Topic 3: Lower Respiratory Problems

normal defense mechanisms (air filtration, epiglottis, closure over trachea, cough reflex, mucociliary escalator, reflex bronchoconstriction, IgA, IgG, and alveolar macrophages) become incompetent or overwhelmed due to aspiration, tracheal intubation, air pollution, smoking, viral URI, aging, and chronic diseases

what is the cause of pneumonia

pneumonia

acute infection of lung parenchyma that is associated with significant morbidity and mortality rates

causative pathogens, disease characteristics, and chest Xray appearance

how is pneumonia classified

community-acquired pneumonia (CAP)

acute infection in patients who have not been hospitalized or resided in a LTC within 14 days of the onset of S/S; can be treated at home or hospital, depending on the patient’s age, VS, mental status, comorbidities, and condition

hospital-acquired pneumonia

occurs 48 hours or longer after hospitalization and not present at time of admission; aka nosocomial pneumonia

• viral

• bacterial

• mycoplasma

• aspiration

• necrotizing

• opportunistic

what are the types of pneumonia

viral pneumonia

the MC type of pneumonia that is mild or life threatening

bacterial pneumonia

type of pneumonia that may require hospitalization

mycoplasma pneumonia

atypical pneumonia that is mild and usually occurs in those younger than 40 y/o

pathophysiology of pneumonia

Pathogens will trigger an immune response which activates inflammatory responses. Neutrophils are released during inflammatory process. The release of neutrophils cause buildup of fluid in the lungs which spill over into the alveoli. Gas exchange is challenged (transport of oxygen) which results in hypoxia and decreased gas exchange. The use of antibiotics may assist with macrophages and removing excess debris which can promote gas exchange and restore normal tissue functioning

• productive or nonproductive cough

• fine or coarse crackles over affected region

• green, yellow, or rust-colored sputum

• fever

• chills

• dyspnea, SOB, tachypnea

• pleuritic chest

• Older or debilitated patients may experience confusion, stupor, hyperthermia, diaphoresis, anorexia/loss of appetite, fatigue, myalgia, HA

what are the S/S of pneumonia

• multidrug-resistant pathogens

• atelectasis

• pleurisy

• pleural effusion

• bacteremia

• pneumothorax

• acute respiratory failure (ARF)

• sepsis/septic shock

what are the complications of pneumonia

atelectasis

complication of pneumonia that results from collapsed alveoli

pleural effusion

complication of pneumonia due to a buildup of liquid in the pleural space

bacteremia

complication of pneumonia in which bacterial infection occurs in the blood

pneumothorax

complication of pneumonia in which lungs collapse due to air in pleural space

acute renal failure (ARF)

The complication of pneumonia is the leading cause of death in severe pneumonia cases

sepsis

complication of pneumonia that occurs when bacteria from alveoli enter the bloodstream

• history and physical exam

• chest X-ray may show pleural effusion

• Bronchoscopy and thoracentesis may be done to get cell/fluid samples

• ABGs will reveal if a patient is experiencing hypoxemia, acidosis, or hypercapnia

• Blood/sputum cultures will be drawn to determine the infectious agent

• CBC with differential will allow the nurse to see elevated WBC, which indicates infection

• pulse oximetry

what diagnostic studies would be done on clients with pneumonia and what would they reveal

• prompt treatment with effective antibiotics

  • response within 48-72 hours

• pneumococcal vaccine

• no definitive treatment for viral pneumonia so provide supportive care

what does treatment of pneumonia consist of

Start with IV and switch to oral once stable. Treatment should not be longer than 5 days

what does treatment look like for a pneumonia patient who is hospitalized

• adequate hydration to thin and loosen secretions

  • monitor I&O

  • prevent dehydration

  • adjust for elderly, patients with heart failure, or with preexisting respiratory conditions

  • replace electrolytes as needed

• small, frequent, high calorie meals: monitor weight

what does nutrition therapy for a patient with pneumonia consist of

pneumonia assessment

• subjective data

  • Past health, medication, and surgical history

  • functional health problems

• objective data

  • general: fever, restlessness, or lethargy

  • Respiratory

  • CV: tachycardia

• impaired respiratory function

• infection

• fluid imbalance

• activity intolerance

• altered body temp

what clinical problems are related to pneumonia

• no signs of hypoxemia

• normal breathing patterns

• clear breath sounds

• normal chest xray

• normal WBC count

• no complications

what are the nursing goals for a client with pneumonia

• teach hygiene, nutrition, rest, and regular exercise

• cough

• avoid cigarette smoke

• avoid exposure to URIs and prompt treatment

• Identify RF

• influenza and pneumococcal vaccines

• monitor assessment findings and response to therapy

• provide supportive measures: O2 therapy, antipyretics, analgesics

• Collaborate with respiratory therapy to monitor the condition and provide chest physiotherapy

