Ch. 28

Which client will the nurse recognize as being at risk for bacterial sinusitis? A 25 year old with seasonal pollen allergies A 35 year old with a 20-pack-year smoking history who now vapes A 45 year old with multiple dental caries and infected gums A 65 year old who has a poor gag reflex after a stroke

A 45 year old with multiple dental caries and infected gums Dental infections of any kind greatly increase the risk for bacterial sinus infection. Smoking and vaping do not increase the risk for sinusitis although they do increase the risk for head and neck cancers. Allergies alone do not increase the risk. A poor gag reflect increases the risk for aspiration pneumonia but not sinusitis.

For which symptom will the nurse assess in an older adult client who is suspected of having pneumonia? Select all that apply. Fever Cough Confusion Weakness TST induration

A, B, C, D The older adult with pneumonia often has fever, cough, weakness, fatigue, lethargy, confusion, and poor appetite. TST induration is associated with tuberculosis; not pneumonia.

The patient with TB has

progressive fatigue, lethargy, nausea, anorexia, weight loss, irregular menses, and a low-grade fever. Symptoms may have been present for weeks or months. Night sweats may occur with the fever. A cough with mucopurulent sputum, often streaked with blood, is present. Chest tightness and a dull, aching chest pain occur with the cough.

COVID: Typically, symptoms appear

2 to 14 days after exposure to the virus.

tb pts need sputum specimens around every ______________ when on drug therapy

4 weeks

Epidemics are common and lead to complications of pneumonia or death, especially in

older adults, those with heart failure or chronic lung disorders, and immunocompromised patients.

empyema

pus in the pleural cavity after infection spreads to lungs

Bedaquiline

targets drug resistant TB

Although annual vaccination is not 100% effective at preventing influenza, it is especially important for adults who:

• Are older than 50 years • Have chronic illness or immune compromise • Reside in institutions • Live with or care for others with health problems that put them at risk for severe complications of influenza • Are health care personnel providing direct care to patients

Nutrition considerations for TB pts

high protein, Vitamin ABCE, phosphorus no alcohol Small snack of simple carbs could reduce nausea when taken w/ drugs fatigue may be normal at first

TB pts are usually no longer contagious after drugs have been taken for

2 to 3 consecutive weeks and clinical improvement is seen; however, he or she must continue with the prescribed drugs for 6 months or longer as prescribed.

For influenza: antiviral agents (oseltamivir (Tamiflu)) may be effective if started within

24-48 hours of symptoms

Adults with influenza are contagious _____ hours before symptoms occur and up to ____ days after they begin.

24; 5

Which factors or conditions will the nurse identify as increasing the risk for clients to develop aspiration pneumonia? (Select all that apply.) Continuous nasogastric (NG) tube feedings Bronchoscopy procedure Magnetic resonance imaging (MRI) procedure Decreased level of consciousness Stroke Chest tube

Continuous nasogastric (NG) tube feedings Bronchoscopy procedure Decreased level of consciousness Stroke

A client's baseline vital signs are as follows: temperature 98.8°F (37.1°C) oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103°F (39.4°C). Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status? Respiratory rate of 12 breaths/min Respiratory rate of 16 breaths/min Respiratory rate of 18 breaths/min Respiratory rate of 22 breaths/min

4 Rationale: Elevations in body temperature cause a corresponding increase in respiratory rate. This occurs because the metabolic needs of the body increase with fever, requiring more oxygen. Therefore, the remaining options are incorrect.

a nursing student is teaching a 72-year-old client about the importance of the pneumonia vaccination. Which teaching will the nurse provide? "You will need two vaccines to best protect yourself." "There are two vaccines available and you can choose just one." "If you have had the PCV13 vaccine, then you will not need the PPSV23 vaccine." "Since you are over 64 years old, only the flu vaccine is suggested."

