Pneumonia (LECTURE3)

8/12/2019 Pneumonia (LECTURE3)

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PneumoniaDr Ibrahim Bashayreh, RN, PhD.


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Pneumonia

Acute inflammation of lung (lowerrespiratory tract) caused by

microorganism, comes with fever,focal chest symptoms, shadowingon CXR

Leading cause of death until 1936Discovery of sulfa drugs and

penicillin


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Classification

Community Acquired Pneumonia

Occur within 48 hrs of admission or inpatients who havent been hospitalized in thelast 2 wks

Strep pneumonia, mycoplasma pneumonia,influenza A, Haemophilus influenza, and

Legionella are more common pathogens Patients with chronic diseases are more prone

to Klebsiella and other gram negativeorganisms

Highest incidence in winter

Smoking important risk factor


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Types of Pneumonia

Hospital-acquired pneumonia (HAP) (Nasocomial Infection)

Develops 2 or more days after admission

Gram negative bacilli (Klebsiella, Pseudomonas, E coli,Proteus) or Staphylococcus are more common pathogens

Aspiration around an ETT/reduced consciousness ordifficulty swallowing allows pathogens in the oropharynx tocolonize the lungs

Ventilator-associated pneumonia (VAP): in patients onventilators

Aspiation: follows aspiration of gastric contents

Immunosuppression: chemotherapy/bone marrowtransplant/HIV patients susceptible to fungi and viralinfections as well as other pathogen

Highest mortality rate of nosocomial infections


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Causes of HAP

Pseudomonas

Enterobacter

S. aureus

S. pneumoniae

Immunosuppressive therapy

General debility

Endotracheal intubation


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Aging, 65 years or older

Male

Children under 2

Having HIV or AIDS

Increased frequency of gram- negative bacilli(leukemia, diabetes, alcoholism)

Smoking

Being around certain chemicals

Living in certain parts of the country

Being hospitalized in ICU & having ETT

Pollution

Malnutrition


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Acquisition of Organisms

Aspirationfrom nasopharynx,

oropharynx

Inhalationof microbes

Hematogenous spreadfrom

primary infection elsewhere


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Signs & Symptoms

Symptoms

Dyspnea

Pleurisy

Cough

Discolored sputum

Signs

Cyanosis

Tachycardia

Tachypnea

Dull percussion

Crepitus

Bronchial breath sounds

Pleural rub

Sweating, cold clammy skin

Non-respiratory features

Confusion, fatigue

Diarrhea, N&V.


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Clinical Manifestations

CAP symptoms

Sudden onset of fever

Chills

Cough productive of purulent

sputum

Pleuritic chest pain


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Pathophysiology:

Pneumococcal Pneumonia

Congestion from outpouring of

fluid into alveoli

Microorganisms multiply and spread

infection, interfering with lung

function


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Pathophysiology:

Pneumococcal Pneumonia

Red hepatization

Massive dilation of capillaries

Alveoli fill with organisms,

neutrophils, RBCs, and fibrin

Causes lungs to appear red and

granular, similar to liver


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Complications

Pleurisy (pain with breathing)

Pleural effusion

Usually is sterile and reabsorbed in 1-2weeks or requires thoracentesis

Atelectasis

Usually clears with cough and deepbreathing


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Complications

Delayed resolution Persistent infection seen on x-ray as

residual consolidation

Lung abscess (pus-containing lesions)Empyema (purulent exudate in pleuralcavity)

Requires antibiotics and drainage ofexudate


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Complications

Pericarditis

From spread of microorganism

Arthritis

Systemic spread of organism

Exudate can be aspirated

Meningitis

Patient who is disoriented, confused, orsomnolent should have lumbar punctureto evaluate meningitis


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Complications

Endocarditis

Microorganisms attack endocardium and

heart valves

Manifestations similar to bacterial

endocarditis


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Diagnostic Tests

History

Physical exam

Chest x-ray

Gram stain of sputum

Sputum culture and sensitivity

Pulse oximetry or ABGs

CBC, differential, chems

Blood cultures


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Collaborative Care

Antibiotic therapy

Oxygen for hypoxemia

Analgesics for chest painAntipyretics

Influenza drugs

Influenza vaccineFluid intake at least 3 L per day

Caloric intake at least 1500 per day


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Collaborative Care

Pneumococcal vaccine

Indicated for those at risk

Chronic illness such as heart and lungdisease, diabetes mellitus

Recovering from severe illness

65 or olderIn long-term care facility


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Nursing Assessment

History of Predisposing/Risk Factors

Lung cancer

COPD

Diabetes mellitus

Debilitating disease

Malnutrition


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Nursing Assessment

History of Predisposing/Risk FactorsAIDS

Use of antibiotics, corticosteroids,chemotherapy, immunosuppressants

Recent abdominal or thoracicsurgery

Smoking, alcoholism, respiratory

infections

Prolonged bed rest


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Nursing Assessment


Dyspnea

Nasal congestion

Pain with breathing

Sore throat

Muscle aches

Fever


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Nursing Assessment


Restlessness or lethargy

Splinting affected area

Tachypnea

Asymmetric chest movements

Use of accessory muscles

Crackles

Green or yellow sputum


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Nursing Assessment


Tachycardia

Changes in mental status

Leukocytosis

Abnormal ABGs

Pleural effusionPneumothorax on CXR


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Nursing Diagnoses

Ineffective breathing pattern

Ineffective airway clearance

Acute painImbalanced nutrition: less than body

requirements

Activity intolerance


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Planning

Goals: Patient will have

Clear breath sounds

Normal breathing patternsNo signs of hypoxia

Normal chest x-ray

No complications related to pneumonia


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Nursing Implementation

Teach nutrition, hygiene, rest, regular

exercise to maintain natural resistance

Prompt treatment of URIs


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Encourage those at risk to obtain

influenza and pneumococcal

vaccinations

Reposition patient q2h

Assist patients at risk for aspiration

with eating, drinking, and taking meds


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Assist immobile patients with turning

and deep breathing

Strict asepsisEmphasize need to take course of

medication(s)