• prompt treatment with effective antibiotics

• pain management: deep breathing and coughing, awake/alert to achieve optimum mobility

• balance rest and activity

• strict medical asepsis and infection control

• reduce risks

  • Elevate HOB to at least 30 degrees

  • Assess for the presence of gag reflex before eating/drinking

• Take all antibiotics

• use cool mist humidifier/warm bath

what are the implementation/nursing interventions for clients with pneumonia

tuberculosis (TB)

Infectious disease caused by Mycobacterium tuberculosis; MC in the lungs but can affect any organ; increasing rates due to HIB and drug-resistance, leading cause of mortality in patient with HIV

• poor, underserved, and minority groups

• homeless

• residents of inner city neighborhoods

• foreign born persons

• living/working in institutions

• IV drug users

• overcrowded living conditions

• poverty/poor access to care

• immunosuppressed

what are the RF to TB

airborne droplets, requires close, frequent, or prolonged exposure

how is TB spread

multidrug resistant TB (MDR-TB)

TB that is resistant to first-line drug therapy (isoniazid and rifampin) or second-line drug therapy, caused by incorrect prescribing/prescribing the wrong drugs, lack of monitoring, and nonadherence to regimen

• initially, dry cough but becomes productive

• fatigue

• malaise

• anorexia

• weight loss

• low grade fever

• night sweats

• late: dyspnea and hemoptysis

• normal or adventitious breath sounds

• hypotension

• hypoxemia

what are the clinical manifestations of pulmonary TB

• not likely to show fever or typical signs of infection

• assess HIV patients for pneumococcal pneumonia

• assess elderly for changes in cognitive function such as confusion

what S/S may the immunocompromised patient (HIV) and the elderly experience if they have penumonia

tuberculin skin test (TST)

diagnostic study that is recommended for HCPs and those with decreased response to allergens; indicates exposure

Interferon-y (INF-gamma) release assays (IGRAs)

screening tool that includes QuantiFERON-TB Gold In-Tube (QFT-GIT) and T-SPOT.TB tests provide rapid results, several advantages over TST, but are more expensive

TB sputum culture

The gold standard diagnostic study for diagnosing TB

• treated outpatient

• infectious for first 2 weeks after starting treatment if sputum positive

• aggressive drug therapy so monitor for adherence

  • lasts months

what is the interprofessional care for TB

1. intensive: 4 drugs

2. continuation: 2 drugs (isoniazid and rifampin)

what are the two phases of treatment for active TB

nonviral hepatitis

what is a major side effect for ¾ first line drugs of TB

A sensitivity test determines drugs

initial: 5 drugs for at least 6 months after sputum culture is negative (1-2 first line, fluoroquinolone, injectable antibiotics and 1 or more second line)

continuation: 4 drugs for 18-24 months

what is the treatment for MDR-TB

directly observed therapy (DOT)

expensive but preferred public health strategy to ensure adherence due to nonadherence being a major factor in MDR-TB and treatment failures

baseline LFTs and again every 2-4 weeks

what should be monitored in clients receiving treatment for TB

TB assessment

• history: TB, chronic illness, immunosuppression, social and occupational RF

• physical symptoms: productive cough, night sweats, fever, weight loss, abnormal breath sounds, pleuritic breath sounds

• impaired respiratory function

• infection

• deficient knowledge

• lack of knowledge

what are the clinical problems for those with TB

• have normal lung function

• adhere to treatment plan

• take measures to prevent spread of TB

• have no recurrence

What are the nursing goals for a client with TB

• eradication worldwide

• selective screening programs for high-risk groups

• Positive TST results: chest x-ray

• Report positive tests to public health authorities

• improve access to healthcare and education

• airborne isolation: private room with airflow exchanges; HCP wear appropriate masks

• appropriate drug therapy

• teach patient to prevent spread (wear face mask outside of the room, proper cough/sneezing, hand washing)

• identify and screen close contacts

• can go home if household members already exposed and responding well to treatment

• stop smoking

what are the nursing implementation/interventions for a clietn with TB