Med Surg - Chapter 31 Patients with Infectious Respiratory Problems (1)

A 70-year-old client has a complicated medical history including chronic obstructive pulmonary disease (COPD). Which client statement indicates the need for further teaching about the disease?

"I am here to receive the yearly pneumonia shot again." Clients 65 years and older, as well as those who have chronic health problems, should be encouraged to receive the pneumonia vaccine, which is not given annually but only once. Older clients are encouraged to receive a flu shot annually because the vaccine changes, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. New recommendations from the Centers for Disease Control and Prevention (CDC) for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.

ethambutol (EMB)

- inhibits bacterial rna synthesis, suppressing grwoth, thus it must be taken with another anti tb drug -no alcohol -changes in vision? blurred? visual fields? eyes -ever had gout? -take 8 ox of fluid

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incidence

-9.6 million sick with tb worldwide and 1.5 tb deaths - 9412 reports in the US. CA, TX, NY, FL 1/2 the cases

chest xray

-active and old tb infection: old you would see the scarring and with active you would notice some inflammation - initiate after a positive mantoux test - detects active tb or old, inflammation and healed lesions - hiv infected people= normal or lymph node enlargement and lung infiltrates

isoniazid (inh)

-bactericidal and inhibits growth of mycobacteria by preventing synthesis of mycolic acid in the cell wall. - empty stomach -hepatotoxicity (jaundice, anorexia, malaise, fatigue, nausea) -vitamin B6 (pyridoxine) is used to prevent neurotoxicity -liver function testing should be completed prior to admin. -no alcohol

rifampin (RIF)

-bacteriostatic and bactericidal antibiotic that inhibits dna dependent rna polymerase activity in susceptible cells. -orange tinged secretions -report signs of yellow skin, pain or swelling joints, loss of appetite -oral contraceptives are a no go -dont touch your contacts

risk factors

-frequent and close contact with someone that has it -lower social class and homelessness -hiv, chemotherapy, kidney disease, dm, crohns disease -poorly ventilated and crowded enviroments -advanced age and recent travel to other areas where tb is an endemic -immigration from Mexico, Philippines, Vietnam, china, japan, eastern Mediterranean -substance use, health care occupation

pyrazinamide PZA

-hepatotoxicity -history of gout? (adverse effect of nongouty polyarthralgias) - drink glass of water with this -yellow skin? painful joints? -no alcohol

health promotion and disease prevention

-high risk areas screened yearly -family members of someone with tb get screened -slow onset, might not be aware until symptoms and disease is advanced. cough, chest pain, weakness, weight loss, anorexia, hemoptysis, dyspnea, fever, night sweats, or chills -latent tb is when you are exposed to tb but do not have clinical symptoms. your body fought it off but did not expel the bacteria. it just sits there waiting for you to become immunicompromised.

tuberculosis

-highly communicable -bacterial infection: mycobacterium tuberculosis -slow growing, acid fast rod transmission include: aerosolization : airborne could be coughing, whistling, singing, sneezing, laughing

active tb disease

-immune response not adequate -bacilli multiply (become active) -progress from ltbi to active tb disease -can develop soon after initial infection or later due to weakened immune system

drug therapy

-inh and rifampin throughout therapy, pyrazinamide added for first 2months, ethambutol is recommend fourth drug in therapy. - rifater = inh+pza+rif

isoniazid (INH)

-kills actively growing tb outside the cell and inhibits growth -empty stomach and avoid antacids -multivitamins while on this drug -NO ALCOHOL -darkened urine? yellow sclera or skin or brusing

pyrazinamide (PZA)

-kills organisms residing within macrophages -ever had gout? -8 oz of water when taking this tablet -protective clothing when outdoors (photosensitivty) -no alcohol -yellow tint? dark urine? bruising?

rifampin (RIF)

-kills slow growing organisms -expect staining of skin and urine reddish tint -women alternate conception other than oral 1mo post drug -no alcohol -darkened urine? yellow appearance? bruise and bleed

combination therapy

-most effective treatment -prevents transmission -organism sensitivity -destroys organisms as fast as possible -emergence of drug resistant organisms -duration of 6 months on medications

