5 Pulmonary Tuberculosis Nursing Care Plans

July 15, 2013

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) and nursing diagnosis (NDx) for pulmonary tuberculosis:

Risk for Infection

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 (active and inactive phases; dissemination of infection through bronchi to adjacent tissues or via bloodstream and/or lymphatic system) and potential spread of infection via airborne droplet during coughing, sneezing, spitting, talking, laughing, singing.	Helps patient realize or accept necessity of adhering to medication regimen to prevent reactivation or complication. Understanding of how the disease is passed and awareness of transmission possibilities help patient and SO take steps to prevent infection of others.
Identify others at risk like household members, close associates and friends.	Those exposed may require a course of drug therapy to prevent spread or development of infection.
Instruct patient to cough or sneeze and expectorate into tissue and to refrain from spitting. Review proper disposal of tissue and good hand washing techniques. Encourage return demonstration.	Behaviors necessary to prevent spread of infection.
Review necessity of infection control measures. Put in temporary respiratory isolation if indicated.	May help patient understand need for protecting others while acknowledging patient’s sense of isolation and social stigma associated with communicable diseases. AFB can pass through standard masks; therefore, particulate respirators are required.
Monitor temperature as indicated.	Febrile reactions are indicators of continuing presence of infection.
Identify individual risk factors for reactivation of tuberculosis: lowered resistance associated with alcoholism, malnutrition, intestinal bypass surgery, use of immunosuppressive drugs, corticosteroids, presence of diabetes mellitus, cancer, postpartum.	Knowledge about these factors helps patient alter lifestyle and avoid or reduce incidence of exacerbation.
Stress importance of uninterrupted drug therapy. Evaluate patient’s potential for cooperation.	Contagious period may last only 2–3 days after initiation of chemotherapy, but in presence of cavitation or moderately advanced disease, risk of spread of infection may continue up to 3 months. Compliance with multidrug regimens for prolonged periods is difficult, so directly observed therapy (DOT) should be considered.
Review importance of follow-up and periodic reculturing of sputum for the duration of therapy.	These second-line drugs may be required when infection is resistant to or intolerant of primary drugs or may be used concurrently with primary anti tubercular drugs. MDR-TB 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. Treatment is often extended to 24 mo in patients with severe symptoms or HIV infection.
Encourage selection and ingestion of well-balanced meals. Provide frequent small “snacks” in place of large meals as appropriate.	Patient who has three consecutive negative sputum smears (takes 3–5 mo), is adhering to drug regimen, and is asymptomatic will be classified a non transmitter.
Liver function studies: AST/ALT.	Monitors adverse effects of drug therapy including hepatitis.
Notify local health department.	Helpful in identifying contacts to reduce spread of infection and is required by law. Treatment course is long and usually handled in the community with public health nurse monitoring.
Administer anti-infective agents as indicated:	Initial therapy of uncomplicated pulmonary disease usually includes four drugs, e.g., four primary drugs or combination of primary and secondary drugs.
Primary drugs: isoniazid (INH), ethambutol (Myambutol), rifampin (RMP/Rifadin), rifampin with isoniazid (Rifamate), pyrazinamide (PZA), streptomycin, rifapentine (Priftin);	INH is usually drug of choice for infected patient and those at risk for developing TB. Short-course chemotherapy, including INH, rifampin (for 6 mo), PZA, and ethambutol or streptomycin, is given for at least 2 mo (or until sensitivities are known or until serial sputums are clear) followed by 3 more months of therapy with INH.Ethambutol should be given if central nervous system (CNS) or disseminated disease is present or if INH resistance is suspected.
Second-line drugs: ethionamide (Trecator-SC), para-aminosalicylate (PAS), cycloserine (Seromycin), capreomycin (Capastat).	Extended therapy (up to 24 mo) is indicated for reactivation cases, extrapulmonary reactivated TB, or in the presence of other medical problems, such as diabetes mellitus or silicosis. Prophylaxis with INH for 12 mo should be considered in HIV-positive patients with positive PPD test.