Care of the Patient with Tuberculosis

Tuberculosis (TB) is a serious infectious disease that can damage any organ system. It primarily affects the lungs and is contagious. The person-to-person spread of TB is preventable with basic infection control techniques. It is easily treated with specific drugs called antituberculars. Still, new cases are reported every year in the United States and worldwide.

In 2023, 9,615 cases of tuberculosis (TB) were reported in the United States (Williams et al., 2024). The number of TB cases in the United States has been declining for many years, but this is a 22% increase from 2022 (Williams et al. 2024).

Unfortunately, the news from the rest of the world is not as good. The 2024 World Health Organization’s (WHO) Global Tuberculosis Report noted that TB is again the leading cause of death from infectious diseases worldwide. The number of people who have been newly diagnosed with TB reached a new high in 2023, 8.2 million, and the number of TB cases has been rising each year since 2021 (WHO, 2024).

If TB is treated quickly and correctly, it is curable about 85% of the time (WHO, 2024). The death rate from TB has continually decreased (WHO, 2024). Control and cure rates are greatly affected by the lack of resources in many parts of the world (WHO, 2024). In some countries, the death rate of untreated TB is 50% within five years of developing an infection (WHO, 2024).

(*Please click on the image above to enlarge.)

Tuberculosis is caused by a bacteria called Mycobacterium tuberculosis. The main organs that are damaged by TB are the lungs (Nardell, 2023). TB bacteria are spread when someone inhales infected droplets(Nardell, 2023). The droplets are spread when an infected person coughs, sneezes, or talks (Nardell, 2023). Some of the infected droplets can remain in the air for several hours. Tuberculosis can also be spread by medical procedures that can create infected droplets. These are procedures like bronchoscopy, intubation, obtaining a saliva sample, and nebulizer treatments (Zachary, 2024).

Tuberculosis is not spread by casual contact, such as shaking hands, sharing food or beverages, kissing, or touching an infected person’s clothes or bed linens (Centers for Disease Control and Prevention [CDC], 2025). The TB bacteria can be transmitted through the skin or other routes, but this is not uncommon.

How contagious untreated, active TB is can be variable. It depends on many things:

Table 1. Risk Factors for TB Transmission (Nardell, 2023; Traiman, 2024)

Close contact with someone who has untreated active TB, especially in a crowded space with bad ventilation, is a high-risk factor for TB transmission and infection (Traiman, 2024).

Tuberculosis can be spread from an infected mother during pregnancy and delivery (Friedman & Tanoue, 2024; Tesini, 2022). No cases of the spread of TB from breastfeeding have been reported (Loveday et al., 2020). Women who have active TB who are being treated with antitubercular drugs can breastfeed (CDC, 2020).

Dormant (latent) tuberculosis is not contagious (CDC, 2025). The next section discusses latent TB.

The risk of an infected person spreading TB decreases when they begin taking antitubercular drugs (Nardell, 2023). When the TB bacteria in their spit is not infectious, they cough much less (Nardell, 2023). Infection control is discussed later in the course. There is evidence that if the patient responds to several weeks of drug treatment, TB will not be transmitted, even with close contact (Nardell, 2023).

When TB bacteria are inhaled and get to the lungs, one of three things occur (Grippi et al., 2023; Pozniak, 2024):

1. No infection:
   1. The TB bacteria does not reach parts of the lung where an infection can begin.
   2. The bacteria does reach the vulnerable areas, but the immune system clears them (Grippi et al., 2023; Pozniak, 2024).
2. Infection: Approximately 90% of people exposed to TB will develop an infection (Pozniak, 2024). When this occurs, there are two outcomes: A primary infection or a latent infection (Grippi et al., 2023; Pozniak, 2024). Primary and latent TB are the two basic types of TB.
   1. Primary infection: The TB bacteria reach the susceptible areas of the lung, and an active, contagious infection develops. About 5% of exposed persons develop primary TB (Pozniak, 2024). People who have a compromised immune system, e.g., HIV infection or certain chronic diseases, have a higher risk for primary infection (Pozniak, 2024). Children have a higher risk than adults for developing primary TB (CDC, 2024a).
      1. Primary TB infection usually develops slowly, and signs and symptoms begin within two years after exposure (Pozniak, 2024).
   2. Latent infection: The immune system isolates and contains the TB bacteria, and the patient is asymptomatic. The patient is infected, but they are not contagious(Grippi et al., 2023; Pozniak, 2024), and this is the most significant difference between primary and latent TB.
      1. People who have latent TB can be asymptomatic for decades and never develop active TB, but latent TB can become active. The risk of latent TB becoming active is 5 to 10 percent (Grippi et al., 2023). People who have a compromised immune system, e.g., HIV infection, certain chronic diseases, or are taking certain drugs have a higher risk of latent TB becoming active (Grippi et al., 2023).

