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54 Cards in this Set

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Inflammation & excess of fluid of the lungs caused by infection
Pneumonia
Highest incidence: older adults, nursing home residents, hospitalized clients, &mechanically ventilated
Pneumonia
Pneumonia stats
 Hospital inpatient care
 Number of discharges: 1.2 million
 Average length of stay: 5.1 days
 Source: 2006 National Hospital Discharge Survey, Tables 2,4
 Mortality
 Number of deaths: 58,564
 Deaths per 100,000 population: 19.9
 Source/more data: Deaths: Final Data for 2004, Tables 10, 11
 Percent of hospital inpatient deaths from pneumonia: 5.4
 Source: National Hospital Discharge Survey: 2004 Annual Summary With Detailed Diagnosis and Procedure Data, Table 25
PNEUMONIA Causes infectious
 Infectious
 Bacteria
 Strep, Tb; Most common & serious in adults
 Virus
 (50%): very young: RSV
 Mycoplasma
 school age
 Fungi
 Pneumocystis carinii (PCP): found in AIDS pts
 Rickettsiae
 Protozoa
 helminths
Noninfectious agents Pneumonia causes
 Inhale-
 Toxic gases
 Chemicals
 Smoke
 Aspirate-
 Water
 Food
 Fluid
 Vomit
 Community acquired: more common; late fall & winter
 Strep. pneumoniae (+)
 Staph aureus (+)
 H. influenzae (-)
 Legionella pneumophila ((-)
 Mycoplasma pneumoniae
 Chlamydia pneumoniae (parasite)
 Hospital acquired (nosocomial): 20-50% mortality
More resistant to abx
 Staph. Aureus (+)
 Pseudomonas aeruginosa (-)
 Enterobacter (-)
 Klebsiella (-)
 H. influenzae (-)
 Acinetobacter (-)
 Candida (fungus)
Pneumonia Affects lungs in 2 ways
 Lobar
 Bronchial: scattered patches
Pathophysiology of Pneumonia
 Inflammation in interstitium, alveoli & bronchioles
 Fluid buildup
 WBC, RBC & fibrin
Complications of Pneumonia
 Septicemia
 Empyema
 Atelectasis
 Hypoxemia: PaO2 <80
 CHF
 Shock
 Dysrhythmias
 tissue necrosis
 Pleural effusion
 Pleurisy
 Ventilatory failure
Risk factors for pneumonia
 Older adult and very young
 No hx of pneumococcal or influenza vaccine
 Chronic or coexisting condition
 COPD, DM, CHF, SCA, asthma
 Recent hx or exposure to viral or influenza infection
 Hx of tobacco or alcohol use
 Immunodeficiency: AIDS, organ transplant
Prevention of pneumonia
 Immunizations
 Pneumococcal: over age 65 & those high-risk
 Every 3-5 years
 http://www.cdc.gov/nip/publications/vis/vis-ppv.pdf
 Influenza Q year
 Hib (Haemophilus influenzae type b) vaccine: children
 http://www.cdc.gov/nip/publications/VIS/vis-hib.pdf
 Clean home respiratory equipment
 Wash hands frequently
Pneumonia prevention
 GI tubes: sterile water & aspiration precautions
 Avoid crowds (fall & winter)
 Avoid indoor pollutants & irritants: wear mask
 Avoid URTI and viruses
 Turn, cough, & deep breathe
 Don’t smoke & avoid 2nd hand smoke
Teaching r/t pneumonia
 Hospitalize infants & elderly
 Complete entire anti-infective therapy
 Call MD if: chills, fever, persistent cough, dyspnea, wheeze, hemoptysis, increased sputum production, chest discomfort, increased fatigue, not getting better
 Rest: gradually increase exercise & sleep
 Fever: ASA or acetaminophen
 Encourage rest, sleep, balanced diet & fluids
Important info to obtain in history
 Age
 Environments (living, work, school)
 Diet, exercise & sleep
 Swallowing, NG tube
 Tobacco, alcohol use
 Mx (past & current)
 Drug addiction IV drug use
 Recent & past illnesses
 Hx of rashes, insect bites, animal exposure
 Vaccinations
Pneumonia clinical presentation and manifestation
 general appearance
 flushed cheeks, bright eyes, anxious
 Chest or pleuritic pain/discomfort
 Myalgia, h/a, chills
 Fever, cough
 Tachycardia, dyspnea
 Tachypnea, sputum
Physical assesment of a pt with pneumonia will reveal...
