This NCLEX review will discuss tuberculosis.
As a nursing student, you must be familiar with tuberculosis along with how to care for a patient experiencing this disease.
These type of questions may be found on NCLEX and definitely on nursing lecture exams.
Don’t forget to take the quiz containing tuberculosis nclex questions.
Lecture on Tuberculosis
Tuberculosis NCLEX Review
What is Tuberculosis: it’s a contagious bacterial infection caused by mycobacterium tuberculosis that affects mainly the lungs BUT it can also affect the kidneys, brain, spine, joints, and liver.
First, let’s talk about mycobacterium tuberculosis:
- It’s acid-fast (it stains bright red with the acid-fast staining smear)
- It’s an AEROBIC bacteria (so it LOVES oxygen and must have it to grow):
- Which is why TB most commonly affects the UPPER part of the lungs because there is a higher oxygen concentration in the apex of the lungs rather than the base
- Tuberculosis is spread through the air (airborne precautions….wear a respirator at all times when providing patient care and special ventilation/negative pressure air room must be used for the patient with an ACTIVE TB infection). The bacteria is very small, so it can suspend itself in the air….it’s different than droplet type of infections:
- If a person with an ACTIVE infection of TB talks, coughs, sneezes, laughs, yells (all these actions create droplets that harbor the bacteria) this can be inhaled by others.
- Must be in contact with the person for a period of time to catch tuberculosis, which is why people who live in close quarters or spend a lot of time together are at risk. Another risk factor is having a weaken immune system (ex: HIV)….see more risk factors below.
Risk Factors for developing Tuberculosis
“TB Risk” (remember these factors for tests)
Tight living quarters: long-term health care facilities, homeless shelters, prisons etc.
Below or at the poverty line (poor…homeless)
Refugees (high incidence of TB in their home country)
Immune system issues: HIV
Substance abusers (IV drugs, ETOH)
Kids less than the age of 4-5….weak immune systems
As the nurse assess your patient for risk, especially patients who are presenting with respiratory symptoms (this is best done at admission…..most paperwork will have questions that are similar to these questions):
- Have you travelled outside of the country or lived outside of the country for a long period of time? If so, where and how long?
- Where do you live? LTC, homeless, prison etc.
- Use drugs? If so, what type?
- If foreign born, ask is they have ever received the BCG (bacilli Calmette-Guerin) vaccine. This is a vaccination administered in some countries to prevent TB in children. If the patient has received this vaccine, they will have a positive TB skin test result (avoid a PPD skin test because it will give a false positive….needs a blood test instead) and a chest x-ray.
- Are you having the following signs and symptoms: night sweats, cough for 3 weeks or more, blood in sputum, chest pain, weight loss and loss of appetite etc.?
- Ever have a tuberculin skin test? If so, what where the results?
****Not everyone who is infected with mycobacterium tuberculosis will develop an active tuberculosis infection. Most of the time when a person inhales the bacteria the immune system detects it, and it becomes encapsulated (so the immune system keeps it under control). Therefore, most people will never develop the active disease unless those encapsulated bacteria become active again.
So, let’s talk about the differences between a latent tuberculosis infection (LTBI) versus an active TB infection.
Latent tuberculosis infection (LTBI): the mycobacterium tuberculosis bacteria is lying dormant and being controlled by the immune system….it’s encapsulated
- Therefore, the person is: NOT contagious and does NOT have signs and symptoms, will have a normal chest x-ray, and negative sputum test
- Only sign the person will have is a positive TB skin test or blood test. This means that the immune system has responded to the bacteria.
- Still need treatment? YES! This will help prevent an ACTIVE TB infection in the future. According to the CDC, 5-10% of patients who do NOT receive treatment for latent TB will develop active TB at some point.
Active TB: the immune system isn’t able to contain the bacteria so it takes over (ex: weaken immune system due to HIV). Most cases of active TB are due to a latent case that turns into an active case
- Therefore, the person is: CONTAGIOUS AND HAS SIGNS/SYMPTOMS, positive PPD or blood test, will have an ABNORMAL chest x-ray and positive sputum culture.
- The bacteria can now spread via the lymphatic system throughout the body and affect other areas of the body like the brain, spine, joints etc.
Signs and Symptoms of Tuberculosis (active)
****remember most patients are asymptomatic until they reach the active stage
- Cough that lasts three weeks or more
- coughing up blood
- night sweats
- unintentional weight loss
- loss of appetite
- chest pain, or pain with breathing or coughing
Testing for Tuberculosis
PPD tuberculin skin test (also called Mantoux Test, TST, TB skin test): this is where purified protein derivative (hence where PPD comes from with the name) is injected with a tuberculin needle on the inner part of the forearm…after the injection it will look like this:
- It is read in 48-72 hours…..(the patient must come back to have the test read and if the patient does NOT return within 72 hours the test will have to be repeated)
- A positive result doesn’t necessarily mean the patient has an active infection of TB. It just means they have been exposed to it.
- Does it tell the difference between a latent vs active infection? NO! The person will need a chest x-ray and sputum culture to confirm.
