Transcript Focus on Pneumonia

Nursing Management of Lower
Respiratory Problems
JSB
Acute Bronchitis
• Inflammation of the bronchi
• Supportive treatments
– Fluids
– Rest
– Anti-inflammatory agents
– Cough suppressants
– Antiviral drugs
– Mucolytic medications
Pertussis
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Highly contagious infection
Whooping cough
Gram-negative bacillus
Symptoms same as bronchitis
Treatment is antibiotics
Pneumonia
• Acute inflammation of lung caused by
microbial organism
– Previously, leading cause of death in the United
States from infectious disease
• Discovery of sulfa drugs and penicillin decreased
morbidity and mortality rates.
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Etiology
• Likely to result when defense mechanisms
become incompetent or overwhelmed
• ↓ Cough and epiglottal reflexes may allow
aspiration
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Etiology
• Mucociliary mechanism impaired
– Pollution
– Cigarette smoking
– Upper respiratory infections
– Tracheal intubation
– Aging
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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
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Types of Pneumonia
• Community-acquired pneumonia
– Lower respiratory infection of lung
– Onset in community or during first
2 days of hospitalization
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Types of Pneumonia
• Community-acquired pneumonia
– Highest incidence in midwinter
– Smoking important risk factor
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Types of Pneumonia
• Organisms implicated
– Streptococcus pneumoniae
– Haemophilus influenzae
– Legionella
– Mycoplasma
– Chlamydia
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Types of Pneumonia
• Three-step approach to treatment
– Assess ability to treat at home.
– Calculate PORT (Pneumonia Patient Outcomes
Research Team).
– Make clinician decision for inpatient or outpatient.
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Types of Pneumonia
• HAP, VAP, HCAP
– HAP: Occurring 48 hours or longer after admission
and not incubating at time of hospitalization
– VAP: Occurring more than 48 hours after
endotracheal intubation
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Types of Pneumonia
• Risk factors for HAP
– Immunosuppressive therapy
– General debility
– Endotracheal intubation
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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
• MDR organisms are major problem in treating
HCAP.
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Types of Pneumonia
• Aspiration pneumonia
– Sequelae occurring from abnormal entry of
secretions into lower airway
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Types of Pneumonia
• Aspiration pneumonia
– Usually with history of loss of consciousness
• Gag and cough reflexes suppressed
– Forms of aspiration pneumonia
• Mechanical obstruction
• Chemical injury
• Bacterial infection
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Types of Pneumonia
• Opportunistic pneumonia
– Patients at risk
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Severe protein-calorie malnutrition
Immune deficiencies
Chemotherapy/radiation recipients
Long-term corticosteroid therapy
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Types of Pneumonia
• Causes of opportunistic pneumonia
– Bacterial and viral causative agents
– Pneumocystis jiroveci (PCP)
– Cytomegalovirus
– Fungi
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Types of Pneumonia
• Clinical manifestations of PCP
– Fever
– Tachypnea
– Tachycardia
– Dyspnea
– Nonproductive cough
– Hypoxemia
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Pathophysiology
• Stage 1: Congestion from outpouring of fluid
to alveoli
– Organisms multiply.
– Infection spreads.
– Interferes with lung function
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Pathophysiology
• Stage 2: Red hepatization
– Massive dilation of capillaries
– Alveoli fill with organisms, neutrophils, RBCs, and
fibrin.
• Causes lungs to appear red and granular, similar to liver
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Pathophysiology
• Gray hepatization
– ↓ Blood flow
– Leukocyte and fibrin consolidate in affected part
of lung.
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Pathophysiology
• Resolution
– Resolution and healing if no complications
– Exudate lysed and processed by macrophages
– Tissue restored
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Pathophysiologic Course of
Pneumococcal Pneumonia
Fig. 28-1. Pathophysiologic course of pneumococcal pneumonia.
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Clinical Manifestations
• CAP symptoms
– Sudden onset of fever
– Shaking chills
– Shortness of breath
– Cough productive of purulent sputum
– Pleuritic chest pain
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Clinical Manifestations
• Physical examination findings
– Dullness to percussion
– ↑ Fremitus
– Bronchial breath sounds
– Crackles
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Clinical Manifestations
• Atypical manifestations
– Gradual onset
– Dry cough
– Extrapulmonary manifestations
– Crackles
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Clinical Manifestations
• Initial manifestations are highly variable in
viral pneumonia.
– Primary pneumonia can be caused by influenza
viral infection.
– Can be a complication of systemic viral disease
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Complications
• Pleurisy
• Pleural effusion
– Usually is sterile and reabsorbed in 1 to 2 weeks
or requires thoracentesis
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Complications
• Atelectasis
– Usually clears with cough and deep breathing
• Bacteremia
– Bacterial infection in the blood
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Complications
• Lung abscess
– Seen when caused by S. aureus and
gram-negative pneumonias
• Empyema
– Requires antibiotics and drainage of exudate
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Complications
• Pericarditis
– Spread of microorganism to heart
• Meningitis
– Patient who is disoriented, confused, or
somnolent should have lumbar puncture.
