Tuberculosis, which is caused by Mycobacterium Tuberculosis, is a chronic respiratory disease usually lasting for more than 3 months. It is commonly associated with poverty, malnutrition, overcrowding, substandard housing and inadequate healthcare.
Tuberculosis is an infection which primarily affects the lung parenchyma, but it can also spread to other areas within the body, such as the meninges, kidneys, bones and lymph nodes.
Tuberculosis Pathophysiology
Inhalation: Tuberculosis is a highly infectious airborne disease that is first acquired through inhalation, when a person inhales the Mycobacterium Tuberculosis (bacteria) and becomes infected.
Transmission: Once inhaled, it is then transmitted through the airways, to the alveoli, and then transported via the lymphatic system and the bloodstream to other areas within the body.
Defence: In response, the body’s immune system causes an inflammatory reaction and phyagocytes engulf many of the bacteria, whilst lymphocytes break down the bacteria.
Protection: Masses of live and dead bacteria called Granulomas become contained (stopped from multiplying and/or spreading) as they are then surrounded by macrophages which form a protective wall around them.
Ghon’s Tubercle: They transform into a mass of fibrous tissue, of which the central portion is called a Ghon’s Tubercle. At this stage, the infected individual shows no signs and symptoms of having Tuberculosis.
Scarring: The bacteria and macrophages turn into a cheesy mass, becoming calcified before forming into a collagenous scar. At this stage, the bacteria is considered to be dormant, stopping any further progression of the disease.
Primary TB Infection: No symptoms are evident up to this stage.
Activation: A compromised or inadequate immune system (eg. individuals on steroids, with cancer, HIV etc.) may cause the disease to activate when dormant bacteria is reactivated and starts multiplying (reactivation TB), becoming also drug resistant. The individual is now symptomatic.
Progression: If no immediate action is taken, Tuberculosis can progress from diagnosis to death in just 4-6 weeks.
Tuberculosis Causes
- Contact – close contact with an individual with active TB
- Low Immunity – individuals considered immunocompromised
- Substance Abuse – alcoholic individuals and individuals who make use of IV drugs
- Inadequate Healthcare – individuals who are poor, homeless etc.
- Immigration – individuals coming from countries in which there is a high prevalence of TB
- Overcrowding – eg. in substandard housing and poor living conditions
Tuberculosis Signs & Symptoms
Primary TB Infection – following a 4-8 week incubation period, patient is usually asymptomatic
Once bacteria becomes active, the patient starts exhibiting signs and symptoms of TB…
Non-Specific Symptoms – fatigue, weakness, anorexia, weight loss, night sweats and low-grade fever, with the latter two being the most common
Cough – productive
Haemoptysis – patient may occasionally start coughing up blood (blood may be visible in the patient’s saliva)
Chest Pain – caused by discomfort due to respiratory distress and infection. Inflammation due to bacteria causes inflammation of the pleural membrane, which then increases the friction in the pleural membrane, resulting in chest pain on coughing.
Tuberculosis Prevention
- Identification and Treatment
- Prevention using infection control principles eg. handwashing, isolating patients with active TB infection, wearing of PPEs
- Surveillance among healthcare workers through periodic testing for TB infection
Tuberculosis Complications
- Respiratory Failure
- Pneumothorax
- Pneumonia (one of the most fatal complications of TB since it may cause infection all over the lungs, leading to TB Pneumonia)
Tuberculosis Assessment & Diagnostic Findings
- Sputum Culture – positive result for Mycobacterium Tuberculosis during the active TB stage (no longer contained by macrophages)
- Mantoux Test – positive reaction indicates a history of infection; it is not a direct indication of active TB (reaction in a healthy person usually indicates dormant TB, while a reaction in a clinically ill patient indicates that active TB cannot be dismissed as a diagnostic possibility
- Chest X-ray – shows evidence of scar /fibrotic tissue
- Bronchoscopy – shows evidence of inflammation; also allows sputum sample collection if needed for further testing
- Needle Biopsy of Lung Tissue – provides positive testing for TB granulomas
- Pulmonary Function Studies – indicates decreased vital capacity (caused by inflammation of the lungs that leads to difficulty in expelling air from the lungs), increased dead space (areas not involved in gaseous exchange), decreased oxygen saturation (TB affects gaseous exchange in the lungs leading to less oxygen saturation), and increased ratio of residual air vs total lung capacity (due to respiratory distress) – can also be indicative of other respiratory conditions so this isn’t used alone to diagnose TB
- TB Blood Test
Tuberculosis Medical Management
TB is primarily treated with antituberculosis agents for 6-12 months…
First Line Agents:
- Isoniazid (INH) – Side Effects include Peripheral Neuritis (nerve inflammation), Hepatitis (inflammation of the liver) and Hypersensitivity to the drug eg. rash, fever, SOB following medication intake.
- Rifampin (RIF) – Side Effects include turning body secretions (eg. urine) into orange or red coloured secretions, Hepatitis, Fever, Purpura (small bruises forming on skin), Nausea and Vomiting.
- Ethambutol (EMB) – Side Effects include Optic Neuritis (inflammation of the optic nerve) and Skin Rash; use with caution in patients with renal disease
- Pyrazinamide – Side Effects include Hyperuricaemia (increased uric acid in the blood), Hepatotoxicity (damage in the liver), Skin Rash, Arthralgias (joint pain) and GI distress.
