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Flashcards in Chapter 27 Lower Respiratory Problems Deck (131)
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1
Q

Acute bronchitis is a self-limiting inflammation of the?

A

bronchi in the lower respiratory tract and a common reason for seeking medical care.

  • Most acute bronchial infections are caused by viruses.
  • Air pollution, dust, inhalation of chemicals, smoking, chronic sinusitis, and asthma are other triggers of acute bronchitis
2
Q

Acute bronchitis

  • most common symptom?
  • The presence of colored (e.g., green) sputum is?
  • Associated symptoms may include?
A
  • Cough, which is the most common symptom, lasts for up to 3 weeks. Clear, mucoid secretions are often present, although some patients produce purulent sputum.
  • The presence of colored (e.g., green) sputum is not a reliable indicator of bacterial infection.
    Associated symptoms include headache, fever, malaise, hoarseness, myalgias, dyspnea, and chest pain
3
Q

Diagnosis of acute bronchitis is based on clinical assessment. Assessment may reveal?

A

1) normal breath sounds or crackles or wheezes, usually on expiration and with exertion.
2) Consolidation (occurs when fluid accumulates in the lungs), suggestive of pneumonia, is ABSENT with bronchitis.
3) Chest x-rays would be normal and are therefore not indicated unless pneumonia is suspected

4
Q

Acute bronchitis

  • The goal in acute bronchitis is to?
  • Treatment is?
  • Generally antibiotics are not prescribed for treating a viral infection, as they may cause?
A
  • goal to relieve symptoms and prevent pneumonia.
  • Treatment is supportive, including cough suppressants, encouraging oral fluid intake, and using a humidifier. β2-agonist (bronchodilator) inhalers are useful for patients with wheezes.
  • may cause side effects and promote antibiotic resistance. However, antibiotics may be prescribed for patients with underlying chronic conditions and who have a prolonged infection associated with systemic symptoms.
5
Q

Acute Bronchitis: Patients should be encouraged not to ?

- If the acute bronchitis is due to an influenza virus, treatment with?

A
  • encouraged not to smoke, avoid secondhand smoke, and to frequently wash their hands.
  • treatment with antiviral drugs, either zanamivir (Relenza) or oseltamivir (Tamiflu), can be started. These drugs should be initiated within 48 hours of the onset of symptoms
6
Q

Acute bronchitis 5 main points

A

1) Inflammation of the bronchi
2) 90% are viral
3) Most common symptom- cough
- HA, fever, malaise, hoarseness, dyspnea, CP
3) Normal breaths sounds/ rhonchi
4) Normal CXR

7
Q

Pertussis is a highly contagious infection of the respiratory tract caused by?

  • The bacteria attach to the cilia of the respiratory tract and?
  • The incidence of pertussis has been steadily increasing in the United States since the 1980s, with the largest increase noted in?
  • It is thought that immunity resulting from childhood vaccination with DPT (diphtheria, pertussis, tetanus) may diminish over time, allowing a milder (but still contagious) infection. The Centers for Disease Control and Prevention (CDC) currently recommends that all adults age ___ years and older who have not received a dose of Tdap (tetanus, diphtheria, and pertussis) receive a?
A
  • caused by a gram-negative bacillus, Bordetella pertussis.
  • release toxins that damage the cilia, causing inflammation and swelling.
  • increase noted in adults.
  • age 19 years and older who have not received a dose of Tdap (tetanus, diphtheria, and pertussis) receive a one-time vaccination as soon as possible
8
Q

Clinical manifestations of pertussis occur in stages.

1) The first (catarrhal) stage, occurring within?
2) The second (paroxysmal) stage, from the second to tenth week of infection, is characterized by paroxysms of cough.
3) The final (convalescent) stage lasts?

A

1) first 2 weeks of infection, manifests as a mild upper respiratory tract infection (URI) with a low-grade or no fever, runny nose, watery eyes, and mild, nonproductive cough
2) second (paroxysmal) stage, from the second to tenth week of infection, is characterized by paroxysms of cough.
3) lasts 2 to 3 weeks and is characterized by less severe cough and weakness

9
Q

The hallmark characteristic of pertussis is?

A

uncontrollable, violent coughing.

  • Inspiration after each cough produces “whooping” sound as patient tries to breathe in air against obstructed glottis. The “whoop” often not present in teens and adults (especially those who have been vaccinated).
  • Like acute bronchitis, coughing more frequent at night.
  • Vomiting may also occur with coughing.
  • Unlike bronchitis, cough with pertussis may last from 6 to 10 weeks
10
Q
  • The primary treatment for pertussis is?
  • The patient is infectious from the?
  • What should NOT be used to treat pertussis?
A
  • tantibiotics, usually macrolides (erythromycin, azithromycin [Zithromax]), to minimize symptoms and prevent spread of the disease.
  • infectious from the beginning of the catarrhal stage through the third week after onset of symptoms or until 5 days after antibiotic therapy has been initiated.
  • Cough suppressants and antihistamines should not be used, since they are ineffective and may induce coughing episodes. Corticosteroids and bronchodilators are also not useful
11
Q

Pertussis main points

A

1) Highly contagious
2) Gram negative bacillus
3) Uncontrolled, violent coughing
4) Low-grade or no fever
5) Runny nose, watery eyes
6) ABX to prevent spread/minimize symptoms
7) Cough suppressants, antihistamines-ineffective
8) Vaccine Dtap
- Tetanus, diphtheria, pertussis

12
Q
  • Pneumonia is an acute infection of the?
  • Until 1936, pneumonia was the leading cause of death in the United States. The discovery of _____ and ____ was pivotal in the treatment of pneumonia.
  • Since that time, remarkable progress has been made in the development of ______ to treat pneumonia.
  • However, despite newer antimicrobial agents, pneumonia is still associated with significant morbidity and mortality rates. The CDC reports that pneumonia and influenza are the?
A
  • acute infection of the lung parenchyma. Until 1936, pneumonia was the leading cause of death in the United States
  • discovery of sulfa drugs and penicillin was pivotal
  • development of antibiotics to treat pneumonia
  • pneumonia and influenza are the eighth leading cause of death in the United States
13
Q

Pneumonia 4 main points

A

1) Acute infection
2) Until 1936- leading cause of death
3) Still associated with high morbidity/mortality
4) Community-acquired (CAP) 6th leading cause of death for pts >65

14
Q

Pneumonia Etiology
Normally, the airway distal to the larynx is protected from infection by various defense mechanisms. Mechanisms that create a mechanical barrier to microorganisms entering the tracheobronchial tree include?
- Immune defense mechanisms include secretion of?

A
  • mechanical barrier to microorganisms include air filtration, epiglottis closure over the trachea, cough reflex, mucociliary escalator mechanism, and reflex bronchoconstrictio.
  • secretion of immunoglobulins A and G and alveolar macrophages
15
Q

1) Pneumonia is more likely to occur when?
2) Decreased consciousness weakens the?
3) Tracheal intubation bypasses normal?
4) What can also impair the mucociliary mechanism?
5) Chronic diseases can?

