Tuberculosis (TB) is an airborne infection caused by a tiny pathogen called Mycobacterium Tuberculosis. In most cases, the TB infection targets the lung parenchyma but the mycobacterium can sometimes travel to the meninges, kidneys, bones and lymph nodes. Tuberculosis nursing care focuses on improving the respiratory function and reducing the risk of transmission.
In these notes, we’ll be going over the Tuberculosis Nursing Care, but before getting into that, make sure that you’ve understood the:
Tuberculosis Nursing Assessment
The goal behind the nursing assessment for patients with TB is to confirm the diagnosis and understand how the infection is affecting the patient. Both at a physiological level as well as on a social and psychological level. You can read the full Tuberculosis Nursing Assessment in detail here, but in summary, there are three main points we take into consideration.
Obtaining a Nursing Health History: Ask about the patient’s exposure to risk factors to determine where the patient most likely contracted TB and how its manifestations are likely to play out.
Performing a Physical Assessment: Check the patient’s vital signs, respiratory function and the possibility of lung consolidation to assess the severity of the infection.
Completing Diagnostic Medical Tests:
Ziehl-Neelsen Sputum Smear
Sputum Culture
Tuberculin Skin Test
IGRA Blood Test
Chest X-ray
MRI
Pulmonary Function Test
Bronchoscopy
ABG Test
Electrolyte Levels Test
Drug Susceptibility Test
Tuberculosis Nursing Diagnosis
From your assessment, you might find the following nursing diagnosis:
Ineffective airway clearance
Ineffective respirations
Impaired gas exchange
Hyperthermia
Inadequate nutrition and hydration
Activity intolerance
Treatment Adherence & Knowledge Deficiency
Anxiety
Tuberculosis Nursing Care Plans
1. Managing Ineffective Airway Clearance
If your patient has ineffective airway clearance it means that they do not have a patent (open) airway. In the case of TB, this would typically be caused by a build-up of mucus in the airways, narrowing of the airways and a persistent cough.
Instruct your patient to sit in an elevated position, either on the chair or by elevating the bed and have the chin parallel to the floor or tilted slightly upwards to obtain an open airway. Once the position is set, encourage your patient to breathe using the pursed-lip technique. This technique makes it easier to breathe during an exacerbation, reduces air trapping and gives a sense of control to your patient.
The next step would be to help your patient get rid of the build-up of secretions in the airways. Teach them how to cough up secretions effectively and how to perform deep breathing exercises to maximise ventilation. You should also ensure that they’re adequately hydrated, as fluids make secretions less viscous and easier to be expectorated. Chest physiotherapy is very useful in preventing aspiration of secretions and further complications. Lastly, if your patient can not remove secretions alone you should use a Suction Set and remove them manually.
Apart from having Anti-TB agents, patients with ineffective airway clearance will likely be prescribed Mucolytic Agents or Expectorants to decrease the viscosity of secretions. Moreover, Oxygen Therapy should be administered accordingly to keep the oxygen saturation within normal range.
2. Managing Ineffective Respirations
As we’ve explained in the Pathophysiology of TB, the infection causes the airways and alveoli to fill up with mucus making it more difficult for the patient to fully inhale and exhale.
Start off by ensuring that your patient has a clear airway and that they’re sitting at an elevated angle, especially when lying in bed. You should instruct the patient to use a pillow and splint their chest when coughing, this will provide support and allow the patient to inhale fully. Use deep breathing techniques to help the patient regulate their respiratory rate, and if necessary administer oxygen therapy as prescribed.
Similar to managing ineffective airway clearance aside the Anti-TB agents, the patient might be prescribed Mucolytics and Expectorants to clear the sputum and decrease shortness of breath. As well as get Oxygen Therapy as needed.
3. Managing Impaired Gas Exchange
One of the symptoms of Tuberculosis is the build-up of mucus in the airways and damage to the alveoli. These factors make it difficult for oxygen and carbon dioxide to exchange and they create an imbalance in the Ventilation-Perfusion Ratio
Ensure that the patient’s airway is cleared, continue nursing at an elevated angle and use a splint when coughing. Administer oxygen therapy as prescribed, keeping in mind that if the patient has COPD they use their hypoxic drive to breathe. This means that the oxygen concentration should be as low as possible, and it can easily be done through the use of a Venturi Mask. You should also encourage your patient to use nasal prongs during meal times, and a portable oxygen tank when moving around.
Non-Invasive Positive Pressure Ventilation (NIPPV) Machines might be indicated during sleep or in severe cases even during the day. NIPPV Machines push oxygen into the lungs, forcing it to perfuse through the alveoli and into the blood. This forces the gases to regain their balance allowing the Ventilation-Perfusion Ratio to return to normal.
