
best environment in which patient can learn;
readiness and is achieved at an individual pace.
how much content; best media and language;
who should be included.

Provide instruction and specific written

Written information relieves patient of the
information for patient to refer to schedule for
burden of having to remember large amounts of
medications and follow-up sputum testing for
information. Repetition strengthens learning.
documenting response to therapy.

Provides opportunity to correct misconceptions

Encourage patient and SO to verbalize fears
and alleviate anxiety. Inadequate finances or
and concerns. Answer questions factually. Note
prolonged denial may affect coping and
prolonged use of denial.
managing the tasks necessary to regain health.

Identify symptoms that should be reported to

May indicate progression or reactivation of
healthcare provider: hemoptysis, chest pain,
disease or side effects of medications, requiring
fever, difficulty breathing, hearing loss,
further evaluation.
vertigo.

Emphasize the importance of maintaining high- Meeting metabolic needs helps minimize
protein and carbohydrate diet and adequate fatigue and promote recovery. Fluids aid in
fluid intake. liquefying or expectorating secretions.

Enhances cooperation with therapeutic regimen

Explain medication dosage, frequency of
and may prevent patient from discontinuing
administration, expected action, and the reason
medication before cure is truly affected.
for long treatment period. Review potential
Directly observed therapy (DOT) is the
Nursing Interventions Rationale

interactions with other drugs and substances. treatment of choice when patient is unable or
unwilling to take medications as prescribed.

Review potential side effects of treatment

(dryness of mouth, constipation, visual May prevent or reduce discomfort associated
disturbances, headache, with therapy and enhance cooperation with
orthostatic hypertension) and problem-solve regimen.
solutions.

Stress need to abstain from alcohol while on Combination of INH and alcohol has been
INH. linked with increased incidence of hepatitis.

Major side effect is reduced visual acuity;

Refer for eye examination after starting and
initial sign may be decreased ability to perceive
then monthly while taking ethambutol.
green.

Excessive exposure to silicone dust enhances

Evaluate job-related risk factors, working in
risk of silicosis, which may negatively affect
foundry or rock quarry, sandblasting.
respiratory function and cause bronchitis.

Although smoking does not stimulate

recurrence of TB, it does increase the
Encourage abstaining from smoking.
likelihood of respiratory dysfunction or
bronchitis.

Knowledge may reduce risk of

transmission/reactivation. Complications
Review how TB is transmitted (primarily by associated with reactivation include cavitation,
inhalation of airborne organisms, but may also abscess formation, destructive emphysema,
spread through stools or urineif infection is spontaneous pneumothorax, diffuse interstitial
present in these systems) and hazards of fibrosis, serous effusion, empyema,
reactivation. bronchiectasis, hemoptysis, GI ulceration,
bronchopleural fistula, tuberculous laryngitis,
and miliary spread.