5 Pulmonary Tuberculosis Nursing Care Plans

Risk for Infection

Most people who develop tuberculosis do so after a long period of latency (usually several years after the initial primary infection). This is known as secondary tuberculosis. Secondary tuberculosis usually occurs because of the reactivation of latent tuberculosis infection. The lesions of secondary tuberculosis are in the lung apices. A smaller proportion of people who develop secondary tuberculosis do so after getting infected a second time (Adigun & Singh, 2022).

Nursing Diagnosis

• Risk for Infection

Risk factors

• 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

• The client will identify interventions to prevent/reduce the risk of the spread of infection.
• The client will demonstrate techniques/initiate lifestyle changes to promote a safe environment.

Nursing Assessment and Rationales

1. Review pathology of disease (active and inactive phases; dissemination of infection through bronchi to adjacent tissues or via the bloodstream and/or lymphatic system) and potential spread of infection via airborne droplet during coughing, sneezing, spitting, talking, laughing, singing.
This helps the client realize or accept the necessity of adhering to a medication regimen to prevent reactivation or complications. Understanding how the disease is passed and awareness of transmission possibilities help the client and SO take steps to prevent the infection of others. Pulmonary tuberculosis can be handled and controlled by giving information to clients to increase their self-efficacy. Increasing self-efficacy could improve the client’s awareness of their health behavior (Bahtiar, 2019).

2. Identify others at risks like household members, close associates, and friends.
Those exposed may require a course of drug therapy to prevent the spread or development of infection. In more advanced countries, high-burden tuberculosis is seen among recent arrivals from tuberculosis-endemic zones, healthcare workers, and HIV-positive individuals (Adigun & Singh, 2022). 

3. Monitor temperature as indicated.
Febrile reactions are indicators of the continuing presence of infection. Fever has been reported to occur in 60 to 85% of clients afflicted with PTB. As a rule, every case of active PTB exhibits some degree of pyrexia which is one of the important signs of TB activity (Rosha, 2011).

4. 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, and postpartum.
Knowledge about these factors helps the client alter their lifestyle and avoid or reduce the incidence of exacerbation. Latent TB is capable of being reactivated after immunosuppression in the host. A small proportion of people would develop an active disease following first exposure. Such cases are referred to as primary progressive tuberculosis. Primary progressive tuberculosis is seen in children, malnourished people, people with immunosuppression, and individuals on long-term steroid use (Adigun & Singh, 2022).

5. Monitor Liver function studies: AST/ALT.
Monitors adverse effects of drug therapy including hepatitis. A liver function test is required for all clients taking isoniazid. Other monitoring in TB includes monitoring for retinopathies for clients on ethambutol (Adigun & Singh, 2022).

Nursing Interventions and Rationales

1. Instruct the client 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.
These behaviors are necessary to prevent the spread of infection. Lack of awareness is one cause of the lack of adherence to medication protocols and negative health behaviors, such as spitting and sneezing, in PTB clients (Bahtiar, 2019).

2. Encourage the client and family members to be active in TB infection control at home.
Clients with suspected or confirmed TB disease are more likely to have already transmitted TB infection to members of their household before their TB disease was diagnosed and treatment was started. Clients diagnosed with TB should be instructed to cover their mouth and nose when coughing or sneezing, sleep alone and not in a room with other household members, and refrain from having visitors in the home until they are non-infectious (Centers for Disease Control and Prevention, 2007).

3. Review the necessity of infection control measures. Put in temporary respiratory isolation if indicated.
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. AFB can pass through standard masks; therefore, particulate respirators are required. Persons who have or are suspected of having infectious TB disease should be placed in an area away from other clients, preferably in an airborne infection isolation room. If a facility does not have this particular room, the client should be placed in a room that has been designated for isolation of persons with suspected or known infectious TB disease (Centers for Disease Control and Prevention, 2007).