A There are two pneumonia vaccines: pneumococcal polysaccharide vaccine (PPSV23) and pneumococcal conjugate vaccine (PCV13) for prevention of pneumonia (Phillips & Swanson, 2016). The CDC recommends that adults older than 65 years be vaccinated with both, first with PCV13 followed by PPSV23 about 6 to 12 months later. Adults who have already received the PPSV23 should have PCV13 about a year or more later. These recommendations also apply to adults between 19 and 64 years of age who have specific risk factors such as chronic illnesses (CDC, 2018b). Because pneumonia often follows influenza, especially among older adults, urge all adults to receive the seasonal vaccination annually.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A 25 year old who had endoscopic sinus surgery 8 hours ago. A 45 year old with a peritonsillar abscess who can no longer swallow. A 55 year old with tuberculosis who is standard first-line therapy. A 65 year old with rhinosinusitis and a fever of 102° F (38.9° C)

A 45 year old with a peritonsillar abscess who can no longer swallow The client at greatest risk for a respiratory complication is the one with a peritonsillar abscess who is no longer able to swallow. This abscess is enlarging and could completely obstruct the client's airway. Rapid assessment is needed immediately to determine the degree of intervention urgency. No other client listed has indications of the need for potential emergency action.

A clinic nurse notes that large numbers of clients present with flulike symptoms. Which recommendations should the nurse include in the plan of care for these clients? Select all that apply. Get plenty of rest. Increase intake of liquids. Take antipyretics for fever. Get a flu shot immediately. Eat fruits and vegetables high in vitamin C.

1,2,3,5 Rationale: Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics also may be used for symptom management. The nurse should teach clients to sneeze or cough into the upper sleeve of their arm rather than into the hand. Respiratory droplets on the hands can contaminate surfaces and be transmitted to other people. Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. Activities should be resumed gradually. Avoid contact with other individuals, except family members, for at least 6 months. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. Respiratory isolation is not necessary because family members already have been exposed. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

1,3,4,5 Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

Cell-mediated immunity against TB develops 2 to 10 weeks after initial infection and is manifested by a positive reaction to a tuberculin test. The primary infection may be so small that it does not appear on a chest x-ray. The process of TB infection occurs in this order:

1. The granulomatous inflammation created by the TB bacillus in the lung becomes surrounded by collagen, fibroblasts, and lymphocytes. 2. Caseation necrosis, which is necrotic tissue being turned into a granular mass, occurs in the center of the lesion. If this area shows on x-ray, it is the primary lesion.

A client for whom the nurse is caring is diagnosed with rhinosinusitis. Which symptom does the nurse anticipate will be found upon assessment? Fever Fatigue Dental pain Sore throat Ear pressure Lack of response to decongestants

A, B, C, D, E, F Symptoms of bacterial rhinosinusitis include purulent nasal drainage with postnasal drip, sore throat, fever, erythema, swelling, fatigue, dental pain, and ear pressure. A lack of response to decongestants can also be indicative of a bacterial infection.

A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. A. Blurry vision B. Constipation C. Difficulty sleeping D. Nausea when drinking beer E. Red-tinged urine F. Sunburn with minimal sun exposure G. Yellowing of the sclera

A, G

Which symptom will the nurse expect as typical in an 82-year-old client with pneumonia? Acute confusion Profound bradycardia Coughing spasms High fever

Acute confusion The most common symptom of pneumonia in the older adult client is acute confusion from hypoxia. Fever and cough may be absent, but hypoxemia is often present. Tachycardia is triggered by hypoxia, not bradycardia.

Which action will the nurse take first when caring for a client with pneumonia who has ineffective airway clearance related to fatigue, chest pain, excessive secretions, and muscle weakness? Administer oxygen to prevent hypoxemia and atelectasis. Administer the prescribed bronchodilator therapy to decrease bronchospasms. Encourage oral fluids to greater than 3000 mL/day to ensure adequate hydration. Maintain semi-Fowler position to facilitate breathing and prevent further fatigue.

Administer the prescribed bronchodilator therapy to decrease bronchospasms. Although all actions are helpful and important, bronchodilator therapy is performed first to increase the size of the airways to improve clearance.

