Although many still believe it to be a problem of the past, pulmonary tuberculosis (TB) is on the rise. Most frequently seen as a pulmonary disease, TB can be extrapulmonary and affect organs and tissues other than the lungs. 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.
CARE SETTING
Most patients are treated as outpatients, but may be hospitalized for diagnostic evaluation/initiation of therapy, adverse drug reactions, or severe illness/debilitation.
RELATED CONCERNS
Extended care
Pneumonia: microbial
Psychosocial aspects of care
Patient Assessment Database
Data depend on stage of disease and degree of involvement.
ACTIVITY/REST
May report: Generalized weakness and fatigue
Shortness of breath with exertion
Difficulty sleeping, with evening or night fever, chills, and/or sweats
Nightmares
May exhibit: Tachycardia, tachypnea/dyspnea on exertion
Muscle wasting, pain, and stiffness (advanced stages)
EGO INTEGRITY
May report: Recent/long-standing stress factors
Financial concerns, poverty
Feelings of helplessness/hopelessness
Cultural/ethnic populations: Native-American or recent immigrants from Central America,
Southeast Asia, Indian subcontinent
May exhibit: Denial (especially during early stages)
Anxiety, apprehension, irritability
FOOD/FLUID
May report: Loss of appetite
Indigestion
Weight loss
May exhibit: Poor skin turgor, dry/flaky skin
Muscle wasting/loss of subcutaneous fat
PAIN/DISCOMFORT
May report: Chest pain aggravated by recurrent cough
May exhibit: Guarding of affected area
Distraction behaviors, restlessness
RESPIRATION
May report: Cough, productive or nonproductive
Shortness of breath
History of tuberculosis/exposure to infected individual
May exhibit: Increased respiratory rate (extensive disease or fibrosis of the lung parenchyma and pleura)
Asymmetry in respiratory excursion (pleural effusion)
Dullness to percussion and decreased fremitus (pleural fluid or pleural thickening)
Breath sounds diminished/absent bilaterally or unilaterally (pleural effusion/pneumothorax); tubular breath sounds and/or whispered pectoriloquies over large lesions; crackles may be noted over apex of lungs during quick inspiration after a short cough (posttussive crackles)
Sputum characteristics green/purulent, yellowish mucoid, or blood-tinged
Tracheal deviation (bronchogenic spread)
Inattention, marked irritability, change in mentation (advanced stages)
SAFETY
May report: Presence of immunosuppressed conditions, e.g., AIDS, cancer
Positive HIV test/HIV infection
Visit to/immigration from or close contact with persons in countries with high prevalence
of TB (e.g., Philippines, Vietnam, Cambodia, Laos, Puerto Rico, Haiti, Russia, Mexico)
May exhibit: Low-grade fever or acute febrile illness
SOCIAL INTERACTION
May report: Feelings of isolation/rejection because of communicable disease
Change in usual patterns of responsibility/change in physical capacity to resume role
TEACHING/LEARNING
May report: Familial history of TB
General debilitation/poor health status
Use/abuse of substances such as IV drugs, alcohol, cocaine, and crack
Failure to improve/reactivation of TB
Nonparticipation in therapy
Discharge plan DRG projected mean length of inpatient stay: 6.3–8.3 days
considerations: May require assistance with/alteration in drug therapy and temporary assistance in selfcare and homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Sputum culture: Positive for Mycobacterium tuberculosis in the active stage of the disease.
Ziehl-Neelsen (acid-fast stain applied to a smear of body fluid): Positive for acid-fast bacilli (AFB).
Skin tests (purified protein derivative [PPD] or Old tuberculin [OT] administered by intradermal injection
[Mantoux]): A positive reaction (area of induration 10 mm or greater, occurring 48–72 hr after interdermal
injection of the antigen) indicates past infection and the presence of antibodies but is not necessarily indicative of active disease. Factors associated with a decreased response to tuberculin include underlying viral or bacterial infection, malnutrition, lymphadenopathy, overwhelming TB infection, insufficient antigen injection, and conscious or unconscious bias. A significant reaction in a patient who is clinically ill means that active TB cannot be dismissed as a diagnostic possibility. A significant reaction in healthy persons usually signifies dormant TB or an infection caused by a different mycobacterium.
Enzyme-linked immunosorbent assay (ELISA)/Western blot: May reveal presence of HIV.
Chest x-ray: May show small, patchy infiltrations of early lesions in the upper-lung field, calcium deposits of healed primary lesions, or fluid of an effusion. Changes indicating more advanced TB may include cavitation, scar tissue/fibrotic areas.
CT or MRI scan: Determines degree of lung damage and may confirm a difficult diagnosis.
Bronchoscopy: Shows inflammation and altered lung tissue. May also be performed to obtain sputum if patient is unable to produce an adequate specimen.
Histologic or tissue cultures (including gastric washings; urine and cerebrospinal fluid [CSF]; skin biopsy): Positive for Mycobacterium tuberculosis and may indicate extrapulmonary involvement.
Needle biopsy of lung tissue: Positive for granulomas of TB; presence of giant cells indicating necrosis.
Electrolytes: May be abnormal depending on the location and severity of infection; e.g., hyponatremia caused by abnormal water retention may be found in extensive chronic pulmonary TB.
ABGs: May be abnormal depending on location, severity, and residual damage to the lungs.
Pulmonary function studies: Decreased vital capacity, increased dead space, increased ratio of residual air to total lung capacity, and decreased oxygen saturation are secondary to parenchymal infiltration/fibrosis, loss of lung tissue, and pleural disease (extensive chronic pulmonary TB).
