Medical 5-Ms34-Pneumonia

Front 1

Define pneumonia?

infectious organisms
inhalation of irritating
agents

Back 1

an excess of fluid in lungs resulting from inflammatory process...inflammation is triggered by what two things?

Front 2

The two classifications of pneumonia are?

community acquired pneumonias and CAPs are more common than nosocomia

Back 2

community-acquired (CAP)
hospital acquired (nosocomial)

which of these two are more likely to resist antibiotics?

Front 3

What is the pathophysiology of pneumonia?
What 3 places does the inflammation occur in?

alveolar...to do this, the organisms must beat the body's defense system, including inflammatory response...wbcs migrate to area of infection, causing capillary leak, edema, exudate...these fluids collect in and around?

sepsis...and if the infection extends into the pleural cavity, what results?

vital capacity...atelectasis (alveolar collapse) further reduces the ability of lungs to oxygenate the blood moving through it...as a result, arterial oxygen tension falls, causing what?

Back 3

interstitial spaces
alveoli
bronchioles

the process begins when organisms penetrate airway mucosa and multiply in which spaces?

alveoli, causing alveoli walls to thicken...both events reduce gas exchange and lead to hypoxemia...rbcs and fibrin also move into alveoli...the capillary leak spreads the infection to other areas of the lung...if the organisms move into the bloodstream, what results?

empyema...the fibrin and edema of inflammation stiffen the lung, reducing compliance and decreasing?

hypoxemia (insufficient oxygen in blood)

Front 4

Pneumonia may occur as what two things?

Back 4

#1 lobar pneumonia with consolidation (which is solidification, lack of air spaces) in a segment..
<lobar pneumonia are the large lobes...if more than one large lobe in both lungs are affected, then there may be double pneumonia (bilteral pneumonia)>

#2 bronchopneumonia with diffusely scattered patches around the bronchi
<this is a LOBULAR pneumonia and this is at the terminal bronchials...the lobulars become clogged with purulent exudate and they form consolidated patches in nearby lobules in bronchioles and alveolar sacs>

Front 5

Tissue necrosis results when?

Back 5

organisms form an abscess that perforates bronchial wall

Front 6

<Pneumonia is caused by?

Back 6

<inflammatory process of lung parenchyma...
often caused by aspiration of oropharyngeal secretions..
types of pneumonia depend on agent and location...
responsible for 10% of hospital admissions...
risk increases with infants, elderly and poor respiratory function>

bacteria
viruses
mycoplasmas
fungi
rickettsiae
protozoa
helminths (worms)

noninfectious causes:
inhalation toxic gases
chemicals
smoke
aspiration of water, food,
fluid, vomitus>

Front 7

<Hospital acquired pneumonia is what percentage mortality rate?

<keep turning, continue deep breathing, particularly after anesthetic because mortality from hospitalized pneumonia is very high>

Back 7

20-50%...and it's higher for patients with complications...and that's why it's important to do what with patients?>

Front 8

<What types of pneumonias are there (4)?

Back 8

lobar pneumonia
broncopneumonia (lobular
pneumonia)
interstitial pneumonia
viral pneumonia>

Front 9

Pneumonia is what percentage cause of death in US?

Back 9

5th leading cause

Front 10

Pneumonia occurs in late fall and winter as a complication of?

Back 10

influenza

Front 11

Nosocomial pneumonia has what percentage of mortality?

Pseudomonas aeruginosa
Acinetobacter
other "high-risk" organisms
secondary bacteremia

Back 11

20% to 50%...and the highest incidence is in those infected with which 2 organisms plus?

Front 12

Pneumonia and influenza are what percentage cause of death for clients older than 85yo?

Back 12

third leading cause

Front 13

<Pneumonias are typed depending on their?

Back 13

location?>

Front 14

What is lobar pneumonia?

Back 14

lobar pneumonia with consolidation (which is solidification, lack of air spaces) in a segment..
<lobar pneumonia are the large lobes...if more than one large lobe in both lungs are affected, then there may be double pneumonia (bilteral pneumonia)>

Front 15

What is lobular pneumonia?

Back 15

#2 bronchopneumonia with diffusely scattered patches around the bronchi
<this is a LOBULAR pneumonia and this is at the terminal bronchials...the lobulars become clogged with purulent exudate and they form consolidated patches in nearby lobules in bronchioles and alveolar sacs>

Front 16

<What is interstitial pneumonia?

Back 16

<confined to alveolar walls and the peribronchial or interlobular tissues>

Front 17

<Define viral pneumonia?

type A...people that have viral pneumonias are more susceptible to?

Back 17

<more frequent than bacterial pneumonias..which influenza is the most common cause of viral pneumonia?

bacterial pneumonias, esp. the elderly>

Front 18

<Define what age mycoplasma pneumonia occurs in?

Back 18

<more common in children that are 5-12 yo>

Front 19

<What are the characteristics of mycoplasma pneumonia?

Back 19

<group of bacteria that actually lack cell walls...they have many shapes>

Front 20

<When does mycoplasma pneumonia occur?

