I. Pathophysiology
a. Bacterial infection by Mycobacterium tuberculosis bacilli
(TB)
i. Primarily affects the lungs (70% per Centers for Disease
Control and Prevention [CDC], 2004) although it can
invade other body systems
ii. Airborne droplets are inhaled, with the droplet nuclei
deposited within the alveoli of the lung.
b. Primary infection followed by a latent or dormant phase, or
by active disease in some individuals
c. When the immune system weakens, dormant TB organisms
can reactivate and multiply (reactivation TB).
II. Classifications
a. Latent: Body’s immune system has encapsulated the bacteria
into tiny capsules called tubercles, infection not transmissible
to others.
b. Active: Infection is spreading in the body and can be transmitted
to others.
III. Etiology
a. Following exposure, the bacilli may (1) be killed by the
immune system, (2) multiply and cause primary TB,
(3) become dormant and remain asymptomatic, or
(4) proliferate after a latency period (reactivation disease)
(Herchline & Amorosa, 2007).
b. Multidrug-resistant tuberculosis (MDR-TB)
i. Primary: caused by person-to-person transmission of a
drug-resistant organism
ii. Secondary: usually the result of nonadherence to
therapy or inappropriate treatment
iii. 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
iv. Can progress from diagnosis to death in as little as 4 to
6 weeks
c. Risk factors: individuals with weakened immune systems
due to chronic conditions, advanced age, and malnutrition;
higher among persons with HIV infection, the homeless,
drug-addicted, and impoverished populations, as well as
among immigrants from or visitors to countries in which
TB is endemic
IV. Statistics (Centers for Disease Control and Prevention
[CDC], 2005, 2007)
a. Morbidity: In 2005, 14,903 cases of TB were reported in
the United States (down from a peak of 25,287 cases in
1993), with foreign-born individuals accounting for a
steadily increasing proportion (54%) of all reported TB
cases (Herschline, 2007); globally, 9.2 million new cases
reported annually.
b. Morbidity: Globally, 1.7 million deaths from TB occurred
in 2006, of which 0.2 million deaths were in HIV-positive
individuals (World Health Organization [WHO], 2008).
Care Setting
Most clients are treated in community clinics, but may be
hospitalized for diagnostic evaluation or initiation of therapy,
adverse drug reactions, or severe illness or debilitation.
This plan of care is intended to reflect care of the person
with active (rather than latent) TB, although if latent, when
TB is diagnosed, treatment will be initiated.
Nursing Priorities
1. Achieve and maintain adequate ventilation and oxygenation.
2. Prevent spread of infection.
3. Support behaviors and tasks to maintain health.
4. Promote effective coping strategies.
5. Provide information about disease process, prognosis,
and treatment needs.
Discharge Goals
1. Respiratory function adequate to meet individual need.
2. Complications prevented.
3. Lifestyle and behavior changes adopted to prevent spread
of infection.
4. Disease process, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
NURSING DIAGNOSIS: risk for Infection [spread/reactivation]
Risk factors may include
Inadequate primary defenses, decreased ciliary action and 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; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Identify interventions to prevent or reduce risk of spread of infection.
Demonstrate techniques and initiate lifestyle changes to promote safe environment.
ACTIONS/INTERVENTIONS
Infection Control
Independent
Review pathology of disease—active or inactive phases, dissemination
of infection through bronchi to adjacent tissues
or via bloodstream and lymphatic system—and potential
spread of infection via airborne droplet during coughing,
sneezing, spitting, talking, laughing, and singing.
Identify others at risk, such as household members, close
associates, and friends.
Instruct client to cough, sneeze, and expectorate into tissue
and to refrain from spitting. Review proper disposal of
tissue and good hand-washing techniques. Request return
demonstration.
Review necessity of infection control measures, such as
temporary respiratory isolation.
Monitor temperature, as indicated.