A

1) defense mechanisms become incompetent or are overwhelmed by the virulence or quantity of infectious agents.
2) weakens the cough and epiglottal reflexes, which may allow aspiration of oropharyngeal contents into the lungs. 3) bypasses normal filtration processes and interferes with the cough reflex and mucociliary escalator mechanism.
4) Air pollution, cigarette smoking, viral URIs, and normal changes that occur with aging
5) suppress the immune system’s ability to inhibit bacterial growth

16
Q

Organisms that cause pneumonia reach the lung by three ways:

A
  1. Aspiration of normal flora from the nasopharynx or oropharynx. Many organisms that cause pneumonia are normal inhabitants of the pharynx in healthy adults.
  2. Inhalation of microbes present in the air. Examples include Mycoplasma pneumoniae and fungal pneumonias.
  3. Hematogenous spread from a primary infection elsewhere in the body. Examples are streptococci and Staphylococcus aureus from infective endocarditis
17
Q

Pneumonia occurs when defense mechanisms are overwhelmed and unable to fight the virus
4 types

A

1) Community-acquired (CAP)
2) Medical Care-associated (MCAP) – usually 48 hrs post admission
3) Aspiration – abnormal entry from mouth or stomach into lungs – triggers inflammatory response
4) Opportunistic – altered immune system – like HIV, chemo or radiation patients

18
Q

Pneumonia patho main points

A

1) Inflammatory response
- Attraction of neutrophils
- Release of inflammatory mediators
2) Alveoli fill w/ fluid- consolidation
3) Increased mucous production
4) Decreased gas exchange
5) Macrophages in alveoli ingest/remove debris

19
Q

18 Risk Factors for Pneumonia

A

Risk Factors for Pneumonia
• Abdominal or thoracic surgery
• Age >65 yr
• Air pollution
• Altered consciousness: alcoholism, head injury, seizures, anesthesia, drug overdose, stroke
• Bed rest and prolonged immobility
• Chronic diseases: chronic lung and liver disease, diabetes mellitus, heart disease, cancer, chronic kidney disease
• Debilitating illness
• Exposure to bats, birds, rabbits, farm animals
• Immunosuppressive disease and/or therapy (corticosteroids, cancer chemotherapy, human immunodeficiency virus [HIV] infection, immunosuppressive therapy after organ transplant)
• Inhalation or aspiration of noxious substances
• Intestinal and gastric feedings via nasogastric or nasointestinal tubes
• IV drug use
• Malnutrition
• Recent antibiotic therapy
• Resident of a long-term care facility
• Smoking
• Tracheal intubation (endotracheal intubation, tracheostomy)
• Upper respiratory tract infection

20
Q

Organisms Causing Pneumonia

Community-Acquired Pneumonia

A
Organisms Causing Pneumonia
Community-Acquired Pneumonia
• Streptococcus pneumoniae*
• Mycoplasma pneumoniae
• Haemophilus influenzae
• Respiratory viruses
• Chlamydophila pneumoniae
• Chlamydophila psittaci
• Coxiella burnettii
• Legionella pneumophila
• Oral anaerobes
• Moraxella catarrhalis
• Staphylococcus aureus
• Pseudomonas aeruginosa
• Enteric aerobic gram-negative bacteria (e.g., Klebsiella species)
• Fungi
• Mycobacterium tuberculosis
21
Q

Organisms Causing Pneumonia

Hospital-Acquired Pneumonia

A
  • Pseudomonas aeruginosa†
  • Escherichia coli†
  • Klebsiella pneumoniae†
  • Acinetobacter species†
  • Haemophilus influenzae
  • Staphylococcus aureus
  • Streptococcus pneumoniae
  • Proteus species
  • Enterobacter species
  • Oral anaerobes
22
Q

Types of Pneumonia

  • potential causes of pneumonia.
  • Although pneumonia can be classified many different ways (e.g., according to the causative organism), the most widely recognized and clinically effective way is to classify pneumonia as?
A
  • Bacteria, viruses, Mycoplasma organisms, fungi,
  • community-acquired or hospital-acquired pneumonia. Classifying pneumonia is important because of the differences in the likely causative organisms and the selection of appropriate antimicrobial therapy
23
Q

Community-acquired pneu­monia (CAP) is an acute infection of the lung occurring in patients who have?
- The decision to treat the patient at home or admit him or her to the hospital is based on several factors such as the?

A
  • not been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms
  • patient’s age, vital signs, mental status, presence of co-morbid conditions, and current physiologic condition. Clinicians can use tools such as the CURB-65 scale to supplement clinical judgment
24
Q

Community-Acquired pneumonia treatment

A

Empiric antibiotic therapy should be started as soon as possible. It is the initiation of treatment before a definitive diagnosis or causative agent is confirmed, and should be started as soon as CAP is suspected. Empiric antibiotic administration is based on experience and knowledge of drugs known to be effective for the most likely causative agent

25
Q

Hospital-acquired pneumonia (HAP), also known as ______ pneumonia, is a pneumonia in a?

  • VAP pneumonia?
  • Once the diagnosis of HAP or VAP is made, treatment of pneumonia is initiated based on?
  • Antibiotic therapy can be?
  • Both HAP and VAP are associated with?
A

nosocomial pneumonia

  • nonintubated patient that begins 48 hours or longer after admission to hospital and was not present at the time of admission.
  • Ventilator-associated pneumonia (VAP), also a type of HAP, refers to pneumonia that occurs more than 48 hours after endotracheal intubation
  • based on known risk factors, early versus late onset, and probable organism.
  • Antibiotic therapy can be adjusted once the results of sputum cultures identify the exact pathogen.
  • longer hospital stays, increased associated costs, sicker patients, and increased risk of morbidity and mortality
26
Q

1) A major problem in treating pneumonia today is the development of?
2) Primary culprits include?
3) Risk factors for development of MDR pneumonia include?
4) Antibiotic susceptibility tests can identify MDR organisms. The virulence of these organisms can severely limit the?

A

1) multidrug-resistant (MDR) organisms.
2) methicillin-resistant Staphylococcus aureus and gram-negative bacilli.
3) advanced age, immunosuppression, history of antibiotic use, and prolonged mechanical ventilation.
4) Available and appropriate antimicrobial therapy. MDR organisms also increase the morbidity and mortality risks associated with pneumonia

27
Q

1) Aspiration pneumonia results from the abnormal entry of material from the?
2) Conditions that increase the risk of aspiration include?
3) With loss of consciousness, the?

A

1) mouth or stomach into the trachea and lungs
2) decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and insertion of nasogastric tubes with or without tube feeding
3) gag and cough reflexes are depressed, and aspiration is more likely to occur

28
Q

Aspiration pneumonia

1) The aspirated material triggers an?
2) most common form of aspiration pneumonia is a?

A

1) aspirated material (food, water, vomitus, or oropharyngeal secretions) triggers an inflammatory response.
2) primary bacterial infection. Typically, more than one organism is identified on sputum culture, including aerobes and anaerobes, since they both make up the flora of the oropharynx

29
Q

Aspiration pneumonia:

1) Until cultures are completed and results obtained, initial antibiotic therapy is based on an assessment of?
2) For patients who aspirate in hospitals, appropriate antibiotics should include coverage for both?
3) In contrast, aspiration of acidic gastric contents causes?

A

1) probable causative organism, severity of illness, patient factors (e.g., malnutrition, current use of antibiotic therapy), and ability to treat common community-acquired organisms.
2) gram-negative organisms and MRSA.
3) chemical (noninfectious) pneumonitis, which may not require antibiotic therapy. However, secondary bacterial infection can occur 48 to 72 hours later

30
Q

1) Necrotizing pneumonia is a rare complication of?
2) It is characterized by?
3) Although the exact pathophysiologic mechanisms involved are controversial, causative organisms include?
4) ____ ______commonly occur.
5) Signs and symptoms of necrotizing pneumonia include?
6) Treatment often includes?

A

1) bacterial lung infection
2) liquefaction and, in some situations, cavitation of lung tissue. This often occurs as a result of community-acquired pneumonia (CAP).
3) Staphylococcus, Klebsiella, and Streptococcus. Lung abscesses commonly occur.
4) Lung abscesses
5) immediate respiratory insufficiency and/or failure, leukopenia, and bleeding into the airways
6) Treatment often includes long-term antibiotic therapy and possible surgery

31
Q

1) Opportunistic pneumonia is inflammation and infection of the lower respiratory tract in?
2) Individuals at risk for opportunistic pneumonia include those with?
3) In addition to the risk of bacterial and viral pneumonia, the immunocompromised person may develop an infection from microorganisms that?

A

1) immunocompromised patients.
2) altered immune responses. This can include people with severe protein-calorie malnutrition or immunodeficiencies (e.g., human immunodeficiency virus [HIV] infection) and those receiving radiation therapy, chemotherapy, and any immunosuppressive therapy, including long-term corticosteroid therapy.
3) do not normally cause disease, such as Pneumocystis jiroveci (formerly carinii) and cytomegalovirus (CMV)

32
Q

Opportunistic pneumonia

1) P. jiroveci pneumonia (PJP) rarely occurs in the healthy individual but is the most common form of pneumonia in? 2) The onset is slow and subtle with symptoms of?
3) The chest x-ray usually shows?
4) In widespread disease, the lungs have?
5) PJP can be life-threatening, causing?
6) Infection can also spread to other organs, including?
7) Bacterial and viral pneumonias must first be ruled out because of the vague presentation of PJP. Although the causative agent is fungal, PJP does not respond to?
8) Treatment consists of a course of?