((-myco is muscle)))

Back 20

fall and winter and is more prevalent in crowded situations>

Front 21

<What is the most common community acquired pneumonia?

viral infection...what ear condition can be acquired with bacterial pneumonia?

pulmonary embolism>

Back 21

<bacterial pneumonia...both adults and children acquire it...bacterial pneumonia usually follows a?

acute otitis media...what SERIOUS condition can occur with this type of pneumonia?

Front 22

<Pneumonias can also be caused by other things such as?

Back 22

<aspiration
fungus
rickettsia
protozoa
helminths (worms)>

Front 23

Atypical pneumonia is also known as?

Back 23

SARS which is severe acute respiratory syndrome

Front 24

<SARS or atypical pneumonia manifests itself as?

Back 24

low grade fever (greater than
100.4F)
headache
cough
shortness of breath
nonproductive cough after
2-7 days
dyspnea>

Front 25

<With atyical pneumonia and with other pneumonias, there can also be a tactile fremitus...which is?

Back 25

vibration or thrill felt while patient is speaking and hand is held against chest>

Front 26

<What is one of the most common manifestations of pneumonia in an older adult?

Back 26

<CONFUSION...because they breathe shallowly and the patient may not be coughing if there's a deep pneumonia...the shallow breathing leads to hypoxemia which leads to confusion>

Front 27

<SARS is diagnosed with what positive test?

21 days...it's treated with (3)?

Back 27

<a positive corona virus antibody...when does it usually show up after illness begins?

antibiotics
antiviral drugs
steroids (with mixed results)>

Front 28

What are nursing considerations for SARS?

Back 28

wear mask...
use strict handwashing techniques...
use contact and airborne
precautions>

Front 29

<What precautions should healthcare workers that are at high risk if they've had unprotected exposure to someone that's been diagnosed with SARS take?

Back 29

<don't go to work and monitor health for 10 days before coming back to work>

Front 30

<A 75yo patient is admitted to hospital with acute cholecystitis...underwent open cholecystectomy and is one day postop...has an NGT to continuous low wall suction...a Foley in place...one peripheral IV...large abdominal dressing...history of emphysema

His orders include?
D5 1/2 NS with KCL 20 mEq/L
at 125 cc/hr
morphine 5 mg IV q2h prn pain
incentive spirometry q2h
while awake
02 @ 2L/min per nasal cannula

VS are?
T100.4
P88
R26
B/P 138/70

What are the factors here that place him at risk for pneumonia?>

Back 30

<age 75yo
immobility
history of emphysema
post surgery...any surgery puts a patient at risk for pneumonia because anesthesia paralyzes cilia so patient can't bring up secretions...so immobility allows secretions to lie there...be SURE to turn, cough, and deep breathe after surgery...and ANY immobile patient every 2 hours if no limitations...check doctors orders FIRST!

(an NGT MIGHT cause pneumonia if it's placed wrong and patient ASPIRATES)..but this scenario DOES NOT say patient has a problem with NGT>

Front 31

<How does surgery put patient at risk for pneumonia?

Back 31

<post surgery...any surgery puts a patient at risk for pneumonia because anesthesia paralyzes cilia so patient can't bring up secretions...so immobility allows secretions to lie there...be SURE to turn, cough, and deep breathe after surgery...and ANY immobile patient every 2 hours if no limitations...check doctors orders FIRST!>

Front 32

Why might an NG tube put patient at risk for pneumonia?>

Back 32

(an NGT MIGHT cause pneumonia if it's placed wrong and patient ASPIRATES)..but this scenario DOES NOT say patient has a problem with NGT>

Front 33

<What is significant for a temperature of 100.4 and how does it put patient at risk for pneumonia?

Back 33

<

Front 34

How does aspiration sometimes cause pneumonia?
(online source)

Back 34

Sometimes the normally harmless bacteria present in the mouth may be aspirated into the lungs, usually if the gag reflex is suppressed.

Front 35

What is the relationship between infections in the body and pneumonia?
(online source)

Back 35

Pneumonia may also be caused from infections that spread to the lungs through the bloodstream from other organs.

Front 36

How do cilia protect the lungs from microorganisms which can cause pneumonia?
(online source)

Back 36

Tiny organisms that are able to reach the bronchioles are trapped in a mucous blanket and are then moved up and out of the lungs by the beating movements of tiny hair-like cells called cilia, a mechanism known as the mucociliary escalator.

Front 37

How do macrophages protect the lungs from contracting pneumonia?
(online source)

Back 37

Bacteria or other infectious agents that evade the airway defense system are attacked in the alveolar sacs by defenders from the body's immune system, particularly macrophages, large white blood cells that literally eat foreign particles.

Front 38

How does the nose and sneezing reflex defend the body against microorganisms that can cause pneumonia?(online source)

Back 38

Large particles are first filtered out in the nasal passage.
When smaller particles are inhaled, sensors along the airways trigger coughing or sneezing reflexes, which force many particles to back out.