As the nurse you will be assessing for induration of the injection site. Induration is a hard or swollen area that is raised on the skin. This will be measured in millimeters (mm). Redness is not measured…the induration is measured (for exams remember the criteria for positive results)
- 15 millimeters (mm) or more: Positive in all persons (doesn’t matter if the person does not have any risk factors)
- 10 mm or more: positive if the person is an immigrant, IV drug user, working or living in tight living quarters, child less than 4
- 5 mm or more: positive if person have HIV, in contact with someone with TB, organ transplant patient, or immunosuppressed
Interferon-Gamma Release Assays (IGRA Test): starting to become more popular
Two types currently on the market: QuantiFERON-TB Gold (QFT) and T-Spot
The blood test will check for the immune system’s reaction to mycobacterium tuberculosis.
- Benefits: just one visit (doesn’t have to come back for results to be read and results are not affected by people who have had the BCG vaccine)
- Downsides: It doesn’t differentiate between latent vs active…again the person will need a sputum culture and chest x-ray to confirm.
Sputum: (AFB “acid-fast bacilli” Smear): the patient provides the specimen through coughing it up or a bronchoscopy to collect the sputum. The sputum is stained with a special dye and given an acid wash. If mycobacterium tuberculosis is present it will stain a bright red color.
- NURSE: collect three different sputum specimens on 3 different days
- It’s best to collect them in the morning before breakfast (most collection of secretions from overnight)
Chest x-ray: assesses for abnormal infiltrate in the lungs.
Nursing Interventions and Treatments for Tuberculosis
Always screen patients
Initiate airborne precautions:
- Negative pressure room (door closed at all times)
- Must wear a respirator when providing care (fitted yearly for this mask)
- Strict hand hygiene
- How about if the patient has to leave the room for testing? Many procedures can be performed by the bedside, but if the patient must leave the room they will need to wear a surgical mask.
Active TB infection education: most patients are treated outpatient because of the duration of how long they must take medications (6 months to a year)
- Isolation at home: can’t go to work, run errands, school etc. until no longer contagious (can go to medical appointments only….must wear surgical mask). To be removed from isolation they will need to be on medications for about 3 weeks, have 3 negative acid-fast sputum cultures, improvement of signs and symptoms, and be taking medications exactly as ordered (TB can become drug resistant)
- No visitors, stay in separate rooms from other family member (stay away from young kids), keep windows and doors closed
- Coughing, sneezing? Do this in a tissue and dispose immediately by flushing or put it an air tight bag and dispose
Medications for Tuberculosis
Educate patient they will be on medication treatment for several months…6 months to a year (depending on if they have LTBI or active TB)…..must be compliant (this is very hard for patients due to the amount of time they must take the medication and the frequency)
DOT (directly observed therapy): CDC recommends this to be used with ALL patient with TB because it is difficult to determine who will and won’t take their medication correctly.
- This ensures the patient takes the correct medication at the right time and continues therapy. A trained individual (public health nurse or trained DOT worker) actually observes the patient swallowing the medication.
- It helps decrease the patient from being noncompliant, monitors the patient for signs and symptoms related to the medications, and helps prevent resistant cases of TB.
- Family members are NOT candidates for DOT.
Most common drug regime used includes four drugs:
“PERI”: This word means “around or surrounds”. Normally, our body would surround this bacteria and encapsulate it, but it has failed to do this. Therefore, these medications must do it!
Pyrazinamide: bactericidal effect (kills the bacteria)
- watch in patients who are diabetic or have kidney problems, gout (increases uric acid which can level to a gout attack)
- Monitor uric acid level, liver and kidney function…can cause liver problems
- GI problems common…take with food
Ethambutol: stop RNA synthesis and is bacteriostatic (stops the bacteria from reproducing)
- Can inflame optic nerve (monitor for blurred or color changes in vision): needs to get eye checked regularly….always ask patient about vision…notify MD if this occurs
- Peripheral neuropathy (damage to peripheral nerves): report numbness or burning in the hands or feet….notify MD if this occurs
Rifampin: kills the bacteria by stopping RNA-polymerase
- Educate about turning body fluids orange and can stain soft contact lenses…so wear hard contact lenses instead
- makes birth control less effective (use back up method), sunburn easily, no alcohol (this drug can cause liver problems: watch for jaundice, issues bleeding etc.)
Isoniazid (INH): kills the bacteria and stops it growth
- decrease Vitamin B6 levels: monitor for tingling in extremities, tried, irritable, depressed (peripheral neuropathy)…need supplementation
- monitor liver function and tell patient for monitor for liver problems as well
- neurotoxicity: mental status
Streptomycin: still used for TB, but not as the first line usually
Stops protein synthesis and kills the bacteria…..watch for hearing changes (ringing in the eyes…can be ototoxicity (eight cranial nerve)
Fact Sheets | General | Tuberculosis: General Information | TB | CDC. Retrieved from https://www.cdc.gov/tb/publications/factsheets/general/tb.htm
Fact Sheets | General | Latent TB Infection vs. TB Disease | TB | CDC. Retrieved from https://www.cdc.gov/tb/publications/factsheets/general/ltbiandactivetb.htm
Fact Sheets | Testing & Diagnosis | Fact Sheet – Recommendations for Human Immunodeficiency… Clinics | TB | CDC. Retrieved from https://www.cdc.gov/tb/publications/factsheets/testing/igra.htm
Fact Sheets | Testing & Diagnosis | Fact Sheet – Tuberculin Skin Testing | TB | CDC. Retrieved from https://www.cdc.gov/tb/publications/factsheets/testing/skintesting.htm