Infectious Respiratory Problems

1. A small amount (0.1mL) of purified protein derivative (PPD) is placed intradermally in the forearm. 2. The rest is "read" in 48-72 hours. 3. An area of induration (localized swelling with hardness of soft tissue), NOT JUST REDNESS, measuring 10mm or greater in diameter, indicates exposure to possible infection with TB. 4. In certain adults (those with decreased immunity), induration of 5mm is a positive result. 5. If possible, the site is re-evaluated after 72 hours because false-negative readings occur more often after only 48 hours. 6. A positive reaction indicates exposure to TB or the presence of inactive (dormant) disease, not active disease. (you have to confirm disease with sputum culture). 7. A reduced skin reaction or negative skin test does not rule out TB disease or infection of the very old or anyone with severely reduced immunity. Failure to have a skin response because of reduced immunity when infection is present is called anergy.

· Laboratory and Diagnostics Assessment of TB: § Chest x-ray: shows caseation and inflammation; may show infiltrations in any lung zone and lymph node enlargement (but may be normal) § The most accurate and rapid test for TB is the fully automated nucleic acid amplification test (NAAT) used on respiratory secretions. Results are available in less than 2 hours § Sputum Culture for acid-fast bacilli confirms the diagnosis. Enhanced TB cultures take up to 4 weeks. After drug therapy is started, sputum samples are obtained at intervals to determine therapy effectiveness (usually are negative after 3 months of treatment) § Blood Analysis is done using Interferon-Gamma release assays (IGRA). There are 2 tests: QuantiFERON-TB Gold In-Tube test and T-STOP TB test. Both show how the patient's immune system responds to the TB bacterium. · A positive result means that the person is infected with TB (does not indicate latent or active TB) § The Tuberculin Test (Mantoux Test) is the most common, reliable screening test for TB. Clients will have positive response within 2-10 weeks of exposure: 1. 2. 3. 4. 5. 6. 7.

Sputum Culture for acid-fast bacilli

· Laboratory and Diagnostics Assessment of TB: § Chest x-ray: shows caseation and inflammation; may show infiltrations in any lung zone and lymph node enlargement (but may be normal) § The most accurate and rapid test for TB is the fully automated nucleic acid amplification test (NAAT) used on respiratory secretions. Results are available in less than 2 hours § ______________________________ confirms the diagnosis. Enhanced TB cultures take up to 4 weeks. After drug therapy is started, sputum samples are obtained at intervals to determine therapy effectiveness (usually are negative after 3 months of treatment) § Blood Analysis is done using Interferon-Gamma release assays (IGRA). There are 2 tests: QuantiFERON-TB Gold In-Tube test and T-STOP TB test. Both show how the patient's immune system responds to the TB bacterium. · A positive result means that the person is infected with TB (does not indicate latent or active TB) § The Tuberculin Test (Mantoux Test) is the most common, reliable screening test for TB. Clients will have positive response within 2-10 weeks of exposure: 1. A small amount (0.1mL) of purified protein derivative (PPD) is placed intradermally in the forearm. 2. The rest is "read" in 48-72 hours. 3. An area of induration (localized swelling with hardness of soft tissue), NOT JUST REDNESS, measuring 10mm or greater in diameter, indicates exposure to possible infection with TB. 4. In certain adults (those with decreased immunity), induration of 5mm is a positive result. 5. If possible, the site is re-evaluated after 72 hours because false-negative readings occur more often after only 48 hours. 6. A positive reaction indicates exposure to TB or the presence of inactive (dormant) disease, not active disease. (you have to confirm disease with sputum culture). 7. A reduced skin reaction or negative skin test does not rule out TB disease or infection of the very old or anyone with severely reduced immunity. Failure to have a skin response because of reduced immunity when infection is present is called anergy.

cough, fever, sore throat. These progress rapidly to shortness of breath and pneumonia. In addition, diarrhea, vomiting, and abdominal pain, and bleeding from the nose and gums can occur

· Nursing Interventions and Treatment for Pandemic Influenza: 1. The care priorities with avian or any pandemic influenza are supporting the patient and preventing spread of the disease. Both are equally important. 2. Initial s/s of avian influenza are similar to those of other respiratory infections: ___________________________________________________________ § Ask any patients with these symptoms if they have recently (in the past 10 days) traveled to areas of the world affected by H5N1. If travel occurred, coordination with health care team to place the patient in airborne isolation room with negative air pressure. § These precautions remain in place until the diagnosis of H5N1 is ruled out or the treat of contagion is over. 3. PPE is essential. Anyone entering the room needs to wear N95 respirator 4. Teach others to monitor themselves for illness (especially respiratory infection) for at least 1 week after last contact with the patient. 5. Use oseltamivir and zanamivir within 48hr of contact with the infected patients.All personnel working with the patient suspected of having avian influenza should get the vaccine in the 2-step process. 6. No effective treatment for this infection currently exists. Interventions are supportive to allow the patient's own immune system to fight the infection. 7. O2 is given when hypoxia, breathlessness, or sudden change in cognition is present 8. If hypoxia is not improved with O2 therapy, intubation and mechanical ventilation is needed. 9. Antibiotics are given for bacterial pneumonia that may occur with H5N1 10. Monitor hydration status and I/O, due to diarrhea. 11. *!!! When performing procedures for the patient with a pandemic influenza that normally induce coughing or promote aerosolization of particles (suctioning, using a positive-pressure facemask, obtaining sputum culture, or giving aerosolized treatments), protect yourself and other workers !!!* § Wear a disposable particulate mask respiratory and protective eyewear during the procedure § Keep the door closed § Avoid touching your face with contaminated gloves § Wash your hands after you remove the gown, gloves, eyewear, and face shield and when you leave the patient's room § Wear gloves when disinfecting contaminated surfaces or equipment.

oseltamivir and zanamivir

· Nursing Interventions and Treatment for Pandemic Influenza: 1. The care priorities with avian or any pandemic influenza are supporting the patient and preventing spread of the disease. Both are equally important. 2. Initial s/s of avian influenza are similar to those of other respiratory infections: cough, fever, sore throat. These progress rapidly to shortness of breath and pneumonia. In addition, diarrhea, vomiting, and abdominal pain, and bleeding from the nose and gums can occur § Ask any patients with these symptoms if they have recently (in the past 10 days) traveled to areas of the world affected by H5N1. If travel occurred, coordination with health care team to place the patient in airborne isolation room with negative air pressure. § These precautions remain in place until the diagnosis of H5N1 is ruled out or the treat of contagion is over. 3. PPE is essential. Anyone entering the room needs to wear N95 respirator 4. Teach others to monitor themselves for illness (especially respiratory infection) for at least 1 week after last contact with the patient. 5. Use ________________________________ within 48hr of contact with the infected patients. All personnel working with the patient suspected of having avian influenza should get the vaccine in the 2-step process. 6. No effective treatment for this infection currently exists. Interventions are supportive to allow the patient's own immune system to fight the infection. 7. O2 is given when hypoxia, breathlessness, or sudden change in cognition is present 8. If hypoxia is not improved with O2 therapy, intubation and mechanical ventilation is needed. 9. Antibiotics are given for bacterial pneumonia that may occur with H5N1 10. Monitor hydration status and I/O, due to diarrhea. 11. *!!! When performing procedures for the patient with a pandemic influenza that normally induce coughing or promote aerosolization of particles (suctioning, using a positive-pressure facemask, obtaining sputum culture, or giving aerosolized treatments), protect yourself and other workers !!!* § Wear a disposable particulate mask respiratory and protective eyewear during the procedure § Keep the door closed § Avoid touching your face with contaminated gloves § Wash your hands after you remove the gown, gloves, eyewear, and face shield and when you leave the patient's room § Wear gloves when disinfecting contaminated surfaces or equipment.

C. "You may notice tingling of your hands."

A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. Which of the following is an appropriate statement by the nurse about this medication? A. "You may notice yellowing of your skin." B. "You may experience pain in your joints." C. "You may notice tingling of your hands." D. "You may experience a loss of appetite."

B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area."

A home health nurse is teaching a client who has active tuberculosis and is following a medication regimen that includes a combination of isoniazid, rifampin, pyrazinamide, and ethambutol. Which of the following client statements indicate understanding? (SATA) A. "I can substitute one medication for another if I run out because they all fight infection." B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area." D. "I am glad I don't have to have any more sputum specimens." E. "I don't need to worry where I go once I start taking my medications."

C. "Watch for any changes in vision."

A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to the medication ethambutol? A. "Your urine may turn a dark orange." B. "Watch for a change in the sclera of your eyes." C. "Watch for any changes in vision." D. "Take vitamin B6 daily."

A. Ask the client where the travel specifically occurred and whether he or she was exposed to anyone who was ill. D. Monitor the results of the client's blood urea nitrogen (BUN), creatinine, and liver function studies. E. Collaborate with the interprofessional team to obtain arterial blood gases and prepare to intubate the client.

A nurse is caring for a client who suddenly developed acute respiratory distress after returning home from an extended business trip in a foreign country. Which actions by the nurse are most appropriate before the cause of the problem is identified? (SATA) A. Ask the client where the travel specifically occurred and whether he or she was exposed to anyone who was ill. B. Use Contact Precautions with this client and use gloves and gown for care. C. Prepare to administer isoniazid (INH) as soon as the first dose is available. D. Monitor the results of the client's blood urea nitrogen (BUN), creatinine, and liver function studies. E. Collaborate with the interprofessional team to obtain arterial blood gases and prepare to intubate the client. F. Assist with obtaining sputum cultures for acid-fast bacilli to send to the laboratory for analysis.