A

1) people with HIV disease.
2) fever, tachypnea, tachycardia, dyspnea, nonproductive cough, and hypoxemia.
3) diffuse bilateral infiltrates.
4) massive consolidation.
5) acute respiratory failure and death.
6) liver, bone marrow, lymph nodes, spleen, and thyroid. 7) does not respond to antifungal agents.
8) trimethoprim/sulfamethoxazole (Bactrim, Septra) either IV or orally depending on the severity of disease and the patient’s response

33
Q

Opportunistic pneumonia

1) Cytomegalovirus CMV, a herpesvirus, can cause?
2) Most CMV infections are?
3) CMV is the most common life-threatening infectious complication after?
4) treatment?

A

1) viral pneumonia
2) asymptomatic or mild, but severe disease can occur in people with an impaired immune response
3) hematopoietic stem cell transplantation
4) Antiviral medications (e.g., ganciclovir [Cytovene], foscarnet [Foscavir], cidofovir) and high-dose immunoglobulin are used for treatment

34
Q

Pneumonia Pathophysiology
Specific pathophysiologic changes related to pneumonia vary according to the offending organism, but the majority of organisms trigger an inflammatory response in the lungs.
1) Inflammation, characterized by an increase in?
2) Normal O2 transport is affected, leading to clinical manifestations of?
3) Consolidation, a feature typical of bacterial pneumonia, occurs when the?
4) Mucus production also increases, which can potentially?
5) Over time and with appropriate antibiotic therapy, what happens?

A

1) increase in blood flow and vascular permeability, activates neutrophils to engulf and kill the offending organisms. As a result, the inflammatory process attracts more neutrophils, edema of the airways occurs, and fluid leaks from the capillaries and tissues into alveoli.
2) hypoxia (e.g., tachypnea, dyspnea, tachycardia).
3) normally air-filled alveoli become filled with fluid and debris.
4) obstruct airflow and impair gas exchange even further. 5) macrophages lyse and process the debris, lung tissue is allowed to recover, and gas exchange returns to normal. Resolution and healing occur if there are no complications

35
Q

Clinical Manifestations for pneumonia

1) The most common presenting symptoms of pneumonia are?
2) Sputum may appear?
3) Viral pneumonia may initially be seen as?

A

1) cough, fever, chills, dyspnea, tachypnea, and pleuritic chest pain. The cough may or may not be productive.
2) green, yellow, or even rust colored (bloody).
3) influenza, with respiratory symptoms appearing and/or worsening 12 to 36 hours after onset

36
Q

Clinical manifestations for pneumonia

The older or debilitated patient may not have classic symptoms of pneumonia.

A

1) Confusion or stupor (possibly related to hypoxia) may be the only finding.
2) Hypothermia, rather than fever, may also be noted with the older patient.
3) Nonspecific clinical manifestations include diaphoresis, anorexia, fatigue, myalgias, and headache

37
Q

Pneumonia: On physical examination, what can be heard when auscultated?

2) If consolidation is present, what is noted?
3) Patients with pleural effusion may exhibit?

A

1) fine or coarse crackles may be auscultated over the affected region.
2) bronchial breath sounds, egophony (a change in the sound of the voice of the patient), and increased fremitus (vibration of the chest wall produced by vocalization) may be noted.
3) dullness to percussion over the affected area

38
Q

Pneumonia Complications develop more frequently in older individuals and those with underlying chronic diseases. Potential complications include the following:

A

• Atelectasis (collapsed, airless alveoli) of one or part of one lobe may occur. These areas may clear with effective deep breathing and coughing.
• Pleurisy (inflammation of the pleura) may occur.
• Pleural effusion (fluid in the pleural space) can occur. In most cases, the effusion is sterile and is reabsorbed in 1 to 2 weeks. Occasionally, effusions require aspiration by thoracentesis.
• Bacteremia (bacterial infection in the blood) is more likely to occur in infections with Streptococcus pneumoniae and Haemophilus influenzae.
• Pneumothorax can occur when air collects in the pleural space, causing the lungs to collapse.
• Meningitis can be caused by Streptococcus pneumoniae. The patient with pneumonia who is disoriented, confused, or drowsy may have a lumbar puncture to evaluate the possibility of meningitis.
• Acute respiratory failure is one of the leading causes of death in patients with severe pneumonia. Failure occurs when pneumonia damages the lungs’ ability to facilitate the exchange of O2 and CO2 across the alveolar-capillary membrane.
• Sepsis/septic shock can occur when bacteria within alveoli enter the bloodstream. Severe sepsis can lead to shock and multisystem organ dysfunction syndrome (MODS) (see Chapter 66).
Lung abscess is not a common complication of pneumonia. However, it may occur with pneumonia caused by S. aureus and gram-negative organisms. Empyema, the accumulation of purulent exudate in the pleural cavity, occurs in less than 5% of cases and requires antibiotic therapy and drainage of the exudate by a chest tube or open surgical drainage

39
Q

Clinical manifestations main points for pneumonia

A
  • Cough, fever, shaking, chills, tachypnea, pleurisy cp
  • Green, yellow or rust colored sputum
  • COMPLICATIONS
  • Pleurisy- inflammation in pleural space
  • Pleural effusion-fluid in pleural space
  • Atelectasis- collapsed alveoli
  • Bacteremia- blood infection
  • Empyema-pus in pleural space
  • Pericarditis-infection that moves to pericardium
  • Meningitis
  • Sepsis
  • Acute respiratory failure
  • Pneumothorax- collapsed lung
40
Q

Pneumonia diagnostic assessment

A
  • History and physical examination
  • Chest x-ray
  • Gram stain of sputum
  • Sputum culture and sensitivity test
  • Pulse oximetry or ABGs (if indicated)
  • Complete blood count, WBC differential, and routine blood chemistries (if indicated)
  • Blood cultures (if indicated)
41
Q

Pneumonia Management

A
  • Increased fluid intake (at least 3 L/day)
  • Balance between activity and rest
  • O2 therapy (if indicated)
42
Q

Pneumonia Drug Therapy

A
  • Appropriate antibiotic therapy
  • Antipyretics
  • Analgesics
43
Q

Pneumonia Diagnostic Studies

1) often provide enough clinical information to make decisions about early treatment.
2) Chest x-ray often shows a typical pattern characteristic of the?
3) This may be used to obtain fluid samples from patients not responding to initial therapy

A

1) History, physical examination, and chest x-ray often provide enough clinical information to make decisions about early treatment.
2) Chest x-ray often shows a typical pattern characteristic of the infecting organism and is important in the diagnosis of pneumonia. X-ray may also show pleural effusions.
3) A thoracentesis and/or bronchoscopy with washings

44
Q

Pneumonia diagnostic studies:

1) sputum specimen for culture and Gram stain to identify the organism are obtained when and can they be delayed?
2) When are Blood cultures done?
3) Arterial blood gases (ABGs) may be obtained to assess for?
4) Leukocytosis occurs in the majority of patients with?

A

1) obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained. Delays in antibiotic therapy can increase the risk of morbidity and mortality. 2) Blood cultures are done for patients who are seriously ill.
3) hypoxemia (partial pressure of O2 in arterial blood [PaO2] less than 80 mm Hg), hypercapnia (partial pressure of carbon dioxide in arterial blood [PaCO2] greater than 45 mm Hg), and acidosis (pH <7.35).
4) bacterial pneumonia; the white blood cell (WBC) count is usually greater than 15,000/µL (15 × 109/L) with the presence of bands (immature neutrophils)

45
Q

Pneumonia Interprofessional Care

1) Pneumococcal vaccine is used to prevent?
2) Prompt treatment with the appropriate antibiotic is essential. Antibiotics are highly effective for both?
3) In uncomplicated cases, the patient responds to drug therapy within?
4) Indications of improvement include?
5) A repeat chest x-ray may be obtained in?