4. 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 chemotherapy, but in presence of cavitation or moderately advanced disease, the risk of spread of infection may continue for up to 3 months. Compliance with multidrug regimens for prolonged periods is difficult, so directly observed therapy (DOT) should be considered. The majority of clients with a diagnosis of TB have a good outcome. This is mainly because of effective treatment. Without treatment, the mortality rate for TB is more than 50% (Adigun & Singh, 2022).

5. Review the importance of follow-up and periodic reculturing of sputum for the duration of therapy.
These second-line drugs may be required when the infection is resistant to or intolerant of primary drugs or may be used concurrently with primary anti-tubercular drugs. MDR-TB requires a minimum of 18 to 24 months of therapy with at least three drugs in the regimen known to be effective against the specific infective organism and which the client has not previously taken. Treatment is often extended to 24 months in clients with severe symptoms or HIV infection.

6. 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. A study found that the number of calories, food frequency per day, types of TB, and nutritional status during registration were found to be associated with recent nutritional status (Gurung et al., 2018).

7. Notify the local health department.
This is helpful in identifying contacts to reduce the spread of infection and is required by law. The treatment course is long and usually handled in the community with public health nurse monitoring. Health departments in the 50 US states and Dc report TB cases to the CDC based on the Council of State and Territorial Epidemiologists’ surveillance case definition, which includes both laboratory and clinically verified cases (Filardo, 2022).

8. Administer anti-infective agents as indicated.
Initial therapy of uncomplicated pulmonary disease usually includes four drugs, e.g., four primary drugs or a combination of primary and secondary drugs. 2020 LTBI guidelines include the NTCA- and CDC-recommended treatment regimens that comprise three preferred rifamycin-based regimens and two alternative monotherapy regimens with daily isoniazid (Adigun & Singh, 2022) (Adigun & Singh, 2022).

9. Administer Primary drugs: isoniazid (INH), ethambutol (Myambutol), rifampin (RMP/Rifadin), rifampin with isoniazid (Rifamate), pyrazinamide (PZA), streptomycin, rifapentine (Priftin) as indicated.
INH is usually the drug of choice for the infected client and those at risk for developing TB. Short-course chemotherapy, including INH, rifampin (for six months), PZA, and ethambutol or streptomycin, is given for at least two months (or until sensitivities are known or until serial sputum is clear) followed by three 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 (Adigun & Singh, 2022).

10. Administer Second-line drugs: ethionamide (Trecator-SC), para-aminosalicylate (PAS), cycloserine (Seromycin), and capreomycin (Capastat) as indicated.
Extended therapy (up to 24 months) 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 months should be considered in HIV-positive clients with positive PPD tests.

11. Administer bedaquiline (Sirturo) as ordered.
On December 28, 2012, the United States Food and Drug Administration Agency (FDA) approved Bedaquiline as a drug for treating MDR-TB. This is the first FDA approval for an anti-TB medication in 40 years. While showing remarkable promise in drug-resistant tuberculosis, cost remains a big obstacle to delivering this drug to the people most affected by MDR-TB (Adigun & Singh, 2022).

12. Educate the client and family members regarding BCG vaccination for children.
Vaccination drive in developing countries has played a bigger role in decreasing the prevalence of TB. The preventative effect of BCG vaccination is controversial but many studies have identified vaccination as a very important tool in the fight against tuberculosis, therefore, the focus should be kept on childhood vaccination, especially in developing countries (Adigun & Singh, 2022).

13. Ensure that the healthcare team is adherent to respiratory protection controls when handling the client.
Respiratory protection control consists of the use of personal protective equipment in situations that pose a high risk for exposure to TB disease. The use of respiratory protection can further reduce the risk of exposure of HCWs to droplet nuclei expelled into the air. These measures include implementing a respiratory protection program, training HCWs on respiratory protection, and educating clients on respiratory hygiene (Centers for Disease Control and Prevention, 2007).