B. All adults older than 49 years should receive a Fluzone immunization annually. C. Sneeze into a disposable tissue or into your sleeve instead of your hand. E. Wash your hands frequently and after blowing your nose, coughing, or sneezing.

A nurse is providing community education on seasonal influenza. What information will the nurse include in the presentation? (SATA) A. Adults older than 65 years should get the Prevnar-13 vaccination annually. B. All adults older than 49 years should receive a Fluzone immunization annually. C. Sneeze into a disposable tissue or into your sleeve instead of your hand. D. Avoid large crowds during spring and summer to limit the chance for getting the flu. E. Wash your hands frequently and after blowing your nose, coughing, or sneezing. F. Call your primary health care provider for an antiviral prescription within 3 days of getting symptoms.

A. Persistent cough C. Fatigue D. Night sweats E. Purulent sputum

A nurse is providing information to a group of clients at a local community center about tuberculosis. Which of the following clinical manifestations should be included in the teaching? Select all that apply. A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum

B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication."

A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? A. "You will need continue to take the multi-medication regimen for 4 months." B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." C. "You will need to remain hospitalized for treatment." D. "You will need to wear a mask at all times."

1. Low-Grade Fever 2. Fatigue 3. Mild chest pain 4. Dry, harsh cough 5. No s/s of upper respiratory infection (like sinusitis or sore throat) 6. Mediastinal "widening" on chest x-ray 7. Usually start to feel better and s/s improve in 2-4 days

Assessment of Inhalation Anthrax · 2 phases: prodromal (incubation period) and fulminant (active disease). · Symptoms take up to 8 weeks to develop after exposure · The Prodromal Stage is early and difficult to distinguish from influenza or pneumonia § S/S of Prodromal Stage of Inhalation Anthrax: 1. 2. 3. 4. 5. 6. 7. § If a patient begins appropriate antibiotics therapy at this stage, the likelihood of survival is high § Diagnostics can be made with a gram-stain of blood or chest x-ray. Positive results may not be evident until the disease has progressed to the fulminant stage · The Fulminant Stage begins after the patient feels a little better. § S/S of Fulminant Stage of Inhalation Anthrax: 1. Sudden onset of severe illness, hematemesis (blood vomit) 2. Sudden onset of breathlessness and respiratory distress 3. Dyspnea 4. Diaphoresis 5. Stridor on inhalation and exhalation 6. Hypoxia, cyanosis 7. High fever 8. Mediastinitis: hemorrhagic mediastinitis 9. Pleural effusion 10. Hypotension 11. Septic shock 12. Decreased LOC § The disease spreads through the blood, causing septic shock and hemorrhagic meningitis. Death often occurs within 24-36 hours, even if antibiotics are started in this stage.

1. Sudden onset of severe illness, hematemesis (blood vomit) 2. Sudden onset of breathlessness and respiratory distress 3. Dyspnea 4. Diaphoresis 5. Stridor on inhalation and exhalation 6. Hypoxia, cyanosis 7. High fever 8. Mediastinitis: hemorrhagic mediastinitis 9. Pleural effusion 10. Hypotension 11. Septic shock 12. Decreased LOC

Assessment of Inhalation Anthrax · 2 phases: prodromal (incubation period) and fulminant (active disease). · Symptoms take up to 8 weeks to develop after exposure · The Prodromal Stage is early and difficult to distinguish from influenza or pneumonia § S/S of Prodromal Stage of Inhalation Anthrax: 1. Low-Grade Fever 2. Fatigue 3. Mild chest pain 4. Dry, harsh cough 5. No s/s of upper respiratory infection (like sinusitis or sore throat) 6. Mediastinal "widening" on chest x-ray 7. Usually start to feel better and s/s improve in 2-4 days § If a patient begins appropriate antibiotics therapy at this stage, the likelihood of survival is high § Diagnostics can be made with a gram-stain of blood or chest x-ray. Positive results may not be evident until the disease has progressed to the fulminant stage · The Fulminant Stage begins after the patient feels a little better. § S/S of Fulminant Stage of Inhalation Anthrax: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. § The disease spreads through the blood, causing septic shock and hemorrhagic meningitis. Death often occurs within 24-36 hours, even if antibiotics are started in this stage.

1. Sputum culture and sensitivity (may cough up sputum, may need to suction sputum) 2. CBC for elevated WBC 3. Blood cultures to determine if organism has entered bloodstream 4. ABGs for severely ill patients to assess need for supplemental O2 5. Serum electrolytes, BUN, and creatinine: high BUN and hypernatremia = dehydration 6. Lactate level may be ordered to assess for sepsis 7. Chest X-Ray shows areas of increased density; may involve a lung segment, a lobe, one lung, or both lungs. In the older adult, chest x-rays are essential for early diagnosis because of their vague symptoms.

Assessment of Pneumonia · History: assess risk factors, aspiration events, past respiratory illnesses, exposure to the flu/pneumonia/viral infections · Signs and Symptoms of Pneumonia: 1. Flushed cheeks, anxious expression 2. Pleuritic chest pain or discomfort 3. Myalgia 4. Headache 5. Chills 6. Fever 7. Cough 8. Tachycardia; rapid, weak pulse may indicate hypoxemia, dehydration, or impending sepsis 9. Dyspnea 10. Tachypnea 11. Hemoptysis 12. Sputum production (purulent, blood-tinged, or rust-colored) 13. Chest muscle weakness from sustained coughing 14. Those with hypoxia and reduced gas exchange may be uncomfortable in lying position and will sit upright, balancing with the hands (tripod positioning) 15. Crackles on auscultation when fluid is interstitial and alveolar areas 16. Breath sounds diminished 17. Wheezing if inflammation or exudate narrows the airways 18. Bronchia breath sounds heard over areas of density or consolidation 19. Fremitus increased over areas of pneumonia, percussion dulled 20. Chest expansion may be diminished or unequal on inspiration 21. Older adults often hypotensive (orthostatic changes) due to vasodilation and dehydration 22. Dysrhythmias may occur from cardiac tissue hypoxia 23. Psychosocial: fatigue/pain/dyspnea promote anxiety, tenseness of muscles; may speak in broken sentences due to dyspnea · Laboratory and Diagnostic Assessment of Pneumonia: 1. 2. 3. 4. 5. 6. 7.

1. SLOW ONSET (most aren't aware of problems until disease is advanced); symptoms may be present for weeks-months 2. Persistent cough with mucopurulent sputum (may be streaked with blood) 3. Unintended weight loss 4. Anorexia (loss of appetite) 5. Night sweats 6. Hemoptysis 7. Shortness of breath, dyspnea 8. Fever 9. Chills 10. Fatigue, lethargy 11. Nausea 12. Chest tightness; dull/aching chest pain with cough 13. Dullness with percussion over involved lung fields 14. Bronchial breath sounds 15. Crackles 16. Wheezing

Assessment of Pulmonary Tuberculosis · History: assess past exposure to TB, travel or foreign countries with high TB rates, previous TB tests; ask about bacilli Calmette-Guerin (BCG) vaccine (anyone who had this in the past 10 years will have positive TB test that can complicate TB test interpretation, so they need blood tests) · Signs and Symptoms of TB: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. · Psychosocial Assessment: TB is frightening. Explain the need for thorough hygiene and avoiding infecting others. They may feel isolated and shunned, so help them resolve concerns and encourage contacts to get tested.

Pneumonia

Assessment of ________________ · History: assess risk factors, aspiration events, past respiratory illnesses, exposure to the flu/pneumonia/viral infections · Signs and Symptoms of ______________________: 1. Flushed cheeks, anxious expression 2. Pleuritic chest pain or discomfort 3. Myalgia 4. Headache 5. Chills 6. Fever 7. Cough 8. Tachycardia; rapid, weak pulse may indicate hypoxemia, dehydration, or impending sepsis 9. Dyspnea 10. Tachypnea 11. Hemoptysis 12. Sputum production (purulent, blood-tinged, or rust-colored) 13. Chest muscle weakness from sustained coughing 14. Those with hypoxia and reduced gas exchange may be uncomfortable in lying position and will sit upright, balancing with the hands (tripod positioning) 15. Crackles on auscultation when fluid is interstitial and alveolar areas 16. Breath sounds diminished 17. Wheezing if inflammation or exudate narrows the airways 18. Bronchia breath sounds heard over areas of density or consolidation 19. Fremitus increased over areas of pneumonia, percussion dulled 20. Chest expansion may be diminished or unequal on inspiration 21. Older adults often hypotensive (orthostatic changes) due to vasodilation and dehydration 22. Dysrhythmias may occur from cardiac tissue hypoxia 23. Psychosocial: fatigue/pain/dyspnea promote anxiety, tenseness of muscles; may speak in broken sentences due to dyspnea

1. Fever 2. Cough 3. Headache 4. Muscle aches 5. Chest pain 6. Night sweats 7. Bone and join pain (more severe infection) 8. Can become widespread and cause hemoptysis, meningitis, and involvement of skin, adrenal glands, liver, and spleen. It can become chronic and debilitating