TB general information

-mycobacterium tuberculosis - aerosolization (airborne route) -body encases the TB bacillus with collagen and other cells. this appears as a ghon tubercle on a chest xray - difference from having tb latent and active tb

tuberculosis risk factors

-north America -constant contact with an ill person -lowered immune function or HIV -crowded living conditions -older homeless people abusers: drug injections -lower socioeconmic groups and foreign immigrants

influencing factors of transmission

-number of organisms expelled in the air -organism concentration -length of exposure time -immune system (is it altered)

client education

-often treated at home so teach about tb -no need for airborne precautions at home because family members have already been exposed -exposed members should test for tb -educate client and family to continued meds for full duration of 6-12 months even up to 2 years with mdrtb -sputum needed every 2-4 weeks to evaluate therapy

tb assessment: history

-past tb exposure - country of origin, travel to foreign country -prior tb results and BCG vaccine -chronic disease or tb treatment -social risk factors of transmission of tb -occupational risk factors for transmission of tb -immunosuppresive medications

rifampin RIF bactericidal

-reddish orange tinge to skin, urine, sweat, tears and saliva -avoid alcoholic beverages -report darkened urine, yellow skin or sclera -brusing or bleeding adverse effects = hepatoxicity, nausea, vomit, diarrhea, rash, flu like syndrome, thrombocytopenia

objectives

-relate pathophysiology to clinical manifestations and disease management -examine diagnostics associated with pulmonary tb -analyze clinical manifestations associated with active tb -distinguish between latent tb and active tb -select appropriate nursing interventions in the management of pulmonary tuberculosis -implement infection control practices -examine appropriate nursing interventions associated with pharm therapy for pulmonary tb -integrate health care resources into nursing management of pulmonary tb

physical and clinical manifestations

-slow onset -progressive: fatigue, lethargy, nausea, anorexia, weight loss, low grade fever, irregular menses -vital signs, o2 sat, arterial blood gases, cough, blood streaked sputum?, -chest exam = inconclusive for TB -chest tightness, percussion: dullness -bronchial breathe sounds, crackles, wheezes, increase transmission of spoken or whispered words

INH therapy

-take on empty stomach -avoid antacids -daily multivitamin -avoid alcohol -report darkened urine, yellow skin or sclera -brusing or bleed -pyridoxine (vitamin b6) for peripheral neurpathy -adverse effects = peripheral nerupathy, hepatoxicity, nausea, vomit, rash, cns, hyperglycemia, optic neuritis and visual disturbances

cell mediated immunity

2-10 weeks after infection positive reaction to tb test

cell mediated immunity (body immune by it's damn self)

2-10 weeks after infection positive reaction to tb test

risk reduction

2-3 weeks of drug therapy, clinical improvement of s/s and decrease in acid fast bacilli in sputum (AFB)

ventilator associated pneumonia

48-72 hours after endotracheal intubation

assessment: diagnostics continued

5mm or greater in someone with HIV - equals to a positive reaction -regarding the very old or severely imuniocompromised people: a smaller skin reaction or a negative skin test does NOT mean there is NO TB INFECTION or TB DISEASE

An older client is diagnosed with pneumonia. To assist with comfort during the admission interview, what does the nurse do?

Allow the client to rest at frequent intervals Clients with pneumonia often have pain, fatigue, and dyspnea, which can cause anxiety. The nurse should allow frequent rest periods and should pace the interview and assessment according to the client's fatigue level. The client should be allowed to choose whether to get into bed or remain up in a chair. Test-Taking Tip: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will help keep you calm and give you energy.

An older client with pneumonia has become more confused during the initial assessment. What action will the nurse take initially?

Assess the client's oxygen saturation Clients who have altered level of consciousness are often hypoxic. The nurse should assess oxygen saturation if this occurs to evaluate the possible cause. The nurse may evaluate orientation, but the oxygen saturation is more important and should be performed initially. It is not necessary to notify the Rapid Response Team. A bronchodilator medication is not indicated. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

A client has lobar pneumonia. To help ensure that the expected outcome of maintaining an oxygen saturation of 95% or greater is met, which nursing intervention is most important?

Assist with coughing, deep-breathing, and incentive spirometry every 2 hours Assisting the client to clear the airway of secretions is most important for increasing oxygen saturation because it allows improved oxygenation. Assessing breath sounds and respiratory effort; monitoring vital signs; and obtaining a complete blood count, sputum, and blood cultures are important interventions, but are not the priority.

An older adult resident in a long-term care facility becomes confused and agitated, telling the nurse "Get out of here! You're going to kill me!" Which action will the nurse take first?

Check the resident's oxygen saturation A common reason for sudden confusion in older clients is hypoxemia caused by undiagnosed pneumonia. The nurse's first action should be to assess oxygenation by checking the pulse oximetry. Determining the cause of the confusion is the primary goal of the RN. A complete neurologic examination may give the RN other indicators of the cause for the client's confusion and agitation; this will take several minutes to complete. Administering lorazepam may make the client more confused and agitated because antianxiety drugs may cause a paradoxical reaction, or opposite effect, in some older clients. Depending on the results of the client's pulse oximetry and neurologic examination, this may be an appropriate next step.

The medical-surgical unit has one negative airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room?

Client with possible pulmonary tuberculosis who currently has hemoptysis A client with possible tuberculosis should be admitted to the negative airflow room to prevent airborne transmission of tuberculosis. A client with bacterial pneumonia does not require a negative airflow room but should be placed in Droplet Precautions. A client with neutropenia should be in a room with positive airflow. The client with a right empyema who also has a chest tube and a fever should be placed in Contact Precautions but does not require a negative airflow room.

