Module 6: Pneumonia, Pleurisy, Empyema, Aspiration, TB; Pleural Effusion, Pulmonary Edema, ARDs (Ch. 19)

Pneumonia

Pneumonia

An inflammation of the alveoli, bronchioles, and arterioles in the lungs caused by microorganisms (bacteria, viruses, fungi)

Types of pneumonia

• Community aquired pneumonia

• Health care associated pneumonia

• Hospital aquired pneumonia

• Ventilator associated pneumonia

Pathophysiology of pneumonia

• Impairment of host defense to microrganisms

• Affects ventilation and diffusion of the body due to inflammatory reaction interfering with O2 and CO2 diffusion

Risk factors of pneumonia

• Older age

• Younger age (infants and children)

• Alcoholism

• Immunosuppressant disorders

• Multiple comorbidities (HF, DM, COPD, AIDS)

• Mucus build up and impaired drainage

• Smoking

• Prolonged immobility

• Shallow breathing patter

• Depressed cough reflex or abnormal swallowing mechanism

• Sedation

• Exposure to infected individuals

s/s of pneumonia

• Sudden onset of chills

• Rapidly rising fever

• Chest pain aggravated by deep breathing and cough

• Tachpynea

• SOB; accessory muscle use

• Breadycardia

• Headache

• Orthopenea

• Poor appetite

• Cyanosis

• Breathsounds can vary due to underlying conditions

Priorities of pneumonia

• Chest x-ray

• Blood culture

• Sputum examination

• Bronchoscopy with severe infection

Treatment of pneumonia

• Antibiotics

• Adequate rest and hydration

• Supplemental oxygen

Nursing considerations of pneumonia

• Vitals

  • Pulse oximetry

  • RR

  • ABGs

• Neurologic assessment

• Respiratory assessment

• Secretion assessment

• Promote coughing

• Incentive spirometry

• Smoking cessation

• Repositioning

• Frequent oral care

• Elevate head of bed

• Equipment sanitization

• Hand hygiene

Community acquired pneumonia

• Pneumonia aquired from the community OR less than 48 hours after hospital admision

• Most common bacterial cause = pneumococcus

• Mycoplasma pnaumonia = droplet to droplet

• “walking” pneumonia = viral

Heathcare associated pneumonia

• Pneumonia occuring in a nonhospitalized individual who has had healthcare contact

• Infection can occur within 90 days of prior hospitalization

• Primarily caused by multi-drug resistant organisms

Hospital acquired pneumonia

• Pneumonia occurring 48 hours after hospitalization; reason for admission is unrelated to pneumonia

• Difficulty with treatment due to many drug resistant organisms colonizing in/around the hospital setting

Ventilator associated pneumonia

• Pneumonia aquired 48 hours after endotrachial intubation with a patient recieving mechanical ventilatory support

• Colonized with bacteria in respiratory tract; does not interact until given access to blood

Pleurisy

• inflammation of both layers of the pleurae (parietal and visceral)

• Can develop with pneumonia, respiratory tract infection, tuberculosis, trauma, or PE

• Inflamed pleural membranes rub together

s/s of pleurisy

• Sever, sharp pleuritic pain

• Pleural fluid development

Priorities of pleurisy

• Auscultation before more fluid build up

• Chest x rays

• Sputum analysis

• Thoracentisis

Treatment of pleurisy

• Pain relief

  • Analgesic agents

  • Heat or cold

  • NSAIDs

• Treat underlying condition (pneumonia or infection)

Nursing considerations of pleurisy

• Turning and positioning for comfortable breathing

• Splinting

Empyema

Occurs when thick, purulent fluid (pus) accumulates within the pleural space, often with fibrin development and a walled off area where the infection is located

Pathophysiology of empyema

• Occurs as a complication of bacterial pneumonia or a lung abscess

• Can also occur from penetrating chest trauma, blood infection of the pleural space, or invasive medical examinations

• Pleural fluid is thin at first but progressess into a thick membrane enclosing the lung