Front 39

What is the anatomy of the lungs?
(online source)

Back 39

The lungs are two spongy organs surrounded by a thin, moist membrane called the pleura. They are the largest organs in our body. Each lung is composed of smooth, shiny lobes; the right lung has three lobes and the left has two. Approximately 90% of the lung is filled with air and only 10% is solid tissue.

When a person inhales, air travels through the following pathways into the lungs.
Air is carried from the trachea (the windpipe) into the lung through flexible airways called bronchi.
Like the branches of a tree, bronchi divide successively into over a million smaller airways called bronchioles.

The bronchioles lead to grape-like clusters of microscopic sacs called alveoli.

In each lung of an adult there are millions of these tiny alveoli, which are composed of a thin membrane through which oxygen and carbon dioxide pass to and from capillaries.

During deep inhalation, the elastic alveoli unfold and unwind to allow this passage to occur.
Capillaries, the smallest of our blood vessels, carry blood throughout the body.


Red blood cells contain factors that fight pollutants; white blood cells are the critical infection fighters in our body.

Front 40

Which microorganism is a majjor cause of nosocomial infections?
(online source)

Back 40

Pseudomonas aeruginosa is a major cause of pneumonia that occurs in the hospital (nosocomial pneumonia). It is common in pneumonia patients with chronic or severe lung disease.

Front 41

What are atypical pneumonias generally caused by?
(online source)

Back 41

Atypical pneumonias are generally caused by tiny nonbacterial organisms called Mycoplasma or Chlamydia pneumoniae and produce mild symptoms with a dry cough. Hospitalization is uncommon with pneumonia from these organisms.

Front 42

Define Mycoplasma pneumoniae?
(online source)

Back 42

Mycoplasma pneumoniae ( M. pneumoniae ) is the most common nonbacterial pneumonia. Mycoplasma is a very small organism that lacks a cell wall. It spreads from prolonged, close contact and is most often found in school-aged children and young adults. The condition is usually mild and is commonly known as walking pneumonia. Estimates of its prevalence in community acquired pneumonias in adults range from 1.9% to 30%. In one study, it accounted for over a third of pneumonia cases in children.

Front 43

Which viruses can cause or lead to pneumonia?
(online source)

Back 43

Viruses that can cause or lead to pneumonia include influenza, respiratory syncytial virus (RSV), herpes simplex virus, varicella-zoster (the cause of chicken pox), and adenovirus. Outbreaks usually occur between January and April.
Influenza is associated with pneumonia directly or by altering the mucous blanket and making a person susceptible to bacterial pneumonia.

Front 44

What age group is affected by RSV?
(online source)

Back 44

Respiratory syncytial virus (RSV) is a major cause of pneumonia in infants and people with damaged immune systems. Studies indicate that RSV pneumonia may also be more common than previously thought in adults, especially the elderly.

Front 45

What do anaerobic bacteria have to do with aspiration

Back 45

The mouth harbors a mixture of bacteria that is harmless in its normal location but can cause a serious condition called aspiration pneumonia if it reaches the lung. This can happen during periods of altered consciousness, often when a patient is affected by drugs or alcohol, or after head injury or anesthesia. In such cases, the gag reflex is diminished, allowing these bacteria to enter the airways to the lung. These organisms are generally different from the usual microbes that enter the lung by inhalation. Many are often anaerobic (meaning they can live in the absence of oxygen).

Front 46

aa

Back 46

Occupational and Regional Pneumonias
A number of people are exposed to pneumonia-causing organisms specific to particular occupations or regions.
Workers exposed to cattle, pigs, sheep, and horses are at risk for pneumonia caused by anthrax, brucellosis, and Q fever.

Agricultural and construction workers in the Southwest are at risk for coccidioidomycosis, and those working in Ohio and the Mississippi Valley are at risk for histoplasmosis.

Workers exposed to pigeons, parrots, parakeets, and turkeys are at risk for psittacosis.
Exposure to chemicals can also cause inflammation and pneumonia.

Hantavirus causes a dangerous form of lung disease and is carried by rodents, but is still rare. It does not appear to be contagious; cases have occurred in New Mexico, Arizona, California, Washington, and Mexico.
People in the southwest are also exposed to the fungus Coccidioides immitis , the cause of Valley fever, which is a lung infection that can cause pneumonia in susceptible individuals.

Front 47

jgm

Back 47

WHAT ARE THE SYMPTOMS OF PNEUMONIA?

Symptoms of Common Pneumonias

General Symptoms.
The symptoms of bacterial pneumonia develop abruptly and may include chest pain, fever, shaking, chills, shortness of breath, and rapid breathing and heart beat.


Symptoms of pneumonia indicating a medical emergency include high fever, a rapid heart rate, low blood pressure, bluish-skin, and mental confusion.


Coughing up sputum containing pus or blood is an indication of serious infection.


Severe abdominal pain may accompany pneumonia occurring in the lower lobes of the lung.


In advanced cases, the patient's skin may become bluish (cyanotic), breathing may become labored and heavy, and the patient may become confused.
Symptoms in the Elderly. It is important to note that older people may have fewer or different symptoms than younger people have. An elderly person who experiences even a minor cough and weakness for more than a day should seek medical help. Some may exhibit confusion, lethargy, and general deterioration.