Which statement about pharyngitis is correct?

Development of stridor or indications of airway obstruction should be considered a medical emergency Pharyngitis can lead to stridor and other indications of airway obstruction due to the swelling of the tissues; this can lead to a medical emergency requiring intubation if not identified early and treated urgently. Diphtheria is a bacterial infection, not viral. Organisms spread throughout the throat can actually be varied and thus a thorough throat culture is needed to facilitate accurate diagnosis. Viral and bacterial pharyngitis are difficult to differentiate on physical examination alone.

The nurse is caring for a client who has had abdominal surgery. Which action does the nurse take to help prevent pulmonary infection in this client?

Encourage regular use of an incentive spirometer Postoperative clients, especially those who have had abdominal surgery, are less likely to take deep breaths and cough, so they do not clear their lungs of mucus, increasing their risk of pulmonary infection. Encouraging use of an incentive spirometer can help with this. Low-molecular-weight heparin is given to prevent blood clots and pulmonary emboli, but not infection. Intravenous antibiotics are usually not given prophylactically unless there is increased risk. Adequate analgesia may be a necessary adjunct to incentive spirometry to assist with comfort while taking deep breaths. Study Tip: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.

A client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first?

Throat culture A throat culture is important for distinguishing a viral infection from a group A beta-hemolytic streptococcal infection. A chest x-ray or TB skin test are not indicated by the symptoms given. A CBC might be indicated to evaluate infection and dehydration, but would not be the first action.

A healthy client expresses worries about developing tuberculosis (TB) after spending time at a family reunion and learning later that a family member is being treated for the disease. What does the nurse tell this client?

With the development of acquired immunity, few of those who are exposed and initially infected actually develop active TB. The disease is spread by inhaling respiratory droplets aerosolized by coughing, sneezing, singing, laughing, and whistling. Unless there is a strong suspicion that TB is present or the client has had a close exposure, testing is not necessary. TB drugs are given only after the disease is identified. Test-Taking Tip: Avoid choosing answers that use words such as always, never, must, all, and none. If you are confused about the question, read the choices, label them true or false, and choose the answer that is the odd one out (i.e., the one false one or the one true one). When a question is framed in the negative, such as "When assessing for pain, you should not," the false option is the correct choice.

PPE

airborne precautions and use of a respirator

spread

an infected person is not infectious to others until manifestations of disease occur.

rhinitis

an inflammation of the nasal mucosa, is a common problem of the nose and often involves sinuses. -can be caused by infection viral or bacterial

expected findings

anxiety, fatigue, weakness, chest discomfort due to coughing, confusion with hypoxia is the most common manifestation of pneumonia in older adult clients.

BCG vaccine

bacille calmette geurin which contains attenuated tubercle bacilli. if you take it within past 10 years will have a positive skin test that can complicate interpretation.

latent tuberculosis infection

bacilli remain in granuloma in non-replicating dormant state. -NOT ACTIVE disease, you don't feel sick, cannot transmit the tb bacteria, usually positive tb skin test or blood test: indicate a tb infection -chest xray- normal, sputum - negative

quantiferon tb gold

blood test that detects release on interferon gamma in fresh heparinized whole blood. -weather active or latent and within 24 hours

acute pharyngitis

can be caused by bacteria, viruses, trauma, irritants, dehydration, and tobacco or alcohol use.

positive mantoux test means

client has developed an immune response to tb. does not confirm that active disease is present. if youve been treated for tb it could remain positive. - people with latent tb can also have positive mantoux results -BCG vaccine within past 10 years could have a false positive. chest xray or gold test to evaluate tb results now.

sputum cultures

confirms a diagnosis. -takes 1-4 weeks -continue withdrawing samples with drug therapy and wait up to 3 months for a negative result

Which manifestation in an older client is the most common indicator for pneumonia?

confusion The most common indication of pneumonia in an older client may be confusion caused by hypoxemia. Cough and fever may be absent, and the white blood cell count may not be elevated until the infection is severe. Treatment should begin if the older client is confused.

client education

continue therapy meds until treatment is complete, encourage rest periods as needed, maintain hand hygiene, avoid crowded areas, treatment takes time, immunizations for influenza and pneumonia, smoking cessation

community acquired pneumonia (CAP)

contracted outside of a health care setting often a complication of influenza more common than HAP often occurs in late fall winter

community acquired pneumonia

contracted outside of a health care setting, in the community

acquired immunity

controls further growth of most initial lesions, lesions left with little or no bacilli

tb and hiv

correlation world wide between the two diseases

expected findings

cough longer than 3 weeks -purulent sputum, possible blood streaked -fatigue and lethargy -weight loss and anorexia -night sweat and low grade fever in the afternoon

lung sounds:

diminished breath sounds? crackles = wet, fluid wheezing = narrowing rhonchi = not normal in lungs, but trachea bronchial breath sounds, fremitus increased (sounds) percussion dulled, chest expansion lowered or unequal

positive reaction

does not mean that active disease is present but indicates exposure to tb or the presence of inactive disease.

a positive ppd

does not mean that active disease is present but rather exposure to tb or the presense of inactive (dormant) disease.

