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25 Cards in this Set
- Front
- Back
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Pneumonia (pneumonitis)-Acute inflammation of the lung
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Lower respiratory tract
Incidence: 4,000,000 cases in the U.S. per year. Attack rate of 12 per 1000 adults. Continues to be a major health problem in the U.S. -Seventh leading cause of death (CDC, 2003) |
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Classifications: CAP-Community Acquired Pneumonia
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Onset in the community or first two days in the hospital
Four categories based on severity |
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Classifications: HAP-Hospital Acquired Pneumonia
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Nosocomial pneumonia that occurs 48 hours or more after admission to hospital
Three groups based on severity and risk factors |
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Risk Factors
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#1 SMOKING
Air Pollution Altered consciousness - aspiration Tracheal intubation Upper respiratory tract infections Chronic diseases Immunosuppression, (HIV, immunosuppressive drugs) Malnutrition Inhalation or aspiration of substances Debilitating illness Bedrest/Prolonged immobility Altered oropharyngeal flora Intestinal and gastric feedings (aspiration) |
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Types of Pneumonia
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Community Acquired
Organism identified only 50% of the time Hospital Acquired Usually bacterial 2nd most common hospital acquired infection |
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Etiology Infectious agent (organisms)
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Aspiration of foreign matter
Inhalation of infected aerosols, chemicals, gas Hematogenous spread from a primary infection (ie. Staph aureus) Fungal Increasing in incidence, very ill, immunosuppressed Opportunistic Pneumocystis Carinii CMV |
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Pathophysiology
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Congestion
Red hepatization Gray hepatization Resolution |
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Causative Agents
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Bacterial
Gram+: Pneumococcus (most common community acquired pneumonia), Staphylococcus, Enterococcus Gram-: E. Coli, Pseudomonas, Enterobacter, Klebsiella Viral CMV (cytomegalovirus-1/2 of all viral pneumonias), Influenza Note: same causative agents 2 names: pneumococcus=streptococcus pneumoni |
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Detailed Pathophysiology
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Aspiration of S. pneumoniae
Release of bacterial endotoxin Inflammatory Response: Attraction of neutrophils; release of inflammatory mediators; accumulation of fibrinous exudate, red blood cells, and bacteria Red hepatization and consolidation of lung parenchyma Leukocyte infiltration (neutrophils and macrophages) Gray hepatization and deposition of fibrin on pleural surfaces; phagocytosis in alveoli Resolution of infection: macrophages in alveoli ingest and remove degenerated neutrophils, fibrin, and bacteria |
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Causative Agents: Fungal
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Fungal
Aspergillas Candida PCP (Pneumocystis Carinii) Mycoplasma (walking pneumonia) characteristics of both bacteria and viruses (treated like a bacteria with antibiotics) |
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Manifestations
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May have one or more of the following:
Fever, chills, sweats Pleuritic chest pain vs Cardiac pain take a deep breath if it hurts rule out cardiac Sputum: hemoptysis or purulent green/yellow sputum Headache, weakness, malaise Dyspnea, tachycardia, tachypnea Older Adults may only show signs of Altered Mental Status fatigue and purulent sputum CAP (nonbacterial): may have only a severe, dry hacking cough and fine rales on auscultation |
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"Typical" Clinical Pattern (usually bacterial)
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Sudden onset - rigor (shaking chills, febrile, bacteremia
fever productive cough leukocytosis pleuritic pain Usually bacterial Legionella can have either a typical or atypical pattern |
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"Atypicals" Clinical Pattern (generally viral)
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Mycoplasma, Chlamydia, Legionella, viral
VIRAL-LIKE ILLNESS - fevers (usually without rigors), myalgias and headache URI symptoms but appear less ill (dry cough) dry nonproductive cough, minimal adventitious lung sounds Little elevation in white blood cell count |
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Diagnostic Studies
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History and Physical Exam
Sputum for gram Stain and C&S CXR ABG's CBC Blood cultures SaO2 |
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Prompt Treatment
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Prompt initiation of effective antibiotics decreases mortality (treat within 4 hours)
90% of admitted patients respond promptly to empiric therapy (based on experience not scientific evidence) Treatment must include therapy against "atypical organisms". |
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PORT: Patient Outcome Research Team
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This is how antibiotic is chosen and how long hospital stay will be
Study 1991 38,000 inpatients |
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Collaborative Care
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Antibiotics
Increased fluid intake (3 liters) Limited activity and rest Antipyretics Analgesics Oxygen |
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Management: CAP
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Macrolide Antibiotics or Doxycycline
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Management: HAP
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Cyclosporins
Aminoglycosides |
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Management
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Treatments (suction, chest PT)
Medications (IV Fluids, Antibiotics) Consultations: Respiratory, Nutritional Monitoring: VS, I&O, WBC Nutrition: 1500 kcal Safety: elevate HOB 30° Teaching: TCDB, frequent rest periods |
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Things to remember
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Clinical improvement should be seen within 72 hours
If not consider: CHF, PE, Ca, airway obstruction, ARDS, hemorrhage, drug reaction, interstitial disease, resistant organism, TB, inadequate host response Change to PO antibiotics when patient has clinically improved within 72 hours CXR's clear VERY SLOWLY-it takes weeks to months. Wait 6 weeks for follow-up CXR unless there is clinical deterioration. |
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Complications
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Pleurisy: inflammation of the pleura
Pleural effusion (1 to 2 weeks to go away) Atelectasis: clear with effective cough and deep breathing Delayed resolution: 3-4 weeks Lung abscess: very uncommon |
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Complications
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Empyema: fluid/pus in the pleural space
Pericarditis Arthritis: organism spreads to joints, treatment with antibiotics should resolve Meningitis Endocarditis |
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Risk factors for a complicated course (consider hospitalization)
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*age >65 yrs
Comorbid Disease: COPD, bronchiectasis, diabetes, cancer, renal failure, CHF, chronic liver disease, ETOH abuse, malnutrition, hospitalization in the prior year, splenectomy |
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Prevention (<65 yrs recovering from chronic illness)
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Pneumococcal Vaccine: lifetime immunity. However, booster may be given q 5 years for immunosuppressed clients.
Guideline: Over 65 years old Chronic illness such as heart or lung disease and DM Recovering from severe illness Lives in nursing home or long-term care facility |