The hospitalized patient with active TB is placed on ___________ Precautions in a well-ventilated room that has at least six exchanges of fresh air per minute. All health care workers must use a ____________________ when caring for the patient. Use _______ Precautions with appropriate protection as with all patients. Airborne Precautions are discontinued when

Airborne personal respirator Standard the patient is no longer contagious.

TB care at home: ___________________ are not necessary in this setting because family members have already been exposed; however, all members of the household need to undergo TB testing.

Airborne Precautions

Which action will the nurse take to ensure that a client who requires drug therapy for multi-drug resistant tuberculosis and also is addicted to heroin adheres to the treatment regimen? Arranging for a health care worker to directly observe the client take the drugs Giving the client written instructions about how and when to take the drugs Instructing the client about the consequences of not taking the drugs Having the client repeat the drug names and side effects

Arranging for a health care worker to directly observe the client take the drugs The most effective action for the nurse to take to ensure that the client complies with the treatment regimen is to arrange for the client to be directly observed during therapy. The heroin addiction reduces the client's likelihood of adherence to long-term treatment unless closely supervised while taking the drugs.Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. Even if the client can state the names and side effects of the drugs does not indicate understanding of the importance of this therapy.

A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action? A. Encourage the client to use the incentive spirometer hourly. B. Increase her O2 flow rate by 2 L and reassess in 5 minutes. C. Increase the flow rate of the IV antibiotic. D. Document the changes as the only action.

B

A nurse interviewing an 82-year-old, somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? A. "Your mother is older now and is more fragile, so she should have one this year, too, as a booster." B. "The virus causing influenza often changes each year, and a new influenza vaccination is needed every flu season." C. "The "flu shot" she had 2 years ago will still protect her this year, but if she has not had a previous pneumonia vaccination, she should have one now." D. "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."

B

Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. 21-year-old college student living in a dorm at a Canadian university B. 38-year-old with HIV-III (AIDS) who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)

B, C, D, E

A nursing home client who has completed a 2-week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheelchair. What is the nurse's best response? A. "No, going out now before you have recovered your strength can cause a relapse of the pneumonia." B. "No, the risk that you could spread this disease to other people is much too high." C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." D. "Yes, if you agree to wear a face mask to prevent spreading droplets."

C

The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4°F (39.7°C). What is the nurse's primary concern for this client? A. The client may not be taking the prescribed antiviral drug correctly B. A second strain of influenza is likely C. Pneumonia may be present D. The client may be dehydrated

C

Development of which symptoms indicates to the nurse that a 48-year-old client with seasonal influenza may actually have COVID-19? Anorexia and weight loss Intermittent fever and sweating Chest tightness and SpO2 of 86% Productive cough and yellow-colored sputum

Chest tightness and SpO2 of 86% Symptoms of COVID-19 are similar to those of seasonal asthma. However, the inflammatory responses occurring in the lungs with serious COVID-19 infection causes lung stiffness with chest tightness and greatly reduced gas exchange. The other symptoms are not specific to COVID-19 or other pandemic respiratory infections.

Which condition indicates to the nurse that the treatment plan for a client with streptococcal pneumonia is effective? Client has been afebrile for 48 hours. Bronchial breath sounds present in lung periphery. White blood cell count is 16, 000 cells/mm3 (16 × 109/L). Oxygen saturation ranges between 90% and 92% on room air.

Client has been afebrile for 48 hours. A positive outcome is indicated by the client having been afebrile for 48 hours.Bronchial breath sounds in lung peripheral areas are abnormal. The normal WBC count is 5000 to 10,000 mm3 (5 to 10 × 109/L). The listed count is elevated and indicates continuing infection. The normal oxygen saturation is expected to be above 95%.

A patient is experiencing hypotension, fever, chills, night sweats, and weight loss. Upon assessment, the nurse notes a displaced PMI. The nurse knows this collection of symptoms are associated most closely with which condition? Influenza Pneumonia Tuberculosis Pulmonary empyema

D Patients with pneumonia, tuberculosis, and influenza may experience some or all of the symptoms of fever, chills, night sweats, and weight loss. However, because pulmonary empyema is a collection of pus in the pleural space that may cause compromised cardiac function, displaced point of maximal impulse (PMI), and hypotension may result.