XDR TB

extensively drug resistent tb

anergy

failure to have a skin response because of reduced immune function when infection is present (no redness but you may have the hardness of soft tissue

physical assessment findings

fever, chills, flushed face, diaphoresis, SOB, tachypnea, chest pain, sputum production (yellow tinged) crackles and wheezes, coughing, dull chest percussion over consolidation, decreased o2, purulent blood tinged or rust colored sputum which may not be present

antibiotic start

first dose given within 6 hours or before you leave the unit.

pneumonia manifestations

flushed cheeks, anxious expression, chest pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, dyspnea, tachypnea, hemoptysis, and sputum production. -crackles are heard with auscultation when fluid is in interstitial and alveolar areas, and breath sounds may be diminished.

vaccinations

for the prevention of influenza are widely available and are recommended for adults by the joint commissions.

seasonal influenza

highly contagious acute viral respiratory infection that can occur at any age, can lead to pneumonia. -often is rapid onset with headache, muscles aches, fever, chills, fatigue, and weakness -infection with influenza strain B can cause nausea, vomiting, and diarrhea

pyrazinamide (PZA) bactericidal

history of gout? -8oz of water with med and increase fluid intake -protective clothing i sun -no alcohol -report darkened urine, yellow skin or sclera -brusing or bleeding -adverse effects = hyperuricemia, nausea, vomit, arthralgia, malaise

assessment

history, risk factors, physical exam, anxiety, pain, headache, speech? amount of words before SOB, myalgia (muscle pain) chills, cough, sputum production, chest pain or discomfort

redness or not in the forearm

if it did not become red does not mean its negative. you will feel for a duration of a hardened area.

reactivation of LTBI

immunosupression, diabetus, poor nutrition, aging, pregnancy, stress, chronic disease, smoking, -hiv infection is the greatest risk for progression from ltbi to atbi

these are caused primarily by

inappropriate use of antibiotics either by selection or accident

non adherence

increase transmission of tb -drug failure -development of resistant mtb -increased morbidity and mortality

serious complications

infection spreading, sepsis, collapsed lung

tonsillitis

inflammation and infection of the tonsils. tonsils filter organisms and protect the respiratory tract from infection. -is contagious airborne infection that can occur in any age group

sinusitis (rhinosinusitis)

inflammation of the mucous membranes of one or more sinuses and is usually associated with rhinitis.

pathophysiology of tb

inhale the bacilli = susceptible host = pneumonitis = granulomatous inflammation = collagen, fibroblasts, and lumphocytes, cessation necrosis = granular mass = necrotic areas: calcify or liquefy

smoking

is a risk factor for pneumonia

stress the fact..

it is the organism not the patient that is tough to cure. what you transfer to other people it doesnt start over, you give them your nightmare

health care associated pneumonia

less than 48 hours after admission in patient with specific risk factors such as living in a nursing home or in the hospital for more than 48 hours.

induration

localized swelling with hardness of soft tissue greater than 10mm within 48-72 hours indicates exposurer and possible infection with tb

rapid, weak pulse

may indicate hypoxemia, dehydration, or impending sepsis and shock.

penicillin

may need be taken with food or 1 hr before meals or 2 hours after. kidney function?

assessment : diagnostics

measured 48-72 hours later reaction: 10mm in diameter indicates; exposure to and possible infection with TB -a positive reaction indicates exposure to tb or presence of inactive disease and does NOT mean ACTIVE DISEASE is present.

older adult:

more atypical presentation, weakness, fatigue, lethargy, acute confusion is huge due to hypoxia, fever and cough could be absent, WBC?, hypoxemia

hospital acquired pneumonia

more than 48 hours (2 day onset) of admission and onset of symptoms start

CAP continued: management considerations

most common bacteria: streptococcus pneumonia, haemphilus influenza most common viral agent: influenza, respiratory syncytial virus, antibiotics: empirical use and should be prompt with treatment

purified protein derivative (ppd)

most common test for tb where a small amount is placed into the forearm.

