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54 Cards in this Set
- Front
- Back
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Inflammation & excess of fluid of the lungs caused by infection
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Pneumonia
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Highest incidence: older adults, nursing home residents, hospitalized clients, &mechanically ventilated
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Pneumonia
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Pneumonia stats
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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 |
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PNEUMONIA Causes infectious
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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 |
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Noninfectious agents Pneumonia causes
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Inhale-
Toxic gases Chemicals Smoke Aspirate- Water Food Fluid Vomit |
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Community acquired: more common; late fall & winter
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Strep. pneumoniae (+)
Staph aureus (+) H. influenzae (-) Legionella pneumophila ((-) Mycoplasma pneumoniae Chlamydia pneumoniae (parasite) |
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Hospital acquired (nosocomial): 20-50% mortality
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More resistant to abx
Staph. Aureus (+) Pseudomonas aeruginosa (-) Enterobacter (-) Klebsiella (-) H. influenzae (-) Acinetobacter (-) Candida (fungus) |
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Pneumonia Affects lungs in 2 ways
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Lobar
Bronchial: scattered patches |
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Pathophysiology of Pneumonia
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Inflammation in interstitium, alveoli & bronchioles
Fluid buildup WBC, RBC & fibrin |
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Complications of Pneumonia
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Septicemia
Empyema Atelectasis Hypoxemia: PaO2 <80 CHF Shock Dysrhythmias tissue necrosis Pleural effusion Pleurisy Ventilatory failure |
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Risk factors for pneumonia
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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 |
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Prevention of pneumonia
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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 |
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Teaching r/t pneumonia
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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 |
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Important info to obtain in history
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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 |
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Pneumonia clinical presentation and manifestation
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general appearance
flushed cheeks, bright eyes, anxious Chest or pleuritic pain/discomfort Myalgia, h/a, chills Fever, cough Tachycardia, dyspnea Tachypnea, sputum |
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Physical assesment of a pt with pneumonia will reveal...
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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 |
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pshychosocial assesment for pneumonia
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Face & shoulder muscle tension
Speaks in broken sentences Nsg dx: anxiety r/t: pain, fatigue, dyspnea Interv: listen calm, slow assessment short interview |
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Laboratory findings in pneumonia
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Pneum: Labs
Sputum: GS, C&S Via: cough or Lukens tube CBC: ^ WBC (bacterial) Sepsis: BC & urine HIV ABG Serum electrolyte: hypernatremia ^BUN & creatinine |
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Radiographic findings and tests
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CXR: increased density
Early diagnoses for elderly d/t vague sx |
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Other invasive dx procedures
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Pulse oximetry
Transtracheal aspiration Bronchoscopy Direct needle aspiration of lung: pleural fluid cx Thoracentesis |
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Collaborative management
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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 |
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Impaired Gas Exchange:
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Same as CAL interventions
Hypoxemia is the primary problem Incentive spirometry Fluid hydration |
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Ineffective Airway Clearance:
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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 |
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Potential for sepsis
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• 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 |
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Home care management
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• 1st floor for a few weeks
• BSC • Home care needs (Chart 34-6) • Fatigue, weakness, and residual cough: can last for weeks |
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Health Care resources
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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 |
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Severe Acute Respiratory Syndrome (SARS)
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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 |
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Symptoms of SARS
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Begins with high fever (>100.4F)
H/a, feeling of discomfort, body aches 10-20% diarrhea 2-7 days: dry cough Most develop pneumonia |
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Spreading SARS
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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 |
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Treatment of SARS
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Same as Community-acquired atypical pneumonia (CAP)
http://www.who.int/csr/sars/en/index.html |
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Prevention of SARS
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Frequent handwashing or alcohol-based rub
Avoid touching eyes, nose & mouth |
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PULMONARY TUBERCULOSIS
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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 |
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Pulmonary TB
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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 |
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Those at Risk
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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) |
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TB assessment history
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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 |
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TB manifestations
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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 |
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TB physical exam
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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 |
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TB nursing diagnoses
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Impaired gas exchange
Ineffective airway clearance Deficient knowledge Fatigue Imbalanced nutrition: less than body requirements Social isolation |
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TB drug therapy
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Combination drug therapy: chart 34-7
*Isoniazid (INH) *Rifampin (RIF) Pyrazinamide (PZA) Ethambutol Streptomycin (SM) |
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TB interventions
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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 |
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TB teaching
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Drug regimen & controlling side effects
Directly observed therapy (DOT) Gradually resume activities Nutrition Test those in close contact High-risk contacts: prophylactic therapy (INH) |
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TB resources
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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 |
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LUNG ABSCESS
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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) |
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Lung abscess Assessment
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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 |
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Lung Abscess interventions
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Dx: CXR & sputum cx
Mgt: Antibiotics & Drain abscess Frequent mouth care Prevent Candida albicans |
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INHALATION ANTHRAX
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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 |
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Inhalation Anthrax: 2 stages
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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 |
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Inhalation Anthrax: Diagnostics
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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 |
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Inhalation anthrax interventions
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Combination therapy (Chart 34-9)
Ciprofloxacin Doxycycline Amoxicillin Prophylactic: PO form |
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PULMONARY EMPYEMA
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• Infection & pus accumulation in pleural space
• Risk Factors: • Bacterial pneumonia • Lung, liver, abdominal abscess • infected pleural effusion • thoracic surgery or chest trauma • Rarely thoracentesis |
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Pulmonary empyema symptoms
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• Dry cough
• Fever & chills, Excessive sweating (night) • General discomfort, uneasiness, or ill feeling (malaise) • Weight loss • PMI displaced & hypotensive • CP: worse on deep inspiration |
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Pulmonary Empyema Assessment
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• 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 |
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Pulmonary Empyema diagnostics
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• CXR
• Thoracentesis: pleural fluid • Pleural fluid CS & CX |
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Pulmonary empyema Interventions
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• Empty empyema, reexpand lungs, control infection
• Antibiotics • Closed-chest drainage • Decortication or Open thoracotomy: pleura removal • Nsg: same as pleural effusion, pneumothorax or infection |