Which order or prescription will the nurse perform first for a client admitted with pneumonia who is febrile and also agitated as a result of alcohol intoxication? Administering intravenous antibiotics Assessing the need for an immediate dose of lorazepam Drawing blood for aerobic and anaerobic blood cultures Requesting a referral to a social worker for alcohol counseling

Drawing blood for aerobic and anaerobic blood cultures The nurse will first obtain aerobic and anaerobic cultures in a febrile client for whom antibiotics have been prescribed to identify the specific causative organism. Initiating antibiotic therapy before cultures are obtained could affect the results of the culture and possibly delay identification an antibiotic more for the infection. Thus, antibiotic therapy is started after blood for cultures is obtained.Unless this client is a danger to self or staff, giving lorazepam for agitation is not the first action. A referral to social work for alcohol counseling will be initiated before the time of discharge, but is not the immediate concern.

Who should get screened for TB?

Health-care workers, foreign-born migrants, those who are high risk People who have been in close contact with a person positive for TB should get a test

Which assessment finding in an older client with pneumonia will the nurse report immediately to the primary health care provider? SpO2 of 86% and confusion Hypotension and rapid, weak pulse Productive cough and normal temperature Flushed cheeks and increased respiratory rate

Hypotension and rapid, weak pulse Hypotension and a rapid, weak pulse are indications of dehydration with possible impending sepsis and shock. This condition all result in poor perfusion and can progress to extreme hypoxemia and death. These symptoms require immediate attention and intervention.The other symptoms are expected with pneumonia and do not represent rapid progression to a more serious problem.

What is the nurse's first priority action to prevent harm when an 82-year-old client with pneumonia has become increasingly confused with an SpO2 change from 91% 1 hour ago to 88% now, and a respiratory rate that has increased from 26 to 32 breaths/min? Assisting the client to a more upright position Increasing the flow rate of the IV piggy-back antibiotic Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes Reporting the change in status to the client's primary health care provider

Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes The client is becoming increasingly hypoxemic and needs more supplemental oxygen. After oxygen delivery is increased, the nurse will determine the client's response to this action.Although moving the client to a more upright position is not harmful and can increase oxygenation, it is not as effective in managing hypoxemia as increasing the oxygen flow rate. It should be the second action, not the first. Although the pneumonia may be worsening, giving the IV antibiotic at a faster rate is not going to make an immediate difference. In addition, infusing it faster may increase the risk for side effects and adverse effects. Before notifying the primary health care provider, the nurse will assess the client's response to increased oxygen flow rate. If the oxygen saturation has not improved or has decreased further in 5 minutes, the nurse would then immediately notify the primary health care provider.

Isoniazid (INH)

Instruct patients to avoid antacids and to take the drug on an empty stomach (1 hour before or 2 hours after meals) to prevent slowing of drug absorption in the GI tract. Teach patients to take a daily multiple vitamin that contains the B-complex vitamins while on this drug because the drug can deplete the body of this vitamin. Remind patients to avoid alcoholic beverages while on this drug because the liver-damaging effects of this drug are potentiated by alcohol. Tell patients to report darkening of the urine, a yellow appearance to the skin or whites of the eyes, and an increased tendency to bruise or bleed, which are signs and symptoms of liver toxicity or failure.