HCAP management considerations

multi-drug resistant organisms critical: hand hygiene

MDR TB

multidrug resistent tb

latent tuberculosis infection continued

need to treat ltbi to prevent an active tb disease. its like a loaded gun in your lungs. -without treatment 5-10% of infected individuals will develop active tb disease

drug therapy

no longer contagious after 2-3 weeks, but you must kill the virus which takes up to 6-12 months

3x consecutive negative results

no longer infectious

etiology of pneumonia

non-infectious causes: toxic gases, chemical fumes, smoke, aspiration of water,food, fluid, saliva, vomit infectious causes: bacteria, viruses, mycoplasmas, fungi, rickettsiae, protozoa, helminths

goals for someone with tb

normal pulmonary function compliance with therapeutic regime implement appropriate measures to prevent transmission prevent disease recurrence

latent tb

not active, asymptomatic, not febrile, not infectious or active

diagnostics

nucleic acid amplification (NAA) test: results in less than 2 hours used if suspected of tb -blood analysis: quantiferon tb gold test : results in less than 24 hours -sputum culture: CONFIRMS DIAGNOSIS results in 1-4 weeks for +/- results

HCAP risk factors

older adult, chronic lung disease, gram negative colon present, altered level of consciousness, recent aspiration occurrence, endotracheal, tracheostomy, ng tube, poor nutrition, immunocompromised, drugs that increase gastric ph or alkaline tube feedings (growth) mechanical vent.

tranmission of tb

only transmitted if you exhibit active symptoms

rhinosinusitis manifestations

pain over the cheek radiating to the teeth, tenderness to percussion over the sinuses, general facial pain that is worse when bending forward.

history

past tb? country of origin? family history of tb?

pharyngitis assessment

patient will have throat soreness and dryness, throat pain, pain on swallowing, difficulty swallowing, and may have a fever.

in simple words

pneumonia is the alveolar being clogged up with mucous, debris, rbcs, wbcs, all trying to solve a problem but consequently make your breathing worst.

client will...

positive tb test within 2-10 weeks of exposure to infection

blood analysis quantiferon tb gold test

pretty rapid, ready in 24 hours used in acute care settings.

secondary infection

reaction to tb after immunocompromise (hiv, smoking)

secondary Tb

reactivation of the disease in a previously infected person, which it is more likely to spread when defenses are lowered such as an older person or HIV disease.

tuberculosis is not transferred by

shaking hands, sharing food, drink, utensils, sharing toothbrushes, touching bed lines or toilets, kissing or any physical contact. it is an airborne disease.

immunization

should encourage people especially over 65 years old with chronic health problems to receive immunization against pneumonia.

scar tissue

shows you have been exposed, does not mean it is active

drug for mdr xdr

sirturo = bedaquiline, pyrazinamide, and moxifloxacin

latent will become active if not treated

sooner or later depending on your immune system

acute viral rhinitis (coryza, or the common cold)

spreads from person to person by droplets from sneezng or coughing or by direct contact. -over 200 viruses. -most contagious during the first 2-3 days after symptoms

lab tests

sputum culture and sensitivity - before starting therapy cbc= elevated wbc count might not be present in older adults abgs= hypoxmia blood culture rules out organisms in blood serum electrolytes to identify causes of dehydration

diagnostic testing

sputum, cbc? blood culture sepsis? ABGs, serum lactate levels, BUN creatine? dehydration

nurse implementation

strict adherence is crucial take meds regular, exactly as prescribed, and as long as they are prescribed

a client wakes up with chest pains on inhalation and is slightly confused and doesn't recognize spouse. what do?

take vital signs and o2 sat -first action should be to use nursing process and assess the client, which is essential in planning care.

early findings

tb should be considered for anyone with a persistent cough, weight loss, anorexia, night sweats, hemopytosis (bloody cough), SOB, fever and chills

miliary tb

tb that spread to bloodstream and can spread to multiple body organs :headache, neck stiffness, drowsiness pericarditis: dyspnea, swollen neck veins, pleueritic pain, hypo tension

pneumonia continued

these events seriously reduce gas exchange and lead to hypoxemia, interfering with oxygenation and possibly leading to death. -hypoxemia can also result from this as vital capacity and alveolar collapse (atelectasis) are occurring.

diagnostics

tuberculin test (mantoux) -most commonly used screening test for tb infection - PPD test 0.1 ml in forearm

whats the big adverse effect of ethambutol

visual changes and disturbances

someone at home treating tb should...

wash hands every time you cough into them wear a mask when out in public

directely observed therapy

watch the patient swallow the drugs

rhinorhea

watery drainage from the nose

post a positive tb test

you than get a chest xray. it would determine if its active or old, with healed lesions. caesaetion and inflammation may be seen on the xray if the disease is active. -chest xray of someone with hiv may be normal or may show infiltrates in any lung zone and lymph node enlargement

with latent tb

you will always have an active tb result

which statement is correct about tb?

you will need to provide sputum samples every 4 weeks to monitor effectiveness of medications

pandemic influenza

viral infections that can be spread from animal to human contact and is usually extremely deadly. -responsibility of everyone to help and prevent this -pandemic influenza is considered a disaster, requiring cooperation of all people

