Exam 4: pneumonia Flashcards
define pneumonia
acute infection of the lung parenchyma
do people still die of pneumonia
yes
8th leading cause of death
s/s of older adults that may indicate they are developing pneumonia
confusion stupor hypothermia diaphoresis anorexia fatigue myalgia headache
true or false
pneumonia typically develops from the weakening of the body’s normal defense mechanisms
true
what are the body’s normal body defenses
air filtration epiglottis closure over the trachea cough reflex mucociliary escalator mechanism reflex bronchoconstriction
what is aspiration
an abnormal substance or object entering trachea and lungs
what should you avoid giving a person who is at high risk of aspiration?
why?
straws
thin liquids
increased possibility of aspiration
liquids shoot down throat faster
3 ways pneumonia causing organisms can reach the lungs?
inhalation
aspiration
hematogenous spread from a primary infection elsewhere in the body
risk factors for pneumonia
abdominal or thoracic surgery age over 65 air pollution altered consciousness: alcoholism, head injury, seizures, anesthesia, drug overdose, stroke bed rest and prolonged immobility chronic disease: chronic lung and liver disease, diabetes mellitus, heart disease, cancer, chronic kidney disease exposure to bats, birds, rabbits, farm animals immunosuppressive disease inhalation or aspiration of noxious substances IV drug use malnutrition recent antibiotic therapy resident of a long term care facility smoking tracheal intubation upper respiratory tract infection
what organism is the most common cause of CAP
streptococcus pneumoniae
what organism is the most common cause of HAP
pseudomonas aeruginosa
e coli
klebsiella pneumoniae
acinetobacter species
what is the CURB65
used as supplement to clinical judgement to determine the severity of pneumonia and if patients need to be hospitalized Confusion bUn > 20 Respiratory rate > or = 30 per min Blood pressure systolic < 90 or diastolic < or = 60 age > or = 65 each is worth 1 point score of.. - 0: treat at home - 1-2: consider hospital admission - 3 +: hospital admission - 4-5: consider admission to intensive care unit
what is empiric antibiotic therapy
when should this be started
the initiation of treatment before a definitive diagnosis or causative agent is confirmed
as soon as CAP is suspected
what is HAP aka?
what other type of pneumonia is a HAP?
nosocomial pneumonia
VAP
what is MDR?
what organisms does this usually include?
what test can identify these?
risk factors for development of MDR?
multidrug resistant organisms
staph aureus and gram negative bacilli
antibiotic susceptibility tests
advanced age, immunosuppression, history of antibiotic use, and prolonged mechanical ventilation
what is a rare complication of bacterial lung infection?
how it is characterized?
what type of pneumonia is it a result of?
s/s?
treatment?
- necrotizing pneumonia
- liquefaction and in some situations cavitation of lung tissue
- result of CAP
- immediate respiratory insufficiency and/or failure, leukopenia, and bleeding into the airways
- long term antibiotic therapy and possible surgery
who is at risk for opportunistic pneumonia?
individuals with :
severe protein calorie malnutrition
immunodeficiencies
those receiving chemotherapy, radiation therapy, and immunosuppressive therapy
what is the most common form of pneumonia in people with HIV? onset? symptoms? what does the x-ray show? is this life threatening? treatment?
- P. jiroveci pneumonia
- slow and subtle onset
- fever, tachypnea, tachycardia, dyspnea, nonproductive cough, and hypoxemia
- x-ray usually shows diffuse bilateral infiltrates
- is life-threatening
- trimethoprim/sulfamethoxazole (Bactrim, Septra) either IV or orally depending on severity of disease and the patient’s response
what is cytomegalovirus (CMV)? what does this cause? symptoms? when is this a life threatening complications? treatment?
- herpesvirus
- can cause viral pneumonia
- most are asymptomatic or mild, but severe disease can occur in people with an impaired immune response
- most common life threatening complication after hematopoietic stem cell transplantation
- treated with antiviral medications (ganciclovir (Cytovene), foscarnet (Foscavir), cidofovir (Vistide)) and high dose immunoglobulin
most common presenting symptoms of pneumonia?
cough (may or may not be productive with sputum green, yellow, or even bloody) fever chills dyspnea tachypnea pleuritic chest pain fine or coarse crackles
how may viral pneumonia initially be seen?
when does it change?
viral pneumonia may initially be seen as influenza, with respiratory symptoms appearing and/or worsening 12-36 hours after onset
what is consolidation of the lungs?
part of the lungs filled with fluid
if consolidation is present, what manifestations may be present?
bronchial breath sounds egophony (a change in the sound of voice) increased fremitus (vibration of the chest wall produced by vocalization)
what patients are more likely to have complications develop?
older adults
those with underlying diseases
what are the 9 complications of pneumonia?
atelectasis pleurisy (inflammation of the pleura) pleural effusion bacteremia (bacterial infection of the blood) pneumothorax (collapsed lung due to air in pleural space) meningitis acute respiratory failure sepsis/septic shock lung abscess (not common)
what is atelectasis? what may help this?
collapsed airless alveoli in one or part of one lobe
may clear with effective deep breathing and coughing
what is pleural effusion? does this ever resolve?
