Pulmonary tuberculosis is an acute or chronic lung infection caused by Mycobacterium tuberculosis. It is characterized by pulmonary infiltrates and the formation of granulomas with caseation, fibrosis, and cavitation.

Pathophysiology

Transmission occurs via airborne droplet nuclei when a person with active disease coughs or sneezes.
Inhaled mycobacterium bacilli travel to the alveoli where they are ingested by macrophages.
Multiplication of M. tuberculosis bacilli initiates an inflammatory process in the lungs.
- A cell-mediated immune response occurs, usually containing the infection in 2 to 8 weeks.
- The T-cell response results in the formation of granulomas around the bacilli, making them dormant. This confers immunity to subsequent infection.
Bacilli within granulomas may remain viable for many years.
Active disease develops in 5% to 10% of those infected.

Causes

Exposure to M. tuberculosis
Exposure to strains of mycobacteria other than TB (not contagious)

Risk Factors

Close contact with a patient with TB who has active disease
History of prior TB exposure
High-risk behaviors (such as drug use and multiple sex partners)
Recent immigration from high-incidence areas
Gastrectomy
History of silicosis, diabetes, malnutrition, cancer, Hodgkin disease, or leukemia
Drug and alcohol abuse
Residence in congregated settings, such as a shelter, an extended-care facility, a mental health facility, or a prison
Immunosuppression, such as from the human immunodeficiency virus (HIV) infection, and the use of corticosteroids
Homelessness

Incidence

TB is the most common cause of infectious disease-related mortality worldwide.
The overall incidence of TB has decreased but is greater among high-risk populations.
Forty percent of HIV deaths are attributed to TB.

Complications

Massive pulmonary tissue damage
Respiratory failure
Bronchopleural fistulas
Bronchiectasis
Hemoptysis
Pneumothorax
Pleural effusion
Pneumonia
Infection of other body organs by small mycobacterial foci
Liver disease secondary to drug therapy
Ototoxicity and retinal toxicity secondary to drug therapy

Assessment

History

Primary infection

May be asymptomatic after a 4- to 8-week incubation period
Cough
Weakness and fatigue
Anorexia, weight loss
Low-grade fever
Night sweats
Chest pain; pleuritic chest pain
Hemoptysis

Reactivated infection

Chest pain
Nonproductive or productive cough containing blood or mucopurulent or blood-tinged sputum
Low-grade fever
Dyspnea
Weight loss

Physical Findings

Cough
Fever
Anorexia, weight loss
Dullness over the affected area
Crepitant crackles
Bronchial breath sounds
Wheezes
Whispered pectoriloquy
Lymphadenopathy (bilateral), primarily of the posterior cervical chain or supraclavicular nodes

Extrapulmonary TB

Based on tissues involved
Confusion
Neurologic impairment
Enlarged lymph nodes
Cutaneous lesions
Back pain, arthritis pain (of one joint) or lower extremity paralysis (skeletal TB)
Flank pain, dysuria (genitourinary TB)
Difficulty swallowing, diarrhea, nonhealing ulcers of the mouth or anus (gastrointestinal TB)

Diagnostic Test Results

Laboratory

Tuberculin skin tests are positive in active and inactive (latent) TB.
T-SPOT TB test identifies interferon-gamma response to specific M. tuberculosis proteins to detect infection.
QuantiFERON-TB gold test or interferon gamma release assay detects latent TB infection.
Nucleic acid amplification tests detect TB complex DNA and common mutations associated with drug resistance.
Stains and cultures of sputum, cerebrospinal fluid, urine, abscess drainage, or pleural fluid show heat-sensitive, nonmotile, aerobic, acid-fast bacilli.
Urinalysis and urine cultures are performed if genitourinary symptoms are present.

Imaging

Chest radiography shows nodular lesions, patchy infiltrates, cavity formation, scar tissue, and calcium deposits—common findings in primary infection.
Computed tomography scanning (thorax) or magnetic resonance imaging shows the presence and extent of lung damage or evaluates vertebral or brain involvement with extrapulmonary TB.

Diagnostic Procedures

Bronchoscopy specimens show heat-sensitive, nonmotile, aerobic, acid-fast bacilli.
Biopsy for extrapulmonary TB is performed based on symptoms.

Treatment

General

When the disease is no longer infectious (in 2 to 4 weeks), resumption of normal activities while continuing to take medication
Airborne precautions (private room with negative pressure airflow; N95 or N100 efficiency masks on caregivers or visitors)
Smoking cessation
Venous thromboembolism (VTE) prophylaxis if hospitalized

Activity

Rest initially, followed by activity as tolerated

Medications

Antitubercular therapy options for drug-susceptible disease:
- 6- to 9-month treatment regimen with isoniazid, rifAMPin (rifampicin), ethambutol hydrochloride, and pyrazinamide
- 4-month treatment regimen with high-dose rifapentine, moxifloxacin hydrochloride, isoniazid, and pyrazinamide (an option for certain patients age 12 years or older with a body weight of at least 40 kg, including patients with HIV who are on an efavirenz-based regimen and have a CD4 cell count greater than 100 cells/microliter)
Antitubercular therapy options for drug-resistant disease (regimens should include only drugs to which the patient's TB isolate has documented or high likelihood of susceptibility):
- Bedaquiline fumarate
- CycloSERINE
- Clofazimine
- Fluoroquinolones, such as levoFLOXacin or moxifloxacin hydrochloride
- Linezolid
- Aminoglycosides, such as streptomycin sulfate or amikacin sulfate
- Ethambutol hydrochloride
- Pyrazinamide
- Carbapenems, such as imipenem–cilastatin sodium or meropenem, plus clavulanate
- Pretomanid