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bacterial vs viral pharyngitis

-enlarged red tonsils, exudate, petechiae on soft palate, purulent discharge, and local lymph node enlargement is seen with bacterial. -viral is contagious for 2-3 days and is self limiting

allergic rhinitis (hay fever or allergies)

-makes you more susceptible to bacterial invasion that may lead to infection -is triggered by hypersensitivity reactions to airborne allergens. -usually resides in 7-10 days w/o complications

health care associated pneumonia (HCAP)

-onset/diagnosis: less than 48 hours from admission -hospital admission more than 48 hours in past 90 days -living in nursing home of assisted living past 30 days: wound care, antibiotics, iv therapy, chemo past 30 days: seen at hospital or dialysis clinic

objectives

-relate pathophysiology of pneumonia to clinical manifestations and disease management -distinguish between the various type of pneumonia. -compare and contrast risk factors associated with the types of pneumonia -examine the diagnostics associated with pneumonia -implement appropriate nursing interventions to effectively manage pneumonia -examine the pharmacological therapy associated with treatment of pneumonia.

incidence and prevalence

2-5 million cases / year higher among older adults, nursing home residents, hospitalized patients, mechanically ventilated patients -a major cause of death in older population

A family member of a client who has been diagnosed with severe acute respiratory syndrome (SARS) asks the nurse why the client is not receiving an antibiotic. How does the nurse respond to this family member?

Antibiotics are not effective because SARS is caused by a virus SARS is a viral infection and antibiotics are not useful for treating this disease. Clients are provided with supportive care to allow their immune systems to fight the disease. Antibiotics are given only when a secondary infection is present. Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.

The nurse is teaching a client newly diagnosed with tuberculosis (TB) about the medication and treatment regimen for this disease. What information does the nurse include when teaching this client?

Avoid alcohol while taking the medications unless the provider says otherwise Because many first-line medications for TB treatment can cause hepatotoxicity, the client should be cautioned against consuming alcohol. It is not necessary to avoid exercise. The skin test is not used to evaluate the response to therapy; sputum specimens are evaluated every 2-4 weeks during drug therapy. Most clients require two to three medications to help combat both drug resistance and the disease. Study Tip: Study goals should set out exactly what you want to accomplish. Do not simply say, "I will study for the exam." Specify how many hours, what day and time, and what material you will cover.

The nurse is counseling a young woman about drug therapy with isoniazid (INH) and rifampin (RIF) to treat tuberculosis. Before developing the teaching plan, what must the nurse assess for first?

Contraceptive methods used Rifampin can interfere with oral contraceptives and women using these should be taught to use a backup method of contraception during treatment and up to 1 month after treatment ends. Ethambutol can have effects on vision, including color vision, but isoniazid and rifampin do not. Other drugs can increase the risk of gout. Pyrazinamide can cause increased sensitivity to sunlight. Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice.

pathophysiology

pneumonia is an inflammatory process sites include: interstitial spaces, alveoli, bronchioles multiplication of organisms making further complications -wbcs migration -fluid accumulation + alveolar wall thickening -less gas exchange = hypoxemia -rbc, fibrin, capillary leaks = possible infection spread -lobar pneumonia with consolidation or bronchopneumonia

A clinic nurse is providing teaching for a client who has been diagnosed with a peritonsillar abscess. What does the nurse include in this client's teaching?

Go to the emergency department if drooling or stridor occur. Clients with peritonsillar abscess should be taught the signs of airway obstruction that include drooling and stridor, and should be told to seek emergency medical care if these occur. Tonsillectomy is sometimes necessary to prevent recurrence, but not always. Gargling with warm saline is a comfort measure and should be encouraged. Clients should be taught to take prescribed antibiotics for the full course of treatment and not to stop when symptoms subside. Study Tip: Enhance your time-management abilities by designing a study program that best suits your needs and current daily routines by considering issues such as the following: (1) Amount of time needed; (2) Amount of time available; (3) "Best" time to study; (4) Time for emergencies and relaxation.

The nurse is teaching a client about isoniazid (INH) and rifampin (RIF) drug therapy for tuberculosis (TB). The nurse instructs that while on these medications, the client should avoid consuming which food?

Isoniazid and rifampin can damage the liver, so alcohol should be avoided for the duration of the medication regimen, which can be 6 months to 2 years. Consuming foods high in tyramine while on these drugs can cause a severe increase in blood pressure. However, not all dairy products need to be avoided; only aged cheeses are high in tyramine. Red meat and eggs are not high in tyramine and can be consumed freely. Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive attitude.

A client who has begun standard multidrug treatment for tuberculosis (TB) reports orange-tinged sputum and urine. The nurse tells the client that this symptom represents which response to the treatment regimen?

