Transcript Pneumonia

Infection: Pneumonia and
Influenza
Lewis ch. 27, 28
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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.
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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 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
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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
• Encourage flu and PN vaccines esp. in highrisk groups
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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
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LLL Pneumonia
QuickTime™ and a
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Risk Factors
• Impaired immunity
• ↓ Cough and epiglottal reflexes
• Impaired mucociliary mechanism by
pollutants, infection, intubation
• Malnutrition
• Increased presence of bacteria in
leukemia, diabetes, alcoholism
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Types of PN
• Community-acquired (CAP)—usually
pneumococcal
• Hospital-acquired
• Aspiration
• Opportunistic (fungal, PCP)
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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
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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
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Clinical Manifestations
• Lung examination findings
 Dullness to percussion
 ↑ Fremitus
 Bronchial breath sounds
 Crackles
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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—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)
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Atelectasis
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Pleural Effusion
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Other Complications
• Pericarditis and Endocarditis
 Spread of microorganism to heart
• Meningitis
 Patient with pneumonia who is
disoriented, confused, or somnolent
should have lumbar puncture
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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
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Collaborative Care
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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
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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
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Nursing Assessment on
Admission: Subjective Info
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Lung cancer
COPD
Diabetes mellitus
Debilitating disease
Malnutrition
AIDS
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History cont’d
• Use of antibiotics, corticosteroids,
chemotherapy, immunosuppressants
• Recent abdominal or thoracic surgery
• Smoking
• Alcoholism
• Respiratory infections
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History cont’d
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Prolonged bed rest
Dyspnea
Nasal congestion
Pain with breathing
Sore throat
Myalgias
Fever
Restlessness
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Objective Nursing Assessment
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Splinting affected area
Tachypnea
Asymmetric chest movements
Use of accessory muscles
Crackles
Green or yellow sputum
Tachycardia
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Nursing Assessment
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Changes in mental status
Leukocytosis
Abnormal ABGs
Pleural effusion
Pneumothorax (total atelectasis) on
x-ray
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Analysis of Info: Formulating
Nursing Diagnoses
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Ineffective breathing pattern
Ineffective airway clearance
Acute pain
Imbalanced nutrition: Less than body
requirements
• Activity intolerance
• Deficient fluid volume
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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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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
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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
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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
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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
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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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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.
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