Risk factors of empyema

• Infection

• Invasive examinations

• Trauma

s/s of empyema

• Fever

• Night sweats

• Pleural pain

• Cough

• Dyspnea

• Anorexia; weight loss

• Impaired lung expansion

Priorities of empyema

• Auscultation

• Chest CT

• Diagnostic thoracentesis

• Ultrasound

Treatment of empyema

• Sterilization of cavity

• Surgical management

• Drainage

  • Thoracentesis = needle aspiration for thin fluid

  • Tube thoracostomy = chest tube used with thrombolytics

  • Open chest thoracostomy

Nursing considerations of empyema

• Coping

• Breathing exercises

• Education on drainage system

Aspiration

Pulmonary consequences resulting from the entry of foreign substances into the lower airway

Pathophysiology of aspiration

Can occur from introduction of upper airway bacteria or GI bacteria

Risk factors of aspiration

• Seizures

• Depressed gag reflex

  • Brain injury

  • Low levels of consciousness

  • Stroke

  • Feeding tubes

  • Dysphasia

  • Sedatives

Nursing considerations of aspiration

• Elevate head of bed

• Avoid stimulation of gag reflex

• Check feeding tube placement

• Check feeding tube residuals

• Thickened fluids

Pleural effusion

A collection of fluid in the pleural space; secondary to other diseases

Risk factors of pleural effusion

• HF

• TB

• Pneumonia

• Infection

• PE

s/s of pleural effusion

• Pleural pain

• SOB

• Dyspnea

• s/s depend on underlying condition/cause and size

Priorities of pleural effusion

• Chest xray

• Chest CT

• Thoracentesis

• Bacterial culture

• WBC counts

• Pleural biopsy

• Respiratory assessment

Treatment of pleural effusion

• Thoracentesis

• Chest tube

• Surgery

Nursing considerations of pleural effusion

• Positioning

• Pain management

Pulmonary edema

• Abnormal accumulation of fluid in the lung tissue, the alveolar space, or both

• Classified as cardiogenic or noncardiogenic

Noncardiogenic pulmonary edema

• Occurs due to damage of the pulmonary capillary lining

  • Due to direct trauma, blood infection in the lungs, pr hydrostatic pressure

Treatment of pulmonary edema

• Oxygenation

  • ET with positive end-expiration pressure

• Diuretics

• Vasodilators

• Positioning

• Monitoring

Tuberculosis

• Infection via M. tuberculosis

• Spreads via airborne transmission

Pathophysiology of TB

• Susceptible individual inhales mycobacteria and becomes infected

• Bacteria is transmitted via airways to the alveoli and inflammatory reaction is initiated

Risk factors of TB

• Droplets from infected individual

  • Talking

  • Coughing

  • Sneezing

  • Laughing

  • Singing

• Immunocompromised

• Substance abuse

• Recent travel

• Overcrowding

s/s of TB

• Low grade fever

• Cough

• Night sweats

• Fatigue

• Weight loss

• hemoptysis

• Crackles

• Positive mantoux test

  • Erythema

  • 5mm or greater induration

• Positive quantiferon test

  • Blood test

Priorities of TB

• Mantoux testing

• Complete health hostory

• Chest x ray

• Breath sounds

• Drug resistance testing

Treatment of TB

• 6-12 months of anti-TB agents; 4 or more medications

• First line medications

  • Isoniazid

  • Rifampin

  • Pyrazinamide

  • Ethambutol

Nursing considerations of TB

• Airway clearance

• Adherence to treatment regimen

• Activity

• Nutrition

• Prevent transmission

Acute respiratory distress syndrome

• Sudden, progressive pulmonary edema, increasing bilateral infiltrates visible on chest x-ray, decreased lung compliance

s/s of ARDS

• rapid onset of severe dyspnea

• hypoxemia unresponsive to supplemental oxygen

treatment of ARDS

• intubation; mechanical ventilation with PEEP

• prone positioning

• nutritional support

• reduce anxiety