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Transcript
LOWER RESPIRATORY PROBLEMS Acute Bronchitis Pneumonia Tuberculosis Copyright 2/4/2013 Michelle Gardner ACUTE BRONCHITIS Inflammation of the bronchi in the lower respiratory tract. Usually occurs with upper respiratory tract infection ACUTE BRONCHITIS Etiology May be viral /bacterial infection At risk -- those with impaired immune defenses/cigarette smoking Marked seasonal incidences ACUTE BRONCHITIS Clinical Manifestations Persistent cough Mildly elevated T, RR, HR Breath sounds Diagnostic Assessment History/Physical CXR – differentiate acute bronchitis/pneumonia ACUTE BRONCHITIS Collaborative Management a. b. c. d. Treatment is generally supportive Fluids Rest Anti-inflammatory agents Other Antibiotics Antitussives Bronchodilators PNEUMONIA Leading cause of death from an infectious disease Excess fluid in the lungs resulting in an inflammatory process Caused by various microbial agent a. Bacterial b. Viral c. Fungal PNEUMONIA Incidence/Prevalence US – 4 million cases of pneumonia 8th leading cause of death Highest incidence in older adults and people with debilitating illness 1. Nursing home residents 2. Those mechanically vented PNEUMONIA PNEUMONIA RISK FACTORS 1. 2. 3. 4. 5. 6. Older Adult Bed rest/prolonged immobility Debilitating illness Human immunodeficiency virus (HIV) Intestinal / gastric feedings Malnutrition PNEUMONIA CLASSIFICATION 1. Community –Acquired Pneumonia (CAP) 2. Hospital –Acquired Pneumonia (HAP) 3. Aspiration Pneumonia 4. Opportunistic Pneumonia COMMUNITY-ACQUIRED PNEUMONIA 1. Onset occurs in the community /first 2 days of hospitalization 2. Incidence 3. Smoking, alcoholism, immunosuppressive disease 4. Age > 65 years, multiple medical co-morbidities 5. Causative organism identified only 50% of the time HOSPITAL ACQUIRED PNEUMONIA 1. Occurs 48 hrs. or longer after admission 2. Bacteria are responsible for the majority of HAP – Pseudomonas, Staph. Aureus 3. Some causes: a. contaminated respiratory therapy equip. b. endotracheal intubation (VAP) c. general debility HOSPITAL ACQUIRED PNEUMONIA • Ventilator –Associated Pneumonia • Nosocomial pneumonia • Associated with endotracheal intubation /mechanical ventilation • Bacterial Pneumonia • Ventilator Bundle HOSPITAL ACQUIRED PNEUMONIA • Methicillin-Resistant Staphylococcus Aureus (MRSA) Specific strains of Staphylococcus are resistant to all available antibiotics except Vancomycin Highly virulent ASPIRATION PNEUMONIA 1. Aspiration of material from the mouth/stomach into the trachea/lungs 2. Typically occurs in clients with altered consciousness and impaired gag reflex 3. Another risk factor – tube feedings 4. Prevention – OPPORTUNISTIC PNEUMONIA Occurs in client’s with altered immune response. Highly susceptible to respiratory infections Pneumocystis jiroveca (carinii) – fungal opportunistic pathogen Affects about 70% of HIV virus infected individuals Common opportunistic infection OPPORTUNISTIC PNEUMONIA At risk: 1. those with immune deficiencies 2. severe protein calorie malnutrition 3. clients who have received organ transplants 4. clients treated with chemotherapy, radiation therapy OPPORTUNISTIC PNEUMONIA Clinical Manifestations Insidious Tachycardia Fever Non-productive cough Tachypnea Dyspnea Treatment Bactrim – primary agent BACTERIAL PNEUMONIA Clinical Manifestations 1. Fever 2. Shaking chills 3. Productive cough 4. Pleuritic chest pain 5. Crackles on auscultation 6. Altered mental status VIRAL PNEUMONIA Clinical Manifestations 1. Fever 2. Dry non-productive cough 3. Chills 4. Malaise DIAGNOSTIC STUDIES 1. History/physical 2. Chest x-ray 3. Sputum gram stain, C&S (should be collected before antibiotic therapy started) 4. CBC 5. Serum electrolyte PNEUMONIA Empiric Therapy Treatment is based on observation and experience without always knowing the exact cause. BACTERIAL PNEUMONIA COLLABORATIVE CARE 1. 2. 3. 4. 5. Antibiotic therapy –Macrolides recommended a. Zithromax (azithromycin) b. Biaxin (clarithromycin) Oxygen therapy Analgesics Antipyretics Rest/restrict client’s activity VIRAL PNEUMONIA No definitive treatment Antiviral agents a. Symmetrel (amantadine) b. Flumadine (rimantadine) VACCINE Influenza vaccine o Mainstay of prevention o Recommended annually for clients Pneumoccal Vaccine o Good for a lifetime o 65yrs and older COMPLICATIONS o Usually runs an uncomplicated course. o Complications may include a. pleural effusion b. confusion NURSING MANAGEMENT a. b. c. d. e. f. g. Assess respiratory status Oxygen therapy – as per MD order Maintain patent airway High-calorie, high –protein foods Hydrate Administer medications as ordered Document findings PULMONARY TUBERCULOSIS TUBERCULOSIS o o o o o o o Bacterial infection Caused by Mycobacterium tuberculosis Communicable disease Primarily affects the lungs Can affect other organs & body structures Transmitted through airborne droplets The disease may be an active process or it may