Download Pneumonia

Infection: Pneumonia, Influenza,
Meningitis
Brunner ch. 23, 64, 70
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Infection Concept Review
• Infection—disease state resulting from the
presence of pathogens in the body. May
be acute or chronic
• Pathogens—disease-producing
microorganisms—bacteria, viruses, fungi,
parasites. The presence of these
pathogens usually produces an
inflammatory response as well.
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Course of Infection
• Incubation period—time between entry of
pathogen and onset of sx
• Prodromal stage—nonspecific sx, most
infectious
• Illness stage—worst sx
• Convalescence—recovery time
• Length of each stage depends on type of
infection—may be local or systemic
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Chain or Cycle of Infection
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Infectious agent (pathogen)
Reservoir (place it lives)
Portal of exit (orifices or breaks)
Mode of transmission (how it moves)
Portal of entry (orifices or breaks)
Susceptible host (stressors)
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Defenses Against Infection
• Normal body flora
• Body system defenses
• Inflammatory response
– Vascular and cellular responses
– Formation of exudates
– Tissue repair
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The Susceptible Host
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Changes in normal body flora
Breakdown in body systems
Flawed inflammatory response
Problems with tissue repair
Stressors
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Clinical Appearance of Infection
• Localized
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Warmth
Swelling
Redness
Drainage
Pain/tenderness
Restricted movement
• Systemic
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Changes in VS
Fatigue
N/V/D
Malaise
Lymphadenopathy
Confusion
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Laboratory Data
• WBC (Totals and differentials) Amount
elevated usually indicates severity.
– “Left shift” (high neutrophils) usually indicates
a severe infection.
– Total elevation not seen in viral infections.
May see a “right shift” (high lymphocytes) in
some viral infections
• +Cultures and gram stains
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Interventions
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Protect clients
Educate clients
Maintain own worker health
Give antimicrobials
Be aware of S&S of infection
Practice medical and surgical asepsis
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Exemplar # 1: Influenza (205, 221-222,
2122, 2131)
• Acute viral respiratory disease
• Caused by different strains of A, B, or C virus
• Flu shot is made from 2 A strains and 1 B
strain
• Spread by droplet. Incubation 24-72h
• A leading cause of morbidity and mortality;
most deaths occur in over 60 age group.
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High-risk Groups
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Any age with chronic illness
Residents of long term care
Immunocompromised
Pregnant
Also recommended for 6 mo-5 yrs, over 50
Required for healthcare workers
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Manifestations
• Abrupt onset with cough, fever, myalgia, HA,
sore throat
• Resolution within 7d unless complications
develop. Most common complication is PN
• Convalescent phase may include malaise and
hyperactive airways
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Collaborative Care
• Relieve sx with mild analgesics and cough meds and
prevent pneumonia.
• Antivirals shorten course of illness and inhibit spread
of virus to other cells—should be given within 2d of
onset of sx or can be given prophylactically.
• Older adults may be hospitalized. Vaccine is less
effective in this group.
• Encourage flu vaccine esp. in high-risk groups.
• Reactions to vaccine required to be reported.
• Pandemics should be planned for by HC agencies.
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Exemplar # 2: Pneumonia (PN) p. 554
• Acute inflammation of lung caused by
microbial organism
• Leading cause of death in the United States
from infectious disease
• Most common type is streptococcal
• Causes: aspiration, inhalation of microbes, or
spread thru blood from a primary infection
site
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LLL Pneumonia
QuickTime™ and a
YUV420 codec decompressor
are needed to see this picture.
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Risk Factors
• Impaired immunity
• Chronic respiratory conditions
• Hospitalization (HCPs, respiratory equipment, NG or
ET tubes)
• Immobility
• Smoking/pollution
• Meds that cause respiratory depression
• ↓ Cough and epiglottal reflexes
• Malnutrition
• Pneumonitis
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Types of PN
• Community-acquired (CAP)—usually
streptococcal. Occurs in community or within
48h after hospitalization
• Hospital-acquired (HAP)—occurs after 48h.
Most common are the antibiotic-resistant
organisms
• Aspiration—usually streptococcal (normal
flora in oropharynx)
• Pneumonia in the Immunocompromised Host
(formally Opportunistic)—fungal, PCP, TB
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Pathophysiology of Pneumonia
• Organism enters respiratory tract and releases toxins
causing inflammation
• In alveoli, serous fluid and mucus are released and
bacteria multiply rapidly in the fluid
• Capillaries dilate adding red cells to alveolar fluid
along with bacteria, white cells, and fibrin
• Venous blood entering the lungs doesn’t get proper
oxygenation leading to hypoxemia
• Lobar involves entire lobe; bronchopneumonia is
patchy
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Clinical Manifestations
• Common to most
– Sudden onset of fever, chills
– Tachycardia, tachypnea, orthopnea
– Cough productive of purulent sputum unless
dehydration is present. Color of sputum not
necessarily indicative of organism
– Pleuritic chest pain
– Confusion or stupor in elderly or symptoms may
not be readily apparent
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Clinical Manifestations
• Lung examination findings
– Dullness to percussion
– ↑ Fremitus (vibration)
– Usually fine crackles
– Bronchial breath sounds—high-pitched and loud,
normally only heard around the trachea. No air
exchange in the alveoli causes no vesicular sounds
to be heard and the high-pitch sound that is heard
is from the tracheobronchial tree and being
transmitted to the chest wall.
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Diagnostic Tests
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Chest x-ray
CBC, differential
Chemistries (if indicated)
Gram stain and C&S of sputum
Pulse oximetry and/or ABGs
Blood cultures
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Most Common Complications
• Pleurisy
• Atelectasis
• Pleural effusion—purulent fluid in pleural
space. Usually is sterile and reabsorbed in 1 to
2 weeks or may require thoracentesis. Occurs
in 40% of cases.