A

1) Streptococcus pneumoniae
2) bacterial and mycoplasma pneumonia.
3) 48 to 72 hours
4) decreased temperature, improved breathing, and reduced chest discomfort. Abnormal physical findings can last more than 7 days.
5) 6 to 8 weeks to assess for resolution

46
Q

Pneumonia interprofessional Care

1) In addition to antibiotic therapy, supportive measures are individualized to the patient’s needs. These may include?
2) Although cough suppressants, mucolytics, bronchodilators, and corticosteroids are often prescribed as adjunctive therapy, the use of these drugs is controversial. However, they may be prescribed for patients with?

A

1) O2 therapy to treat hypoxemia, analgesics to relieve chest pain, and antipyretics (e.g., aspirin, acetaminophen) for elevated temperature.
2) underlying chronic conditions.

47
Q

Pneumonia: Individualize rest and activity to each patient’s tolerance. Benefits of mobility include?

A

improved diaphragm movement and chest expansion, mobilization of secretions, and prevention of venous stasis.

48
Q

Pneumonia: Currently, no definitive treatment exists for the majority of viral pneumonias. As identified earlier, care is generally supportive. In most circumstances, viral pneumonia is self-limiting and will often resolve in?

A

resolve in 3 to 4 days. Antiviral therapy may be used to treat pneumonia caused by influenza (e.g., 504oseltamivir, zanamivir) and a few other viruses (e.g., acyclovir [Zovirax] for herpes simplex virus)

49
Q

Drug therapy for pneumonia:

1) For all types of pneumonia, empiric antibiotic therapy is based on whether the patient has?
2) The prevalence and resistance patterns of MDR pathogens vary among localities and institutions. Therefore the antibiotic regimen must be adapted to?
3) Multiple regimens exist, but all should initially include antibiotics that are effective against?

A

1) risk factors for MDR organisms.
2) local patterns of antibiotic resistance.
3) both resistant gram-negative and resistant gram-positive organisms

50
Q

Pneumonia:

1) Clinical improvement usually occurs in?
2) Patients who deteriorate or fail to respond to therapy require?

A

1) 3 to 5 days
2) aggressive reevaluation to assess for noninfectious etiologies, complications, coexisting infectious processes, or pneumonia caused by a drug-resistant pathogen

51
Q

Pneumonia drug therapy:

1) IV antibiotic therapy should be switched to oral therapy as soon as the patient is?
2) Stable patients do not need to be?
3) Total treatment time for patients with CAP should be a minimum of?
4) Longer treatment time may be needed if initial therapy was?

A

1) hemodynamically stable, is improv­ing clinically, is able to ingest oral medication, and has a functioning gastrointestinal tract.
2) observed in the hospital and can be discharged to home on oral antibiotics.
3) 5 days, and the patient should be afebrile for 48 to 72 hours before stopping treatment. However, you need to emphasize the importance of completing the full course of antibiotic treatment.
4) not active against the identified pathogen or complications occur

52
Q

Pneumonia Nutritional Therapy.

1) Hydration is important in the?
2) Individualize and carefully monitor fluid intake. When is IV administration of fluids and electrolytes necessary?
3) Weight loss may occur in patients with pneumonia because of?

A

1) supportive treatment of pneumonia to prevent dehydration and to thin and loosen secretions.
2) If the patient is an older adult, has heart failure, or has a known preexisting respiratory condition
3) increased metabolic needs and difficulty eating due to nonspecific abdominal complaints or shortness of breath. Small, frequent meals are easier for dyspneic patients to tolerate. Offer foods high in calories and nutrients

53
Q

Pneumonia diagnostic studies main points

A
  • Hx and physical
  • CXR, sputum, lab tests
    • CBC
    • WBC
    • Blood cultures
    • ABGs
54
Q

Pneumonia collaborative care main points

A
  • Vaccinations
  • ABX therapy for bacterial pneumonia
  • O2
  • Analgesics
  • Antipyretics for fever control
  • Cough suppressants
  • Bronchodilators
  • Corticosteroids
55
Q

Nursing management for pneumonia main points

A
  • Assessment
  • Dx – impaired gas exchange, ineffective breathing, pain
  • Health promotion
56
Q

Pneumonia Subjective Data: Important Health Information

1) Past health history:
2) Medications:
3) Surgery or other treatments:

A

1) Past health history: Lung cancer, COPD, diabetes mellitus, chronic debilitating disease, malnutrition, altered consciousness, immunosuppression, exposure to chemical toxins, dust, or allergens
2) Medications: Antibiotics, corticosteroids, chemotherapy, or any immunosuppressants
3) Surgery or other treatments: Recent abdominal or thoracic surgery, splenectomy, endotracheal intubation, or any surgery with general anesthesia. Tube feedings

57
Q

Pneumonia Functional Health Patterns

1) Health perception–health management:
2) Nutritional-metabolic:
3) Activity-exercise:
4) Cognitive-perceptual:

A

1) Health perception–health management: Cigarette smoking, alcoholism; recent upper respiratory tract infection, malaise
2) Nutritional-metabolic: Anorexia, nausea, vomiting. Chills
3) Activity-exercise: Prolonged bed rest or immobility. Fatigue, weakness. Dyspnea, cough (productive or nonproductive). Nasal congestion
4) Cognitive-perceptual: Pain with breathing, chest pain, sore throat, headache, abdominal pain, muscle aches

58
Q

Pneumonia Objective Data

General

A

Fever, restlessness or lethargy. Splinting of affected area

59
Q

Pneumonia Objective data: Respiratory

A

Tachypnea, pharyngitis, asymmetric chest movements or retraction, decreased excursion, nasal flaring. Use of accessory muscles (neck, abdomen). Crackles, friction rub on auscultation, dullness on percussion over consolidated areas, increased tactile fremitus on palpation. Pink, rusty, purulent, green, yellow, or white sputum (amount may be scant to copious)

60
Q

Pneumonia objective data: Cardiovascular

A

Tachycardia

61
Q

Pneumonia objective data: Neurologic

A

Changes in mental status, ranging from confusion to delirium

62
Q

Pneumonia objective data: Possible Diagnostic Findings

A

1) Leukocytosis.
2) Abnormal ABGs with ↓ or normal PaO2, ↓ or normal PaCO2, and ↑ or normal pH initially, and later ↓ PaO2, ↑ PaCO2, and ↓ pH
3) Positive sputum on Gram stain and culture.
4) Patchy or diffuse infiltrates, abscesses, pleural effusion, or pneumothorax on chest x-ray

63
Q

Nursing diagnoses for the patient with pneumonia may include, but are not limited to, the following:

A
  • Impaired gas exchange related to fluid and exudate accumulation within the alveoli and surrounding lung tissue
  • Ineffective breathing pattern related to inflammation and chest discomfort
  • Acute pain (chest) related to inflammation and ineffective pain management and/or comfort measures
  • Activity intolerance related to chest discomfort, inflammation, shortness of breath, generalized weakness
64
Q

Pneumonia Planning

The overall goals are that the patient with pneumonia will have?

A

(1) clear breath sounds
(2) normal breathing patterns
(3) no signs of hypoxia
(4) normal chest x-ray
(5) normal white blood cell (WBC) count
(6) absence of complications related to pneumonia

65
Q

Pneumonia Health Promotion.

1) To reduce the risk of pneumonia, teach individuals to practice good health habits, such as frequent?
2) Avoidance of cigarette smoke is one of the most important health-promoting behaviors. If possible, avoid exposure to people with?
3) Encourage those at risk for pneumonia (e.g., chronically ill, older adult) to obtain both?
4) What are priority interventions?

A

1) hand washing, proper nutrition, adequate rest, regular exercise, and coughing or sneezing into the elbow rather than hands.
2) URIs. If a URI occurs, it requires prompt attention with supportive measures (e.g., rest, fluids). If symptoms persist for longer than 7 days, the person should seek medical care.
3) influenza and pneumococcal vaccines
4) Identifying patients at risk and taking measures to prevent pneumonia are priority interventions

66
Q

Pneumonia Health promotion:

1) In the acute care setting, place the patient with altered consciousness in?
2) In the ICU, strict adherence to all aspects of the?