 Breathing pattern, position & accessory muscle use
 Uncomfortable lying
 Auscultate: crackles, wheeze, bronchial BS
 Increased Tactile fremitus
 dull percussion
 Diminished or unequal chest expansion
 VS: hypotensive w/orthostatic changes
 Rapid, weak pulse; dysrhythmias
 Skin rash: Mycoplasm, CMV or Rocky Mountain spotted fever
pshychosocial assesment for pneumonia
 Face & shoulder muscle tension
 Speaks in broken sentences
 Nsg dx: anxiety r/t: pain, fatigue, dyspnea
 Interv: listen
 calm, slow assessment
 short interview
Laboratory findings in pneumonia
Pneum: Labs
 Sputum: GS, C&S
 Via: cough or Lukens tube
 CBC: ^ WBC (bacterial)
 Sepsis: BC & urine
 HIV
 ABG
 Serum electrolyte: hypernatremia
 ^BUN & creatinine
Radiographic findings and tests
 CXR: increased density
 Early diagnoses for elderly d/t vague sx
Other invasive dx procedures
 Pulse oximetry
 Transtracheal aspiration
 Bronchoscopy
 Direct needle aspiration of lung: pleural fluid cx
 Thoracentesis
Collaborative management
 Pneumonia Nursing interventions: (Chart 34-5)
 Impaired gas exchange
 Ineffective Airway clearance
 Acute pain
 Deficient fluid volume
 Disturbed sleep Pattern
 Potential for Pleural Effusion
I
Impaired Gas Exchange:
 Same as CAL interventions
 Hypoxemia is the primary problem
 Incentive spirometry
 Fluid hydration
Ineffective Airway Clearance:
 Cough & deep breathe Q 2hrs
• Incentive spirometer
• Adequate hydration, I&O
• Bronchodilators for bronchospasm
• Nebulizer then MDI
• Steroids only for bronchial asthma or respiratory failure
Potential for sepsis
• Based on organism & risk factors
• CAP
• 7-10 days
• 21 days if immunocompromised
• IV to PO therapy in 2-3 dys
• Drug-resistant S.pneumoniae (DRSP)
• >65 years, exposure from day-care children
• If acidic aspiration: Steroids, NSAIDS & Abx
Home care management
• 1st floor for a few weeks
• BSC
• Home care needs (Chart 34-6)
• Fatigue, weakness, and residual cough: can last for weeks
Health Care resources
 Smoke cessation
 American Lung Association (ALA) http://www.lungnc.org
 American Cancer Society (ACS) www.cancer.org
 Nicotine patches & smoke = risk MI
 Information booklets
 Vaccinations when well
Severe Acute Respiratory Syndrome (SARS)
 Coronavirus
 Looks like a halo or “corona”
 1st reported in China Feb 2003
 WHO: 8,098 worldwide outbreak; 774 died
 U.S: 8 people with evidence of infection
Symptoms of SARS
 Begins with high fever (>100.4F)
 H/a, feeling of discomfort, body aches
 10-20% diarrhea
 2-7 days: dry cough
 Most develop pneumonia
Spreading SARS
 Respiratory droplets (airborne)
 Mouth, nose, eyes
 Close contact: direct contact with secretions; kiss, hug, sharing food/drink, talking within 3 feet
 Indirect contact; does not survive long on nonliving surfaces
 http://www.cdc.gov/ncidod/sars/faq.htm
Treatment of SARS
 Same as Community-acquired atypical pneumonia (CAP)
 http://www.who.int/csr/sars/en/index.html
Prevention of SARS
 Frequent handwashing or alcohol-based rub
 Avoid touching eyes, nose & mouth
PULMONARY TUBERCULOSIS
 Highly communicable bacterial infection
 Mycobacterium tuberuclosis: nonmoving, slow-growing, acid-fast rod
 Droplet Transmission: cough, laugh, sneeze, whistle, sing
 Metastasis: brain, meninges, liver, kidney, bone marrow
 Via: lymph or blood
 If infected, 5-15% develop active TB
Pulmonary TB
 Positive PPD test: 2-10 weeks p infection
 Asymptomatic pd: p infection for years ->decades before sx
 Not infectious unless have manifestations
 Secondary TB/reactivation
 http://www.textbookofbacteriology.net/tuberculosis.html
Those at Risk
 HIV negative in 1st 2 years p infection, elderly
 Risk reduces with 2-3 weeks of mx
 Frequent contact with untreated, infected person
 Live in crowded areas: LTC & mental health facilities, prisons
 Elderly, homeless
 Abuser or injection drugs or alcohol
 Low socioeconomic
 Foreign immigrants (Mexico, Philippines, Vietnam)
TB assessment history
 Early detection is subjective
 ?Dx if: persistent cough, weight loss, anorexia, night sweats, hemoptysis, SOB, fever or chills
 Past exposure to TB
 Country of origin & travel
 Results of previous TB test
 Bacillus Calmette-Guerin (BCG) vaccine
TB manifestations
 progressive fatigue, lethargy
 nausea, anorexia, weight loss
 irregular menses
 and low-grade fever, night sweats
 Cough (with dull, aching CP),
 mucopurulent or streaked blood sputum
 chest tightness
TB physical exam
 Percussion: dull
 Bronchial breath sounds, crackles
 Wheezing from obstruction
 CXR: caseation necrosis (Ghon tubercle or primary lesion)
TB diagnostics
 manifestations & + smear for acid-fast bacillus: screening
 sputum cx of M. tuberculosis: definitive
 BACTEC
 Polymerase chain reaction (PCR)
 Tuberculin test (Mantoux test)
 If +: CXR
 High risks are screened yearly
Positive PPD test
 http://www.med.ucla.edu/modules/wfsection/article.php?articleid=144
TB nursing diagnoses
 Impaired gas exchange
 Ineffective airway clearance
 Deficient knowledge
 Fatigue
 Imbalanced nutrition: less than body requirements
 Social isolation
TB drug therapy
 Combination drug therapy: chart 34-7
 *Isoniazid (INH)
 *Rifampin (RIF)
 Pyrazinamide (PZA)
 Ethambutol
 Streptomycin (SM)
TB interventions
 Sputum samples used for therapy effectiveness (Q2-4wks).