Community-Acquired Pneumonia risk factors

Is an older adult Has never received the pneumococcal vaccination or received it more than 5 years ago Did not receive the influenza vaccine in the previous year Has a chronic health problem or other coexisting condition that reduces immunity Has recently been exposed to respiratory viral or influenza infection Uses tobacco or alcohol or is exposed to high amounts of secondhand smoke

First-Line Treatment for Tuberculosis

Isoniazid, Rifampin

Which adults will the nurse identify as having a higher risk for active tuberculosis? (Select all that apply.) Kidney transplant recipients Those in the local prison Homeless adults Recent immigrants to the United States Those who have received bacille Calmette-Guérin (BCG) vaccine Those who were treated previously for active tuberculosis

Kidney transplant recipients Those in the local prison Homeless adults Recent immigrants to the United States Those who were treated previously for active tuberculosis

Covid-19 Hospital setting:

N-95 Mask Standard, single-patient room Private bathroom Door to room closed at all times

3 Negative sputum cultures =

No longer infectious

Which complication of seasonal influenza will the nurse suspect in a 78-year-old client whose temperature remains elevated and now has new-onset confusion? Pneumonia Emphysema Heart failure Tuberculosis

Pneumonia Pneumonia is the most common complication of seasonal influenza, especially among older clients. The symptoms of pneumonia include fever that does not resolve and acute confusion.Although heart failure is a complication of pneumonia, it is less common and not accompanied by fever. Neither emphysema nor tuberculosis is a complication of seasonal influenza.

Which is the priority action for the nurse to take first after applying oxygen when caring for an older client admitted with symptoms of possible seasonal influenza accompanied by vomiting and high fever? Asking the client when symptoms began Administering IM influenza vaccination Starting an IV line to begin hydration therapy Placing the client in a negative air pressure room

Starting an IV line to begin hydration therapy The nurse's first priority is to start an IV line and begin intravenous hydration to maintain perfusion. Older clients with influenza symptoms can develop dehydration quickly because of fever, vomiting, and possible diarrhea.Asking when the symptoms first started is not important. A negative airflow room is not required and is usually in short supply. The seasonal influenza vaccine is designed to prevent influenza. This client already is infected with influenza and if not vaccinated, can receive the vaccine prior to discharge but this is not the priority because it takes weeks for full immunity to develop.

Which action to prevent harm is has the highest priority for the nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy regimen? Expect a change in urine color. Be sure to drink at least 2 L of fluids daily. Take these drugs daily exactly as prescribed. Wear use sunscreen and wear protective clothing when you are out-of-doors.

Take these drugs daily exactly as prescribed. The most important action is to take the drugs as prescribed to be effective and to prevent development of drug-resistant tuberculosis organisms. One drug in the regimen does change urine to a reddish color, but this is harmless. Two other drugs cause some degree of photosensitivity and increase the risk for sunburn; however, this is not a reason to stop the therapy.

Calmette-Guérin (BCG) vaccine

The BCG vaccine contains attenuated tubercle bacilli and is used in many countries to produce increased resistance to TB. Anyone who has received BCG vaccine within the previous 10 years will have a positive skin test that can complicate interpretation. Usually the size of the skin response decreases each year after BCG vaccination. These patients should be evaluated for TB with a chest x-ray or the QuantiFERON-TB Gold test. The effectiveness of BCG vaccine in preventing TB is controversial, and it is not used widely for this purpose in the United States or Canada.

Rifampin

Warn patients to expect an orange-reddish staining of the skin and urine and all other secretions to have a reddish-orange tinge; also, soft contact lenses will become permanently stained because knowing the expected side effects decreases anxiety when they appear. Instruct sexually active women using oral contraceptives to use an additional method of contraception while taking this drug and for 1 month after stopping it because this drug reduces the effectiveness of oral contraceptives. Remind patients to avoid alcoholic beverages while on this drug because the liver-damaging effects of this drug are potentiated by alcohol. Tell patients to report darkening of the urine, a yellow appearance to the skin or whites of the eyes, and an increased tendency to bruise or bleed, which are signs and symptoms of liver toxicity or failure. Ask patients about all other drugs in use because this drug interacts with many other drugs.

