Pulmonary Tuberculosis

  1. General information
    1. Bacterial infectious disease caused by M. tuberculosis and spread via airborne droplets when infected persons cough, sneeze, or laugh
    2. Once inhaled, the organisms implant themselves in the lung and begin dividing slowly, causing inflammation, development of the primary tubercle, and eventual caseation and fibrosis.
    3. Infection spreads via the lymph and circulatory systems.
    4. Half of the cases occur in inner-city neighborhoods, and incidence is highest in areas with a large population of native Americans. Nonwhites affected four times more often than whites. Men affected more often than women. The greatest number of cases occur in persons age 65 and over. Socially and economically disadvantaged, alcoholic, and malnourished individuals affected more often.
    5. The causative agent, M. tuberculosis, is an acid-fast bacillus spread via droplet nuclei from infected persons.
  2. Assessment findings
    1. Cough (yellow mucoid sputum), dyspnea, hemoptysis, rales or crackles
    2. Anorexia, malaise, weight loss, afternoon low-grade fever, pallor, pain, fatigue, night sweats
    3. Diagnostic tests
      1. Chest x-ray indicates presence and extent of disease process but cannot differentiate active from inactive form
      2. Skin test (PPD) positive; area of induration 10 mm or more in diameter after 48 hours
      3. Sputum positive for acid-fast bacillus (three samples is diagnostic for disease)
      4. Culture positive
      5. WBC and ESR increased
  3. Nursing interventions
    1. Administer medications as ordered (see Table 2.23).
    2. Prevent transmission.
      1. Strict isolation not required if client/significant others adhere to special respiratory precautions for tuberculosis.
      2. Client should be in a well-ventilated private room, with the door kept closed at all times.
      3. All visitors and staff should wear masks when in contact with the client and should discard the used masks before leaving the room; client should wear a mask when leaving the room for tests.
      4. All specimens should be labelled "AFB precautions."
      5. Handwashing is required after direct contact with the client or contaminated articles.
    3. Promote adequate nutrition.
      1. Make ongoing assessments of client's appetite and do kcal counts for 3 days; consult dietitian for diet guidelines.
      2. Offer small, frequent feedings and nutritional supplements; assist client with menu selection stressing balanced nutrition.
      3. Weigh client at least twice a week.
      4. Encourage activity as tolerated to increase appetite.
    4. Prevent social isolation.
      1. Impart a comfortable, confident attitude when caring for the client.
      2. Explain the nature of the disease to the client, significant others, and visitors in simple terms.
      3. Stress that visits are important, but isolation precautions must be followed.
    5. Vary the client's routine to prevent boredom.
    6. Discuss the client's feelings and assess for boredom, depression, anxiety, fatigue, or apathy; provide support and encourage expression of concerns.
    7. Provide client teaching and discharge planning concerning
      1. Medication regimen: prepare a sheet with each drug name, dosage, time due, and major side effects; stress importance of following medication schedule for prescribed period of time (usually 9 months); include significant others
      2. Transmission prevention: client should cover mouth when coughing, expectorate into a tissue and place it in a paper bag; client should also wash hands after coughing or sneezing; stress importance of plenty of fresh air; include significant others
      3. Importance of notifying physician at the first sign of persistent cough, fever, or hemoptysis (may indicate recurrence)
      4. Need for follow-up care including physical exam, sputum cultures, and chest x-rays
      5. Availability of community health services
      6. Importance of high-protein, high-carbohydrate diet with inclusion of supplemental vitamins