Coccidioidomycosis · Coccidioidomycosis is a fungal infection caused by the Coccidioides organism common in the desert southwest regions of the US, Mexico, and Central/South America · It is also known as "Valley Fever" · The organism is present in the soil as inactive and nonreproducing microfilaments. When the soil is disturbed by excavation or dust storms, the microfilaments become airborne. When inhaled, they change into the reproductively active spore form of the organism (which can lead to pulmonary infection within 1-4 weeks after exposure) · Signs and Symptoms of Coccidioidomycosis: similar to other URI 1. 2. 3. 4. 5. 6. 7. 8. · Most younger adults recover from mild infection without treatment. · For moderate infection, oral therapy with antifungal agents, like fluconazole, ketoconazole, or voriconazole is needed. Antibiotics/virals DON'T HELP · For those with severe disease or women who are pregnant, IV amphotericin B may be needed · It is not spread from person-person, so isolation precautions are not needed · Assess these clients for this disease if they have traveled to areas with high incidence, such as winter vacation destinations. · Educate them on wearing masks, gloves when excavating soil

oral therapy with antifungal agents, like fluconazole, ketoconazole, or voriconazole is needed. Antibiotics/virals DON'T HELP

Coccidioidomycosis · Coccidioidomycosis is a fungal infection caused by the Coccidioides organism common in the desert southwest regions of the US, Mexico, and Central/South America · It is also known as "Valley Fever" · The organism is present in the soil as inactive and nonreproducing microfilaments. When the soil is disturbed by excavation or dust storms, the microfilaments become airborne. When inhaled, they change into the reproductively active spore form of the organism (which can lead to pulmonary infection within 1-4 weeks after exposure) · Signs and Symptoms of Coccidioidomycosis: similar to other URI 1. Fever 2. Cough 3. Headache 4. Muscle aches 5. Chest pain 6. Night sweats 7. Bone and join pain (more severe infection) 8. Can become widespread and cause hemoptysis, meningitis, and involvement of skin, adrenal glands, liver, and spleen. It can become chronic and debilitating · Most younger adults recover from mild infection without treatment. · For moderate infection, _________________________________________________________ · For those with severe disease or women who are pregnant, IV amphotericin B may be needed · It is not spread from person-person, so isolation precautions are not needed · Assess these clients for this disease if they have traveled to areas with high incidence, such as winter vacation destinations. · Educate them on wearing masks, gloves when excavating soil

contracted outside a healthcare setting, or acquired in the community 1. Treatment is usually a minimum of 5 days 2. Prompt initiation of antibiotics; in ED setting, first dose is given before the patient leaves the unit for inpatient bed or within 6 hours of presentation to the ED

Different Types of Pneumonia: · Community Acquired Pneumonia (CAP): _____________________________________________________________ 1. 2. · Healthcare Associated (HCA) Pneumonia: onset/diagnosis of pneumonia occurs less than 48 hours after admission in patient with specific risk factors (in hospital for more than 48 hours in past 90 days, living in LTC or nursing home, received IV therapy/wound care/antibiotics/chemo in the past 30 days, seen at hospital/dialysis clinic within past 30 days) 1. May have multi-drug resistant organisms 2. Hand hygiene is critical · Hospital Acquired Pneumonia (HAP): onset/diagnosis of pneumonia after 48 hours of admission to the hospital 1. Encourage pulmonary hygiene and progressive ambulation 2. Provide adequate hydration 3. Assess risk for aspiration using an evidence-based tool 4. Monitor for early signs of sepsis 5. Hand hygiene critical 6. Provide vigorous oral care · Ventilator-Associated Pneumonia (VAP): onset/diagnosis of pneumonia within 48-72 hours after ET intubation § Presence of ET tube increases risk by bypassing protective airway mechanisms and allowing aspiration of secretions from the oropharynx and stomach; dental plaque increases risk § Initiate ventilator bundle order set including: 1. Elevate HOB at least 30-45 degrees 2. Daily sedation "vacation" and weaning assessment 3. DVT prophylaxis 4. Oral care regimen with chlorhexidine 5. Stress ulcer prophylaxis: on a PPI to decrease gastric acidity 6. Suctioning AS NEEDED because the more you suction, the more risk you have of introducing bacteria into the ET tube. 7. Hand hygiene

onset/diagnosis of pneumonia occurs less than 48 hours after admission in patient with specific risk factors (in hospital for more than 48 hours in past 90 days, living in LTC or nursing home, received IV therapy/wound care/antibiotics/chemo in the past 30 days, seen at hospital/dialysis clinic within past 30 days) 1. May have multi-drug resistant organisms 2. Hand hygiene is critical

Different Types of Pneumonia: · Community Acquired Pneumonia (CAP): contracted outside a healthcare setting, or acquired in the community 1. Treatment is usually a minimum of 5 days 2. Prompt initiation of antibiotics; in ED setting, first dose is given before the patient leaves the unit for inpatient bed or within 6 hours of presentation to the ED · Healthcare Associated (HCA) Pneumonia: __________________________________________________________ 1. 2. · Hospital Acquired Pneumonia (HAP): onset/diagnosis of pneumonia after 48 hours of admission to the hospital 1. Encourage pulmonary hygiene and progressive ambulation 2. Provide adequate hydration 3. Assess risk for aspiration using an evidence-based tool 4. Monitor for early signs of sepsis 5. Hand hygiene critical 6. Provide vigorous oral care · Ventilator-Associated Pneumonia (VAP): onset/diagnosis of pneumonia within 48-72 hours after ET intubation § Presence of ET tube increases risk by bypassing protective airway mechanisms and allowing aspiration of secretions from the oropharynx and stomach; dental plaque increases risk § Initiate ventilator bundle order set including: 1. Elevate HOB at least 30-45 degrees 2. Daily sedation "vacation" and weaning assessment 3. DVT prophylaxis 4. Oral care regimen with chlorhexidine 5. Stress ulcer prophylaxis: on a PPI to decrease gastric acidity 6. Suctioning AS NEEDED because the more you suction, the more risk you have of introducing bacteria into the ET tube. 7. Hand hygiene

onset/diagnosis of pneumonia after 48 hours of admission to the hospital 1. Encourage pulmonary hygiene and progressive ambulation 2. Provide adequate hydration 3. Assess risk for aspiration using an evidence-based tool 4. Monitor for early signs of sepsis 5. Hand hygiene critical 6. Provide vigorous oral care

Different Types of Pneumonia: · Community Acquired Pneumonia (CAP): contracted outside a healthcare setting, or acquired in the community 1. Treatment is usually a minimum of 5 days 2. Prompt initiation of antibiotics; in ED setting, first dose is given before the patient leaves the unit for inpatient bed or within 6 hours of presentation to the ED · Healthcare Associated (HCA) Pneumonia: onset/diagnosis of pneumonia occurs less than 48 hours after admission in patient with specific risk factors (in hospital for more than 48 hours in past 90 days, living in LTC or nursing home, received IV therapy/wound care/antibiotics/chemo in the past 30 days, seen at hospital/dialysis clinic within past 30 days) 1. May have multi-drug resistant organisms 2. Hand hygiene is critical · Hospital Acquired Pneumonia (HAP): ____________________________________________ 1. 2. 3. 4. 5. 6. · Ventilator-Associated Pneumonia (VAP): onset/diagnosis of pneumonia within 48-72 hours after ET intubation § Presence of ET tube increases risk by bypassing protective airway mechanisms and allowing aspiration of secretions from the oropharynx and stomach; dental plaque increases risk § Initiate ventilator bundle order set including: 1. Elevate HOB at least 30-45 degrees 2. Daily sedation "vacation" and weaning assessment 3. DVT prophylaxis 4. Oral care regimen with chlorhexidine 5. Stress ulcer prophylaxis: on a PPI to decrease gastric acidity 6. Suctioning AS NEEDED because the more you suction, the more risk you have of introducing bacteria into the ET tube. 7. Hand hygiene

onset/diagnosis of pneumonia within 48-72 hours after ET intubation § Presence of ET tube increases risk by bypassing protective airway mechanisms and allowing aspiration of secretions from the oropharynx and stomach; dental plaque increases risk § Initiate ventilator bundle order set including: 1. Elevate HOB at least 30-45 degrees 2. Daily sedation "vacation" and weaning assessment 3. DVT prophylaxis 4. Oral care regimen with chlorhexidine 5. Stress ulcer prophylaxis: on a PPI to decrease gastric acidity 6. Suctioning AS NEEDED because the more you suction, the more risk you have of introducing bacteria into the ET tube. 7. Hand hygiene

Different Types of Pneumonia: · Community Acquired Pneumonia (CAP): contracted outside a healthcare setting, or acquired in the community 1. Treatment is usually a minimum of 5 days 2. Prompt initiation of antibiotics; in ED setting, first dose is given before the patient leaves the unit for inpatient bed or within 6 hours of presentation to the ED · Healthcare Associated (HCA) Pneumonia: onset/diagnosis of pneumonia occurs less than 48 hours after admission in patient with specific risk factors (in hospital for more than 48 hours in past 90 days, living in LTC or nursing home, received IV therapy/wound care/antibiotics/chemo in the past 30 days, seen at hospital/dialysis clinic within past 30 days) 1. May have multi-drug resistant organisms 2. Hand hygiene is critical · Hospital Acquired Pneumonia (HAP): onset/diagnosis of pneumonia after 48 hours of admission to the hospital 1. Encourage pulmonary hygiene and progressive ambulation 2. Provide adequate hydration 3. Assess risk for aspiration using an evidence-based tool 4. Monitor for early signs of sepsis 5. Hand hygiene critical 6. Provide vigorous oral care · Ventilator-Associated Pneumonia (VAP): _______________________________________________________________ - - 1. 2. 3. 4. 5. 6. 7.

first with the pneumococcal conjugate vaccine (PCV-13 or Prevnar 13), FOLLOWED BY the pneumococcal polysaccharide vaccine (PPSV 23 or pneumovax) about 6-12 months later.