Surgery

Lobectomy or pneumonectomy for patients with multidrug-resistant TB and poor medical treatment prognosis

Nursing Considerations

Nursing Interventions

Administer drug therapy, as prescribed; give isoniazid on an empty stomach 1 hour before or 2 hours after meals.
Isolate the patient in a negative pressure airflow room.
Institute airborne precautions for pulmonary TB until the patient has at least three consecutive negative sputum cultures; institute airborne and contact precautions for extrapulmonary TB with draining lesions until drainage has stopped and the patient has three consecutive negative sputum cultures.
Provide diversional activities.
Properly dispose of secretions; encourage respiratory hygiene measures.
Provide adequate rest. Cluster care activities to provide for uninterrupted periods of rest.
Apply antiembolism stockings or sequential compression stockings to prevent VTE.
Provide well-balanced, high-calorie foods.
Provide small, frequent meals.
Consult with a dietitian if oral supplements are needed.
Perform chest physiotherapy. Encourage frequent coughing and deep-breathing exercises.
Provide supportive care:
- Encourage the patient to verbalize concerns and fears.
- Answer questions honestly.
- Provide clear explanations about procedures and care measures.
Include the patient in care decisions.
Obtain specimens for laboratory testing, such as sputum cultures, as indicated.
Notify the local health department if required by state regulations.

Monitoring

Vital signs
Intake and output
Respiratory status, including airway patency and sputum production
Daily weight
Complications
Adverse reactions
Visual acuity if taking ethambutol
Liver and kidney function tests
Pain level and effectiveness of interventions

Associated Nursing Procedures

Airborne precautions
Antiembolism stocking application, knee-length
Antiembolism stocking application, thigh-length
Chest physiotherapy
Contact precautions
Incentive spirometry
Intake and output measurement
Nutritional screening
Oral drug administration
Pain assessment
Pain management
Personal protective equipment (PPE), putting on
Personal protective equipment (PPE), removal
Safe medication administration practices, general
Sequential compression therapy
Sputum collection by expectoration
Sputum collection by tracheal suctioning
Tuberculin skin testing
Weight measurement

Patient Teaching

General

Include the patient's family or caregiver in your teaching, when appropriate. Provide information according to their individual communication and learning needs. Be sure to cover:

disorder, diagnostic testing, and treatment, including the duration of prescribed medication therapy
possible exposure of family members and the need for testing and possible treatment
drugs and potential adverse effects, including the importance of adhering to the regimen to ensure eradication of the infection
signs and symptoms of recurrence and complications, including when to notify the physician
appropriate infection control precautions and respiratory hygiene measures
postural drainage and chest percussion
coughing and diaphragmatic breathing exercises
importance of regular follow-up examinations, including weekly sputum analysis until a negative result occurs; periodic laboratory testing of blood count, liver enzymes, and serum creatinine level; and periodic serum uric acid testing if the patient is taking pyrazinamide
possibility of decreased hormonal contraceptive effectiveness while taking rifAMPin (rifampicin)
possibility of permanent staining of contact lenses with rifAMPin (rifampicin)
need for a high-calorie, high-protein, balanced diet
measures to prevent TB and its transmission.

tuberculosis

Explain airborne and standard precautions to a hospitalized patient with tuberculosis. Before discharge, tell the patient that precautions to prevent spreading the disease, such as wearing a mask around others, should be taken until the physician reports that the infection is no longer contagious. The patient should tell all health care practitioners, including dentists and optometrists, about the diagnosis of tuberculosis so that they can institute infection-control precautions.

Teach the patient other specific precautions to take to avoid spreading the infection. Tell the patient to cough and sneeze into tissues and to dispose of the tissues properly. Stress the importance of performing hand hygiene with hot, soapy water after handling secretions. Also instruct the patient to wash all eating utensils separately in hot, soapy water.

Discharge Planning

Participate as part of a multidisciplinary team to coordinate discharge planning efforts. The team may include a bedside nurse, care manager, nutritionist, physical therapist, respiratory therapist, pulmonologist, and primary care practitioner.
Assess the patient's and family's understanding of the diagnosis, treatment, follow-up, and warning signs for which to seek medical attention.
Assess the patient's level of independence before admission.
Evaluate how the current illness will affect the patient's independence.
Identify the patient's formal and informal supports.
Identify the patient's and family's goals, preferences, comprehension, and concerns about discharge.
Confirm arrangements for transportation to initial follow-up appointments.
Provide a list of prescribed drugs, including the dosage, prescribed time schedule, and adverse reactions to report to the practitioner. Provide the patient (and family or caregiver, as needed) with written information on the medications that the patient should take after discharge.
Assess the patient's and family's understanding of prescribed medication, including dosage, administration, expected results, duration, and possible adverse effects.
Assess the patient's ability to obtain medications; identify the party responsible for obtaining medications.
Instruct the patient to provide a list of medications to the practitioner who will be caring for the patient after discharge; to update the information when the practitioner discontinues medications, changes doses, or adds new medications (including over-the-counter products); and to carry a medication list that contains all of this information at all times in the event of an emergency.
Assist with arrangement of home health care, if needed.
Provide information on smoking cessation, if appropriate.
Ensure that the patient and caregivers receive the proper medical contact information.
Ensure that the patient or caregiver receives a copy of the discharge instructions and that a copy is placed in the patient's medical record.
Assess the patient's and family's understanding of teaching by using the teach-back method, when possible.
Document the discharge planning evaluation in the patient's clinical record, including who was involved in discharge planning and teaching, their understanding of teaching provided, and any need for follow-up teaching.