• Sepsis
• Shock and respiratory failure (delayed or
inadequate tx or at risk populations)
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Atelectasis
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Pleural Effusion
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Collaborative Care
– Assess ability to treat at home.
– HCP should check with Case Management to see if
patient meets inpatient criteria.
– Ultimately, HCP can decide, but hospital may not
get paid for inpatient stay.
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Collaborative Care
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Antibiotic therapy (only if bacterial)
Oxygen for hypoxemia
Analgesics for chest pain
Antitussives for cough
Antipyretics for fever
May need nebulizer treatments
Fluid intake at least 3 L per day
Caloric intake at least 1500 per day (high
calorie fluids if severe anorexia is present)
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Commonly Used Antibiotics
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Penicillins—amoxicillin, penicillin-G
Cephalosporins—Ancef, Rocephin
Methicillin resistant—vancomycin, linzeloid
Fluoroquinolone—Cipro (tendonitis)
Levofloxacin—Levaquin (“)
Macrolides—azithromycin, erythromycin
Antivirals—Tamiflu, Relenza
Antifungals—v
Anti-TB—isoniazid + rifampin
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Preventative Care
• Influenza drugs and influenza vaccine
• Pneumococcal vaccine indicated for those at risk:
• Chronic illness such as heart disease, lung disease, or
diabetes mellitus, or asplenia
• Recovering from severe illness
• 65 or older
• In long-term care facility or other environments that
may increase risk
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Nursing Diagnoses
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Impaired gas exchange
Ineffective breathing pattern
Ineffective airway clearance
Impaired tissue perfusion
Acute pain
Imbalanced nutrition: Less than body requirements
Activity intolerance
Deficient fluid volume
Deficient knowledge
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Planning: Outcome Criteria
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Clear breath sounds
Normal breathing patterns
No signs of hypoxia
Normal chest x-ray
No complications related to pneumonia
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Nursing Management
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Admission history, med list, and physical assessment
Identify risk factors
Labs and radiology
Monitor O2 status and oxygen therapy
Monitor effects of respiratory therapy
HOB elevated
Promote C&DB and use of IS
Monitor IV fluids and encourage po fluids
Administer and evaluate antibiotic therapy
Balance rest and activity
Evaluate activity tolerance
MonitorCopyright
for changes
inMosby,
status
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Patient Education
• Causes
• Individual risk factors and how to minimize
risk such as stopping smoking
• Managing symptoms
• Importance of med therapy
• S & S to report
• Keeping FU appts
• May need to teach IV antibiotic therapy
• Vaccines
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Evaluation
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Dyspnea not present
SpO2 ≥ 95
Free of adventitious breath sounds
Clears sputum from airway
Reports pain control
Verbalizes causal factors
Adequate fluid and caloric intake
Performs activities of daily living
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Developmental Issues
• Very young and very old are more susceptible to
the complications of PN and influenza. Both can
become ill very quickly and mortality rates are
generally higher
• Both groups also become dehydrated quicker
than adults.
• Remember that elderly may have atypical
symptoms.
• Children have shorter, straighter passageways in
their respiratory system, making spread of
infectious organisms more rapid.
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Cultural and Socioeconomic Issues
• Be sensitive to another cultures need to treat
infections with alternative therapies and
healers: herbal, acupuncture, hot-cold, prayer,
charms, etc.
• Be aware that $ play an important role today
with limited access to health care and expense
of prescriptions. HCPs should try to be
sensitive to what they prescribe.
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Exemplar #3: Meningitis (1950-2)
• Inflammation of the lining around the brain
and spinal cord
• Caused by bacteria or virus
• 80% are caused by the bacteria Streptococcus
pneumoniae and Neisseria meningitides
• Viral infections are usually caused by mumps,
herpes, or mosquitoes or other insects.
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Risk Factors
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Pneumonia
Otitis media
Mastoiditis
URI
AIDS
Lyme Disease
Smoking
Immunosuppression
Crowded living conditions
Facial trauma
Invasive procedures
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Pathophysiology
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Bacteria enters bloodstream
Crosses blood-brain barrier
Invades CSF
Inflammation occurs
IICP results
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Complications
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Vision and hearing impairments
Seizures
Hydrocephalus
Paralysis
Septic shock
Brain damage
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Manifestations
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Fever
HA
Nuchal rigidity
Photophobia
Hemorrhagic rash
Confusion, irritability, lethargy, decreased LOC
+Kernig’s sign—flexed hip and knee cannot be
extended
• +Brudzinski sign—neck flexion causes flexion of the
hips and knees
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Diagnostics
• CT or MRI to detect brain shift
• LP with evaluation of CSF
• Blood cultures
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Preventative Management
• Hib vaccine has almost eradicated Hemophilus
influenza, a past major cause of meningitis in
children.
• Meningococcal vaccine should be given to all
college-bound adolescents, especially those
planning on living in dorms.
• People who have close contact with
meningitis should get Rocephin.
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Medical Management
• IV antibiotic therapy usually with Vancomycin
and a cephalosporin such as Rocephin.
• Decadron steroid therapy decreases swelling
and inflammation
• Antiseizure meds if indicated
• Contact precautions
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Nursing Management
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VS and O2 sat
Neuro checks
Low lights
Administration of meds (antibiotics, antiseizure,
antipyretics, analgesics)
Seizure precautions
Monitor IV therapy and fluid status
Maintain isolation precautions
Prevent complications from decreased mobility
Family support
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