Health Promotion and Maintenance for Pneumonia: · VACCINATION!!! JTC recommends that nurses encourage adults over 65 and those with chronic health problems to receive the immunization against pneumonia · 2 Pneumonia Vaccines: pneumococcal polysaccharide vaccine (PPSV 23 or pneumovax) and the pneumococcal conjugate vaccine (PCV-13 or Prevnar 13) 1. CDC recommends that adults older than 65 be vaccinated: ___________________________________________________________________ 2. Adults who have already had the pneumococcal polysaccharide vaccine (PPSV 23 or pneumovax) should have the pneumococcal conjugate vaccine (PCV-13 or Prevnar 13) about a year or more later 3. These recommendations also apply to anyone age 19-64 with risk factors (chronic illness) 4. They should also all get the seasonal influenza vaccine because pneumonia often follows influenza infection. · TJC include that all inpatients should have their pneumonia vaccine status checked, and if needed, be vaccinated while on in-patient status. ' · Strick handwashing · Avoid crowds during cold/flu season · Anyone who has a cold/the flu should see their doctor if fever lasts more than 24hrs, if the problem lasts longer than 1 week, or if symptoms worsen. · Clean RT equipment · Use sterile water in GI tubes · Use aspiration precautions as indicated · Use a sepsis screening tool to monitor patients with pneumonia, because pneumonia is a frequent causes of sepsis.

Directly observed therapy (DOT)

Home Care Coordination and Transition Management for Pulmonary Tuberculosis 1. Discharge may be delayed if the living situation is high risk or if nonadherence is likely. COLLABORATE WITH CASE MANAGER OR SOCIAL WORKER 2. Teach patient to follow drug regimen as prescribed and to always have a supply on hand. 3. Remind them that the disease is no longer contagious after drugs have been taken for 2-3 consecutive weeks and clinical improvement is seen. a. However, the must continue with prescribed drugs for 6 months or longer as prescribed. b. ______________________is where a healthcare professional watches the patient swallow the drugs, and may be indicated in some situations. 4. Educate on prevention of transmission: have close contacts be tested (DO CONTACT TRACING), avoid crowds and others 5. Receive follow-up care for at least 1 year after active treatment. 6. Urge those who use illicit drugs to locate a drug treatment program. Urge smokers to quit and help them find an appropriate smoking-cessation program.

protein, iron, vitamins A/B/C/E, and abundant fresh produce

Improving Nutrition for Pulmonary Tuberculosis 1. The patient with TB often has a long-standing history of malnutrition. Conduct a nutrition assessment, determine patient likes/dislikes, the ability to buy healthy foods, condition of teeth/dentures, weight and BMI, and history of substance abuse. 2. Consult dietician 3. Drugs used for TB often cause nausea, so, if this happens, teach the patient to takes once-a-day drugs at night. Antiemetics can be prescribed 4. If food doesn't interfere with drug absorption, taking pills with a small snack of simple carbs may help 5. Refer them to Meals on Wheels or other meal-deliver services 6. Teach them about oral hygiene, which makes food taste better 7. Weigh once a week 8. Eat a diet with quality ____________________________________________ 9. Avoid alcohol, which can cause liver damage and so can many TB drugs. Alcohol is also a course of "empty calories" (increases malnourishment). Adults who get many calories from alcohol will not eel hungry (they won't eat enough phosphorus, which causes a lack of energy) REMEMBER MEASURABLE GOALS: How do we measure if a client's nutrition is getting better? a. Client ate 4 meals a day b. Client takes supplements between meals c. Client eats high protein snacks between meals d. Client gains 4 pounds in 2 weeks (CORRECT)

any occurrence in a person who does not have an occupational risk is considered an intentional act of bioterrorist. REPORT the presence of symptoms consistent with inhalation anthrax to hospital authorities immediately

Inhalation Anthrax · Inhalation Anthrax (respiratory anthrax) is a bacterial infection caused by the gram-positive organism, Bacillus anthracis. This organisms lives as a spore in soil where grass-eating animals live and graze. § Most cases of anthrax are on the skin (cutaneous) § Inhalation anthrax is rare, and GI anthrax is even rarer § When infection occurs in the lungs, the disease is nearly 100% fatal without treatment. It is not spread by person-person contact. § It is an occupational hazard to veterinarians, farmers, taxidermists, and others who frequently contact animal wool, hides, bone meal, and skin § Because inhalation anthrax is so rare, __________________________________________________________ · Inhalation Anthrax organisms forms a spore (encapsulated organism that is inactive). These can live for years, even decades. When spores are inhaled deeply into the lungs, macrophages engulf them (when this happens, the organism leaves the spore to replicate). § The active bacteria then produce several toxins into tissues/blood which may infection worse. § Massive edema occurs along with hemorrhage and destruction of lung cells § Infected macrophages carry the organism to lymph nodes, and the organism spreads rapidly, causing bacteria, sepsis, and meningitis. § Lethal toxins produced by the bacteria re the most common cause of death

improving nutrition. Poor nutrition can lead directly to fatigue

Managing Anxiety for Pulmonary Tuberculosis 1. Assess for reports of anxiety and determine the cause. Most patients need education regarding the disease 2. While teaching the patient/family about either MDR TB or XDR TB, stress that it is the organism, not the patient, that is drug resistant because that can sometimes be misunderstood. 3. Patients can be anxious about isolation or spreading the disease to housemates or visitors; they can be concerned about contacting their employer 4. Provide education and support; refer to social services if they do not have sick leave and will lose pay during the time off work Managing Fatigue for Pulmonary Tuberculosis 1. Many interventions to improve fatigue are the same as those for ________________________________ 2. Encourage patient to resume normal activities slowly and get plenty of rest 3. Reassure them that fatigue will improve as therapy progresses 4. Assess sleep-wake habits and encourage a full-night's sleep with short daytime naps 5. Reassure the patient that, by taking drugs as directed, the disease will be cured and energy levels will increase

pneumonia, multi-system organ failure, sepsis, and death

Middle East Respiratory Syndrome (MERS) · Middle East Respiratory Syndrome (MERS) is a disease that could cause a pandemic. MERS is caused by a "novel" or new virus from the large family of coronaviruses. Viruses from this family cause many respiratory illnesses such as the common cold. § They can also cause critical infections, such as Severe Acute Respiratory Syndrome (SARS). § MERS was first identified in Saudi Arabia. The most recent outbreak was reported in 2015 in South Korea. Only 2 confirmed cases have occurred in North America · Patients with MERS typically report respiratory symptoms, like cough, shortness of breath, and fever. § GI problems: diarrhea § Symptoms can progress rapidly to ________________________________________________________ · The only tests for MERS are available through the CDC. To be tested, patients must have symptoms of MERS and have traveled to areas where MERS has been reported or have had close contact with someone who has confirmed MERS. § CDC test uses the reverse-transcriptase polymerase chain reaction assay (rRT-PCR) · There is no specific treatment for MERS. · Supportive care is used to manage and prevent complications · The patient may need mechanical ventilation and fluids · If kidney function is reduced, dialysis can be performed. · Hemorrhage from disseminated intravascular coagulation is managed with blood products. · "Convalescent serum" (serum taken from a patient who has recovered the disease) is a potential treatment but requires the patient have the same blood type as the Convalescent patient!!!!!!!!!!!!!!!!!!!!!!!

symptoms of MERS and have traveled to areas where MERS has been reported or have had close contact with someone who has confirmed MERS.