Front 48

Symptoms of atypical pneumonia?
(online source)

Back 48

Atypical nonbacterial pneumonia is most commonly caused by Mycoplasma and usually appears in children and young adults.
Symptoms progress gradually, often beginning with general flu-like symptoms, such as fatigue, fever, weakness, headache, nasal discharge, sore throat, ear ache, and stomach and intestinal distress.
Vague pain under and around the breast bone may occur, but the severe chest pain associated with typical bacterial pneumonia is uncommon.
Patients may experience a severe hacking cough, but it usually does not produce sputum.

Front 49

Complications of pneumonia are abscesses...how are they formed?
(online source)

Back 49

Abscesses in the lung are thick-walled, pus-filled cavities that are formed when infection has destroyed lung tissue. They are frequently a result of aspiration pneumonia, when a mixture of organisms is carried into the lung. Abscesses can cause hemorrhage in the lung if untreated, but antibiotics that target specific anaerobic bacteria and other organisms have significantly reduced their danger. Abscesses are more common with Staphylococcus aureus or Klebsiella pneumoniae , and uncommon with Streptococcus pneumoniae .

Front 50

What is one of the most important causes of death in patients with pneumococcal pneumonia?
(online source)

Back 50

Respiratory failure is one of the most important causes of death in patients with pneumococcal pneumonia. Acute respiratory distress syndrome (ARDS) is the specific condition that occurs when the lungs are unable to function and oxygen is so severely reduced that the patient's life is at risk. Failure can occur from mechanical changes in the lungs caused by the pneumonia (called ventilatory failure) or from loss of oxygen in the arteries when pneumonia results in abnormal blood flow (called hypoxemic respiratory failure).

Front 51

Explain pleural effusions and empyema?
(online source)

Back 51

The pleura are two thin membranes:
The visceral pleura covers the lungs.
The parietal pleura covers the chest wall.
The narrow zone between these two pleural membranes normally contains a tiny amount of fluid that helps lubricate the lung. In about 20% of patients who are hospitalized for pneumonia, this fluid builds up around the lung.
In most cases, particularly in Streptococcus pneumoniae , the fluid remains sterile, but occasionally it can become infected and even filled with pus (a condition called empyema). Empyema sometimes occurs with Staphylococcus aureus or Klebsiella pneumoniae . The condition can cause permanent scarring. Pneumonia may also cause the pleura to become inflamed, which can result in breathlessness and acute pain.

Front 52

Explain collapsed lung as a complication of pneumonia?
(online source)

Back 52

Air may fill up the area between the pleural membranes causing pneumothorax, or collapsed lung. The condition can be a complication of pneumonia (particularly pneumococcal pneumonia) or of some of the invasive procedures used to treat pleural effusion.

Front 53

How does the spread of infection associated with pneumonia affect other organs?
(online source)

Back 53

In rare cases, infection may spread from the lungs to the heart and can even spread throughout the body, sometimes causing abscesses in the brain and other organs. Severe hemoptysis (coughing up blood) is another potentially serious complication of pneumonia, particularly in patients with other lung problems such as cystic fibrosis.

Front 54

Which conditions put hospitalized people at higher risk for pneumonia?
(online source)

Back 54

Surgery, particularly splenectomy or operations that impair coughing.
Being in the intensive care unit on mechanical ventilators. Ventilated patients who lie flat on their backs are at particular risk for aspiration pneumonia; raising the patient up may reduce this risk.
Hospitalized patients are particularly vulnerable to gram-negative bacteria and staphylococci, which can be very dangerous, particularly in people who are already ill

Front 55

What is the effect of smoking on cilia?
(online source)

Back 55

The risk for pneumonia in smokers of more than a pack a day is three times that of nonsmokers. Those who are chronically exposed to cigarette smoke, which can injure airways and damage the cilia, are also at risk. Quitting smoking reduces the risk of dying from pneumonia to normal, but the full benefit takes ten years to be realized. Toxic fumes, industrial smoke, and other air pollutants may also damage cilia function.

Front 56

How do alcohol and drugs put abusers at risk for pneumonia?
(online source)

Back 56

Alcohol or drug abuse is strongly associated with pneumonia. These substances act as sedatives and can diminish the reflexes that trigger coughing and sneezing. Alcohol also interferes with the actions of macrophages, the white blood cells that destroy bacteria and other microbes. Intravenous drug abusers are at risk for pneumonia from infections that originate at the injection site and spread through the blood stream.

Front 57

How do corticosteroids put patient at risk for pneumonia?
(online source)

Back 57

Patients who are on corticosteroid or other medications that suppress the immune system are also prone to infection.

Front 58

What type of COPD illnesses put patient at risk for pneumonia?
(online source)

Back 58

Chronic obstructive lung diseases, including chronic bronchitis and emphysema, are major risk factors for pneumonia.

Front 59

Children with the following illneses are at high risk for pneumonia?
(online source)

Back 59

Conditions that predispose infants and small children to pneumonia include the following:
Impaired immune system.
Gastroesophageal reflux disorder.
Inborn lung or heart defects.
Abnormalities in muscle coordination in the mouth and throat.
Asthma.