remain dormant RISK FACTORS * Persons in constant, frequent contact with untreated/undiagnosed individuals * Abuse IV drugs or alcohol * Homeless persons, residents of inner-city neighborhoods * Foreign-born immigrants from countries with high prevalence * Those living in crowded areas -- mental health facilities, long-term care facilities * Those with immune dysfunction or HIV PATHOPHYSIOLOGY a. M. tuberculosis, a gram-positive, acid-fastbacillus, & a slow-growing organism b. Transmitted via airborne droplets c. Bacilli are inhaled & deposit themselves on the bronchioles/alveoli d. Here they may be killed by the host's immune system, or lie dormant without causing symptoms, or produce primary TB e. It’s possible for the bacilli to proliferate after a period of dormancy, causing reactivation of TB. TUBERCULOSIS Contraction of TB typically requires close, repeated contact over a long period of time CLINICAL MANIFESTATIONS Early stages the client may be symptom free • Active disease: 1. Fatigue 2. Low-grade fever / night sweats 3. Anorexia / weight loss 4. Persistent cough 5. Chest tightness, & dull, aching chest pain may accompany the cough TUBERCULIN SKIN TESTING Mantoux test - PPD (purified protein derivative) * Gold standard for screening * Most reliable determinant of TB infection * Skin test should be read 48-72 hrs. after PPD administration * A positive test is determined by the size of the area of induration (hardened & raised area) MANTOUX TEST MANTOUX TEST (cont’d) * A positive reaction indicates the presence of a tuberculosis infection * Does not show whether the infection is inactive (dormant) disease or active. * Immunosuppressed clients or those with HIVinfection with a induration reaction 5mm or greater are considered positive TUBERCULOSIS * An area of induration measuring 10mm or more in diameter, 4872 hours after injection, indicates the individual has been exposed to TB QuantiFERON-TB Gold New test for detection of TB Test is an enzyme-linked immunosorbent assay (ELISA) Detects the release of interferon-gamma by WBC’S when the blood of a pt. with TB is incubated. Results of the test are available in less than 24 hr. DIAGNOSTIC ASSESSMENT Chest x-ray Sputum cultures –most accurate means of making a diagnosis. a. (3) consecutive sputum specimens on three different days are obtained for C&S b. A positive sputum culture of tubercle bacilli confirms the diagnosis VACCINE Immunization with bacille Calmette-Guerin (BCG) is still given to prevent TB in many parts of the world. Given to children in high prevalence areas in developing countries BCG vaccination can result in a positive reaction on TST COLLABORATIVE CARE Most client's are treated on an outpatient basis 1. Hospitalization used for – severely ill, debilited, & those who experience adverse drug reactions 2. Mainstay of TB treatment – Drug Therapy TUBERCULOSIS What is multidrug – resistant TB? Resistance develops to at least two or more antiTB drugs Standard therapy has been revised TUBERCULOSIS Treatment consist of a combination of at least 4 drugs Reason for the combination therapy a. Increase therapeutic effectiveness b. Decrease the development of resistant strains of M. tuberculosis TUBERCULOSIS FIRST LINE DRUGS 1. Isoniazid (INH) 2. Rifampin (Rifadin) 3. Ethambutol (Myambutol) 4. Streptomycin 5. Pyrazinamide DRUG THERAPY * Length of time medication must be taken 6/12 months * Strict adherence to the drug regimen is crucial to suppress the disease * Non-compliance is a major factor in the emergence of MDR - TB DRUG THERAPY Isoniazid- (INH) First drug of choice for TB prophylaxis Adverse effects Administer pyridoxine (vitamin B6) Hepatitis – hepatotoxic DRUG THERAPY Rifampin (Rifadin) Used in combination with INH and other antitubercular meds Can cause hepatitis, flu-like symptoms Causes body fluids – turn red/orange. Monitor liver function studies, renal studies for evidence of toxicity DRUG THERAPY Pyrazinamide (Tebrazid) Used with INH and Rifampin Toxic to the liver Monitor liver function DRUG THERAPY Ethambutol (Myambutol) Toxic effect Early signs Baseline visual exam prior to therapy Schedule periodic eye exams DRUG THERAPY Streptomycin Aminoglycoside antibiotic 2 drawbacks *must be given parenterally * has toxic effect on the kidneys Monitor u/o, weight, renal function studies Ototoxicity NURSING INTERVENTIONS 1. Hospitalization 2. Respirator masks used when entering the client’s room 3. Instruct client to cough into tissues & wear a mask when leaving the hospital room 4. Monitor the client’s respiratory status, breath sounds, O2 saturation & document NURSING INTERVENTIONS 5. Administer medications as ordered by MD 6. Encourage high-protein & high CHO foods 7. Monitor laboratory results periodically -- (liver function test) 8. Educate the client about strict compliance with medications 9. Inform client about adverse effects of medications 10. Encourage close follow-up THE END PLEASE REVIEW & STUDY