Middle East Respiratory Syndrome (MERS) · Middle East Respiratory Syndrome (MERS) is a disease that could cause a pandemic. MERS is caused by a "novel" or new virus from the large family of coronaviruses. Viruses from this family cause many respiratory illnesses such as the common cold. § They can also cause critical infections, such as Severe Acute Respiratory Syndrome (SARS). § MERS was first identified in Saudi Arabia. The most recent outbreak was reported in 2015 in South Korea. Only 2 confirmed cases have occurred in North America · Patients with MERS typically report respiratory symptoms, like cough, shortness of breath, and fever. § GI problems: diarrhea § Symptoms can progress rapidly to pneumonia, multi-system organ failure, sepsis, and death · The only tests for MERS are available through the CDC. To be tested, patients must have ___________________________________________________________________________________ § CDC test uses the reverse-transcriptase polymerase chain reaction assay (rRT-PCR) · There is no specific treatment for MERS. · Supportive care is used to manage and prevent complications · The patient may need mechanical ventilation and fluids · If kidney function is reduced, dialysis can be performed. · Hemorrhage from disseminated intravascular coagulation is managed with blood products. · "Convalescent serum" (serum taken from a patient who has recovered the disease) is a potential treatment but requires the patient have the same blood type as the Convalescent patient!!!!!!!!!!!!!!!!!!!!!!!

chills, fever, persistent cough, dyspnea, wheezing, hemoptysis, increased sputum production, chest discomfort, or increasing fatigue

Nursing Interventions and Treatment for Pneumonia · Home Care Coordination and Transition Management For Patients With Pneumonia: 1. Continue anti-infective drugs as prescribed 2. If the home has a second-story, the patient may prefer to stay on one floor for a few weeks, because stair climbing can be tiring. 3. Toileting needs may be met by using a bedside commode if bathroom is not located on the level 4. The long recovery phase, especially in the older adult, can be frustrating. Fatigue, weakness, and residual cough can last for weeks. Some fear they will never return to a "normal" level of functioning. Prepare them for the disease course and offer reassurance that complete recovery will occur 5. Teach the patient to notify the doctor if ________________________________________________________________ returns or fails to go away completely. 6. Increase activity gradually, and get plenty of rest 7. Avoid crowds, people who have a cold or flu, and exposure to lung irritants 8. Balanced diet and fluid intake is essential

If you get an arterial oxygen (PaO2) of less than 70, TELL THE DOCTOR. They're having some kind of oxygenation failure.

Nursing Interventions and Treatment for Pneumonia · Improving Gas Exchange For Patients With Pneumonia: 1. Nursing priorities include O2 therapy and assisting with pulmonary hygiene 2. O2 therapy is usually given via nasal cannula or mas unless hypoxemia does not improve with these devices. Confused patients may not tolerate a facemask 3. Check the skin under O2 devices or elastic bands (around ears) for skin breakdown 4. Incentive spirometry is used to improve inspiratory muscle action and prevent/reverse atelectasis (alveolar collapse). Teach patient to sit up, exhale fully, place mouthpiece in mouth, and take a long/slow/deep breath in, raising the piston as high as possible, then hold the breath for 2-4 seconds before slowly exhaling. Do 5-10 breaths per session every hour while awake 5. Monitor ABGs: ________________________________

draining the empyema cavity, re-expanding the lung, and controlling infection.

Nursing Interventions and Treatment for Pneumonia · Managing Empyema For Patients With Pneumonia: 1. Pulmonary empyema: a collection of pus in the pleural space most commonly caused by pulmonary infection. It impairs gas exchange 2. Empyema is suspected when chest wall motion is reduced, fremitus is reduced or absent, percussion is flat, and breath sounds are decreased. Bronchial sounds, egophony, and whispered pectoriloquy may be present 3. Diagnosis is made by chest x-ray or CT scan and a sample of pleural fluid (via thoracentesis) 4. Empyema fluid is thick, opaque, exudative, and foul-smelling. 5. Treatment includes __________________________________________________________ 6. Antibiotics are given 7. A chest tube is used to promote lung expansion and drainage. The tube is removed when the lung re-expands and the infection is under control

2L of fluids to prevent dehydration and thin secretions unless they have fluid restriction

Nursing Interventions and Treatment for Pneumonia · Preventing Airway Obstruction For Patients With Pneumonia: 1. Due to fatigue, muscle weakness, chest discomfort, and excessive secretions, the patient often has difficulty clearing secretions 2. Help them cough and deep breath every 2 hours 3. The alert patient may use an incentive spirometer to facilitate deep breathing and stimulate coughing 4. Encourage at least _______________________________ 5. Monitor I/O, oral mucous membranes, and skin turgor to assess hydration, especially when fever and tachypnea are present 6. Bronchodilators (beta2 agonists) may be given if bronchospasm is present. These are given by nebulizer or MDI. IV/inhaled steroids may be given when airway swelling is present. Expectorants, like guaifenesin may be used.

focus on preventing lung damage and treating the infection. Aspiration of acidic stomach contents can cause widespread inflammation, reading to acute respiratory distress syndrome (ARDS) and permanent lung damage

Nursing Interventions and Treatment for Pneumonia · Preventing Sepsis For Patients With Pneumonia: 1. Anti-infectives are given for all types of pneumonia, expect those caused by viruses. 2. Drug resistance is becoming increasingly common, especially for streptococcus pneumoniae. 3. Usually anti-infectives are used for 5-7 days for a patients with uncomplicated CAP and up to 21 days for a patient with severely impaired immunity or one with HAP 4. For pneumonia caused by aspiration of food/stomach contents, __________________________________________________________

Decreased gas exchange due to decreased diffusion at the alveolar membrane

Nursing Interventions and Treatment for Pneumonia · Priority Problems For Patients With Pneumonia: 1. _______________________ 2. Potential for airway obstruction due to excessive pulmonary secretions, fatigue, and muscle weakness 3. Potential for sepsis due to presence of organisms in very vascular areas and decreased immunity 4. Potential for pulmonary empyema due to spread of infectious organisms from lung to pleural space

1. Treated as outpatients with antibiotics 2. May need steroids to reduce swelling 3. Some may need drainage of the abscess 4. Pain control: topical analgesics, OTC analgesics, opioids 5. Liquid drugs due to swallowing difficulty may be needed 6. COMPLETE THE COURSE OF ANTIBIOTICS and COME TO THE ED QUICKLY IF S/S OF OBSTRUCTION (DROOLING/STRIDOR) APPEAR 7. A tonsillectomy may be performed to prevent recurrence

Peritonsillar Abscess (PTA) · Peritonsillar Abscess (PTA) is a rare complication of acute tonsillitis. The infection spreads from the tonsil to the surrounding tissue and forms an abscess. Most common cause is group A beta-hemolytic Streptococcus · Signs and Symptoms of Peritonsillar Abscess (PTA): 1. Collection of pus behind the tonsil causing swelling on one side of the throat, pushing the uvula toward the unaffected side 2. Severe throat pain radiation to ear/teeth 3. Muffled voice 4. Fever 5. Difficulty swallowing 6. Tonic contraction of muscles of chewing (trismus) 7. Difficulty breathing 8. Bad breath 9. Swollen lymph nodes on affected side · Diagnosis is based of symptoms, but needle aspiration and culture of pus is the preferred test · Nursing Interventions and Treatment of Peritonsillar Abscess (PTA): 1. 2. 3. 4. 5. 6. 7.

isoniazid, rifampin, pyrazinamide, and ethambutol for the first 8 weeks (initial phase of treatment).

Nursing Interventions and Treatment for Pulmonary Tuberculosis Decreasing Drug Resistance and Infection Spread for Pulmonary Tuberculosis · Combination Drug Therapy is the most effective method of treating TB and preventing transmission. Active BT is treated with a combination of drugs to which the organisms are sensitive too. Therapy continues until the disease is under control · Multiple-Drug Regimens destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms § First-Line Therapy uses ____________________________________________ § These drugs can damage the liver. Warn the patient not to drink any alcoholic beverages for the entire duration of TB therapy § The continuation phase lasts another 18 weeks and the patient takes INH and rifampin wither twice daily or twice a week § Bedaquiline Fumarate is specifically targeted to multidrug-resistant TB (MDR TB). 1. Side Effects can be life-threatening so it is not used when other drugs will work 2. It can prolong QT interval, cause ventricular dysrhythmias, and lead to sudden death 3. Patients NEED to have regular electrocardiograms (ECGs) and serum electrolyte evaluations. 4. It should be given through directly observed therapy · Strict Adherence to the prescribed drug regimen is crucial for suppressing the disease. Adherence is difficult because of the 26 weeks duration of treatment (but it can be as long as 2 years for MDR TB) 1. The major role of nurse is teaching the patient about drug therapy and stressing the importance of taking each drug regularly, exactly as prescribed, for as long as it is prescribed. 2. Provide pamphlets, videos, or drug-schedule worksheets. 3. With current resistant strains of TB, emphasize that not taking the drugs as prescribed could lead to an infection that is drug resistant 4. Some MDR TB strains are emerging as extensively drug-resistant (XDR TB). Warn patients with XDR TB that absolute adherence to therapy is critical for survival and cure of the disease. These patients should receive directly observed therapy. (DOT)

1. Side Effects can be life-threatening so it is not used when other drugs will work 2. It can prolong QT interval, cause ventricular dysrhythmias, and lead to sudden death 3. Patients NEED to have regular electrocardiograms (ECGs) and serum electrolyte evaluations. 4. It should be given through directly observed therapy

Nursing Interventions and Treatment for Pulmonary Tuberculosis Decreasing Drug Resistance and Infection Spread for Pulmonary Tuberculosis · Combination Drug Therapy is the most effective method of treating TB and preventing transmission. Active BT is treated with a combination of drugs to which the organisms are sensitive too. Therapy continues until the disease is under control · Multiple-Drug Regimens destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms § First-Line Therapy uses isoniazid, rifampin, pyrazinamide, and ethambutol for the first 8 weeks (initial phase of treatment). § These drugs can damage the liver. Warn the patient not to drink any alcoholic beverages for the entire duration of TB therapy § The continuation phase lasts another 18 weeks and the patient takes INH and rifampin wither twice daily or twice a week § Bedaquiline Fumarate is specifically targeted to multidrug-resistant TB (MDR TB): 1. 2. 3. 4. · Strict Adherence to the prescribed drug regimen is crucial for suppressing the disease. Adherence is difficult because of the 26 weeks duration of treatment (but it can be as long as 2 years for MDR TB) 1. The major role of nurse is teaching the patient about drug therapy and stressing the importance of taking each drug regularly, exactly as prescribed, for as long as it is prescribed. 2. Provide pamphlets, videos, or drug-schedule worksheets. 3. With current resistant strains of TB, emphasize that not taking the drugs as prescribed could lead to an infection that is drug resistant 4. Some MDR TB strains are emerging as extensively drug-resistant (XDR TB). Warn patients with XDR TB that absolute adherence to therapy is critical for survival and cure of the disease. These patients should receive directly observed therapy. (DOT)

the results of 3 consecutive sputum cultures are negative, the patient is no longer infectious (contagious) and may return to former activities. Remind them to avoid exposure to inhalation irritants which can further lung damage