A

1) positions (e.g., side-lying, upright) that will prevent or minimize the risk of aspiration. Turn and reposition the patient at least every 2 hours to facilitate adequate lung expansion and mobilization of secretions. Encourage and assist with ambulation and positioning into a chair.
2) ventilator bundle, a group of interventions aimed at reducing the risk of VAP, has been shown to significantly reduce VAP

67
Q

Pneumonia Health promotion

1) For the patient who has difficulty swallowing and needs assistance in eating, drinking, and taking medication to prevent aspiration, elevate the?
2) Assess for ____before giving food or fluids.
3) Patients who have orogastric or nasogastric tubes are at risk for aspiration pneumonia. Although feeding tubes are small, any interruption in the integrity of the lower esophageal sphincter can allow?
4) To prevent aspiration?

A

1) patient’s head-of-bed to at least 30 degrees and have the patient sit up for all meals.
2) Assess for a gag reflex before giving food or fluids.
3) reflux of gastric contents.
4) elevate the head of the bed to at least 30 degrees and monitor gastric residual volumes

68
Q

Pneumonia health promotion:

1) Patients with impaired mobility from any cause need assistance with?
2) Observe the patient’s skin and all pressure points for any evidence of?
3) How to reduce the incidence of pneumonia in postoperative patients?
4) Treat pain to a?

A

1) turning and moving as well as encouragement to breathe deeply at frequent intervals.
2) redness or breakdown, especially the sacrum and coccyx.
3) Early mobilization, the use of an incentive spirometer, and twice-daily oral hygiene with chlorhexidine swabs
4) comfort level that permits the patient to deep breathe and cough but yet remain awake and alert and achieve optimum mobility

69
Q

Pneumonia health promotion:

1) Practice strict medical asepsis and adherence to infection control guidelines to reduce the incidence of?
2) Staff and visitors should wash their hands on entering and leaving the patient’s room. Staff must wash or use sanitizing hand gel?
3) Use strict sterile aseptic technique when?
4) Avoid inappropriate use of antibiotics to prevent?

A

1) health care–associated infection (HAI).
2) before and after providing care and on removing gloves.
3) suctioning the patient’s trachea, and use caution when handling ventilator circuits, tracheostomy tubing, and nebulizer circuits that can become contaminated from patient secretions.
4) development of drug-resistant organisms

70
Q

Pneumonia Acute Care.

1) Although many patients with pneumonia are treated on an outpatient basis, the nursing care plan for a patient with pneumonia applies to?
2) Essential nursing care for patients with pneumonia includes?
3) Along with physical assessment (including pulse oximetry monitoring), prompt?
4) What measures are part of the nursing management?
5) Collaborate with?

A

1) both individuals at home and in-hospital patients.
2) monitoring physical assessment parameters, providing treatment, and monitoring the patient’s response to treatment.
3) collection of specimens and initiation of antibiotics are critical.
4) O2 therapy, hydration, nutritional support, breathing exercises, early ambulation, and therapeutic positioning 5) respiratory therapists for assistance in monitoring the patient’s condition and with physical therapy for postural drainage and chest percussion

71
Q

Pneumonia Ambulatory Care.

1) Teach the patient about the importance of taking every dose of the?
2) Instruct the patient to drink plenty of?
3) What may help the patient breathe easier?
4) Tell patients that it may be several weeks before their?
5) Explain that a follow-up chest x-ray may be done in?
6) A prolonged period of convalescence may be necessary for?

A

1) prescribed antibiotic, any drug-drug and food-drug interactions for the prescribed antibiotic, and the need for adequate rest to facilitate recovery.
2) liquids (at least 6 to 10 glasses/day, unless contraindicated) and to avoid alcohol and smoking.
3) A cool mist humidifier or warm bath
4) usual vigor and sense of well-being return.
5) 6 to 8 weeks to evaluate resolution of pneumonia.
6) older adult or chronically ill patient.

72
Q

Pneumonia Evaluation

A

The expected outcomes are that the patient with pneumonia will have
• Effective respiratory rate, rhythm, and depth of respirations
• Lungs clear to auscultation

73
Q

TB Main points

A
  • Infectious- leading cause of death in HIV pts
  • Spread person to person via droplets
  • MDR-TB??? Multi-drug resistant
  • Clinical manifestations-
    • 2-3 weeks after infection- fever, malaise anorexia, unexplained weight loss, low-grade fevers and night sweats
  • Hemoptysis- <10%- late symptom
74
Q

Tuberculosis

1) Tuberculosis (TB) is an infectious disease caused by?
2) It usually involves the?
3) The CDC reports that more than 2 billion people (one third of the world’s population) are infected with TB. It is the leading cause of mortality in patients with?
4) The incidence of TB worldwide declined until the mid-1980s when HIV disease emerged. The major factors contributing to the resurgence of TB were?
5) Although the prevalence of TB has increased in Europe, it has steadily declined in the United States since?

A

1) Mycobacterium tuberculosis.
2) lungs, but any organ can be infected, including brain, kidneys, and bones.
3) HIV infection.
4) (1) high rates of TB among patients with HIV infection and (2) the emergence of MDR strains of M. tuberculosis. 5) reaching a resurgence peak in 1992

75
Q

1) TB occurs disproportionately in the?
2) People most at risk include the?
3) Immunosuppression from any etiology (e.g., HIV infection, malignancy, long-term corticosteroid use) increases the?

A

1) poor, underserved, and minorities.
2) homeless, residents of inner-city neighborhoods, foreign-born people, those living or working in institutions (long-term care facilities, prisons, shelters, hospitals), IV injecting drug users, poor people, and those with poor access to health care.
3) risk of active TB infection

76
Q

TB:

1) Once a strain of M. tuberculosis develops resistance to two of the most potent first-line antituberculous drugs (e.g., isoniazid [INH], rifampin [Rifadin]), it is defined as?
2) Extensively drug-resistant TB (XDR-TB) occurs when the organism is?
3) Resistance results from several problems, including?

A

1) multidrug-resistant tuberculosis (MDR-TB)
2) resistant to any of the fluoroquinolones plus any injectable antibiotic agent.
3) incorrect prescribing, lack of public health case management, and patient nonadherence to the prescribed regimen

77
Q

Etiology and Pathophysiology

1) M. tuberculosis is a gram-positive, acid-fast bacillus (AFB) that is usually spread from person to person via?
2) A process of evaporation leaves small droplet nuclei, 1 to 5 µm in size, suspended in the air for?
3) These bacteria are then inhaled by another person. TB is not highly infectious, as transmission usually requires?
4) The disease cannot be spread by?

A

1) airborne particles expectorated when breathing, talking, singing, sneezing, and coughing.
2) minutes to hours.
3) close, frequent, or prolonged exposure.
4) touching, sharing food utensils, kissing, or any other type of physical contact

78
Q

TB:

  • Factors that influence the likelihood of transmission include?
  • Once inhaled, these small particles lodge in?
A

(1) number of organisms expelled into the air
(2) concentration of organisms (small spaces with limited ventilation would mean higher concentration)
(3) length of time of exposure
(4) immune system of the exposed person.
- bronchioles and alveoli. A local inflammatory reaction occurs, and the focus of infection is established. This is called the Ghon lesion or focus, which represents a calcified TB granuloma, the hallmark of a primary TB infection. The formation of a granuloma is a defense mechanism aimed at walling off the infection and preventing further spread. Replication of the bacillus is inhibited and the infection is stopped.

79
Q

1) Most immunocompetent adults infected with TB are able to completely kill the mycobacteria. Some people contain the mycobacteria in a nonreplicating dormant state. Of these individuals, ____% develop active TB infection when the bacteria begin to multiply months or years later.
2) M. tuberculosis is aerophilic (O2 loving) and thus has an affinity for the lungs. However, the infection can spread via the?

A

1) 5% to 10%
2) lymphatic system and find favorable environments for growth in other organs, including the cerebral cortex, spine, epiphyses of the bone, and adrenal glands.

80
Q

Classification
Several systems can be used to classify TB. The American Thoracic Society classifies TB based on development of the disease. TB can also be classified according to?

A

(1) its presentation (primary, latent, or reactivated)

(2) whether it is pulmonary or extrapulmonary

81
Q

Primary TB infection occurs when the bacteria are?

A

inhaled and initiate an inflammatory reaction. The majority of people mount effective immune responses to encapsulate these organisms for the rest of their lives, preventing primary infection from progressing to disease.

82
Q

Latent TB infection (LTBI) occurs in a person who does not have active TB disease.

