Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Focus on Pneumonia (Relates to Chapter 28, “Nursing Management: Lower Respiratory Problems,” in the textbook) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pneumonia • Acute inflammation of lung caused by microbial organism Leading cause of death in the United States from infectious disease • Discovery of sulfa drugs and penicillin decreased morbidity and mortality rates Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology • Likely to result when defense mechanisms become incompetent or overwhelmed Predisposing Factors • Depression of cough and gag reflexes • Decreased LOC • Tracheal intubation • Impaired mucociliary mechanism • Immunosuppression • Age • Bedrest Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology • Three ways organisms reach lungs Aspiration from nasopharynx or oropharynx Inhalation of microbes such as Mycoplasma pneumoniae Hematogenous spread from primary infection elsewhere in body Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pathophysiology of Pneumococcal Pneumonia Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia • Community-acquired pneumonia Lower respiratory infection of lung Onset in community or during first 2 days of hospitalization Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia • Community-acquired pneumonia 4 million U.S. adults diagnosed yearly Highest incidence in midwinter Smoking important risk factor Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia • Organisms implicated Streptococcus pneumoniae Haemophilus influenzae Legionella Mycoplasma Chlamydia Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia • Three-step approach to treatment Assess ability to treat at home Calculate PORT (Pneumonia Patient Outcomes Research Team) severity index (table 28-3) Clinician decision for inpatient or outpatient Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia • Hospital-acquired pneumonia Occurring 48 hours or longer after admission and not incubating at time of hospitalization Second most common nosocomial infection Includes ventilator - associated PNA and healthcare-associated PNA Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia • Risk factors for HAP Immunosuppressive therapy General debility Endotracheal intubation • Higher risk of MDR organism Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia • Treatment is based on Known risk factors Severity of illness Early (5 days post admission) or late (more than 5 days post admission) onset Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia Aspiration pneumonia Sequelae occurring from abnormal entry of secretions into lower airway May have a history of loss of consciousness • Gag and cough reflexes suppressed Other risk factors specific to aspiration PNA • Tube feeding Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia • Aspiration pneumonia Forms of aspiration pneumonia • Mechanical obstruction • Chemical injury • Bacterial infection Prevention! Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia • Opportunistic pneumonia Bacterial and viral causative agents • Pneumocystis jiroveci (PCP) • Cytomegalovirus • Fungi Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia • Opportunistic pneumonia Patients at risk • Severe protein-calorie malnutrition • Immune deficiencies • Chemotherapy/radiation recipients • Transplant recipients Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pathophysiologic Course of Pneumococcal Pneumonia Fig. 28-1 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations • Typical manifestation of PNA Sudden onset of fever Chills Cough productive of purulent sputum Pleuritic chest pain Malaise and fatigue Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations • Physical examination findings Dullness to percussion Bronchial breath sounds Crackles or rhonchi Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations • Atypical manifestations of PNA Gradual onset Dry cough Extrapulmonary manifestations • Fatigue, myalgias, sore throat, vomiting, diarrhea Confusion or stupor may manifest in older or debilitated patient Patients with infection from Staphylococcus aureus may present only with dyspnea and fever while lung tissue is necrotized Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications • Pleurisy • Pleural effusion Usually is sterile and reabsorbed in 1 to 2 weeks or requires thoracentesis Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications • Atelectasis Collapses alveoli Usually clears with cough and deep breathing • Bacteremia Bacterial infection in the blood High mortality rate Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications • Lung abscess Seen when caused by S. aureus and gram-negative pneumonias • Empyema Requires antibiotics and surgical drainage of exudate Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications • Pericarditis Spread of microorganism to heart • Meningitis Patient who is disoriented, confused, or somnolent should have lumbar puncture Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications • Endocarditis Microorganisms attack endocardium and heart valves Manifestations similar to bacterial endocarditis Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Tests • • • • • • History Physical examination Chest x-ray Gram stain of sputum Sputum culture and sensitivity Pulse oximetry or ABGs Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Tests • CBC, differential, chemistries • Blood cultures Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care • Antibiotic therapy CAP is usually treated empirically First line is a macrolide or doxycyline Other drugs for present comorbidities HAP and aspiration PNA often require longer therapy and multiple drugs • Oxygen for hypoxemia • Analgesics for chest pain • Antipyretics Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care • Fluid intake at least 3 L per day, as able • Caloric intake at least 1500 per day Small, frequent meals may be better tolerated due to dyspnea and fatigue Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care • 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 • Influenza vaccine Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment • History Lung cancer COPD Diabetes mellitus Debilitating disease Malnutrition AIDS Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment • History Use of antibiotics, corticosteroids, chemotherapy, or immunosuppressants Recent abdominal or thoracic surgery Smoking Alcoholism Respiratory infections Prolonged bedrest Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment • Symptoms Cough, sputum, SOB, DOE, fever, chills, fatigue, malaise, anorexia, nasal congestion Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment • Signs Fever Splinting affected area Tachypnea, asymmetric chest movements, use of accessory muscles Crackles, rhonchi, friction rub, dullness to percussion Sputum color and amount Tachycardia Altered level of consciousness Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment • Leukocytosis • Abnormal ABGs Pa02 PaC02 pH • Xray findings Infiltrate(s) Pleural effusion Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Diagnoses • • • • Ineffective breathing pattern Ineffective airway clearance Acute pain Imbalanced nutrition: Less than body requirements • Activity intolerance Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation • Health Promotion Teach nutrition, hygiene, rest, regular exercise to maintain natural resistance Prompt treatment of URIs Identification of at risk individuals Encourage those at risk to obtain influenza and pneumococcal vaccinations Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation • Acute interventions Reposition patient at least q2h ATS recommends intubated patients be placed in semi Fowler’s position - HOB should be >=30 degrees Consider “good lung down” Prompt collection of specimens and initiation of antibiotics (4 hrs of arrival) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation • Oxygen administration as needed • Monitor vitals signs, lung sounds, work of breathing , oxygen saturation • Assist patients at risk for aspiration with eating, drinking, and taking medications • Assist immobile patients with turning and deep breathing Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation • Emphasize need to take course of medication(s) • Teach drug–drug interactions • Monitor for adverse drug reactions 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 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Evaluation • • • • Reports pain control Verbalizes causal factors Adequate fluid and caloric intake Perform activities of daily living Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.