Nursing Interventions and Treatment for Pulmonary Tuberculosis Decreasing Drug Resistance and Infection Spread for Pulmonary Tuberculosis · Patients hospitalized with active TB are placed on Airborne Precautions in a negative pressure room! It is a well-ventilated room that has at least 6 exchanges of fresh air per minute. 1. All healthcare workers must use a personal respirator when caring for the patient. 2. Perform handwashing BEFORE and AFTER patient care 3. Patient needs a mask during transport out of the room, and they need to be transported using the shortest and least busy route 4. TB is often treated outside the acute care setting, in the patient's home. Airborne precautions are not necessary in this setting because family members have already been exposed; however, all members of the household should be tested. 5. Teach the patient to cover the mouth and nose with a tissue when coughing or sneezing, to place tissues in plastic bags, and to weak a mask when in contact with crowds until the drugs suppress infection 6. Teach the patient that sputum specimens are needed usually every 2-4 weeks once drug therapy is initiated. When __________________________________________________________

Potential for airway obstruction due to thick secretions and weak cough effort

Nursing Interventions and Treatment for Pulmonary Tuberculosis · The priority collaborative problems for patients with TB: 1. _____________________________________ 2. Potential for development of drug-resistant disease and spread of infection due to inadequate adherence to therapy regimen 3. Anxiety due to diagnosis 4. Weight loss due to inadequate intake and nausea from therapy regimen 5. Fatigue due to length illness, poor gas exchange, and increased energy demands

1. Antihistamines, leukotriene inhibitors, and mast cell stabilizers block or reduce the amount of chemical mediators in nasal and sinus tissues and prevent local edema/itching 2. Decongestants constrict blood vessels and decrease edema 3. Antipyretics are given if fever is present 4. Analgesics are given for pain · Treatment for Bacterial Rhinosinusitis includes broad-spectrum antibiotics (amoxicillin), decongestants (phenylephrine), and antipyretics; sometimes nasal steroids or systemic steroids

Nursing Interventions and Treatment for Rhinosinusitis: · Often managed as outpatient problem · Check for s/s of Rhinosinusitis: 1. Pain over cheek radiating to the teeth 2. Tenderness to percussion over the sinuses 3. Referred pain to the temple or back of the head 4. General facial pain that is worse when bending forward 5. Bacterial infection: purulent nasal drainage with postnasal drip, sore throat, fever, erythema, swelling, fatigue, dental pain, and ear pressure · Management focuses on symptoms relief and education. Teach them about correct use of drug therapy · Drug Therapy often involves decongestants and intranasal steroid spray 1. 2. 3. 4. § If no improvement is seen in 48hr, the patient may need further evaluation · Supportive therapy: humidification, nasal irrigation, applying hot wet packs over the sinus area 1. Rest (8-10hr/day) and fluid intake of at least 2000mL/day 2. Humidification helps relieve congestion 3. Nasal saline irrigation helps 4. Sleeping with the HOB elevated and avoiding smoking can help 5. If caused by allergies, limit exposure to the offending agent · Reduce risk of spreading infection by thoroughly washing the hands (especially after blowing the nose, sneezing, rubbing face, or coughing) § Stay home from work/school or crowded places; avoid close contact w/others § Cover the mouth/nose with tissue when sneezing/coughing and dispose of tissues immediately

early recognition of cases and implementing community and personal quarantine. Social distancing behaviors also help reduce viral exposure

Pandemic Influenza · Many viral infections in animals and birds are not usually transmitted to humans, but a few historic exceptions have occurred when these viruses have mutated and became highly infectious to humans. These are termed Pandemic because they have the potential to spread globally because the virus is new to humans who have no immunity to it. § This includes the 1918 "Spanish" influenza (H1N1 strain, swine flu) § A new avian virus is the H5N1 strain, known as "avian influenza" or "bird flu". It infected millions of birds in Asia, and has started to spread to human-human contact. · Health Promotion and Maintenance for Pandemic Influenza: 1. The prevention of worldwide influenza pandemic of any virus is the responsibility of everyone 2. A vaccine for H5N1 is available in case of H5N1 outbreaks 3. The recommended approach for any potential pandemic is __________________________________________________________________ 4. When a pandemic flu occurs in US, stockpiled vaccines will be made available for immunization. (for example, Vepacel (vaccine for H5N1) requires 2 vaccines, 28 days apart) 5. Antiviral drugs, oseltamivir and zanamivir should be widely distributed to reduce severity of infection and mortality rate. 6. Infected patients should be cared for in strict isolation 7. All nonessential public activities should be stopped, including social gatherings, school attendance, religious services, shopping, and certain types of employment. 8. Adults should stay home and use the food, water, and drugs they have stockpiled to last at least 2 weeks per person. 9. Travel to and from the area should be stopped 10. Urge adults to pay attention to public health announcements and early warning systems for disease outbreaks. 11. Teach them the important of starting prevention ASAP. 12. Keep battery-powered radio (and batteries) to keep informed of updates 13. An influenza pandemic is a disaster, and containing it requires cooperation of all adults.

nonessential public activities should be stopped, including social gatherings, school attendance, religious services, shopping, and certain types of employment.

Pandemic Influenza · Many viral infections in animals and birds are not usually transmitted to humans, but a few historic exceptions have occurred when these viruses have mutated and became highly infectious to humans. These are termed Pandemic because they have the potential to spread globally because the virus is new to humans who have no immunity to it. § This includes the 1918 "Spanish" influenza (H1N1 strain, swine flu) § A new avian virus is the H5N1 strain, known as "avian influenza" or "bird flu". It infected millions of birds in Asia, and has started to spread to human-human contact. · Health Promotion and Maintenance for Pandemic Influenza: 1. The prevention of worldwide influenza pandemic of any virus is the responsibility of everyone 2. A vaccine for H5N1 is available in case of H5N1 outbreaks 3. The recommended approach for any potential pandemic is early recognition of cases and implementing community and personal quarantine. Social distancing behaviors also help reduce viral exposure 4. When a pandemic flu occurs in US, stockpiled vaccines will be made available for immunization. (for example, Vepacel (vaccine for H5N1) requires 2 vaccines, 28 days apart) 5. Antiviral drugs, oseltamivir and zanamivir should be widely distributed to reduce severity of infection and mortality rate. 6. Infected patients should be cared for in strict isolation 7. All ________________________________________________________________________________________________________ 8. Adults should stay home and use the food, water, and drugs they have stockpiled to last at least 2 weeks per person. 9. Travel to and from the area should be stopped 10. Urge adults to pay attention to public health announcements and early warning systems for disease outbreaks. 11. Teach them the important of starting prevention ASAP. 12. Keep battery-powered radio (and batteries) to keep informed of updates 13. An influenza pandemic is a disaster, and containing it requires cooperation of all adults.

starts after 1-2 weeks, and the patient has severe coughing "fits" lasting several minutes. During the coughing spasms that patient may turn red or vomit. They are frequently exhausted by the coughing. The distinct "whooping' sound common in children at the end of a cough may not be present in adults. There is bloody, purulent, thick exudate in the small airways that can lead to atelectasis and pneumonia. Tis stage lasts up to 10 weeks

Pertussis · Pertussis is a respiratory infection caused by Bordetella pertussis. It is highly contagious and spreads easily from person-person via respiratory droplets. · Pertussis has 3 phases: § Catarrhal Phase: patient has s/s resembling the common cold (mild cough) § Paroxysmal Phase: ____________________________________________________________ § Convalescent (recovery) Phase: lasts for months

empyema (pus in pleural cavity)

Pneumonia · Pneumonia is excess fluid in the lungs from an inflammatory process. This disease can seriously reduce gas exchange (O2 transport to the cells and CO2 transport away from cells through ventilation and diffusion). § Inflammation causing pneumonia can be triggered by infectious organisms by inhaling irritating agents. Inflammation occurs in the interstitial spaces, the alveoli, and often the bronchioles. § This process begins when organisms penetrate the airway mucosa and multiply § WBCs migrate to the area of infection, causing local capillary leak, edema, and exudate. These fluids collect in/around the alveoli, and the alveolar walls thicken § Both evens seriously reduce gas exchange, leading to hypoxemia, which has the potential to cause death § RBCs and fibrin move into the alveoli and capillary leak spreads the infection to other areas of the lung. If organisms move into the bloodstream, septicemia results; if infection moves into the pleural cavity, ______________________________ results. Atelectasis (alveolar collapse) reduces gas exchange even more, arterial O2 levels fall, causing more hypoxemia. § Pneumonia may occur as lobal pneumonia with consolidation (solidification, lack of air spaces) in a segment or an entire lobe of the lung, or as bronchopneumonia with diffusely scattered patches around the bronchi. The extent of lung involvement depends on host defenses. Bacteria multiply quickly in a person who is immunocompromised. § Tissue necrosis results when abscesses form and perforates the bronchial wall. · Pneumonia develops when a patient's immunity cannot overcome the invading organisms. · Organisms from environment, invasive devices, equipment, supplies, or other people can invade the body · Pneumonia can be caused by viruses, bacteria, mycoplasmas, fungi, rickettsiae, protozoa, and helminths (worms) · Noninfectious causes include inhalation of toxic gases, chemicals, fumes, smoke, and aspiration of water, food, fluid, or vomit.