Front 60

What aspects of patient's medical history are important when diagnosing pneumonia?
(online source)

Back 60

recent or chronic respiratory infection,
exposure to people with pneumonia or other respiratory illnesses (such as tuberculosis),
history of smoking,
alcohol or drug abuse,
recent travel, and occupational risks.

(or anything else that impairs cilia activity)

Front 61

What is the most valuable tool in diagnosing pneumonia?
(online source)

Back 61

The most important diagnostic tool for pneumonia is the stethoscope. Sounds in the chest that may indicate pneumonia are the following:
Rales (a bubbling or crackling sound). Rales on one side of the chest and rales heard while the patient is lying down is strongly suggestive of pneumonia.


Rhonchi (abnormal rumblings indicating the presence of thick fluid).
Percussion. The physician will also use a test called percussion, in which he or she taps the chest lightly. A dull thud instead of a healthy hollow-drum-like sound, indicates certain condition that suggest pneumonia, including the following:
Consolidation (a condition, in which the lung becomes firm and inelastic).
Use of the Stethoscope. The most important diagnostic tool for pneumonia is the stethoscope. Sounds in the chest that may indicate pneumonia are the following:
Rales (a bubbling or crackling sound). Rales on one side of the chest and rales heard while the patient is lying down is strongly suggestive of pneumonia.


Rhonchi (abnormal rumblings indicating the presence of thick fluid).
Percussion. The physician will also use a test called percussion, in which he or she taps the chest lightly. A dull thud instead of a healthy hollow-drum-like sound, indicates certain condition that suggest pneumonia, including the following:
Consolidation (a condition, in which the lung becomes firm and inelastic).


Pleural effusion (fluid build-up in the space between the lungs and the lining around it).

Front 62

What is pleural effusion?

Back 62

fluid build-up in the space between the lungs and the lining around it

Front 63

What is consolidation?

Back 63

a condition, in which the lung becomes firm and inelastic

Front 64

What is a rale or crackle?

Back 64

Rales (a bubbling or crackling sound). Rales on one side of the chest and rales heard while the patient is lying down is strongly suggestive of pneumonia.

Front 65

What is a rhonchi?

Back 65

abnormal rumblings indicating the presence of thick fluid

Front 66

Why is it difficult to diagnose pneumonia in a hospitalized setting?
(online source)

Back 66

Diagnosing pneumonia is particularly difficult in hospitalized patients (called nosocomial pneumonia) for a number of reasons, including the following:
Many hospitalized patients have similar symptoms, including fever or signs of lung infiltration on x-rays.
In hospitalized patients, sputum or blood tests often indicate the presence of bacteria or other organisms, but such agents do not necessarily indicate pneumonia.

Front 67

Why is it necessary to use invasive diagnostic measures to identify an infecting agent that may cause pneumonia?
(onlline source)

Back 67

Unfortunately, people harbor many bacteria, and sputum and blood tests are not always effective in distinguishing between harmless and harmful microscopic agents. In severe cases, physicians particularly need to use invasive diagnostic measures to identify the infecting agent.

Front 68

How accurate is a urine test for identifying Streptococcus pneumonia?
(online source)

Back 68

A urine test (NOW) is up to 93% accurate in identifying S. pneumoniae within 15 minutes. However, a 2000 study indicated that it is not likely to be useful in diagnosing S. pneumoniae as a cause of pneumonia in children, since the organism is very common in the noses and throats of children. This organism, then, would very likely be picked up by the test even if it were not the cause of the pneumonia.

Front 69

What is the effective rate of sputum test when evaluating for cause of pneumonia and what are steps taken for acquiring sputum sample?
(online source)

Back 69

Only a sample of sputum coughed from the lungs will yield the infecting organism, and, even then, tests are not always successful in revealing the culprit. The following steps may be required:
The physician first asks the patient to cough as deeply as possible to produce an adequate sputum sample. A shallow cough produces a sample that usually only contains normal mouth bacteria.


A patient who is not able to cough sufficiently may be asked to inhale a saline spray that helps produce an adequate sputum sample.


In some cases, a tube will be inserted through the nose down into the lower respiratory tract to induce a deeper cough.

Even before sending the sample to the laboratory, the physician will check it for the following:
Presence of blood (an indication of infection).


Color and consistency. If the sputum is opaque and colored yellow, green, or brown, then infection is likely. Clear, white, glistening sputum indicates no infection.
In the laboratory, the sputum sample may be used as follows:
A Gram's stain is made, which may reveal the presence of bacteria and whether they are gram-negative or positive.


A sputum culture may be performed, in which organisms are grown in the laboratory.

Front 70

How are blood tests used to determine cause of pneumonia?
(online source)

Back 70

Blood tests may be used for the following:
White blood cell count. High levels indicate infection.
Blood cultures. They may be performed for detecting the specific organism causing the pneumonia, but are not often helpful in distinguishing harmful from harmless organisms. They are accurate in only 10% to 30% of cases, and their use should generally be limited to severe cases.