1) People with LTBI have a?
2) These individuals can?
3) What can precipitate the reactivation of LTBI?

A

1) positive skin test but are asymptomatic.
2) These individuals cannot transmit the TB bacteria to others but can develop active TB disease at some point. 3) Immunosuppression, diabetes mellitus, poor nutrition, aging, pregnancy, stress, and chronic disease

83
Q

TB:

1) If the initial immune response is not adequate, the body cannot contain the organisms. As a result, the bacteria?
2) What is primary TB?
3) Individuals co-infected with HIV are at greatest risk for?
4) Post-primary TB, or reactivation TB, is defined as?
5) If the site of TB is pulmonary or laryngeal, the individual is considered?

A

1) replicate and active TB disease results.
2) When active disease develops within the first 2 years of infection, it is termed primary TB.
3) developing active TB.
4) TB disease occurring 2 or more years after the initial infection.
5) infectious and can transmit the disease to others.

84
Q

Clinical Manifestations of TB

1) Symptoms of pulmonary TB usually do not develop until?
2) The characteristic pulmonary manifestation is an?
3) Active TB disease may initially manifest with constitutional symptoms such as?
4) Dyspnea is a late symptom that may signify?
5) Hemoptysis occurs?

A

1) 2 to 3 weeks after infection or reactivation.
2) initial dry cough that frequently becomes productive with mucoid or mucopurulent sputum.
3) fatigue, malaise, anorexia, unexplained weight loss, low-grade fevers, and night sweats.
4) considerable pulmonary disease or a pleural effusion. 5) in less than 10% of patients with TB, is also a late symptom.

85
Q

Clinical manifestations of TB:

1) Sometimes TB has a more acute, sudden presentation. The patient may have a?
2) Auscultation of the lungs may be?

A

1) high fever, chills, generalized flu-like symptoms, pleuritic pain, and a productive cough.
2) normal or reveal crackles, and/or adventitious (such as bronchial) breath sounds

86
Q

Clinical manifestations of TB:

1) Immunosuppressed (e.g., HIV-infected) people and older adults are?
2) In patients with HIV, classic manifestations of TB such as fever, cough, and weight loss may be wrongly attributed to?
3) Clinical manifestations of respiratory problems in patients with HIV must be carefully investigated to determine the cause. A change in cognitive function may be the only initial presenting sign of TB in?

A

1) less likely to have fever and other signs of an infection. 2) P. jiroveci pneumonia (PJP) or other HIV-associated opportunistic diseases.
3) an older person

87
Q

1) The clinical manifestations of extrapulmonary TB depend on?
- For example, renal TB can cause?
- Bone and joint TB may cause?
- TB meningitis may cause?

A

1) the organs infected.
- renal TB: dysuria and hematuria
- Bone and joint TB: severe pain
- Headaches, vomiting, and lymphadenopathy may be present with TB meningitis.

88
Q

TB:

1) Diagnostic tests
2) Complications

A

1) Diagnostic tests
- TB skin test
- CXR, bacterial studies- sputum smears
2) Complications
- Can heal if treated correctly
- Severe pulmonary damage if treated poorly
- TB in central nervous system- meningitis
- Abdominal TB- peritonitis
- Bacteria travels through the blood stream

89
Q

Complications of TB

1) Appropriately treated pulmonary TB typically heals without complications, except for?
2) Significant pulmonary damage, although rare, can occur in patients who are?

A

1) scarring and residual cavitation within the lung.

2) poorly treated or who do not respond to TB treatment.

90
Q
  • Miliary TB is the widespread dissemination of the mycobacterium. The bacteria are spread via?
  • The infection is characterized by a large amount of?
  • It can occur as a result of?
  • Clinical manifestations of miliary TB slowly progress over a period of days, weeks, or even months. Symptoms vary depending on the organs that are affected. What is present and what may also occur?
A
  • bloodstream to several distant organs.
  • large amount of TB bacilli and may be fatal if left untreated.
  • primary disease or reactivation of latent infection.
  • Fever, cough, and lymphadenopathy are present. Hepatomegaly and splenomegaly may also occur
91
Q

Pleural TB, a specific type of extrapulmonary TB, can result from either primary disease or reactivation of a latent infection.

1) What manifestations are common?
2) A pleural effusion is caused by?
3) Empyema is less common than effusion but may occur from?
4) Diagnosis is confirmed b?

A

1) Chest pain, fever, cough, and presence of a unilateral pleural effusion are common.
2) bacteria in the pleural space, which trigger an inflammatory reaction and a pleural exudate of protein-rich fluid.
3) may occur from large numbers of tubercular organisms in the pleural space.
4) AFB cultures and a pleural biopsy.

92
Q

TB Complications:
Because TB can infect organs throughout the body, various acute and long-term complications can result.
1) TB in the spine (Pott’s disease) can lead to?
2) Central nervous system TB can cause?
3) Abdominal TB can lead to?
4) What may also be affected?

A

1) (Pott’s disease) can lead to destruction of the intervertebral disc and adjacent vertebrae.
2) Central nervous system TB can cause severe bacterial meningitis.
3) Abdominal TB can lead to peritonitis, especially in HIV-positive patients.
4) The kidneys, adrenal glands, lymph nodes, and urogenital tract may also be affected.

93
Q

Diagnostic Studies
Tuberculin Skin Test.
1) The tuberculin skin test (TST) (Mantoux test) using purified protein derivative (PPD) is the standard method to screen people for M. tuberculosis. The test is administered by injecting?
2) The test is read by?
3) Induration, a palpable, raised, hardened area or swelling (not redness) at the injection site means?
4) The indurated area (if present) is measured and recorded in millimeters. Based on the size of the induration and the risk factors, an interpretation is made according to standards for determining a positive test reaction. Because the immunocompromised patient may have a decreased response to TST, what size induration is considered positive?

A

1) 0.1 mL of PPD intradermally on the ventral surface of the forearm.
2) inspection and palpation 48 to 72 hours later for the presence or absence of induration.
3) the person has been exposed to TB and has developed antibodies. (Antibody formation occurs 2 to 12 weeks after initial exposure to the bacteria.)
4) smaller induration reactions (5 mm or larger) are considered positive

94
Q

Tuberculin Skin Test

1) Some people who were previously infected with TB may have a waning immune response to the TST, resulting in?
2) However, repeating the TST may stimulate (boost) the body’s ability to react to tuberculin in future tests. A positive reaction to a subsequent test could then be misinterpreted as a new infection, rather than the result of the boosted reaction to an old infection. To prevent misinterpretation in future testing, a?

A

1) a false negative result.
2) two-step testing process is recommended for initial testing for health care workers (who get repeated testing) and for individuals who have a decreased response to allergens. A previously negative two-step TST ensures that any future positive results can be accurately interpreted as being caused by a new infection

95
Q

TB Diagnostic tests:
Interferon-γ Release Assays.
1) Interferon-γ (INF-gamma) release assays (IGRAs) provide another screening tool for TB. IGRAs are?
2) IGRAs offer several advantages over the TST in that they?
3) Current guidelines suggest that both tests are viable options and that selection should be based on context and reasons for testing. Neither IGRAs nor TST can distinguish between?

A

1) blood tests that detect INF-gamma release from T cells in response to Mycobacterium tuberculosis. Examples of IGRAs include QuantiFERON-TB test and the T-SPOT.TB test. Test results are available in a few hours.
2) require only one patient visit, are not subject to reader bias, have no booster phenomenon, and are not affected by prior bacillus Calmette-Guérin (BCG) vaccination. The cost of an IGRA is substantially higher than the TST.
3) LTBI and active TB infection. LTBI can only be diagnosed by excluding active TB

96
Q

TB Chest X-ray.

1) Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely on chest x-ray findings. The chest x-ray may appear normal in a patient with TB. Findings suggestive of TB include?
2) Other diseases, such as sarcoidosis, can?

A

1) upper lobe infiltrates, cavitary infiltrates, lymph node involvement, and pleural and/or pericardial effusion.
2) Other diseases, such as sarcoidosis, can mimic the appearance of TB

97
Q

TB Bacteriologic Studies.