further growth of bacilli is controlled in most cases. The lesions usually resolve and leave little/no residual bacilli. Only a small percentage ever develop active TB

Pulmonary Tuberculosis · Pulmonary Tuberculosis is a highly communicable disease that affects the lung parenchyma caused by Mycobacterium tuberculosis. It is transmitted via aerosolization (airborne route). When a person with active TB coughs, laughs, sneezes, whistles, or signs, infected respiratory droplets become airborne and may be inhaled by others. § Far more adults are infected with the bacillus than actually develop active TB. This is because the normal protection of immunity prevents full development of TB in a healthy person. § The bacillus multiplies freely when it reaches a susceptible site (bronchus or alveoli). An exudative response occurs, causing pneumonitis. § With the development of acquired immunity to TB, ____________________________________________ § Cell-mediated immunity against TB develops 2-10 weeks after 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.

inflammation of the mucous membranes of one or more of the sinuses and is usually seen with rhinitis, especially the common cold (coryza)

Rhinosinusitis · Rhinosinusitis is an ____________________________________________________ § Anything that interferes with sinus drainage (deviated nasal septum, nasal polyps, tumors, inhaled air pollutants, cocaine, allergies, facial trauma, dental infection) can lead to Rhinosinusitis. § Even when the problem starts with a noninfectious cause (like allergies), swelling can block flow of secretions and cause infection § Most episodes of Rhinosinusitis are caused by viruses and develop in the maxillary and frontal sinuses. § Complications include cellulitis, accesses, and meningitis · Diagnosis is made based on patient's history and symptoms, but other tests for complicated cases include endoscopic exams, CT § Purulent drainage, fever, and lack of response to decongestants can indicate a bacterial infection

1. Older adult 2. chronic lung disease 3. gram negative colonization of the mouth, throat, and stomach 4. altered level of consciousness 5. recent aspiration event 6. ET/tracheostomy/NG tubes 7. poor nutrition 8. reduced immunity (from disease or drug therapy) 9. Drugs that increase gastric pH: H2 blockers, PPIs, or alkaline tube feedings 10. mechanical ventilation (ventilator-associated pneumonia (VAP)

Risk Factors For Pneumonia · Risk factors for Healthcare Acquired Pneumonia (HAP): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. · Risk Factors for Community Acquired Pneumonia: 1. Older adults 2. Tobacco use, Smoking, or smoke (2nd-hand) exposure 3. No pneumococcal vaccine or had vaccine >5 years ago 4. no flu vaccine in the previous year 5. has chronic health problem or other co-existing condition that reduces immunity 6. Recent exposure to viral or influenza infections

1. Close contact with an infectious person who has not yet been diagnosed with TB (risk for transmission is reduced after the infectious person has received proper drug therapy for 2-3 weeks) 2. Those in constant, frequent contact with an untreated person 3. Reduced immunity (HIV, chemo, kidney disease, DM, crohn's disease) 4. Adults who live in crowded areas like LTCs, dormitories, prisons, homeless shelters, and psych facilities (poorly-ventilated environments) 5. Older homeless adults 6. Abusers of IV drugs or alcohol 7. Lower socioeconomic groups 8. Healthcare workers which involvement in performance of high-risk activities (respiratory treatments, suctioning, coughing procedures) 9. Older Adults 10. Foreign immigrants, or migrant workers (Mexico, Philippines, Vietnam, China, Japan)

Risk Factors for Pulmonary Tuberculosis 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Health Promotion and Prevention of Pulmonary Tuberculosis 1. Providing adequate housing 2. Substance abuse programs (that are accessible) 3. Feeding centers or food banks for those in need 4. Adults with risk factors should avoid people who are ill, stay nourished, practice good hand-hygiene 5. Those who work with TB patients should be screened regularly

older than 50, those with chronic illness or immune compromise, those living in institutions, adults living with or caring for adults with health problems that put them at risk for severe complications of influenza, and health care personnel.

Seasonal Influenza · Health Promotion and Maintenance for Seasonal Influenza: 1. Vaccinations: the vaccine is changed every year based on which specific viral strains are most likely to cause illness during the influenza season (late fall and winter) § Usually vaccine has antigens for 3-4 expected viral strains § IM injection is recommended (intranasal was found to be ineffective and is no longer available) § Annual vaccination is especially important for those __________________________________________________________________________________________ 2. HAND WASHING, especially after nose blowing, sneezing, coughing, rubbing the eyes, or touching the face. 3. Stay home from work, school, or crowded places 4. Cover the nose/mouth with tissue when sneezing or coughing 5. Disposing tissues immediately after using them 6. Avoid close contact with other people (when someone is sick) 7. Sneeze or cough into the upper sleeve rather than the hand (respiratory droplets on hands can contaminate surfaces and be transmitted to others)

has high false-negative rates, and the patient should be treated if influenza is suspected even if RIDT is negative.

Seasonal Influenza · Nursing Interventions and Treatment for Seasonal Influenza: 1. Diagnosis: Testing for Influenza or diagnosis is based on report of symptoms 2. Rapid Influenza Diagnostic Test (RIDT) is common but _____________________________________________ 3. Viral infection = NO ANTIBIOTICS 4. Antivirals: oseltamivir (Tamiflu), zanamivir (Relenza), peramivir (Rapivab) have been effective in prevention/treatment of some strains of influenza A and B a. They can be given to adults at high risk for complications who have been exposed to influenza but not yet vaccinated b. These drugs also shorten the duration of influenza c. They prevent viral spread in the respiratory tract by inhibiting viral enzyme that allows the virus to penetrate respiratory cells d. To be effective as treatment, they must be taken within 24-48hr after symptoms begin e. zanamivir (Relenza) should be used with caution in those with COPD or asthma and in older adults f. peramivir (Rapivab) is IV ONLY g. Patients older than 65 should be treated with antivirals ASAP to reduce risk of hospitalization, complications, and disability 5. Rest for several days and increase fluid intake (unless they have another diagnosis that requires fluid restriction) 6. Saline gargles can ease sore throat pain 7. Antihistamines may reduce rhinorrhea 8. Other supportive measures for rhinitis

within 24-48hr after symptoms begin

Seasonal Influenza · Nursing Interventions and Treatment for Seasonal Influenza: 1. Diagnosis: Testing for Influenza or diagnosis is based on report of symptoms 2. Rapid Influenza Diagnostic Test (RIDT) is common but has high false-negative rates, and the patient should be treated if influenza is suspected even if RIDT is negative. 3. Viral infection = NO ANTIBIOTICS 4. Antivirals: oseltamivir (Tamiflu), zanamivir (Relenza), peramivir (Rapivab) have been effective in prevention/treatment of some strains of influenza A and B a. They can be given to adults at high risk for complications who have been exposed to influenza but not yet vaccinated b. These drugs also shorten the duration of influenza c. They prevent viral spread in the respiratory tract by inhibiting viral enzyme that allows the virus to penetrate respiratory cells d. To be effective as treatment, they must be taken ________________________________________________________ e. zanamivir (Relenza) should be used with caution in those with COPD or asthma and in older adults f. peramivir (Rapivab) is IV ONLY g. Patients older than 65 should be treated with antivirals ASAP to reduce risk of hospitalization, complications, and disability 5. Rest for several days and increase fluid intake (unless they have another diagnosis that requires fluid restriction) 6. Saline gargles can ease sore throat pain 7. Antihistamines may reduce rhinorrhea 8. Other supportive measures for rhinitis

1. Rapid onset of severe headache, muscle aches, fever, chills, fatigue, and weakness 2. Adults are contagious from 24hr before symptoms occur and up to 5 days after symptoms begin. 3. Sore throat, cough, and watery nasal discharge can occur 4. Infection with Influenza strain B can lead to nausea, vomiting, and diarrhea 5. Most patients feel fatigued for 1-2 weeks after acute episode resolves.

Seasonal Influenza · Seasonal Influenza or "flu" is a highly contagious acute viral respiratory infection that can occur at any age. Epidemics are common and lead to complications of pneumonia or death. Up to 49,000 deaths in a single year have been caused by the flu. § Most are treated at home, but hospitalization may be needed when symptoms are severe or the patient develops COMPLICATIONS (PNEUMONIA, ESPECIALLY IN THE OLDER ADULT AND IMMUNOCOMPROMISED) § Influenza can be caused by one of several virus families, referred to as A, B, and C · The patient with Seasonal Influenza has: 1. 2. 3. 4. 5.