Primary and latent TB are often called active TB.

Latent TB is the most common type of TB in the US. About 13 million Americans have it (CDC, 2024b). Some populations have a higher rate of TB (CDC, 2024c).

Table 2. Ethnicity and TB in the US

About 30% of TB infections are not in the lungs. This is called extrapulmonary TB (Nardell, 2023). In these cases, TB bacteria get into the bloodstream and move to other organs (Nardell, 2023).

Latent TB that becomes active is more likely to cause TB in other parts of the body (Nardell, 2023).

Some examples of TB in other parts of the body are (Grippi et al., 2023; Nardell, 2022):

• Bones and joints
• Genitourinary tract: Kidneys, prostate gland, urinary bladder
• Heart: Pericardial sac surrounding the heart
• Liver
• The sac around the lungs (pleura)
• Lymph nodes
• Skin

Drug-resistant TB (DR-TB) is TB that does not respond to standard drug treatment (CDC, 2023; Grippi et al., 2023; Nardell, 2023). Because the TB bacteria are resistant to typical medications, a long course of treatment is required (Grippi et al., 2023; Nardell, 2023). There are three types of DR-TB (Nardell, 2023).

1. Multidrug-resistant TB (MDR-TB).
2. Pre-XDR-TB.
3. Extensively drug-resistant TB (XDR-TB)

Common causes of DR-TB are exposure to DR-TB, living in an area where DR-TB is common, and non-compliance with drug therapy (CDC, 2023; Nardell, 2023). Non-compliance, e.g., skipping doses or not completing the treatment, allows DR-TB bacteria to develop, and this is a serious complication.

Drug-resistant TB is uncommon in the US. In 2023, only 1.4% of TB cases were MDR TB, 0.2% were pre-XDR TB, and there were no reported cases of XDR-TB (CDC, 2024d).

Drug-resistant TB is a serious disease. Patients who have DR-TB often do not respond well to treatment. The death rate of DR-TB is higher than that of drug-susceptible TB (Alemu et al., 2021).

The signs and symptoms of active TB are not specific (Grippi et al., 2023; Nardell, 2023). They mimic many other diseases. They also develop slowly over many weeks (Grippi et al., 2023).

Patients may complain that they “just don’t feel well” (Nardell, 2023). This is often called malaise. Most patients have a low-grade fever, a common sign of active TB (Nardell, 2023). Cough is also a common sign of active TB. At first, the cough is dry. As the infection progresses, the patient develops a productive cough with large amounts of sputum. (Grippi et al., 2023; Nardell, 2023). In advanced cases, a bloody cough, weight loss, and loss of appetite (anorexia) occur (Grippi et al., 2023). Night sweats are common (Grippi et al., 2023; Nardell, 2023).

Table 3: Signs and Symptoms of TB

There may be questions on forms you complete to help the RN assess the patient. One question may be, “Have you been out of the country recently?” This is important to know because TB signs and symptoms can also be caused by many diseases.  TB and DR-TB are more common in some countries. It is also helpful to determine the patient’s living situation because a crowded living space, either a personal residence, a correctional facility, or a homeless shelter, increases the risk of developing TB.

Other questions that you might need to ask the patient are about signs and symptoms, as well as compliance with drug therapy. You should also ask if they understand how TB is transmitted and how TB transmission is prevented. The last two, transmission and prevention, are especially important for patients who have TB and are at home.