 Become negative p 3 mos of tx
 no longer infectious p 3 negative cx’s
 Strict adherence to suppress & avoid drug resistance
 Test all members of household
 Cover mouth & nose when cough or sneeze
 Tissues in plastic bags
 Wear mask in crowds
TB interventions
 Avoid inhalation irritants
 Hospitalized with active TB
 Airborne & standard precautions
 N95 or high-efficiency particulate air (HEPA) respirator
 Nausea: take mx @HS; antiemetics
 Well-balanced diet: iron, protein, Vit C
TB teaching
 Drug regimen & controlling side effects
 Directly observed therapy (DOT)
 Gradually resume activities
 Nutrition
 Test those in close contact
 High-risk contacts: prophylactic therapy (INH)
TB resources
 http://www.cdc.gov/nchstp/tb/faqs/qa.htm
 American Lung Association: http://www.lungusa.org
 NIH: http://www.pbs.org/ppol/ala.html
 Alcoholics Anonymous (AA)
 Smoking-cessation or drug tx program
LUNG ABSCESS
 Localized area of lung destruction c/b liquefaction necrosis
 At risk:
 TB, fungal infection of lung, immunosuppressed, chemotherapy, (leukemia or AIDS pts)
 Hx of pneumonia, aspiration or obstruction
 Common organisms:
 anaerobic, Staph (gram-positive), gram-negative, opportunistic infections (fungi)
Lung abscess Assessment
 Recent hx: influenza, pneumonia, febrile illness, cough, foul-smelling sputum
 Sputum
 Pleuritic chest pain: stabbing with deep breath
 Pale, fatigue, cachectic
 Decreased BS, dull percussion
 Bronchial BS & crackles over site
Lung Abscess interventions
 Dx: CXR & sputum cx
 Mgt: Antibiotics & Drain abscess
 Frequent mouth care
 Prevent Candida albicans
INHALATION ANTHRAX
 Bacterial infection of gram-positive, rod-shaped Bacillus anthracis
 In contaminated soil
 Via skin, intestinal tract or lungs (not person-person)
 Inhalation fatality rate of 100% without tx
 Can metastasize via nodes & blood -> sepsis & meningitis
 Etiology: http://www.mayoclinic.com/print/anthrax/DS00422/DSECTION=all&METHOD=print
Inhalation Anthrax: 2 stages
 Manifestations my begin 8 weeks p exposure
 Prodromal stage: nonspecific
 Fever, fatigue, mild CP, dry, harsh cough
 No URI or manifestations
 Sx improve in 2-4 days
 Fulminant stage: begins p feels better
 Sudden onset of breathlessness
 Rapid progression to severe respiratory distress
 Leads to:
 high fever->mediastinitis & pleural effusions, septic shock, meningitis
Inhalation Anthrax: Diagnostics
 Prodromal stage: Survival high with abx therapy
 WBC: elevated (band neutrophils)
 Serum: + Gram stain
 CXR: mediastinal widening
 BC: +
 Polymerase chain reaction (PCR)
 Fulminant stage: Death within 24-36 hrs after onset even with abx
 Can do more definitive tests
Inhalation anthrax interventions
 Combination therapy (Chart 34-9)
 Ciprofloxacin
 Doxycycline
 Amoxicillin
 Prophylactic: PO form
PULMONARY EMPYEMA
• Infection & pus accumulation in pleural space
• Risk Factors:
• Bacterial pneumonia
• Lung, liver, abdominal abscess
• infected pleural effusion
• thoracic surgery or chest trauma
• Rarely thoracentesis
Pulmonary empyema symptoms
• Dry cough
• Fever & chills, Excessive sweating (night)
• General discomfort, uneasiness, or ill feeling (malaise)
• Weight loss
• PMI displaced & hypotensive
• CP: worse on deep inspiration
Pulmonary Empyema Assessment
• Recent hx: febrile illness, CP, dyspnea, cough & trauma
• Sputum: thick, opaque, exudative, foul smell
• Reduced Chest expansion
• If pleural effusion:
• Decreased to absent fremitus
• Flat percussion
• Decreased BS
• BBS, egophony, whispered pectoriloquy
Pulmonary Empyema diagnostics
• CXR
• Thoracentesis: pleural fluid
• Pleural fluid CS & CX
Pulmonary empyema Interventions
• Empty empyema, reexpand lungs, control infection
• Antibiotics
• Closed-chest drainage
• Decortication or Open thoracotomy: pleura removal
• Nsg: same as pleural effusion, pneumothorax or infection