1. Report changes in vision, reduced color vision, blurred vision, or reduced visual fields immediately because it can cause optic neuritis, especially at high doses, and can lead to blindness. Minor eye problems are usually reversed when the drug is stopped. 2. Obtain a baseline vision test and monitor vision month because it can cause optic neuritis. 3. Avoid alcohol because it will cause severe nausea and vomiting with this drug; and increases liver damage and risk of Liver Failure 4. This drug increases uric acid formation and can worsen gout 5. Drink at least 8 ounces of water when taking the tablet and increase fluid intake to prevent uric acid from precipitating, making gout or kidney problems worse.

Tuberculosis Drugs · Ethambutol: inhibits bacterial RNA synthesis, thus suppressing bacterial growth. It is bacteriostatic (not bactericidal) so it has to be used in combo with other TB drugs 1. 2. 3. 4. 5.

1. Side effects: loss of appetite, n/v, jaundice, ABD pain, tingling in toes/fingers 2. Avoid antacids. Take the drug on an empty stomach (1hr before or 2hr after meal) to prevent slowing of drug absorption in the GI tract. 3. Take a vitamin B6 (pyridoxine) supplement or multi-vitamin because the drug depletes the body of this vitamin and can cause neurotoxicity 4. Avoid alcohol because it increases liver damage and risk of Liver Failure 5. Report darkening of the urine, yellow eyes/skin, malaise, fatigue, nausea, anorexia, pain/swelling of joints, and increased bleeding which are s/s of liver toxicity/failure (Assess LFTs prior to and during therapy)

Tuberculosis Drugs · Isoniazid: kills actively growing mycobacteria outside the cell and inhibits the growth of dormant bacteria inside macrophages and caseating granulomas 1. 2. 3. 4. 5.

1. Ciprofloxacin 400mg IV q12hr or... 2. Doxycycline 100mg IV q12hr 3. Plus one or two of the following secondary agents (parenteral): a. Rifampin, Clindamycin, or Vancomycin 4. Treatment with IV drugs continues for at least 7 days. When response is good, IV drugs are changed to oral and continued for 60 days.

Treatment/Prevention of Inhalation Anthrax · The organism found naturally in the environment is sensitive to common antibiotics; but organisms grown for bioterrorism may be altered to be resistant to these antibiotics. Therefore, antibiotics used for anthrax include a combination of drugs, and can be used when a person has had exposure but no symptoms yet: § Inhalation Anthrax Prophylaxis: 1. Ciprofloxacin 500mg oral BID or... 2. Doxycycline 100mg oral BID or... 3. Amoxicillin 500mg orally q8h or 875mg orally BID 4. Prophylaxis must continue for 60 days (or longer if exposure was heavy) § Inhalation Anthrax Treatment: 1. 2. 3. 4. · A vaccine is available to be used BEFORE exposure occurs, but distribution is limited to at-risk adults. · Teach patients with any type of lower respiratory infection to be especially vigilant for changes after they think they are getting well. They need to seek medical attention immediately on having a setback that starts with breathlessness

1. This drug increases uric acid formation and can worsen gout 2. Drink at least 8 ounces of water when taking the tablet and increase fluid intake to prevent uric acid from precipitating, making gout or kidney problems worse. 3. Photosensitivity and increased risk for sunburn: wear sunscreen, hats, protective clothing, especially when in direct sun 4. Avoid alcohol because it increases liver damage and risk of Liver Failure 5. Report darkening of the urine, yellow eyes/skin, malaise, fatigue, nausea, anorexia, pain/swelling of joints and increased bleeding which are s/s of liver toxicity/failure (Assess LFTs prior to and during therapy)

Tuberculosis Drugs · Pyrazinamide: kills organisms residing in a very acidic environment of macrophages (where TB lives); available on in combo with other anti-TB drugs 1. 2. 3. 4. 5.

1. Expect an orange-reddish staining of the skin/urine. Body secretions have an orange tint, so contact lenses can be permanently stained (knowing these side effects can reduce anxiety when they occur) 2. Sexually active women need another form of birth control while taking and for 1 month after because the drug decreases oral contraceptive effectiveness 3. Avoid alcohol because it increases liver damage and risk of Liver Failure 4. Report darkening of the urine, yellow eyes/skin, malaise, fatigue, nausea, anorexia, pain/swelling of joints, and increased bleeding which are s/s of liver toxicity/failure (Assess LFTs prior to and during therapy) 5. Ask the patient about all other drugs in use because this one interacts with many drugs

Tuberculosis Drugs · Rifampin: kills slower-growing organisms that reside in macrophages and caseating granulomas 1. 2. 3. 4. 5.

B. PaO2 68 mm Hg

When reviewing the laboratory values for a client admitted with pneumonia, which result will cause the nurse to collaborate quickly with the primary health care provider? A. White blood cell (WBC) count of 14,526 mm3 B. PaO2 68 mm Hg C. PaCO2 46 mm Hg D. Blood glucose 146 mg/dL

B. "Do not drink alcohol in any quantity while taking Isoniazid."

Which information is most important for a nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy? A. "Report darkening or reddening of the urine while taking Rifampin." B. "Do not drink alcohol in any quantity while taking Isoniazid." C. "Restrict fluid intake to 2 quarts of liquid a day on pyrazinamide." D. "Temporary visual changes while taking ethambutol are not serious."

§ Wear a disposable particulate mask respiratory and protective eyewear during the procedure § Keep the door closed § Avoid touching your face with contaminated gloves § Wash your hands after you remove the gown, gloves, eyewear, and face shield and when you leave the patient's room § Wear gloves when disinfecting contaminated surfaces or equipment.

· Nursing Interventions and Treatment for Pandemic Influenza: 1. The care priorities with avian or any pandemic influenza are supporting the patient and preventing spread of the disease. Both are equally important. 2. Initial s/s of avian influenza are similar to those of other respiratory infections: cough, fever, sore throat. These progress rapidly to shortness of breath and pneumonia. In addition, diarrhea, vomiting, and abdominal pain, and bleeding from the nose and gums can occur § Ask any patients with these symptoms if they have recently (in the past 10 days) traveled to areas of the world affected by H5N1. If travel occurred, coordination with health care team to place the patient in airborne isolation room with negative air pressure. § These precautions remain in place until the diagnosis of H5N1 is ruled out or the treat of contagion is over. 3. PPE is essential. Anyone entering the room needs to wear N95 respirator 4. Teach others to monitor themselves for illness (especially respiratory infection) for at least 1 week after last contact with the patient. 5. Use oseltamivir and zanamivir within 48hr of contact with the infected patients.All personnel working with the patient suspected of having avian influenza should get the vaccine in the 2-step process. 6. No effective treatment for this infection currently exists. Interventions are supportive to allow the patient's own immune system to fight the infection. 7. O2 is given when hypoxia, breathlessness, or sudden change in cognition is present 8. If hypoxia is not improved with O2 therapy, intubation and mechanical ventilation is needed. 9. Antibiotics are given for bacterial pneumonia that may occur with H5N1 10. Monitor hydration status and I/O, due to diarrhea. 11. *!!! When performing procedures for the patient with a pandemic influenza that normally induce coughing or promote aerosolization of particles (suctioning, using a positive-pressure facemask, obtaining sputum culture, or giving aerosolized treatments), protect yourself and other workers !!!*: - - - - -

cough, turn, move about as much as possible, and perform deep-breathing exercises

· Patient/Family Education on Preventing Pneumonia (chart 31-1): 1. Know if you are at risk for pneumonia (older than 65, have chronic health problems, have limited mobility, are confined to a bed/chair during waking hours) 2. Have the annual flu vaccine after discussing appropriate timing for the vaccine with your doctor 3. Discuss pneumococcal vaccine with doctor and get the vaccine as recommended 4. Avoid crowded public areas during flu and holiday seasons 5. If you have a mobility problem: __________________________________________ 6. If using respiratory equipment at home, clean the equipment 7. Avoid indoor pollutants (dust, secondhand smoke, aerosols) 8. If you smoke, stop. If you don't smoke, don't start smoking 9. Be sure to get enough rest and sleep on a daily basis 10. Eat a healthy, balanced diet 11. Drink at least 3L of nonalcoholic fluids everyday (unless contraindicated)

spread of TB throughout the body when a large number of organisms enter the blood. Many tiny nodules scattered throughout the lung are seen on x-ray. Other body areas can become infected due to this spread (like vital organs)

· The Process of TB infection: 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. On X-ray, this is the primary lesion 3. Areas of caseation then undergo resorption, degeneration, and fibrosis. The necrotic areas may calcify or liquefy. If liquification occurs, the material then empties into the bronchus, and the emptied area becomes a cavity. Bacilli continue to grow in the necrotic cavity wall and spread through the lymph into new areas of the lung 4. A lesion can also grow by direct extension if bacilli multiply rapidly during inflammation. Lesions can extend through the pleura, resulting in pleural or pericardial effusion. a. Miliary or hematogenous TB is the __________________________________________________ 5. Initial infection is seen more often in the middle or lower lobes of the lung. The local lymph nodes are infected and enlarged. An asymptomatic period usually follows the primary infection and can last for years or decades before clinical symptoms develop. This is called latent TB. An infected person is not contagious until symptoms of disease occur. 6. Secondary TB is a reactivation of the disease in a previously infected person. It is more likely when defenses are lowered and immunity is decreased (seen in older adults, those with chronic disease, those with HIV). Upper lobes are common sites of reactivation