Pneumonia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Pneumonia Acute infection of the lung parenchyma Associated with significant morbidity and mortality rates Community-acquired pneumonia (CAP) 6th leading cause of death in people aged 65 years or older in United States Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Etiology Likely to result when defense mechanisms become incompetent or overwhelmed ↓ Cough and epiglottal reflexes may allow aspiration. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Types of Pneumonia Can be classified according to causative organism Clinical classification: Community-acquired (CAP) Medical care-associated acquired (MCAP) Hospital-associated (HAP) Ventilator-associated (VAP) Health care-associated (HCAP) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Types of Pneumonia Cytomegalovirus (CMV) pneumonia Herpes virus Asymptomatic and mild to severe disease Life-threatening in immunosuppressed Treat with antiviral medications and high- dose immunoglobulin Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Pathophysiology Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations Most common Change in mentation for older or debilitated patients Nonspecific manifestations Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations Physical examination findings Rhonchi and crackles Bronchial breath sounds Egophony ↑ Fremitus Dullness to percussion if pleural effusion present Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Complications Pleurisy Pleural effusion Atelectasis Bacteremia Empyema Pericarditis Meningitis Sepsis Acute respiratory failure Pneumothorax Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Tests History Physical examination Chest x-ray Sputum analysis CBC with differential Pulse oximetry or ABGs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care Pneumococcal vaccine To prevent S. pneumoniae (pneumococcus) pneumonia Indicated for those at risk Age 65 or older Age 2-64 years with long-term health problem or immunosuppression Age 19-64 who smoke or have asthma Live in nursing homes or long-term care facility have elapsed since last vaccination. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care Antibiotic therapy Repeat chest x-ray Supportive care Oxygen for hypoxemia Analgesics for chest pain Antipyretics Individualize rest and activity Antivirals for influenza pneumonia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy Start with empiric therapy. Based on likely infecting organism and risk factors for MDR organisms Varies with localities Should see improvement in 3-5 days. Start with IV and then switch to oral therapy as soon as patient stable. Minimum 5 days of antibiotic therapy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nutritional Therapy Adequate hydration Hi-calorie, small, frequent meals Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Assessment Subjective Data Past health history: lung cancer, COPD, diabetes, malnutrition, chronic debilitating disease Use of antibiotics, corticosteroids, chemotherapy, or immunosuppressants Recent abdominal or thoracic surgery Recent intubation Tube feedings Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Assessment Subjective Data Smoking Alcoholism Respiratory infections Nutritional intake Activity Dyspnea Cough Pain Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Assessment Objective Data Fever Restlessness or lethargy Splinting affected area Tachypnea Asymmetric chest movements Use of accessory muscles Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Assessment Crackles Friction rub Dullness on percussion Increased tactile fremitus Sputum amount and color Tachycardia Changes in mental status Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Planning Clear breath sounds Normal breathing patterns No signs of hypoxia Normal chest x-ray No complications related to pneumonia to pneumonia. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Health Promotion Teach hygiene, nutrition, rest, regular exercise to maintain natural resistance. Cough or sneeze into elbow, not hands. Avoid cigarette smoke. Prompt treatment of URIs. Influenza and pneumococcal vaccination . Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Prevent pneumonia in at risk patients. Proper positioning to prevent aspiration Reposition patient every 2 hours. Strict adherence to ventilator bundle to prevent VAP Elevate head of bed 30 to 45 degrees for patients with feeding tube. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Prevent pneumonia in at risk patients. Elevate head-of-bed 30 degrees and have sit up for all meals. Assist with eating, drinking, taking meds as needed. Assess for gag reflex. Early mobilization Incentive spirometry Twice-daily oral hygiene Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Prevent pneumonia in at risk patients. Pain management Strict medical asepsis Hand hygiene Respiratory devices Suctioning Avoid unnecessary antibiotic usage. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Acute Intervention Frequent assessments Prompt initiation of antibiotics Oxygen therapy Hydration Nutritional support Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Acute Intervention Breathing exercises Early ambulation Therapeutic positioning Pain management Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Patient teaching for home care Emphasize need to take course of medication(s). Drug-drug and drug-food interactions Adequate rest Adequate hydration Avoid alcohol and smoking. Cool mist humidifier Chest x-ray, vaccinations Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Evaluation Effective respiratory rate, rhythm, and depth of respirations Lungs clear to auscultation Reports pain control SpO2 ≥ 95 Free of adventitious breath sounds Clear sputum from airway Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Tuberculosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Tuberculosis (TB) Infectious disease caused by Mycobacterium tuberculosis Lungs most commonly infected Primary cause of death worldwide Leading cause of death in patients with HIV/AIDs Greater than 2 billion people infected worldwide Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Risk Factors Homeless Residents of inner-city neighborhoods Foreign-born persons Living or working in institutions (includes health care workers) IV injecting drug users Poverty, poor access to health care Immunosuppression Asian descent Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Multidrug-Resistant Tuberculosis (MDR-TB) Occurs when a strain develops resistance to two of the most potent first-line anti-TB drugs Extensively drug-resistant TB (XDR-TB) resistant to any fluoroquinolone plus any injectable antibiotic Several causes for resistance occur. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and Pathophysiology Spread via airborne droplets Can be suspended in air for minutes to hours Transmission requires close, frequent, or prolonged exposure. NOT spread by touching, sharing food utensils, kissing, or other physical contact Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and Pathophysiology Once inhaled, particles lodge in bronchiole and alveolus. Local inflammatory reaction occurs. Ghon focus – develops into granuloma Infection walled off and further spread stopped Only 5-10% will develop active TB. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and Pathophysiology Aerophilic (oxygen-loving) – causes affinity for lungs Infection can spread via lymphatics and grow in other organs as well: Kidneys Bones Brain Adrenal glands Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classification Classes 0 = No TB exposure 1 = Exposure, no infection 2 = Latent TB, no disease 3 = TB, clinically active 4 = TB, not clinically active 5 = TB suspected Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classification Primary infection Latent TB infection (LTBI) When bacteria are inhaled Latent TB infection (LTBI) Infected but no active disease Active TB disease Primary TB Reactivation TB (post-primary) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations LTBI – asymptomatic Pulmonary TB Takes 2-3 weeks to develop symptoms. Initial dry cough that becomes productive Constitutional symptoms (fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats) Dyspnea and hemoptysis late symptoms Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations Cough becomes frequent. Hemoptysis is not common and is usually associated with advanced disease. Dyspnea is unusual. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations Can also present more acutely High fever Chills, generalized flulike symptoms Pleuritic pain Productive cough Adventitious breath sounds Extrapulmonary TB manifestations dependent on organs infected Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Complications Miliary TB Large numbers of organisms spread via the bloodstream to distant organs. Fatal if untreated Manifestations progress slowly and vary depending on which organs are infected. Can include hepatomegaly, splenomegaly, and generalized lymphadenopathy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Complications Pleural TB Pleural effusion Empyema Bacteria in pleural space cause inflammation. Pleural exudates of protein-rich fluid Empyema Large numbers of tubercular organisms in pleural space Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Complications TB pneumonia Other organ development Large amounts of bacilli discharged from granulomas into lung or lymph nodes Manifests as bacterial pneumonia Other organ development Spinal destruction Bacterial meningitis Peritonitis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies Tuberculin skin test (TST) AKA: Mantoux test Uses purified protein derivative (PPD) injected intradermally Assess for induration in 48 – 72 hours Presence of induration (not redness) at injection site indicates development of antibodies secondary to exposure to TB. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies Tuberculin skin test (TST) Positive if ≥15 mm induration in low-risk individuals Response ↓ in immune-compromised patients Reactions ≥5 mm considered positive Basil J. Zitelli, MD and Holly W. Davis, MD, Atlas of Pediatric Physical Diagnosis, Mosby Elsevier, 2007. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies Tuberculin skin test (TST) A waning immune response can cause false negative results. Repeating TST may boost reaction. Two-step testing recommended for health care workers getting repeated testing and those with decreased response to allergens Two-step testing ensures future positive results accurately interpreted. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies Interferon-γ release assays (IGRAs) Detects T-cell lymphocytes in response to mycobacteria Includes QuantiFERON-TB and the T-SPOT.TB tests Rapid results Several advantages over TST but more expensive Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies Chest x-ray Cannot make diagnosis solely on x-ray Upper lobe infiltrates, cavitary infiltrates, and lymph node involvement suggest TB. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies Bacteriologic studies Required for diagnosis Sputum samples obtained (usually) on 2-3 consecutive days Stained sputum smears examined for acid-fast bacilli Culture results can take up to 8 weeks. Can also examine samples from other suspected TB sites Picture from:Richard L. Kradin, MD Diagnostic Pathology of Infectious Disease, Saunders, 2010. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care Hospitalization not necessary for most patients Infectious for first 2 weeks after starting treatment if sputum + Drug therapy used to prevent or treat active disease Need to monitor compliance Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy Active disease Treatment is aggressive. Two phases of treatment Initial (8 weeks) Continuation (18 weeks) Four-drug regimen INH Rifampin (Rifadin) Pyrazinamide (PZA) Ethambutol Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy Directly observed therapy (DOT) Noncompliance is major factor in multidrug resistance and treatment failures. Requires watching patient swallow drugs Preferred strategy to ensure adherence May be administered by public health nurses at clinic site Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy Latent TB infection Usually treated with INH for 6 to 9 months HIV patients should take INH for 9 months. Alternative 3-month regimen of INH and rifapentine OR 4 months of rifampin Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy Vaccine Bacille Calmette-Guérin (BCG) vaccine to prevent TB is currently in use in many parts of the world. In United States, not recommended except for very select individuals Can result in positive PPD reaction Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Assessment History Physical symptoms Sputum collection Productive cough Night sweats Afternoon temperature elevation Weight loss Pleuritic chest pain Crackles over apices of lungs Sputum collection Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Planning Goals Comply with therapeutic regimen. Have no recurrence of disease. Have normal pulmonary function. Take appropriate measures to prevent spread of disease. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Health Promotion Ultimate goal in the United States is eradication. Selective screening programs in high-risk groups to detect TB Treatment of LTBI Follow-up positive TST results Reportable disease Address social determinants of TB Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Acute Intervention Airborne isolation Single-occupancy room with 6-12 airflow exchanges/hour Health care workers wear high-efficiency particulate air (HEPA) masks Immediate medical workup Appropriate drug therapy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Teach patient to prevent spread. Cover nose and mouth with tissue when coughing, sneezing, or producing sputum Hand washing after handling sputum-soiled tissues Patient wears mask if outside of negative-pressure room. Identify and screen close contacts. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Ambulatory and Home Care Can go home even if cultures positive Monthly sputum cultures Teach patient how to minimize exposure to others. Ensure that patient can adhere to treatment. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Ambulatory and Home Care Notify health department. Teach symptoms of recurrence. Instruct about factors that could reactivate TB. Smoking cessation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Evaluation Expected Outcomes Complete resolution of disease Normal pulmonary function Absence of any complications No transmission of TB Copyright © 2014 by Mosby, an imprint of Elsevier Inc.