What is the most important personal infection control measure that the nurse will take when suctioning a client with COVID-19 or any other pandemic influenza? Keeping the door to the client room closed Washing hands and donning gloves prior to the procedure Performing oral care before, as well as after, suctioning the oropharynx Wearing a disposable particulate mask N95 respirator with face shield or goggles

Wearing a disposable particulate mask N95 respirator with face shield or goggles The most important infection control precaution the nurse must take before suctioning a client with any pandemic influenza is to wear a particulate mask respirator with protective eyewear or a face shield to prevent infectious organisms from entering the nurse's mucous membranes and respiratory tract.The door to the room needs to be closed during any care of the client with a pandemic influenza. The immediate concern while suctioning is spread of infection to the nurse who is at risk for infection due to aerosolized secretions. It is unlikely organisms could aerosolize as far as the door. Performing oral care is a part of the oral suctioning procedure process. Washing hands and donning gloves are necessary, but not the most important measure.

Pandemic Influenza

a respiratory illness caused by virulent human influenza A virus; spreads easily and sustainably and can cause global outbreaks of serious illness in humans some start out only effecting animals but can mutate and start to effect humans

pathophysiology of pneumonia

a. Fluid exudate accumulates in lower airways b. Spread of inflammation, alveolar walls thicken c. Impaired gas exchange d. May form abscesses (collection of pus) or pleural effusion. Tissue necrosis results when an abscess forms and perforates the bronchial wall. may occur as lobar pneumonia with consolidation (an abnormal solidification with lack of air spaces) in a segment or an entire lobe of the lung or as bronchopneumonia with diffusely scattered patches around the bronchi.

airborne infection isolation room (AIIR) should be placed when

aerosolized-generating interventions occur such as: Intubation NPPV Tracheotomy CPR Bronchoscopy Sputum induction

How is TB spread?

airborne (aerolization) when a person coughs, laughs, sneezes, whistles, or sings

TB tests

chest x-ray- do once we have positive TB test See calcifications if old disease Inflammation and caseation when it is active sputum cultures of blood- confirms the diagnosis and is also used to evaluate treatment effectiveness. respiratory secretions can be tested (nucleic acid amplification tests (NAATs)) TST- induration of 5 mm is a positive result. Blood analysis- Positive result- infected but don't know if its latent or active

COVID-19 is spread via

droplet transmission

When assessing the TB patient, you may note

dullness with percussion over the involved lung fields, bronchial breath sounds, crackles, and increased transmission of spoken or whispered sounds. Partial obstruction of a bronchus from the disease or compression by lymph nodes may produce localized wheezing.

TST: A positive reaction indicates

exposure to TB or the presence of inactive (dormant) disease, not active disease. A reduced skin reaction or a negative skin test does not rule out TB disease or infection of the very old or anyone who has severely reduced immunity.

Until the specific type of potentially pandemic influenza is identified and its routes of transmission are known, patients must be Infected patients in the hospital setting should be placed on

isolated, and Airborne, Droplet, and Contact Precautions must be used. Droplet Precautions for 7 days and placed in a private room.

The rate of pneumonia is higher among

older adults, nursing home residents, hospitalized patients, patients with neurologic problems or difficulty swallowing, and those being mechanically ventilated

Health Care-Acquired Pneumonia risk factors

• Is an older adult • Has a chronic lung disease • Has presence of gram-negative colonization of the mouth, throat, and stomach • Has an altered level of consciousness • Has had a recent aspiration event • Has presence of endotracheal, tracheostomy, or nasogastric tube • Has poor nutritional status • Has reduced immunity (from disease or drug therapy) • Uses drugs that increase gastric pH (histamine [H2] blockers, antacids) or alkaline tube feedings • Is currently receiving mechanical ventilation (ventilator-associated pneumonia [VAP])

In North America, the adults who are at greatest risk for development of TB are:

• Those in constant, frequent contact with an untreated infected person • Those who have reduced immunity or HIV disease • Adults who live in crowded areas such as long-term care facilities, prisons, homeless shelters, and mental health facilities • Older homeless adults • Users of injection drugs or alcohol • Lower socioeconomic groups • Foreign immigrants from less affluent countries

COVID: Indications for Emergency Interventions

• Trouble breathing • Persistent pain or pressure in the chest • New confusion • Inability to wake or stay awake • Bluish lips or face