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Infection: Pneumonia and Influenza Lewis ch. 27, 28 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Objectives (pp.5-6) • The Infection concept will be reviewed in this presentation. • Pneumonia and influenza are the exemplars for the Infection concept and are included in this presentation. 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. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chain or Cycle of Infection • • • • • • 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) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Defenses Against Infection • Normal body flora • Body system defenses • Inflammatory response Vascular and cellular responses Formation of exudates Tissue repair Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. The Susceptible Host • • • • • Changes in normal body flora Breakdown in body systems Flawed inflammatory response Problems with tissue repair Stressors Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Appearance of Infection • Localized Warmth Swelling Redness Drainage Pain/tenderness Restricted movement • Systemic Changes in VS Fatigue N/V/D Malaise Lymphadenopathy Confusion Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Interventions • • • • • • Protect clients Educate clients Maintain own worker health Give antimicrobials Be aware of S&S of infection Practice medical and surgical asepsis Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Exemplar # 1: Influenza p. 538 • Caused by different strains of A or B virus • A leading cause of morbidity and mortality; most deaths occur in over 60 age group • Most could be prevented with vaccinationneed new one each year. Inactivated in >50 and live, attenuated in younger groups • Table 27-3, p. 539 shows hi-risk groups and those who could transmit to them Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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 • Encourage flu and PN vaccines esp. in highrisk groups Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Exemplar # 2: Pneumonia (PN) p. 561 • Acute inflammation of lung caused by microbial organism • Leading cause of death in the United States from infectious disease • Most common type is pneumococcal (strep) • Causes: aspiration, inhalation of microbes, or spread thru blood from a primary infection site Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. LLL Pneumonia QuickTime™ and a YUV420 codec decompressor are needed to see this picture. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Risk Factors • Impaired immunity • ↓ Cough and epiglottal reflexes • Impaired mucociliary mechanism by pollutants, infection, intubation • Malnutrition • Increased presence of bacteria in leukemia, diabetes, alcoholism Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of PN • Community-acquired (CAP)—usually pneumococcal • Hospital-acquired • Aspiration • Opportunistic (fungal, PCP) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pathophysiology of Pneumococcal Pneumonia • Strep enters respiratory tract and releases toxins causing inflammation • In alveoli, serous fluid is released and bacteria multiply rapidly in the fluid • Capillaries dilate adding red cells to alveolar fluid along with bacteria, white cells, and fibrin (red hepatization) • Consolidation of white cells and fibrin in one part of lung (gray hepatization) • Resolution Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations • CAP symptoms Sudden onset of fever (atypical-gradual) Chills Cough productive of purulent sputum (atypical-dry cough) Pleuritic chest pain Confusion or stupor in elderly/debilitated Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations • Lung examination findings Dullness to percussion ↑ Fremitus Bronchial breath sounds Crackles Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Tests • • • • • • Chest x-ray CBC, differential Chemistries (if indicated) Gram stain and C&S of sputum Pulse oximetry and/or ABGs Blood cultures Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Most Common Complications • Pleurisy—pain with inflammation • Atelectasis—partial or full (partial may clear with C&DB) • Pleural effusion—fluid in pleural space. Usually is sterile and reabsorbed in 1 to 2 weeks or may require thoracentesis. Occurs in 40% of cases. • Bacteremia (sepsis) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Atelectasis Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pleural Effusion Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Other Complications • Pericarditis and Endocarditis Spread of microorganism to heart • Meningitis Patient with pneumonia who is disoriented, confused, or somnolent should have lumbar puncture Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care • Three-step approach to treatment Assess ability to treat at home Calculate Pneumonia Severity Index (PSI) Table 28-3, p. 562 Clinician decision for inpatient or outpatient Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care • • • • • • • Antibiotic therapy Oxygen for hypoxemia Analgesics for chest pain Antipyretics for fever May need nebulizer treatments Fluid intake at least 3 L per day Caloric intake at least 1500 per day Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care • Influenza drugs and influenza vaccine • Pneumococcal vaccine indicated for those at risk: • Chronic illness such as heart and lung disease, diabetes mellitus • Recovering from severe illness • 65 or older • In long-term care facility Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment on Admission: Subjective Info • • • • • • Lung cancer COPD Diabetes mellitus Debilitating disease Malnutrition AIDS Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. History cont’d • Use of antibiotics, corticosteroids, chemotherapy, immunosuppressants • Recent abdominal or thoracic surgery • Smoking • Alcoholism • Respiratory infections Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. History cont’d • • • • • • • • Prolonged bed rest Dyspnea Nasal congestion Pain with breathing Sore throat Myalgias Fever Restlessness Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Objective Nursing Assessment • • • • • • • Splinting affected area Tachypnea Asymmetric chest movements Use of accessory muscles Crackles Green or yellow sputum Tachycardia Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment • • • • • Changes in mental status Leukocytosis Abnormal ABGs Pleural effusion Pneumothorax (total atelectasis) on x-ray Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Analysis of Info: Formulating Nursing Diagnoses • • • • Ineffective breathing pattern Ineffective airway clearance Acute pain Imbalanced nutrition: Less than body requirements • Activity intolerance • Deficient fluid volume Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Planning: Outcome Criteria • • • • • Clear breath sounds Normal breathing patterns No signs of hypoxia Normal chest x-ray No complications related to pneumonia Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Interventions & Rationales • Maintain ongoing respiratory assessment: to prevent complications • Prompt treatment of URIs: to prevent spread • Increase fluid volume: to liquefy secretions and prevent dehydration • Strict asepsis: to prevent spread • Monitor and control pain: to promote increased activity Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Interventions & Rationales • Initiate and maintain oxygen supplementation: to improve oxygen status • Assist patients with turning and deep breathing, IS, and ambulation q2h: mobilize secretions • HOB up/overbed table positioned: improves oxygen status • Assist patients at risk for aspiration with eating, drinking, taking meds: to prevent aspiration and subsequent pneumonia Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Interventions & Rationales • Emphasize need to take course of medication(s): to ensure effective tx of current infection and prevent resistant strains from developing • Teach drug–drug, drug-food interactions: to ensure drug is as effective as possible • Encourage those at risk to obtain influenza and pneumococcal vaccinations and other preventative techniques: to prevent recurrence • Teach nutrition, hygiene, rest, regular exercise: to maintain natural resistance Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Evaluation • • • • • • • • 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 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Comparison of Nursing Care • Remember the concept of infection: regardless of where the infection is or what organism causes it, people have the same general manifestations: fever, malaise, myalgia, and sometimes elevated labs for systemic; and redness, swelling, and pain for localized infections. • We do treat viruses consistently with antivirals and other infections with other antimicrobials. • Nursing care is very similar: provide supportive care for symptoms, give meds, promote health, and do teaching. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.