Detection of antibodies to S. pneumoniae. Researchers are using specialized techniques to detect antibodies to S. pneumoniae (immune factors that target specific foreign invaders), but it is not clear if they are accurate.

Front 71

What may CXR reveal about the cause of pneumonia?
(online source)

Back 71

A chest x-ray is nearly always taken to confirm a diagnosis of pneumonia. It may reveal the following:
White areas in the lung called infiltrates, which indicate infection.
Complications of pneumonia, including pleural effusions (fluid around the lungs) and abscesses.

Front 72

What are infiltrates?

Back 72

white areas found on CXR which indicate infection

Front 73

When is a lung biopsy required to ascertain pneumonia?
(online source)

Back 73

Lung Biopsy. In very severe cases of pneumonia or when the diagnosis is unclear in specific cases, particularly in patients with damaged immune systems, a lung biopsy may be required. Biopsies can be performed in one of two ways:
A Lung Tap. This procedure typically uses a needle inserted between the ribs to draw fluid out of the lung for analysis. It is known by a number of names including lung aspiration, lung puncture, thoracic puncture, transthoracic needle aspiration, percutaneous needle aspiration, and needle aspiration. It is a very old procedure that is not done often any more, particularly in children, since it is invasive and poses a slight risk for collapsed lung. Some experts argue, however, that a lung tap offers a more accurate solution than other methods for identifying bacteria and the risk it poses is slight. Given the increase in resistant bacteria, they believe its use should be reappraised in young people.

Front 74

When is a thoractomy performed to ascertain pneumonia?
(online source)

Back 74

Surgically (thoracotomy), using general anesthesia and an incision. This is used for diagnosis only in very severe cases. As with bronchoscopy, the procedure can also be used to treat the patient, removing damaging lung tissue and, in severe cases, removing the entire lobe (lobectomy). (In such cases, remaining lung tissue re-expands after surgery to compensate for any removed tissue.)

Front 75

When are CT scans and MRIs used in pneumonia cases?
(online source)

Back 75

Computed tomography (CT) scans or MRIs may be obtained in the following circumstances:
If x-ray results are unclear.
When patients do not respond to antibiotics.
When patients have complications.
When patients have other serious health problems.
These more sophisticated imaging techniques can help detect the presence of tissue damage, abscesses, and enlarged lymph nodes. They can also detect some tumors that block bronchial tubes. No imaging technique can determine the actual organism causing the infection.

Front 76

Invasive diagnostic procedures may be required in the following circumstances?
(online source)

Back 76

When patients have life-threatening complications.

When patients have failed standard treatments for no known reason.

When AIDS or other immune problems are present.
Each of the procedures has potential complications and is not used under ordinary conditions.

Thoracentesis. If a physician detects pleural effusion and suspects that empyema (pus) is present, thoracentesis is performed:
Fluid in the pleura is withdrawn using a long thin needle inserted between the ribs.
The fluid is then tested using blood cell counts, Gram stains, cultures, and chemical tests.
Complications of this procedure include collapsed lung, bleeding, and introduction of infection.

Bronchoscopy. A bronchoscopy employs the following:
The patient is given a local anesthetic, supplementary oxygen, and sedatives.


The physician inserts a fiberoptic tube into the lower respiratory tract through the nose or mouth.


The tube acts like a telescope into the body, allowing the physician to view the wind-pipe and major airways for pus, abnormal mucus, or other problems.


The doctor removes specimens for analysis and can also treat the patient by removing any foreign bodies or infected tissue encountered during the process.


Bronchoalveolar lavage (BAL) may be employed. This involves injecting high amounts of saline through the bronchoscope into the lung and then immediately suctioning the fluid back, which is then analyzed in the laboratory. Studies find BAL to be an effective method for detecting specific infection-causing organisms in patients with serious pneumonia.
The procedure is usually very safe, but complications can occur. They include allergic reactions to the sedatives or anesthetics, asthma attacks in susceptible patients, and bleeding. Fever may follow the procedure.

Lung Biopsy. In very severe cases of pneumonia or when the diagnosis is unclear in specific cases, particularly in patients with damaged immune systems, a lung biopsy may be required. Biopsies can be performed in one of two ways:
A Lung Tap. This procedure typically uses a needle inserted between the ribs to draw fluid out of the lung for analysis. It is known by a number of names including lung aspiration, lung puncture, thoracic puncture, transthoracic needle aspiration, percutaneous needle aspiration, and needle aspiration. It is a very old procedure that is not done often any more, particularly in children, since it is invasive and poses a slight risk for collapsed lung. Some experts argue, however, that a lung tap offers a more accurate solution than other methods for identifying bacteria and the risk it poses is slight. Given the increase in resistant bacteria, they believe its use should be reappraised in young people.


Surgically (thoracotomy), using general anesthesia and an incision. This is used for diagnosis only in very severe cases. As with bronchoscopy, the procedure can also be used to treat the patient, removing damaging lung tissue and, in severe cases, removing the entire lobe (lobectomy). (In such cases, remaining lung tissue re-expands after surgery to compensate for any removed tissue.)