1) Three consecutive sputum specimens obtained on different days are sent for smear and culture. The initial testing involves a microscopic examination of stained sputum smears for AFB. However, the definitive diagnosis of TB requires the?
2) Treatment is warranted pending the culture results for patients in whom clinical suspicion of TB is high. Samples for other suspected TB sites can be collected from?

A

1) demonstration of tubercle bacilli bacteriologically by sputum culture, which can take up to 8 weeks.
2) gastric washings, cerebrospinal fluid (CSF), or fluid from an effusion or abscess

98
Q

TB Interprofessional Care

1) Most patients with TB are treated on an outpatient basis. Many people can continue to work and maintain their lifestyles with few changes. Patients with sputum smear–positive TB are generally considered infectious for the?
2) Advise these patients to restrict?
3) Remind them of the importance of good handwashing and oral hygiene. Hospitalization may be needed for the severely ill or debilitated. The mainstay of TB treatment is?

A

1) first 2 weeks after starting treatment.
2) restrict visitors and avoid travel on public transportation and trips to public places.
3) drug therapy. Promoting and monitoring adherence are critical for treatment to be successful

99
Q

Pulmonary Tuberculosis

Diagnostic Assessment

A
  • History and physical examination
  • Tuberculin skin test (TST)
  • QuantiFERON-TB test
  • Chest x-ray
  • Bacteriologic studies
  • Sputum smear for acid-fast bacilli (AFB)
  • Sputum culture
100
Q

Pulmonary Tuberculosis

Management

A
  • Long-term treatment with antimicrobial drugs
  • Follow-up AFB smears, cultures, and chest x-rays
  • Follow-up care involving community health care workers and social workers
101
Q

Drug Therapy
Active TB Disease.
1) Because of the growing prevalence of MDR-TB, it is important to manage the patient with active TB aggressively. Drug therapy is divided into two phases:
2) In most circumstances the treatment regimen for patients with previously untreated TB consists of a 2-month initial phase with four drugs?
3) If drug susceptibility test results indicate that the bacteria are susceptible to all drugs, ethambutol may be discontinued. If pyrazinamide cannot be included in the initial phase (because of liver disease, pregnancy, etc.), the?
4) If the patient develops a toxic reaction to the primary drugs, other drugs can be used, including rifabutin and rifapentine (Priftin). Treatment for drug-resistant TB is guided by?
5) MDR-TB therapy typically includes a fluoroquinolone and an injectable antibiotic. Bedaquiline (Sirturo), a relatively new drug, is used in combination with other drugs to treat MDR-TB. It works by inhibiting an?

A

1) initial and continuation.
2) isoniazid, rifampin, pyrazinamide, and ethambutol
3) remaining three drugs are used for the initial phase.
4) sensitivity testing.
5) enzyme needed for M. tuberculosis to replicate.

102
Q

TB:

1) Directly observed therapy (DOT) involves providing the?
2) To ensure adherence, it is the preferred strategy for all patients with TB, especially for those at risk for nonadherence. Nonadherence is a major factor in the?
3) Many individuals do not adhere to the treatment program in spite of understanding the disease process and value of treatment. DOT is an expensive but essential public health measure. The risk for reactivation of TB and MDR-TB is increased in patients who?

A

1) antituberculosis drugs directly to patients and watching as they swallow the medications.
2) emergence of multidrug resistance and treatment failures.
3) do not complete the full course of therapy. In many areas, the public health nurse administers DOT at a clinic site.

103
Q

TB:

1) When DOT is not used, fixed-dose combination drugs may enhance adherence. Combinations of isoniazid and rifampin (Rifamate) and of isoniazid, rifampin, and pyrazinamide (Rifater) are available to simplify therapy. The therapy for people with HIV follows the same therapy options. However, alternative regimens that include once-weekly isoniazid plus rifapentine continuation dosing in any HIV-infected patient and twice-weekly isoniazid plus rifampin or rifabutin should not be used if CD4+ counts are less than ____
2) HCPs must also be alert for possible drug interactions between?

A

1) should not be used if CD4+ counts are less than 100/µL.

2) antiretrovirals (used to treat HIV) and rifamycins

104
Q

TB:

1) Teaching patients about the adverse effects of these drugs and when to seek prompt medical attention is critical. The major side effect of isoniazid, rifampin, and pyrazinamide is?
2) Baseline liver function tests (LFTs) are done at the?

A

1) nonviral hepatitis.

2) start of treatment and monitored closely (e.g., every 2 to 4 weeks), if results are abnormal.

105
Q

Latent Tuberculosis Infection.

1) In people with LTBI, drug therapy helps prevent a TB infection from developing into active TB disease. Because a person with LTBI has fewer bacteria, treatment is much easier. Usually it involves the use of?
2) The standard treatment regimen for LTBI is 9 months of daily isoniazid. It is an effective and inexpensive drug that the patient can take orally. The 9-month regimen is more effective, but adherence issues may make a 6-month regimen preferable. For HIV patients and those with fibrotic lesions on chest x-ray, what is given?
3) An alternative 3-month regimen of isoniazid and rifapentine may be used for otherwise healthy patients who are not presumed to be infected with drug-resistant bacilli. Four-month therapy with rifampin may be indicated if the patient is resistant to?
4) Because of severe liver injury and deaths, the CDC does not recommend the combination of?

A

1) only one drug that is needed
2) isoniazid is given for 9 months
3) resistant to isoniazid.
4) rifampin and pyrazinamide for treatment of LTBI

106
Q

TB: Bacille-Calmette-Guerin Vaccine.
1) Bacille-Calmette-Guerin (BCG) vaccine is a live, attenuated strain of Mycobacterium bovis. The vaccine is given to infants in parts of the world with a high prevalence of TB. In the United States it is typically not recommended because of the low risk of infection, the vaccine’s variable effectiveness against adult pulmonary TB, and potential interference with TB skin test reactivity. The BCG vaccination can result in a false-positive TST. IGRA results are not affected. The BCG vaccine should be considered only for select individuals who meet specific criteria (e.g., health care workers who are continually exposed to patients with MDR-TB and when infection control precautions are not successful).

A
  • vaccine is given to infants where high prevalence of TB, not in US
  • result in false-positive TST, IGRA results not affected
  • considered only for individuals who meet criteria (e.g., health care workers who are continually exposed to patients with MDR-TB and when infection control precautions are not successful)
107
Q

Nursing Management: Tuberculosis
Nursing Assessment
1) Ask the patient about a previous history of?
2) Obtain a social and occupational history to determine?
3) Assess the patient for what s/s?
4) If the patient has a productive cough, when should you get a sputum specimen?

A

1) TB, chronic illness, or any immunosuppressive medications.
2) risk factors for transmission of TB.
3) productive cough, night sweats, temperature elevation, weight loss, pleuritic chest pain, and abnormal lung sounds.
4) early morning is the ideal time to collect sputum specimens for an AFB smear

108
Q

Nursing Diagnoses

Nursing diagnoses for the patient with TB may include, but are not limited to, the following:

A
  • Ineffective breathing pattern related to decreased lung capacity
  • Ineffective airway clearance related to increased secretions, fatigue, and decreased lung capacity
  • Risk for infection (spread of infection to others) related to cough and sputum production, lack of knowledge of disease process, and social/economic circumstances
  • Noncompliance and ineffective health management related to lack of knowledge of disease process, lack of motivation, long-term nature of treatment, and lack of resources
109
Q

Planning

The overall goals are that the patient with TB will

A

(1) comply with the therapeutic regimen
(2) have no recurrence of disease
(3) have normal pulmonary function
(4) take appropriate measures to prevent the spread of the disease

110
Q

TB Health Promotion

1) The ultimate goal is to?
2) Screening programs in known risk groups are of value in detecting individuals with TB. Treatment of LTBI reduces the?
3) The person with a positive TST should have a?
4) Individuals with a diagnosis of TB must be?
5) Programs to address the social determinants of TB are necessary to decrease transmission of TB. Reducing HIV infection, poverty, overcrowded living conditions, malnutrition, smoking, and drug and alcohol abuse can help minimize TB infection rates. Improving access to?

A

1) eradicate TB worldwide.
2) number of TB carriers in the community.
3) chest x-ray to assess for active TB disease.
4) reported to the public health authorities for identification and assessment of contacts and risk to the community.
5) health care and education is also important.