Normal drug side effects of rifampin Orange-colored body secretions are an expected side effect of rifampin (RIF), one of the standard medications used for TB treatment. The orange color does not indicate spread of infection or hemolysis. Although alcohol and rifampin can cause hepatotoxicity, the orange color is not a sign of this complication.

A public health nurse is providing education to a community about preparation for a possible influenza epidemic leading to worldwide pandemic. What does the nurse instruct community members to do upon learning that an influenza outbreak has occurred?

Obtain a vaccine if not already vaccinated against influenza People should be taught to receive vaccinations if not already vaccinated if an outbreak occurs. People should stay home as much as possible and avoid crowds. Stockpiling food and medicines should occur in anticipation of an outbreak, not at the onset when people should be advised to stay home. Antiviral medications are given to those who contract the virus to limit symptoms.

What is a key difference between seasonal influenza and pandemic influenza

Pandemic influenza has the potential to spread globally because of its highly infectious nature in humans. Mutated animal and bird viruses can be highly infectious to humans and spread globally very quickly, because humans have no natural resistance to the mutated virus. Both seasonal and pandemic influenza are caused by viruses. Although there is the potential to develop a monovalent vaccine to a given mutated virus, widespread prophylactic vaccination is not realistic as a preventive measure. People over age 50 with chronic illnesses and those who are immunocompromised should receive a yearly flu vaccine for the seasonal variety.

The nurse is performing an admission assessment on a 90-year-old client and notes confusion with poor orientation to person, place, and time. The client's daughter tells the nurse that this isn't normal. Which initial action by the nurse is correct?

Perform a detailed respiratory assessment including lung sounds, pulse oximetry, and temperature In older clients, a frequent first indication of pneumonia is a change in mental status due to hypoxemia. The nurse should first perform a respiratory assessment and then notify the provider of the findings. Antibiotics are not indicated unless an assessment and tests indicate an infection is present. Lab work may be ordered by the provider as part of the ongoing evaluation of this client. Nurses should listen to family members' reports about the usual status of clients and respond if a client is not acting normally. Study Tip: Avoid planning other activities that will add stress to your life between now and the time you take the licensure examination. Enough will happen spontaneously; do not plan to add to it.

A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first?

Place the client in a negative air pressure room If a client is exhibiting symptoms of avian flu or any other pandemic influenza, he or she is assumed to be contagious until proven otherwise. Protecting the spread of disease to the community is the top priority, so placing the client in a negative air pressure room is the nurse's first action. If avian influenza is diagnosed, it is important that those exposed receive oseltamivir or zanamivir (Relenza) within 48 hours of contact with the client. Obtaining specimens will be important to determine whether the client has avian influenza; this test takes approximately 40 minutes to complete. A client with avian flu will become dehydrated because of diarrhea so starting an IV to administer rehydration fluid is important, but is not the first priority.

A client who is taking isoniazid (INH) and rifampin (RIF) to treat tuberculosis reports reddish-orange urine. Which action by the nurse is correct?

Reassure the client that this is an expected drug side effect Reddish-orange urine and other body fluids are a common, harmless side effect of rifampin. It does not indicate dehydration or alterations in blood cell levels or kidney function. It is not necessary to change the drug regimen. Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.

A client with nasal congestion, fever, and cough has been using over-the-counter medications for a week without improvement. The client exhibits tenderness to percussion over the sinuses and referred pain to the back of the head. These findings may indicate which condition?

Rhinosinusitis Prolonged upper respiratory symptoms can indicate that a sinus infection has developed. Tenderness to percussion over the sinuses and referred pain to the back of the head are common manifestations of rhinosinusitis. Manifestations of rhinitis include headache, nasal irritation, sneezing, nasal congestion, rhinorrhea, and itchy, watery eyes. The patient with pharyngitis has throat soreness and dryness, throat pain, odynophagia, difficulty swallowing, and may have fever. Tonsillitis is manifested by a sudden sore throat, fever, muscle aches, chills, and dysphagia. The tonsils are visibly swollen and red. Test-Taking Tip: Avoid selecting answers that state hospital rules or regulations as a reason or rationale for action.

nursing care

position the client for maximize ventilation (high fowlers) encourage coughing or suctioning to remove secretions administer breathing treats and orders o2 therapy skin breakdown around nose and ears, encourage deep breathing with an incentive spirometer to prevent alveolar collapse, determine clients physical limits and structure activity around those needs, 2-3l fluid a day, provide rest periods, reassure client with respiratory distress

other diagnostics

pulse oximetry, transtracheal aspiration, bronchoscopy, direct needle aspiration, thoracentesis

severe acute respiratory syndrome (SARS)

respiratory infection from a new virus known as coronaviruses. it infects cells of the respiratory tract triggering inflammation, and stays in the respiratory passageways rather than spreading into the blood. -airborne droplet spreads

A coworker tells the nurse that she will not get the flu shot because she believes it is better to develop her own immunity to the flu. What does the nurse tell this coworker?