Primary TB is always treated.  In some situations, latent TB is treated (CDC, 2018).

For healthy patients with a normal immune system who faithfully follow the drug regimen, the cure rate of TB is very high (CDC, 2024e; Nardell, 2023). But TB drug therapy is a long process (CDC, 2024f; Nardell, 2023). Even the simplest treatment is four or six months long (Nardell, 2023). Some treatments are much longer, and patients will need to take four to five drugs a day (Nardell, 2023). Many people have difficulty taking the drugs correctly because of how long the treatments are and the unpleasant drug effects. Very often, people feel better, and their symptoms go away soon after they start treatment (CDC, 2024f). Sometimes, when they feel better, they stop taking the medicine. Because of these issues, non-compliance is a significant problem (Nardell, 2023). Non-compliance is very serious. It can cause TB to recur, it increases the risk of developing DR-TB, and it puts patients, healthcare workers, and others at risk. Every member of the healthcare team should encourage the patient to take their medications as directed. If the patient is or might become non-compliant, there is an effective intervention. This is called directly observed therapy (DOT) (Nardell, 2023). With DOT, a healthcare worker or a designated person watches the patient swallow each dose, and they monitor patients for adverse drug effects (CDC, 2024f). Directly observed therapy is highly effective. It has been shown to increase compliance from 61% to 86% and higher (Nardell, 2023).

Patient monitoring and knowing what to report to the nurse are important when caring for patients with TB. The primary parts of  patient monitoring that CNAs should be familiar with are:

1. Signs and symptoms of TB
2. Adverse drug effects
3. Compliance with drug therapy
4. Infection control
5. Nutrition

The nurse should be notified immediately if the patient has the signs listed in Table 3. The nurse should also be notified if these signs are present.  The nurse should also be notified if the symptoms change or worsen.  For example, if a patient has trouble breathing or their breathing becomes more difficult. Or if a patient’s fever increases.

Table 4: Immediate Reporting, Signs and Symptoms

Patients who have TB may (Pozniak, 2024) or may not have difficulty breathing and they are usually not drowsy.  However, TB can prevent oxygen from moving through the lungs and being delivered to the body (Pozniak, 2024).  This can cause difficulty breathing and drowsiness.  

Fever is usually defined as a temperature > 38.0° C, 100.4° F (Spelman, 2023). Fever is common in people who have active TB. But in patients who are being treated, it may mean that drug therapy is not working or that they have developed another type of infection, like a viral illness. Also, fever is stressful to the body, and it can cause fluid loss. 

Hemoptysis means bleeding in the respiratory system. Regardless of the amount of bleeding, the nurse should be notified immediately.

Anorexia, cough, weakness, night sweats, and weight loss are not dangerous. But if a patient develops one of these signs/symptoms or if they have one and it changes or gets worse, the nurse should be notified. For example, the patient had a dry cough, but now it’s productive.  Another example is if the patient’s appetite was good, and now it’s poor, or they have been losing weight. 

The nurse should be notified immediately if the patient has an adverse drug effect. 

Table 5: Antitubercular Adverse Drug Effects (CDC, 2024e)

Compliance with drug therapy is critical. If the patient misses a dose, the nurse should be notified immediately.

Patients who have or might have active TB should be placed in an airborne precautions isolation room (Siegel et al., 2007). Airborne precautions and standard precautions should be used (Siegel et al., 2007). Everyone entering the room must wear an N-95 respirator(CDC, 2024e; Siegel et al., 2007). A surgical mask is not sufficient protection!

Airborne precautions include:

1. Placement of the patient in an airborne infection isolation room. The door should be kept shut.
2. Staff and visitors must use an N-95 respirator.
3. Patients should cover their mouth when coughing or sneezing.
4. Patients leaving the room should wear a surgical mask (Zachary, 2024).

Linens and reusable medical equipment like blood pressure cuffs that come into contact with the skin are not considered infectious, but standard precautions are used when handling these items (Jensen et al., 2005). Procedures like bronchoscopy and obtaining a sputum sample should be done in the room, if possible (Zachary, 2024).