111
Q

Acute Care for TB
Patients admitted to the emergency department or directly to the nursing unit with respiratory symptoms should be assessed for the possibility of TB. Those strongly suspected of having TB should

A

(1) be placed on airborne isolation
(2) receive a medical workup, including chest x-ray, sputum smear, and culture
(3) receive appropriate drug therapy.
- Airborne infection isolation is indicated for the patient with pulmonary or laryngeal TB until the patient is noninfectious.

112
Q

Acute Care for TB
Airborne infection isolation refers to isolation of patients infected with organisms spread by the airborne route. It requires a?

A

single-occupancy room with negative pressure and airflow of 6 to 12 exchanges per hour.

113
Q

Acute care for TB
High-efficiency particulate air (HEPA) masks are worn whenever entering the patient’s room. These masks are highly effective at protecting from small particles 5 µm or less in diameter. Because there are many different types of HEPA masks currently available, health care professionals should be “fit tested” each time a different brand or model of mask is used to ensure proper mask size. Otherwise, the CDC recommends that?

A

yearly mask “fit testing” is acceptable.20 To be effective, the mask must be molded to fit tightly around the nose and mouth.

114
Q

Acute care for TB

1) Teach patients to cover the nose and mouth with paper tissues every time they cough, sneeze, or produce sputum. The tissues should be?
2) Emphasize careful hand washing after handling sputum and soiled tissues. If patients need to be out of the negative-pressure room, they must wear a?
3) Identify and screen close contacts of the person with TB. Anyone testing positive for TB infection will undergo further evaluation and needs to be treated for?

A

1) tissues should be thrown into a paper bag and disposed of with the trash or flushed down the toilet.
2) standard isolation mask to prevent exposure to others. Minimize prolonged visitation to other parts of the hospital.
3) either LTBI or active TB disease.

115
Q

Ambulatory Care for TB

1) Patients who respond clinically are discharged home (even with positive cultures) if their household contacts have already been exposed and the patient is not posing a risk to others. A sputum specimen for AFB smear and culture should be obtained at a minimum of?
2) More frequent AFB smears may be useful to assess the?

A

1) monthly intervals until two consecutive specimens are negative on culture.
2) early response to treatment and provide an indication of infectious­ness. Negative cultures are needed to declare the patient not infectious.

116
Q

Ambulatory Care for TB

Teach the patient how to minimize exposure to close contacts and household members.

A
  • Homes well ventilated, especially areas where infected person spends time.
  • While still infectious, patient should sleep alone
  • spend as much time as possible outdoors
  • minimize time in congregate settings or on public transportation.
117
Q

Ambulatory Care for TB
Teach the patient and caregiver about adherence with the prescribed regimen. This is important, since most treatment failures occur because?

A
  • patient neglects to take the drug, discontinues it prematurely, or takes it irregularly.
  • Strategies to improve adherence to drug therapy include teaching and counseling, reminder systems, incentives or rewards, contracts, and DOT.
118
Q

Ambulatory Care for TB
Notification of the public health department is required.
1) The public health nurse is responsible for?
2) If adherence is an issue, the public health agency may be responsible for DOT. Most individuals can be considered adequately treated when?

A

1) follow-up on household contacts and assessment of the patient for adherence.
2) the therapy regimen has been completed and there is evidence of negative cultures, clinical improvement, and improvement on chest x-ray

119
Q

Ambulatory Care for TB

1) Because about 5% of individuals experience relapses, teach the patient to recognize the symptoms that indicate recurrence of TB. If these symptoms occur, the patient should?
2) Instruct the patient about certain factors that could reactivate TB, such as?
3) In some situations it is necessary to put the patient on anti-TB therapy. Because smoking is associated with poor outcomes in TB, patients should be?

A

1) seek immediate medical attention.
2) immunosuppressive therapy, malignancy, and prolonged debilitating illness. If the patient experiences any of these events, the HCP must be told so that TB can be closely monitored for reactivation.
3) encouraged to quit. Provide patients with teaching and resources to help them stop smoking.

120
Q

Evaluation.

The expected outcomes are that the patient with TB will have

A
  • Resolution of the disease
  • Normal pulmonary function
  • Absence of any complications
  • No further transmission of TB
121
Q

Drug Therapy for Tuberculosis (TB)

Drug: rifampin (Rifadin)

A

Hepatitis, thrombocytopenia, orange discoloration of bodily fluids (sputum, urine, sweat, tears)

122
Q

For TB if a patient has difficulty of compliance for meds due to homelessness or other factors what should the nurse do?

A

Call social worker so the patient can keep taking the medications

123
Q

Collaborative care for TB main points

A
  • Treat on out-patient basis
  • Nursing management
  • Assess for s/s
  • Health promotion- screening programs
  • Tb mask fit test
  • Follow prescribed regimen
  • Drug therapy-
  • Some medications are taken any where from 3-9 months
124
Q

Atypical mycobacteria

  • varieties
  • what does it cause?
A
  • 30 varieties

- Doesn’t cause TB but pulmonary infections

125
Q

Atypical Mycobacteria

1) There are more than 30 varieties of acid-fast mycobacteria that do not cause TB but can cause?
2) Pulmonary disease is indistinguishable from TB clinically and radiologically but can be differentiated by? 3) Atypical mycobacteria are not airborne and not transmitted by droplets. They can be found in?
4) Mycobacterium avium complex (MAC), found in?
5) Only a small number of people exposed to the organism actually develop MAC lung disease. People who are?
6) Treatment is?

A

1) pulmonary disease, lymphadenitis, skin or soft tissue disease, or disseminated disease
2) bacteriologic culture.
3) tap water, soil, bird feces, and house dust.
4) aerosols generated from baths, hot spas, and swimming pools, is one cause of atypical mycobacteria pulmonary infection.
5) immunosuppressed (e.g., HIV/AIDS) or have chronic pulmonary disease are most susceptible.
6) similar to that for TB.

126
Q
Lung cancer
Etiology
Patho- 
Clinical manifestations-
Diagnostic studies-
Collaborative care-
A
  • Etiology-80-90% from smoking
  • Patho- tumors arise from mutated epithelial cells
  • Clinical manifestations-non-specific/appear late
  • Diagnostic studies- CXR, CT/PET scan, MRI,labs
  • Collaborative care-
    • Surgery
    • Radiation
    • chemotherapy
127
Q

Pulmonary fungal infections

A
  • Inhalation of spores

- Valley fever

128
Q

Lung abscess

A

Necrosis of lung tissue/cxr/atb therapy

129
Q

Nursing Management ofLung Cancer

A
  • Assessment- anxiety level
  • Nursing DX
    • Ineffective airway clearance
    • Anxiety
    • Self-management
    • Ineffective breathing pattern
    • Impaired gas exchange
  • Health promotion- QUIT SMOKING!!
130
Q

Chest trauma

1) Pneumothorax-
2) Hemothorax-
3) Fractured ribs
4) Flail chest-
- Chest surgeries

A

1) Pneumothorax-air enters pleural cavity
2) Hemothorax- blood enters pleural cavity
3) Fractured ribs
4) Flail chest-fx of several consecutive ribs in two or more separate places
- Chest surgeries
* Pre-op care
* Thoracotomy-lateral incision
* Post-op care

131
Q

Restrictive Respiratory Disorders

1) Pleural effusion-
2) Empyema-
3) Pleurisy-
4) Atelectasis-
5) Pulmonary fibrosis/sarcoidosis-
6) Pulmonary edema-
7) Pulmonary embolism-
8) Pulmonary hypertension-
9) Cor Pulmonary-
10) Lung transplant

A

1) Pleural effusion- fluid buildup
2) Empyema- pus in the pleural space/ pneumonia
3) Pleurisy-inflammation
4) Atelectasis-collapsed, airless alveoli
5) Pulmonary fibrosis/sarcoidosis-interstital lung disease
6) Pulmonary edema-fluid in alveoli/interstitial spaces
7) Pulmonary embolism-pulmonary artery blockage
* 10% die within first hour/ 90% come from DVT’s
8) Pulmonary hypertension-elevated pulmonary artery pressure-sob/fatigue
9) Cor Pulmonary-enlargement of right ventricle- common cause COPD
10) Lung transplant