Identify individual risk factors for reactivation of tuberculosis,
such as lowered resistance associated with alcoholism,
malnutrition, intestinal bypass surgery, use of immunosuppressant
drugs, presence of diabetes mellitus or cancer, or
postpartum.
Stress importance of uninterrupted drug therapy. Evaluate
client’s potential for cooperation.
Review importance of follow-up and periodic reculturing of
sputum for the duration of therapy.
Encourage selection and ingestion of well-balanced meals.
Provide frequent small “snacks” in place of large meals as
appropriate.
Collaborative
Administer anti-infective agents, as indicated, for example:
Primary drugs: isoniazid (INH, Liniazid), rifampin (RIF,
Rifadin, Rimactane), pyrazinamide (PZA, Tebrazid), and
ethambutol (Etbi, Myambutol)
Rufabutin (Mucobutin)
Second-line drugs, such as ethionamide (Trecator-SC), paraaminosalicylate
(PAS), cycloserine (Seromycin), amikacin
(Amikin), and levofloxacin (Levoquin)
Investigational agents such as diarylquinoline (R207910)
Monitor laboratory studies, such as the following:
Sputum smear results
Liver function studies, such as aspartate aminotransferase
(AST), alinine aminotransferase (ALT)
Notify local health department.
RATIONALE
Helps client realize and accept necessity of adhering to medication
regimen to prevent reactivation and complications.
Understanding of how the disease is passed and awareness
of transmission possibilities help client and significant
other (SO) take steps to prevent infection of others.
Those exposed may require a course of drug therapy to
prevent development of infection.
Behaviors necessary to prevent spread of infection.
May help client understand need for protecting others while
acknowledging client’s sense of isolation and social stigma
associated with communicable diseases. Note: AFB can
pass through standard masks; therefore, particulate
respirators are required.
Febrile reactions are indicators of continuing presence of
infection.
Knowledge about these factors helps client alter lifestyle and
avoid or reduce incidence of exacerbation.
Contagious period may last only 2 to 3 days after initiation of
drug regimen, but in the 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; therefore, DOT
should be considered.
Aids in monitoring the effects of medications and client’s
response to therapy.
Presence of anorexia or preexisting malnutrition lowers
resistance to infectious process and impairs healing. Small
snacks may enhance overall intake.
The goals for treatment of TB are to cure the individual and to
minimize transmission to other persons. It is essential that
treatment be tailored and supervision be based on each
client’s clinical and social circumstances. DOT may be the
most effective way to maximize the completion of therapy.
These four drugs should not be given in divided doses; all four
drugs should be given together. Evidence shows this
promotes the therapy’s effectiveness (CDC, 2005). INH is
usually drug of choice for those exposed and who are
at risk for developing TB. Extended therapy for 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 test.
Therapeutic agent for atypical mycobacterium. May be used in
client with advanced HIV disease with TB.
These second-line drugs may be required when infection is
resistant to or intolerant of primary drugs or may be used
concurrently with primary antitubercular drugs. Note:
MDR-TB requires minimum of 18 to 24 months’ therapy
with at least three drugs in the regimen known to be
effective against the specific infective organism and that
client has not previously taken. Treatment is often extended
to 24 months in clients with severe symptoms or HIV
infection.
Innovative compounds are being developed based on new
drug targets and structure to provide shorter and more
effective treatment options. This agent, currently starting
human trials, cuts off the energy supply of the mycobacterium
and may be effective against drug-resistant forms
of TB.
Client who has three consecutive negative sputum smears
over a 3- to 5-month period is adhering to drug regimen
and who is asymptomatic will be classified as a nontransmitter.
The most common serious adverse effect of drug
therapy—particularly RIF, but possibly others as well—is
drug-induced hepatitis.
Required by law, and should be reported within 1 week of
diagnosis. Helpful in identifying contacts to reduce spread
of infection. Treatment course is long and usually handled
in the community, with public health nurse monitoring.
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