The N-95 respirator is a single-user, disposable item. The N-95 must be fit-tested to be effective, and the correct model and size must be used. Seal testing should be done each time the N-95 is used (NIOSH, 2023). The N-95 must be used if airborne precautions are in place. Surgical masks are discarded after one use, but an N-95 can be used more than once. Every healthcare facility and organization has guidelines for extended use of the N-95 and when to discard the N-95 and use a new one. Do not wash an N-95. Discard it if it is wet, dirty, damaged, or contaminated (NIOSH, 2023).

Follow these steps when putting on and taking off an N-95 (NIOSH, 2023): Wash hands, put on the N-95, and do a seal test. When finished, remove the N-95 and wash your hands.

Standard precautions include handwashing, the correct use of personal protective equipment (PPE), cough etiquette, proper handling of any items that could be contaminated, and sharps safety. The proper sequences for putting on and taking off PPE are listed below (CDC, n.d.).

Tuberculosis and antitubercular drugs can cause loss of appetite, nausea, vomiting, abdominal pain, and weight loss. This can result in poor nutrition. Poor nutrition in a patient with TB can weaken their immune system and increase the risk of activating latent TB (WHO, 2013). Notify the nurse if the patient is eating poorly, is losing weight, or has a loss of appetite.

Patients with uncomplicated TB can stay at home, depending on their living circumstances (Nardell, 2023). Patients, family members, and anyone who will have close contact with the patient should be instructed on TB transmission. Social contacts should be as limited as possible (Nardell, 2023). Proper cough etiquette should be used.

Healthcare workers who visit TB patients at their homes should take these precautions to protect themselves from exposure to TB:

• Instruct patients to cover their mouth and nose with a tissue when coughing or sneezing.
• Wear an N-95 when doing a home visit or when transporting a patient in a vehicle.
• If you need to collect a sputum specimen at the patient’s home, do the collection in a well-ventilated area, away from other household members; if possible, the specimen should be collected outdoors.

If you were exposed to TB or may have been exposed, do not decide by yourself the level of risk. Notify your supervisor as soon as you can. Testing for TB is done by a skin test or a blood test. Other tests, like a chest X-ray, can be done if needed (Nardell, 2023).

The TB vaccine is Bacillus Calmette-Guérin, aka BCG (CDC, 2024f; Nardell, 2023).

BCG is used in countries with a high prevalence of TB to prevent TB in children (CDC, 2024f; Nardell, 2023). BCG vaccine is rarely used in the US (CDC, 2024f; Nardell, 2023), and routine use of BCG for healthcare workers is not recommended.

The CNA is caring for a 27-year-old female who has latent TB and developed an active infection. Aside from TB, she is healthy and has no other medical problems. She is responding well to antitubercular drug therapy with no adverse effects. Her appetite has decreased a bit, and she has an occasional dry cough. Otherwise, she is well. The provider feels that after four weeks of treatment, she is no longer infectious, and she can be discharged and finish drug therapy at home.

At the beginning of the shift, the patient was feeling more tired than usual, and she had a headache. These are new, but the patient has no other complaints, and her temperature and other vital signs are normal. The CNA does not notify the nurse. Six hours later, the CNA notes that when she walks to the bathroom, the patient has difficulty breathing. This stops when she is back in bed, and her pulse oximetry is 98%. She is also drowsy and nodding off, but she wakes easily when spoken to and lightly touched. All her vital signs are normal.

The CNA notifies the nurse immediately and does so for these reasons:

1. The dyspnea (difficulty breathing) and the drowsiness are new, and a new sign/symptom should always be reported to the nurse.
2. Dyspnea indicates that the patient may not be getting sufficient oxygen. Also, ambulating a short distance and becoming dyspneic is not normal for an otherwise healthy 27-year-old.
3. Drowsiness can also be a sign of insufficient oxygen.
4. Finally, the drowsiness and dyspnea are new for this patient. Any new sign/symptom should be reported to the nurse, but some should be reported immediately.

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