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.
In these notes, we’ll be going over the Tuberculosis Nursing Assessment, but before getting into that, make sure that you’ve understood the:
Tuberculosis Nursing Assessment: Health History
As we mentioned above, TB is an airborne infection that can easily be transmitted to other individuals close by. If a patient is suspected to have TB, you and any other caregivers approaching the patient need to wear full PPEs (Personal Protective Equipment.) Typically these include disposable shoe covers, gown and gloves, an N99 Mask and a visor.
Keep in mind that having a health care professional talking to you in full PPEs can be a bit overwhelming, so before you initiate the assessment take time to explain the situation. Tell the patient that whether they have suspected or have already gotten the diagnosis, all protection measures need to be taken to stop transmission of TB. You could also ask your patient to cover their mouth and nose when coughing or sneezing.
Once the patient is comfortable, ask about their Exposure to Risk Factors specifically if they’ve been in contact with someone who had an active TB infection and if they have any immunosuppressive conditions. You should also ask questions to understand the patient’s knowledge of the infection as well as their social and familial support system.
Tuberculosis Nursing Assessment: Physical Assessment
Before starting, take a quick look at your patient’s overall stature. Individuals with TB are likely to experience weight loss, anorexia and shortness of breath. All of which would make the patient look frail and in need of support.
Next up check their vital signs including:
Temperature
Pulse
Oxygen Saturation
Blood pressure
Respiration Rate
After you’ve recorded their vital signs you should check their Respiratory Function, this means that you need to assess:
Respiratory Pattern
Cough
Sputum production
Haemoptysis
You should also lookout for any signs of lung consolidation including:
Unusual breath sounds (crackles, bronchial sounds or diminished sounds)
Fremitus
Egophony
Tuberculosis Nursing Assessment: Medical Tests
After completing the health history and physical examination, the patient will need to perform a series of tests to confirm the diagnosis and determine the extent of the infection.
First up, patients are usually required to provide a Sputum Specimen which is investigated for the presence of Acid Fast Bacilli (AFB). These bacilli can be spotted either in a sputum culture where the sample is taken into the lab and grown for 6-8weeks or with a Ziehl-Neelsen Test. This test smears sputum onto a slide and then uses a fast staining technique that detects AFB within 1-2days. However, several studies have reported cases in which patients had an active TB infection but tested negative for the sputum culture. So further testing is necessary to confirm the presence of TB.
Another common practice to detect active or latent TB is the Tuberculin Skin Test using the Mantoux method. When performing this test, a trained professional would inject a purified protein derivative of Tubercle bacillus extract into the intradermal layer of the skin. Typically, 0.1ml of the extract is injected on the inner forearm, around 4 inches below the elbow crease.
The area is assessed again 72 hrs after injection. Irritation around the site of injection and an induration (aka. Hardening of tissue) means that the patient most likely has active TB. If the patient does not develop any reaction it means that their immune system did not respond to the injection. This means that it is unlikely that the patient has active or latent TB. But it does not exclude the disease entirely, because a non-responsive immune system could be a result of immunosuppressive conditions such as HIV.
The next diagnostic test used when investigating TB is the Interferon-Gamma Release Assays (IGRAs) blood test. This test investigates the presence of IGRA in the blood and the results are typically issued within 24-48hrs. A positive result (ie. IGRAs are present) means that the patient likely has latent or active TB.
A chest x-ray can be performed to reveal lesions in the upper lobes and an MRI can determine the severity of the infection. Pulmonary Function Studies and Bronchoscopy would be able to determine the severity of the inflammation and the level of reversible damage done to the parenchyma. In addition, ABG tests are typically done to determine the patient’s physiological status and assess the level of gas exchange, while electrolyte levels are checked to determine the patient’s hydration status.
Lastly, as the incidence of drug resistance continues to rise, it is often indicated to perform a drug susceptibility test.
Summary of the Tuberculosis Nursing Assessment:
Health History: Ask about the patient’s exposure to risk factors.
Physical Assessment: Check the patient’s vital signs, their respiratory function and the possibility of lung consolidation.
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
If you follow those 3 steps, you should obtain a very thorough assessment for Tuberculosis Patients. And if you want to know anything else just use the search button at the top or send me a message on my Instagram Account @Miriana.Nurse for a quick reply.
References:
Heemskerk D, Caws M, Marais B, et al. Tuberculosis in Adults and Children. London: Springer; 2015. Chapter 4, Diagnosis. Available from: https://www.ncbi.nlm.nih.gov/books/NBK344401/
Asghar, M. U., Mehta, S. S., Cheema, H. A., Patti, R., & Pascal, W. (2018). Sputum Smear and Culture-negative Tuberculosis with Associated Pleural Effusion: A Diagnostic Challenge. Cureus, 10(10), e3513. https://doi.org/10.7759/cureus.3513
Dacso CC. Skin Testing for Tuberculosis. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 47. Available from: https://www.ncbi.nlm.nih.gov/books/NBK369/