In adults with Active TB, treatment consists of all 4 drugs (this avoids the microorganism from becoming resistant to the antibiotic) usually administered daily for 2 months, followed by 4 months of INH and RIF.
In adults with Latent TB, treatment with INH is usually administered daily for 9 months.
Nursing Assessment
- past and present medical history to identify the possibility of exposure to someone with active TB
- assess physical appearance with emphasis on dramatic loss of weight
- SPO2 and ABGs
Nursing Care
for patients with TB…
- promote airway clearance
- treatment adherence
- promote activity and adequate nutrition
- prevent TB infection spread
for patients with risk of TB infection…
- identify interventions to prevent and reduce risk of infection spread
- educate patient about airborne spreading of TB infection
- identify patient’s close contacts at risk of contracting TB eg. associates, household members etc (these may require a course of drug therapy eg. Isoniazid, to prevent infection development
- instruct patient to use tissue when coughing and sneezing
- educate patient about proper tissue disposal as well as infection control measures eg. handwashing
- isolate patient if needed esp. if infection control measures are not being adhered to (nurse should wear PPEs to protect self from TB infection eg. N95 mask)
- monitor temperature due to febrile reaction being a sign of active TB infection
- identify risk factors for reactivation of TB eg. use of alcohol, malnutrition, cancer, diabetes mellitus, steroid use etc.
- emphasise importance of uninterrupted drug therapy
- emphasise importance of follow-up and periodic re-culturing of sputum during drug therapy stage
- emphasise importance of periodic liver function tests to monitor treatment side effects
- notify Public Health Department regarding TB infection (similar to what happens in individuals with COVID-19 for contact tracing purposes)
If patient has a fever:
- administer antipyretics
- start IV if patient is unable to tolerate fluids to avoid dehydration
Sometimes a patient with TB is unable to clear secretions from the respiratory tract due to thick, viscous or bloody secretions as well as fatigue and poor coughing. Here the nurse should focus on the following objectives for the patient:
- maintain patent airway
- expectorate secretions without assistance
- follow treatment regimen
- identify possible complications and initiate appropriate actions
The nurse should…
- assess respiratory function eg. breathing sounds (rhonchi and wheezing), respiratory rate, rhythm and depth, as well as for use of accessory muscles during breathing
- assess patient’s ability to expectorate mucus and cough effectively
- document amount of sputum, character and haemoptysis if present
- place patient in semi or high fowler’s position
- teach coughing and deep breathing exercises
- clear secretions from mouth and trachea if required
- maintain fluid intake of 2500ml per day (unless contraindicated)
- administer mucolytic agents and bronchodilators when necessary
In patients at risk for impaired gas exchange, the nurse should focus on the following objectives for the patient…
- absence or decreased dyspnoea
- improved ventilation and adequate oxygen saturation through acceptable ABG results
- no symptoms of respiratory distress
The nurse should…
- assess for dyspnoea, tachypnoea, abnormal/diminished breath sounds, increased respiratory effort and fatigue
- assess for cyanosis including in mucous membranes and nail beds
- teach pursed lip breathing
- promote bed rest / limit activity and assist with self care to decrease oxygen consumption
- check PEFR (would be low due to lack of gaseous exchange)
- monitor ABGs (for respiratory alkalosis) and pulse oximetry
- administer supplemental oxygen if necessary
Patients with imbalanced nutrition usually show a drastic decrease in weight (10-20% less than their ideal weight), and complain about an altered taste sensation and lack of interest in food. They also have evident poor muscle tone. In patients with evident imbalanced nutrition, the nurse should focus on the following outcomes…
- show an increase in weight
- show no signs of malnutrition
- show behavioural changes aiming to regain/maintain appropriate weight
The nurse should…
- document patient’s nutritional status
- take note of the patient’s normal dietary pattern and include in food selection
- monitor weight during hospital stay
- investigate anorexia, nausea and vomiting, and check for possible connection with medication intake
- ensure proper oral hygiene to improve taste sensation and thus, appetite, plus reducing the chance of developing oral thrush and infection (mucocytis)
- encourage small frequent high protein and high carbohydrate meals (helps reduce gastric irritation)
- encourage patient’s family members to bring in food from home to help increase patient’s appetite and nutritional intake
- refer patient to dietitian
- administer antiemetics if patient is experiencing nausea and vomiting
Discharge Planning
- provide patient with written instructions regarding scheduling of medications and follow-up sputum testing following therapy
- teach patient about symptoms which should be reported to healthcare if present eg. haemoptysis, chest pain, fever and dyspnoea
- emphasise importance of a high protein high carbohydrate diet and adequate fluid intake
- provide information about side effects of treatments being given on discharge
- encourage smoking cessation and alcohol cessation
Below you can find a collection of videos that can help provide a more visual approach to Tuberculosis nursing care.
Tuberculosis Animation
Tuberculosis Symptoms, Treatment, Causes and Nursing Management
Inactive Tuberculosis on Chest X-Ray
Active Tuberculosis on Chest X-Ray
Mantoux Test
Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Alila Medical Media, RegisteredNurseRN, hammadshams and GreyBruceHealthUnit.
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Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
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