Front 77

When is a thoracentesis performed?
(online source)

Back 77

If a physician detects pleural effusion and suspects that empyema (pus) is present, thoracentesis is performed:
Fluid in the pleura is withdrawn using a long thin needle inserted between the ribs.
The fluid is then tested using blood cell counts, Gram stains, cultures, and chemical tests.
Complications of this procedure include collapsed lung, bleeding, and introduction of infection.

Front 78

When is a bronchoscopy performed?
(online source)

Back 78

Bronchoscopy. A bronchoscopy employs the following:
The patient is given a local anesthetic, supplementary oxygen, and sedatives.


The physician inserts a fiberoptic tube into the lower respiratory tract through the nose or mouth.


The tube acts like a telescope into the body, allowing the physician to view the wind-pipe and major airways for pus, abnormal mucus, or other problems.


The doctor removes specimens for analysis and can also treat the patient by removing any foreign bodies or infected tissue encountered during the process.

Front 79

When is a bronchalveolar lavage employed?
(online source)

Back 79

Bronchoalveolar lavage (BAL) may be employed. This involves injecting high amounts of saline through the bronchoscope into the lung and then immediately suctioning the fluid back, which is then analyzed in the laboratory. Studies find BAL to be an effective method for detecting specific infection-causing organisms in patients with serious pneumonia.
The procedure is usually very safe, but complications can occur. They include allergic reactions to the sedatives or anesthetics, asthma attacks in susceptible patients, and bleeding. Fever may follow the procedure.

Front 80

Even though coughing is an important indicator of pneumonia, it should not be confused with the following..so rule out the following?
(online source)

Back 80

Roughly, the first four most common causes of persistent coughing are asthma, postnasal drip, gastroesophageal reflux disease, and chronic bronchitis. Other obvious common causes of chronic cough include heavy smoking or the use of drugs known as ACE inhibitors.

Front 81

What are other disorders that affect the lung and should be investigated?
(online source)

Back 81

Many conditions mimic pneumonia, particularly in hospitalized patients. Some include the following:
Tuberculosis.
Bronchial asthma. Bronchiectasis (irreversible widening of the airways, usually associated with birth defects, chronic sinus or bronchial infection, or blockage).
Atelectasis (collapse of lung tissue).
Congestive heart failure. (If heart failure affects the lungs, fluid-build up can occur and cause persistent cough, shortness of breath, and wheezing. In such cases, symptoms are usually worse at night.)
Severe allergic reactions, such as to drugs.
Adult respiratory distress syndrome (ARDS).

Lung cancer.
Interstitial pulmonary fibrosis (a non-infectious inflammation of the is marked by progressive damage and scarring). It can occur from a number of conditions, including chemicals, injury, autoimmune disease, and cancer. The cause is often unknown.

Front 82

What are seven variables that can be measured to determine if patient can go home?
(online source)

Back 82

Many experts use seven variables to measure such stability and to determine if the patient can go home:
Temperature. (Opinions differ on temperature goal. Some experts believe that a patient can go home if the temperature levels drop to 101 degrees F. Stricter criteria would require that it be at or close to normal.)
Respiration rate. (Goal is a normal breathing rate, although expert opinion differs on the degree of normality required to be discharged.)

Heart rate. (Goal is 100 beats per minute or less.)

Blood pressure. (Goal is systolic blood pressure of 90 mmHg or greater.)
Oxygenation. (Goal of oxygen levels in the blood determined by the physician.)

The ability to eat. (Goal is regular appetite.)
Mental function. (Goal is normal.)

Front 83

What are chest therapy measures to loosen sputum and record oxygen levels?
(online source)

Back 83

Chest therapy using incentive spirometry, rhythmic inhalation and coughing, and chest tapping are all important techniques to loosen the mucus and move it up out of the lungs. It should be used both in the hospital and when the patient returns home during recovery.

Incentive Spirometry. The patient uses an incentive spirometer at regular intervals.
The spirometer is a hand-held clear plastic device that includes a breathing tube and a container with a movable gauge.
The patient first exhales through the tube.
Then the patient inhales as strongly as possible.
The force of the inhalation raises a gauge inside the device to the highest level possible.
This practice helps the patient exercise the lungs. The height of the gauge at inhalation also helps the health professional to determine the state of the patient's lung function.

Rhythmic Breathing and Coughing. During recovery, the patient performs rhythmic breathing and coughing every four hours:
Before starting the breathing exercise, the patient should tap lightly on the chest to loosen mucus within the lung. If available, a caregiver should also tap on the patient's back.
The patient inhales rhythmically and deeply three or four times.

The patient then coughs as deeply as possible with the goal of producing sputum.

Front 84

When is a chest tube inserted?
(online source)

Back 84

Chest tubes are needed if empyema is present in order to drain the infected pleural fluid, but they are not required for pneumonia or abscesses.
If needed, the tubes are inserted under local anesthetic and remain in place for two to four days.
Complications include infection, accidental injury of the lung, perforation of the diaphragm, and fluid build-up within the lung if the pleural fluid is removed too rapidly.
Removal of the tubes is done in one quick movement without anesthetic and can be very distressing, although some patients experience no discomfort.
Removing the chest tubes occasionally causes the lung to collapse requiring the reintroduction of a chest tube to inflate the lung.