NURSING PRIORITIES
1. Achieve/maintain adequate ventilation/oxygenation.
2. Prevent spread of infection.
3. Support behaviors/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/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.
CARE SETTING
Most patients are treated as outpatients, but may be hospitalized for diagnostic evaluation/initiation of therapy, adverse drug reactions, or severe illness/debilitation.
RELATED CONCERNS
Extended care
Pneumonia: microbial
Psychosocial aspects of care
Patient Assessment Database
Data depend on stage of disease and degree of involvement.
ACTIVITY/REST
May report: Generalized weakness and fatigue
Shortness of breath with exertion
Difficulty sleeping, with evening or night fever, chills, and/or sweats
Nightmares
May exhibit: Tachycardia, tachypnea/dyspnea on exertion
Muscle wasting, pain, and stiffness (advanced stages)
EGO INTEGRITY
May report: Recent/long-standing stress factors
Financial concerns, poverty
Feelings of helplessness/hopelessness
Cultural/ethnic populations: Native-American or recent immigrants from Central America,
Southeast Asia, Indian subcontinent
May exhibit: Denial (especially during early stages)
Anxiety, apprehension, irritability
FOOD/FLUID
May report: Loss of appetite
Indigestion
Weight loss
May exhibit: Poor skin turgor, dry/flaky skin
Muscle wasting/loss of subcutaneous fat
PAIN/DISCOMFORT
May report: Chest pain aggravated by recurrent cough
May exhibit: Guarding of affected area
Distraction behaviors, restlessness
RESPIRATION
May report: Cough, productive or nonproductive
Shortness of breath
History of tuberculosis/exposure to infected individual
May exhibit: Increased respiratory rate (extensive disease or fibrosis of the lung parenchyma and pleura)
Asymmetry in respiratory excursion (pleural effusion)
Dullness to percussion and decreased fremitus (pleural fluid or pleural thickening)
Breath sounds diminished/absent bilaterally or unilaterally (pleural effusion/pneumothorax); tubular breath sounds and/or whispered pectoriloquies over large lesions; crackles may be noted over apex of lungs during quick inspiration after a short cough (posttussive crackles)
Sputum characteristics green/purulent, yellowish mucoid, or blood-tinged
Tracheal deviation (bronchogenic spread)
Inattention, marked irritability, change in mentation (advanced stages)
SAFETY
May report: Presence of immunosuppressed conditions, e.g., AIDS, cancer
Positive HIV test/HIV infection
Visit to/immigration from or close contact with persons in countries with high prevalence
of TB (e.g., Philippines, Vietnam, Cambodia, Laos, Puerto Rico, Haiti, Russia, Mexico)
May exhibit: Low-grade fever or acute febrile illness
SOCIAL INTERACTION
May report: Feelings of isolation/rejection because of communicable disease
Change in usual patterns of responsibility/change in physical capacity to resume role
TEACHING/LEARNING
May report: Familial history of TB
General debilitation/poor health status
Use/abuse of substances such as IV drugs, alcohol, cocaine, and crack
Failure to improve/reactivation of TB
Nonparticipation in therapy
Discharge plan DRG projected mean length of inpatient stay: 6.3–8.3 days
considerations: May require assistance with/alteration in drug therapy and temporary assistance in selfcare and homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Sputum culture: Positive for Mycobacterium tuberculosis in the active stage of the disease.
Ziehl-Neelsen (acid-fast stain applied to a smear of body fluid): Positive for acid-fast bacilli (AFB).
Skin tests (purified protein derivative [PPD] or Old tuberculin [OT] administered by intradermal injection
[Mantoux]): A positive reaction (area of induration 10 mm or greater, occurring 48–72 hr after interdermal
injection of the antigen) indicates past infection and the presence of antibodies but is not necessarily indicative of active disease. Factors associated with a decreased response to tuberculin include underlying viral or bacterial infection, malnutrition, lymphadenopathy, overwhelming TB infection, insufficient antigen injection, and conscious or unconscious bias. A significant reaction in a patient who is clinically ill means that active TB cannot be dismissed as a diagnostic possibility. A significant reaction in healthy persons usually signifies dormant TB or an infection caused by a different mycobacterium.
Enzyme-linked immunosorbent assay (ELISA)/Western blot: May reveal presence of HIV.
Chest x-ray: May show small, patchy infiltrations of early lesions in the upper-lung field, calcium deposits of healed primary lesions, or fluid of an effusion. Changes indicating more advanced TB may include cavitation, scar tissue/fibrotic areas.
CT or MRI scan: Determines degree of lung damage and may confirm a difficult diagnosis.
Bronchoscopy: Shows inflammation and altered lung tissue. May also be performed to obtain sputum if patient is unable to produce an adequate specimen.
Histologic or tissue cultures (including gastric washings; urine and cerebrospinal fluid [CSF]; skin biopsy): Positive for Mycobacterium tuberculosis and may indicate extrapulmonary involvement.
Needle biopsy of lung tissue: Positive for granulomas of TB; presence of giant cells indicating necrosis.
Electrolytes: May be abnormal depending on the location and severity of infection; e.g., hyponatremia caused by abnormal water retention may be found in extensive chronic pulmonary TB.
ABGs: May be abnormal depending on location, severity, and residual damage to the lungs.
Pulmonary function studies: Decreased vital capacity, increased dead space, increased ratio of residual air to total lung capacity, and decreased oxygen saturation are secondary to parenchymal infiltration/fibrosis, loss of lung tissue, and pleural disease (extensive chronic pulmonary TB).
NURSING PRIORITIES
1. Achieve/maintain adequate ventilation/oxygenation.
2. Prevent spread of infection.
3. Support behaviors/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/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.
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