Teach drug-drug interactions


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Evaluation

Dyspnea not present

SpO2> 95

Free of adventitious breath soundsClears sputum from airway


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Evaluation

Reports pain controlled

Verbalizes causal factors

Adequate fluid and caloric intakePerforms ADLs


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Tuberculosis

Famous people who have had TB

Fredr ic Chopin*

Eleanor Roosevelt*

Nelson M andela

Ringo Starr

Tom JonesTina Turner

*Died of TB


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What is tuberculosis (TB)?

Disease caused by bacteria calledMycobacter ium tuberculosis

Chronic bacterial infection

Was once the leading cause of death in US

The number of cases declined in the 1940swhen drugs were developed to treat TB

TB is still a problem worldwide

8 million people develop TB yearly

3 million die


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Tuberculosis

5-10% becomeactive

Only contagiouswhen active

Primarily affectlungs but

Kidneys

Liver Brain

Bone


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How is TB spread?

Through the air from person to

person by coughing

Usually attacks lungs

Two stages

Latent TB asymptomatic and not contagious

can take medication to prevent developmentof disease

Active TB Disease May spread to others

May have abnormal chest x-ray

Usually have positive skin test


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Symptoms of TB

Chills

Fever

Weakness or fatigue

Sweating while sleeping, Night sweats

Cough that lasts longer than 2 weeks

Pain in chest

Coughing up blood or sputum


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Risk Factors

Close contact with someone who is infectedwith TB

Traveling to a country where TB is common

Foreign-born individuals and minoritieshave a higher incidence of developing TB

2002: 50% of US cases were in foreign-born individuals.

2002: 80% of all US TB cases were inethnic and racial minorities.


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Risk Factors

Immunocompromise

Substance abuse

Indigent (POVERTY)Living in overcrowded, substandard housing

Health care workers performing high riskactivities


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Multi-drug resistant TB (MDR TB)

Bacteria become resistant to antibiotics

Arose from improper use of antibiotics in thetreatment of TB

Treatment of one case can cost up to $1.3 million

45 states and Washington, DC have confirmed casesof MDR TB

Treatment is difficult and costly

Can develop from not taking proper course of

antibiotics for TBMDR TB can be spread by an infected person


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How to protect yourself

BCG vaccine for TB is given in many countries

Not recommended for healthcare workers

unless a high percentage of patients areinfected with MDR TB

PPD test if exposure is suspected

USE proper PPE when in contact with patientswho may have TB


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PPD Skin Test Procedure

Intradermal administration of PPD

L forearm

Must be read between 48 and 72 hoursTo accurately read

Visual inspection for erythema

Tactile inspection to monitor size ofinduration

10 mm or > area of induration

Consider positive and must be referred


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Tuberculosis

Diagnostic examsPPD

Mantoux skin test

> 10mm in diameter

induration

Indicates: Latent TB

Read

48-72 after

Intradermal: 15-degrees

Do not rub


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Confirmation of Disease

Positive reaction does not

necessarily mean active disease.

May indicate exposure to TBDiagnosis confirmed by:

Positive smear for AFB and

Sputum culture of

Mycobacterium tuberculosis


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Interventions

Combination drug

therapy

Isoniazid

Rifampicin

Pyrazinamide

Ethambutol orstreptomycin

Education

Must follow

exact drug

regimen

Proper

nutrition

Reverse weight

loss and lethargy

About disease


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Tuberculosis Treatment

INH

Isonicotinyl Hydrazine

Isoniazid

Toxic to the liverRifampicin

Turns urine red

Streptomycin

Causes 8th cranial nervedamage

Acoustic nerve


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CLASSIFICATION

Class 0no exposure

Class 1exposure, no infection

Class 2latent infection; no disease (positive

PPD but no evidence of active TB

Class 3disease; clinically active

Class 4disease; not clinically active

Class 5suspected disease; diagnosispending


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MEDICAL MANAGEMENT

Treated with chemotherapeutic agents for 6-

12 months

Resistance increasing. May beprimary,

secondary, ormultidrug resistant.Primaryresistance to one of first line drugs

in those who have not had prior treatment

Secondaryresistance to one or more anti-

TB drugs in patientsundergoing tx

Multidrug resistanceresistance to two

agents, INH and Rifampicin.


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Tuberculosis

Complications

Pleurisy

Pericarditis

Meningitis

Bone infections

MalnutritionDrug-toxicity


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Tuberculosis

Nursing Dx

Impaired gas exchange

Ineffective airway clearance

Anxiety

Knowledge deficit

Alt. nutrition


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Tuberculosis

Preventative measures

Clean well ventilated living areas

Resp. isolation

Vaccine?

BCG

Does not prevent TB

Causes a + PPD

If exposed take

INH


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Tuberculosis Summary

Chronic bacterial infectionspread through the air

Fever, chills, sweating while

sleeping, persistent cough,coughing up blood or sputum

Multi-drug-resistant tuberculosis

MDR TB

Use proper PPE and get PPD testif exposed

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Pneumonia (LECTURE3)

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