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Complications
• Endocarditis
– Microorganisms attack endocardium and heart
valves.
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Diagnostic Tests
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History
Physical examination
Chest x-ray
Gram stain of sputum
Sputum culture and sensitivity
Pulse oximetry or ABGs
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Diagnostic Tests
• CBC, differential, chemistries
• Blood cultures
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Collaborative Care
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Antibiotic therapy
Oxygen for hypoxemia
Analgesics for chest pain
Antipyretics
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Question
• A patient diagnosed with a community-acquired
pneumonia is being admitted to the medical unit.
Which nursing intervention has the highest
priority?
– A. Administer the ordered oral antibiotic STAT.
– B. Order the meal tray to be delivered as soon as
possible.
– C. Obtain a sputum specimen for culture and
sensitivity.
– D. Have the unlicensed assistive personal weigh the
client.
Collaborative Care
• Fluid intake at least 3 L per day
• Caloric intake at least 1500 per day
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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
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Nursing Assessment
• History
– Lung cancer
– COPD
– Diabetes mellitus
– Debilitating disease
– Malnutrition
– AIDS
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Nursing Assessment
• History
– Use of antibiotics, corticosteroids, chemotherapy,
or immunosuppressants
– Recent abdominal or thoracic surgery
– Smoking
– Alcoholism
– Respiratory infections
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Nursing Assessment
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Prolonged bed rest
Dyspnea
Nasal congestion
Pain with breathing
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Nursing Assessment
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Sore throat
Muscle ache
Fever
Restlessness
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Nursing Assessment
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Splinting affected area
Tachypnea
Asymmetric chest movements
Use of accessory muscles
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Nursing Assessment
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Crackles
Green or yellow sputum
Tachycardia
Changes in mental status
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Nursing Assessment
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Leukocytosis
Abnormal ABGs
Pleural effusion
Pneumothorax on x-ray
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Nursing Diagnoses
• Ineffective breathing pattern
• Ineffective airway clearance
• Acute pain
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Nursing Diagnoses
• Imbalanced nutrition: Less than body
requirements
• Activity intolerance
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Planning
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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 Implementation
• Teach nutrition, hygiene, rest, regular exercise
to maintain natural resistance.
• Prompt treatment of URIs
• Strict asepsis
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Nursing Implementation
• Encourage those at risk to obtain influenza
and pneumococcal vaccinations.
• Reposition patient every 2 hours.
• Elevate head of bed 30 to 45 degrees for
patients with feeding tube.
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Nursing Implementation
• Assist patients at risk for aspiration with
eating, drinking, and taking medications.
• Assist immobile patients with turning and
deep breathing.
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Nursing Implementation
• Emphasize need to take course of
medication(s).
• Teach drug–drug interactions.
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Evaluation
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Dyspnea not present
SpO2 ≥ 95
Free of adventitious breath sounds
Clear sputum from airway
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Evaluation
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Reports pain control
Verbalizes causal factors
Adequate fluid and caloric intake
Performs activities of daily living
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Question
During the assessment of a patient with pneumonia, the nurse
suspects the development of a pleural effusion upon finding:
1. A barrel chest.
2. Paradoxical respirations.
3. Hyperresonance on percussion.
4. Localized absence of breath sounds.
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Case Study
• 88-year-old woman who lives alone
• Feeling weaker over past 2 days, and last night
became confused and disoriented
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Case Study
• Housekeeper notified her daughter, who
brought her to the clinic.
• She complains of coughing over the past 3
days but has no other history.
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Case Study
• Examination findings
– Bronchial breath sounds and dullness of left
posterior lung base with egophony
– O2 Sat 87%
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Case Study
• Examination findings
– WBC 18,000/µL
– Segs 85%
– Bands 15%
– PA/lat chest x-ray: Lobar infiltrate
– Sputum gram stain: Gram-positive diplococci,
many WBCs
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Discussion Questions
1. What are the risk factors for her developing
pneumonia?
2. What is her priority of care?
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Discussion Questions
3.
What important teaching should you
provide to the patient and family?
