1. Pneumonia
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2. 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
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3. Etiology
Likely to result when defense mechanisms become incompetent or overwhelmed
↓ Cough and epiglottal reflexes may allow aspiration.
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4. 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)
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5. 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
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6. Pathophysiology
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7. Clinical Manifestations
Most common
Change in mentation for older or debilitated patients
Nonspecific manifestations
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8. Clinical Manifestations
Physical examination findings
Rhonchi and crackles
Bronchial breath sounds
Egophony
↑ Fremitus
Dullness to percussion if pleural effusion present
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9. Complications Pleurisy Pleural effusion Atelectasis Bacteremia Empyema
Pericarditis
Meningitis
Sepsis
Acute respiratory failure
Pneumothorax
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10. Diagnostic Tests History Physical examination Chest x-ray
Sputum analysis
CBC with differential
Pulse oximetry or ABGs
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11. 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 who smoke or have asthma
Live in nursing homes or long-term care facility
have elapsed since last vaccination.
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12. 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
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13. 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
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14. Nutritional Therapy Adequate hydration
Hi-calorie, small, frequent meals
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15. 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
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16. Nursing Assessment Subjective Data Smoking Alcoholism
Respiratory infections
Nutritional intake
Activity
Dyspnea
Cough
Pain
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17. Nursing Assessment Objective Data Fever Restlessness or lethargy
Splinting affected area
Tachypnea
Asymmetric chest movements
Use of accessory muscles
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18. Nursing Assessment Crackles Friction rub Dullness on percussion
Increased tactile fremitus
Sputum amount and color
Tachycardia
Changes in mental status
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19. Planning Clear breath sounds Normal breathing patterns
No signs of hypoxia
Normal chest x-ray
No complications related to pneumonia
to pneumonia.
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20. 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 .
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21. 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.
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22. 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
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23. Nursing Implementation
Prevent pneumonia in at risk patients.
Pain management
Strict medical asepsis
Hand hygiene
Respiratory devices
Suctioning
Avoid unnecessary antibiotic usage.
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24. Nursing Implementation
Acute Intervention
Frequent assessments
Prompt initiation of antibiotics
Oxygen therapy
Hydration
Nutritional support
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25. Nursing Implementation
Acute Intervention
Breathing exercises
Early ambulation
Therapeutic positioning
Pain management
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26. 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
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27. 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
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28. Tuberculosis
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29. 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
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30. 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
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31. 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.
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32. 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
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33. 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.
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34. 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
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35. 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
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36. 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)
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37. 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
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38. Clinical Manifestations
Cough becomes frequent.
Hemoptysis is not common and is usually associated with advanced disease.
Dyspnea is unusual.
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39. 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
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40. 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
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41. 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
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42. 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
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43. 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.
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44. 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.
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45. 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.
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46. 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
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47. Diagnostic Studies Chest x-ray Cannot make diagnosis solely on x-ray
Upper lobe infiltrates, cavitary infiltrates, and lymph node involvement suggest TB.
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48. 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.
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49. 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
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50. 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
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51. 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
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52. 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
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53. 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
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54. 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
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55. Planning Goals Comply with therapeutic regimen.
Have no recurrence of disease.
Have normal pulmonary function.
Take appropriate measures to prevent spread of disease.
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56. 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
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57. 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
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58. 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.
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59. 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.
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60. Nursing Implementation
Ambulatory and Home Care
Notify health department.
Teach symptoms of recurrence.
Instruct about factors that could reactivate TB.
Smoking cessation
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61. Evaluation Expected Outcomes Complete resolution of disease
Normal pulmonary function
Absence of any complications
No transmission of TB
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