Front 85

<What is the significance of a temperature of 100.4?>

Back 85

<usually a sign of ATELECTASIS!...fever of around 100.4 within 48 hours is usually a sign of alveolar collapse...more likely to occur in:
elderly
COPD
smokers
obese patients
upper abdominal incisions

treat with:
mobilization
encourage
deep breathing and coughing
chest physiotherapy

Front 86

A common complication of pneumonia is hypoxemia which is?

Back 86

an arterial oxygen less than 80mmHg

Front 87

A common complication of pneumonia is ventilatory failure?

Back 87

lungs unable to move gas in and out of lungs mechanically, resulting in hypoxemia and hypercarbia

Front 88

A common complication of pneumonia is atelectasis?

Back 88

collapse of the affected alveoli and associated lobes of the lung

Front 89

A common complication of pneumonia is pleural effusion is?

Back 89

collection of fluid in the pleural space (usually sterile fluid that resolves)

Front 90

A common complication of pneumonia is pleurisy?

Back 90

pain caused by friction between layers of pleura

Front 91

<What should a nurse do to prevent patient from developing pneumonia?

Back 91

<turn, cough, deep breathe, use incentive spirometer

Front 92

Part 1...
A patient is three days postop cholecystectomy, has an NGT, Foley, peripheral IV, abdominal dressing, history of emphysema...the nurse enters the room and the patient appears QUITE ANXIOUS and COUGHS A LOT..he complains of SOB and PAIN in his chest and incision site. He states, "I feel hot, and I'm extremely tired."
What are the nurses actiivties at this time?
See Part #1


Part 2...
After assessing, nurse finds patient's respirations are LABORED and SHALLOW with the use of accessory muscles of neck and abdomen
Vital signs: 142/80, P120, R26 T103.4
SpO2 is 84% on room air
Crackles are auscultated over
both posterior lower lobes
His IV is running at the prescribed rate and there are no signs of infection at the IV site
His pain level is 5/10

The nurse calls the physician and receives the following orders:
Stat blood C&S x 2
sputum C&S
Stat ABGs
CXR and EKG
O2 2L/nc
Ampicillin 1.5 mg IVPB q6h
acetaminophen 650 mg po for
temp over 102F
Based on this assessment, what is going on with theh patient? See Part #2>

See Part #3...
So the doctor ordered Stat blood C&Sx2 and Ampicillin 1.5 mg IVPB q6h...what should the nurse do before starting Ampicillin?
See Part #3

Part 4...
ABG results on 2L cannula
ph 7.33
pCO2 52
pO2 65
O2 sat 88%
HCO3 29
What is the interpretation of these results?
See #4

Part #5...
The O2 sat shows that the patient has hypoxemia...why didn't the doctor order the oxygen increased if the patient is hypoxic?

Part #6...
What does the collaborative management of pneumonia entail?>

Back 92

<Part #1...
check vital signs including
temperature, heart rate,
respiration rate...
auscultate lungs...
assess repiratory effort...
check saturation oxygen level
note intensity of pain...
check IV rate for over-
hydration leading to too
much fluid in lungs...

Call doctor with all of these findings.

Part #2...
probably had atelectasis with low grade fever which has now probably progressed to pneumonia...the problems that he's having that leads one to believe he's heading into pneumonia is a history of emphysema, older, fever about 102, hypoxemia, labored respirations, tachycardic and there are crackles in his lungs...CXR may show an infiltrate (fluid or pus in the lungs)...CXR may show atelectasis....CXR may show hyperinflation (one lung may be elongated, diaphragm flattens out (makes is more difficult to breathe as the lungs try to compensate for the other lung not being able to oxygenate as well)...so with pneumonia, expect to see:
hyperinflation
atelectasis
infiltrate>

Part #3...
Nurse should take culture and sensitivity tests first before giving Ampicillin to avoid changing results of C&S
tests. He also ordered some sputum culture and sensitivities...would the nurse wait before ordering those antibiotics...nurse DOES NOT have to wait on the sputum cultures, because sometimes it takes a couple of days to even get those back, so don't wait...get the patient on antibiotics ASAP....
in summary, do blood test first, give antibiotic, take sputum cultures

#4 respiratory acidosis

#5 too much oxygen takes away the repiratory drive...patient has history of emphysema

#6 pharmacist and pnarmacy will be involved as patient will be put on antibiotics...he'll probably be on antitussives and expectorants and analgesics and antipyretics...patient needs to be on bedrest...probably will increase fluids to liquify secretions so fluid can be coughed up out of lungs...respiratory therapy might also be involved in the care...dietician will be involved because patient needs to be on a high protein high calorie diet for repair and maintenance of tissues...respiratory therapy...depending on the organism that's causing the pneumonia, the patient might be in isolation...an infection control nurse would handle this...floor nurse would continue to assess lung sounds and oxygen level>