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Tuberculosis
• Infectious diseases caused by mycobacterium
tuberculosis
• Gram positive
• Acid – fast bacillus
• Spread via airborne droplets
– Contact with in 6 inches of persons mouth
Clinical Manifestation
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Classification -Table 28-8
Positive skin test
Fatigue
Malaise
Anorexia
Unexplained weight loss
Low grade fever
Night sweats
Mucopurulent sputum
HIV high risk
Complications
• Miliary TB
– Spread via blood stream to all body organs
• Pleural effusion and empyema
• Tuberculosis pneumonia
• Other organ involvement
Diagnostic Studies
• Tuberculin Skin Test
• Chest x-ray
• AFB test (acid fast bacilli)
Collaborative Care
• Drug therapy
– Isoniazid
– Rifampin
– Pyrazinamide
– Ethambutol
– Rifabutin
– Rifapentine
– Fluoroquinolones
– Table 28-11
Nursing Management
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Ethical dilemmas
Health promotion
Acute intervention
Ambulatory and home care
Fungal infections of the lung
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Table 28-14
Candidiasis
Pheumosystis Pneumonia (PCP)
Amphotericin B standard of care
Chest Trauma and Thoracic
Injuries
JSBrinley, RN, MSN/Ed, CNE
Types
• Blunt
– Steering-wheel
– Shoulder-harness seat belt
– crush
• Penetrating
– Stab wound
– Gunshot wound
Types of Pneumothorax
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Closed pneumothorax
Open pneumothorax
Tension pneumothorax
Hemothorax
Chylothorax
Manifestations
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Tachycardia
Dyspnea
Hypoxemia
Chest pain
Cough
Absent breath sounds
CXR shows the presence of air or fluid in the
plural space and reduction in lung volume
Question
• The client is admitted to the emergency
department with chest trauma. Which
signs/symptoms indicate to the nurse the
diagnosis of pneumothorax
• A. Bronchovesicular lung sound and
bradypnea.
• B. Unequal lung expansion and dyspnea.
• C. Frothy, bloody sputum and consolidation.
• D. Barrel chest and polycythemia
Collaborative Care
• Medical emergency!
• Thoracentesis
• Chest tube insertion and water seal drainage
system
Fractured Ribs
• Most common type of chest injury resulting
from blunt trauma
– Complication is pneumonia from atelectasis
• Flail chest
– Fracture of two or more ribs
– Apparent on visual examination
– Asymmetric and uncoordinated chest movement
– Treatment is mechanical ventilation
Chest tubes and Pleural Drainage
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Chest tube insertion
Flutter or heimlich valve
Plural drainage
Three compartments
– Collection chamber
– Water-seal chamber
– Suction control chamber
Nursing Management of Chest
Drainage
• Table 28-23
• Know this table!
Question
• The client had a right-sided chest tube
inserted two (2) hours ago for a
pheumothorax. Which action should the
nurse implement if there is no fluctuation
(tidaling) in the water-seal compartment?
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Obtain an order for a STAT chest x-ray.
Increase the amount of wall suction.
Check the tubing for kinks or clots.
Monitor the client’s pulse oximeter reading.
Question
• Which assessment data indicate to the nurse the
chest tubes inserted three (3) days ago have been
effective in treating the client with a
hemothorax?
– A. Gentle bubbling in the suction compartment.
– B. No fluctuation (tidaling) in the water-seal
compartment.
– C. The drainage compartment has 250 mL of blood
– D. The client is able to deep breathe without any
pain.
Question
• The nurse is caring for a client with a right-sided
chest tube secondary to a pneumothorax. Which
interventions should the nurse implement when
caring for this client? Select all that apply
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A. Place the client in the low fowler’s position.
B. Assess chest tube drainage system frequently.
C. Maintain strict bedrest for the client.
D. Secure a loop of drainage tubing to the sheet.
E. Observe the site for subcutaneous emphysema.
Chest Surgery
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Baseline assessment
Encourage patient to stop smoking
Teach deep breathing and cough exercises
Explain purpose of chest tube and oxygen
supplement
Types
• Thoracotomy
• Video-Assisted Thoracic Surgery (VAT)
Post-Op Care
• 28-2 pg 574
Plural Effusion
• Abnormal collection of fluid in the plural space
• Empyema
• Manifestations
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Dyspnea
Decreased movement of the chest wall
Pain
Absent breath sounds
Fever night sweats, cough and weight loss
CXR reveal volume and location of the effusion
Pulmonary Edema
• Abnormal accumulation of fluid in the alveoli and
interstitial spaces of the lungs
• Causes
– Heart failure
– Overhydration with intravenous fluids
– Hypoalbuminemia
• Nephrotic syndrome, hepatic disease, nutritional disorders
– Altered capillary permeability of lungs
• Toxins, inflammation, severe hypoxia, near drowning
– Malignancies of the lymph system
– Respiratory distress syndrome
– Unknown causes
Pulmonary Embolism
• Is a blockage of pulmonary arteries by a
thrombus, fat, air, or tumor tissue
• Causes
– DVT
– Atrial fibrillation
– Fat emboli
– Bacterial vegetations
– Amniotic fluid
– Tumors
Pulmonary Embolism
– Most common risk factors
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Immobility
Surgery
Stroke
Paresis
Paralysis
Obesity
Smoking
hypertension
Manifestation of PE
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Dyspnea
Chest pain
Hemoptysis
Hypoxemia
Abrupt hypotension
Vague symptoms
Can be difficult to diagnose
Complications Of PE
• Pulmonary infarction
• pulmonary hypertension
– Diagnostic studies
• CT
• V/Q
• D-dimer
– Measures the amount of cross-linked fibrin fragments
Treatment of PE
• See pg 579