You are putting your clients at increased risk for serious respiratory illness." All people who provide direct care to clients should get the influenza vaccine to prevent the spread of influenza to clients who are at risk for serious respiratory illness. The flu vaccine does not cause influenza symptoms. Antiviral medications are only effective if given early and do not cure influenza. Even young, relatively healthy individuals can have severe influenza. Study Tip: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts.

A client tells the nurse that after 3 weeks of multidrug therapy to treat tuberculosis (TB), the symptoms seem to have resolved. What does the nurse tell this client?

You will need to continue therapy for at least 6 months." Even though clients feel better and are no longer contagious, TB drug therapy must continue for 6 months or longer to avoid relapse and drug resistance. Directly observed therapy is used for clients who may have difficulty complying with treatment. It is important to continue taking all drugs in the regimen to avoid drug resistance. Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.

graph of pneumonia

start with inflammatory process = attraction of neutrophils, release of inflammatory mediators, accumulation of fibrinous exudates, rbc, and bacteria leads to = alveoli filling with fluid and debris (consolidation) and increased production of mucus (obstruction) this information leads to = decreased gas exchange resolution= macrophages in alveoli ingest and remove debris, normal lung tissue restored, gas exchange goes back to normal.

tb etiology

being in contact with someone for a long time who has not yet been diagnosed with TB is a great way for it to spread.

physical exam assessment

breathing pattern, dyspnea? accessory muscles? tripod position? severe chest muscle weakness?

best diagnostic

chest xray most common diagnostic test, changes may not appear until 2-3 days after clinical s/s area of increased density older adult= ESSENTIAL FOR EARLY DIAGNOSIS they have vague and atypical s/s best way to diagnosis

peritonsillar abscess

complication of acute tonsillitis in which the infection spreads from the tonsils to the surrounding tissue and forms an abscess.

hospital acquired pneumonia (HAP)

onset: 2 days or more post admission management considerations: pulmonary hygiene, ambulation, adequate hydration, aspiration risk?, monitor early signs of sepsis, critical: hand hygiene

ventilator associated pneumonia (VAP)

onset: within 48-72 hours after endotracheal intubation management: et tube = aspiration (secretions) elevate hob above 30 degrees or more, assess weaning and daily sedation vacation, oral care regime, DVT, hand hygiene, suctioning, stress ulcer

who is at risk for developing pnemuonia

dysphagia patient (difficulty swallowing) aids patient closed head injury with ventilation myasthenia gravis (weak muscles in face)

pneumonia

excess fluid in the lungs resulting from an inflammatory process. -the inflammation is triggered by many infectious organisms and by inhalation of irritating agents. -organisms penetrate the airway mucosa and multiply in the alveolar spaces, wbcs then migrate to the area of infection, causing edema, exudate, and extra fluid collect in and around alveoli, and the alveolar walls thicken

cephalosporin

frequent stools? kidney function? with food

antibiotics

given to destroy infectious pathogens. commonly used are penicillin and cephalosporins. any culture should be taken before therapy begins.

pulmonary tuberculosis

highly communicable disease caused by mycobacterium tuberculosis. one of the most common bacterial infections worldwide. transmitted via airborne

vital signs would be:

hypotension with orthostatic changes, rapid weak pulse, increased RR, fever, o2 sat? dysrhythmias

pneumonia etiology

immune system cannot overcome the invading organisms. -can also be caused by bacteria, viruses, mycoplasmas, fungi -noninfectious causes include inhalation of toxic gases, chemical fumes, and smoke and aspiration of water, food, fluid, and vomit

Incentive spirometry for the treatment of pneumonia has which outcome objective?

increased inspiratory muscle action and decreased atelectasis Incentive spirometry helps improve inspiratory muscle action and prevents or reverses atelectasis. It does not increase respiratory effort, reduce crackles and wheezes, or reduce sputum production. Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it

rare complication of pharyngitis

infection of the epiglottis (epiglottitis) which can obstruct the airway.

pharyngitis (sore throat)

inflammation of the paryngeal mucous membranes that often occurs with rhinitis and sinusitis.

perennial rhinitis

intermittently with no seasonal pattern or continuously whenever the person is exposed to an offending allergen such as dust, animal dander, wool, or foods.

pneumonia from aspiration of food or stomach contents

interventions focus on preventing lung damage and treating the infection. can cause inflammation and lead to acute respiratory distress syndrome (ARDS)

risk factors of CAP

older adult, no pneumococcal vaccine, received pneumococcal more than 5 years ago, no influenza vaccine prior year, chronic health conditions, conditions that reduce immune responses, recent exposure to respiratory infections: viral or infleunza, tobacco or alcohol use, immunocompromised?, copd? asthma? smoke cessation education is huge