It’s important to regularly monitor your patient if impaired gas exchange is present as if it’s not treated effectively it will lead to further complications. So lookout for any signs of cyanosis, changes in mental status, abnormal ABG results, or abnormal vital signs because they can all indicate a deterioration in the patient’s physiological status.
4. Managing Hyperthermia
Like any other infection, Tuberculosis will most likely cause a spike in temperature and the patient will have a fever for a couple of days.
Fever in TB is primarily treated with the regular administration of Anti-TB agents to treat the infection and Paracetamol. Moreover, you should try to adjust the environmental factors to lower the patient’s temperature. Remove excess clothes and blankets, adjust the room temperature to avoid overheating and encourage the patient to stay hydrated.
5. Managing Inadequate Nutrition and Hydration
Patients with aggressive TB will often have inadequate nutrition because dyspnoea affects their eating habits. Eating becomes stressful and tiring, so they start to eat smaller portions. Moreover, secretions could also make it difficult for patients to swallow the food.
Ensure that the patient gets a rest period before and after eating, position them upright and maintain a clear airway. Provide high-calorie meals or meal replacements such as shakes that come in small volumes, and encourage the patient to drink sports drinks that have additional electrolytes. You should also provide the patient with nasal prongs to supplement oxygen while they’re eating.
Encourage your patient to drink water as staying hydrated will help to decrease the viscosity of the sputum and lower the patient’s body temperature. If these steps are not enough, the patient might need additional support such as intravenous fluids and enteral feeding.
6. Managing Activity Intolerance
Much like dyspnoea interferes with eating, it will also interfere with the patient’s activities of daily living and their social life.
Assess the patient’s needs and figure out what their concerns are, and then find coping mechanisms that work for that patient. Teach the patient to plan their activities, so they can schedule a rest period before and after each activity. Explain that they can use energy-conserving techniques such as using an electric wheelchair instead of walking long distances and using assistive devices to pick things up from the floor or high surfaces.
Teach your patients breathing exercises and low impact physical exercises to rebuild their stamina and regain independence. In some hospitals, you could also refer the patient to a pulmonary rehab specialist so they can learn to cope with their condition over time.
7. Managing Deficient Knowledge & Treatment Adherence
Overcoming Mycobacterium Tuberculosis is no easy task, in fact, Anti-TB agents are often prescribed for 6-12 months after the initial diagnosis. This ensures full destruction of the pathogen and avoids reoccurring infections. Moreover, adhering to the prescribed medication reduces the chances of developing drug-resistant TB.
However, given that a big majority of patients with TB come from developing countries or countries where healthcare is underfunded and not given importance, adhering to treatment can be a challenging task. The pharmacological treatment of TB is complex and expensive making it challenging for patients to follow through. In addition, when their infection reaches the latent phase, some patients assume that they’re cured because they no longer have any symptoms, and as a result, they stop taking the medication.
As their nurse, you should educate your patient about TB and how adhering to the prescribed treatment will cure the patient and stop the spread of infection. Advise the patient to take the Anti-TB agents at least 1 hour before meals because food can interact with the absorption of the medication. Go through the side effects and the interactions of their prescribed medications, and explain how missing doses or stopping medication can result in developing drug-resistant TB.
Since TB is a communicable disease, and essentially a pandemic, most communities have a program in place set up by the public health authorities to continue monitoring the patient’s progress outside of the hospital. Advise the patient to comply with the program and seek help if symptoms reoccur or if they have any concerns.
Morever, explain to the patient ways to lower the risk of transmission. This includes, proper hygiene, covering nose and mouth whenever coughing or sneezing and keeping a distance from other individuals.
8. Managing Anxiety
Since TB affects the lung tissues, many patients will feel like they are suffocating. Moreover, because it’s airborne the isolation period can become very daunting and patients often develop feelings of frustration or depression. Such an experience will increase stress and anxiety levels, and unfortunately, most patients would be too scared to open up about these feelings. Often because they do not want to seem childish or they don’t want to burden others with their worries.
As their nurse, you should create a safe space where your patient can voice their feelings and express their concerns. Explain the situation to the patient, what symptoms they have and how you’re treating them. Give them an expected timeline of when they can start to feel relief from the symptoms and how they are progressing. Use deep breathing exercises and the pursed-lip technique to regain control of their breathing, as well as distraction techniques to shift their focus onto other things.
Tuberculosis Nursing Discharge
After having gone through all the diagnoses and management, you will need to re-evaluate the situation and see if there’s been any improvement or deterioration in your patient. If you don’t notice any improvement, or you notice that your patient’s overall condition is worsening you will need to contact the medical team and alter the treatment plan accordingly.
But if your patient improves you can plan their discharge to ensure that they regain independence and avoid future infections. Before discharging a patient with TB into the community, you must follow the country guidelines and refer the case to the public health authorities to ensure the continuation of care.