- fluid in the pleural space
- in most cases, the effusion is reabsorbed in 1-2 weeks
- occasionally requires aspiration by thoracentesis
what is meningitis caused by?
what signs and symptoms indicate the need for a lumbar puncture to evaluate the possibility of meningitis?
streptococcus pneumoniae
disorientation, confusion, or drowsiness
is acute respiratory failure fatal?
yes
it is the leading cause of death in patients with severe pneumonia
pneumonia damages the lung’s ability to facilitate the exchange of oxygen and carbon dioxide
what are the diagnostic assessment tools for pneumonia? (7)
history and physical exam
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 (done for seriously ill pt)
why is an x-ray important in the diagnosis of pneumonia?
it shows a characteristic pattern of the infecting organism
may also show pleural effusion
at what ages should one receive the pneumococcal conjugate vaccine?
all children under 5
all adults over 65
anyone 2-64 with certain medical conditions (immunosuppressive)
at what ages should one receive the pneumococcal polysaccharide vaccine?
all adults over 65
anyone 2-64 with certain long term health problems (heart disease and diabetes)
anyone 2-64 with a disease or condition that weakens the immune system
adults 19-64 who smoke cigarettes or have asthma
what treatment is appropriate for someone with either bacterial or mycoplasma pneumonia? how long does this take to take effect?
what indicates improvement?
when should pt get a repeat chest x-ray done?
antibiotics
48-72 hours
decreased temperature, improved breathing, reduced chest discomfort
repeat chest x-ray should be done in 6-8 weeks to assess for resolution
what are other treatment options for pneumonia pts?
oxygen therapy for hypoxemia
analgesics to relieve chest pain
antipyretics for elevated temperature
how long does viral pneumonia take to resolve? is there treatment for this?
3-4 days no definitive treatment for the majority of viral pneumonias antiviral therapy may be used for: - influenza: oseltamivir, zanamivir - herpes virus: acyclovir (Zovirax)
which drugs may a physician prescribe for a pneumonia outpatient with no recent antibiotic therapy in past 3 months and no risk for drug resistant staph pneumoniae?
macrolide
OR
doxycycline
which drugs may a physician prescribe for a pneumonia outpatient with comorbidities such as COPD, diabetes, chronic heart, liver, lung, or renal disease, malignancy, or use of antibiotics in the past 3 months?
respiratory fluoroquinolone
OR
beta-lactam plus macrolide (doxycycline may be substituted for macrolide)
which drugs may a physician prescribe for a pneumonia outpatient in a region with > or = 25% macrolide-resisitant S. pneumoniae?
respiratory fluoroquinolone
OR
beta-lactam plus macrolide
which drugs may a physician prescribe for a pneumonia inpatient on a medical unit?
respiratory fluoroquinolone
OR
beta-lactam plus macrolide
which drugs may a physician prescribe for a pneumonia inpatient in the ICU?
beta-lactam plus either azithromycin
OR
respiratory fluoroquinolone
what are the macrolides given for pneumonia?
-mycin
erythromycin
azithromycin (Zithromax)
clarithromycin (Biaxin)
what are the fluoroquinolones given for pneumonia?
-floxacin
moxifloxacin (Avelox, Vigamox)
levofloxacin (Levaquin)
gemifloxacin (Factive)
what are the beta-lactams given for pneumonia?
high dose amoxicillin amoxicillin/clavulante (Augmentin) cefpodoxime ceftriaxone (Rocephin) cefuroxime (Ceftin)
what are the antipneumococcal, antipsuedomonal beta-lactams given for pneumonia?
imipenem/cilastatin (Primaxin)
meropenem (Merrem)
cefepime (Maxipime)
piperacillin/tazobactam (Zosyn)
what are the 4 classes of antibiotics given for pneumonia?
macrolides
fluoroquinolones
beta-lactams
antipneumococcal, antipseudomonal beta-lactams
which drugs may a physician prescribe for a pneumonia patient with a psudomonas infection?
antipneumococcal, antipseudomonal beta-lactams
PLUS
ciprofloxacin or levofloxacin
OR PLUS
aminoglycoside and azithromycin
OR PLUS
aminoglycoside and an antipneumococcal fluroquinolone
how long is total treatment time for a CAP patient?
minimum of 5 days
pt must be afebrile for 48-72 hours before stopping treatment
it is important to complete the full course of antibiotics
why is hydration important for pneumonia patients?
to prevent dehydration
to thin and loosen secretions
what are the 6 overall goals for patients with pneumonia?
patients will have…
- clear breath sounds
- normal breathing patterns
- no signs of hypoxia
- normal chest x-ray
- normal white blood cell (WBC)
- absence of complications related to pneumonia
how should a nurse position a patient with altered consciousness?
side lying
upright
to prevent or minimize the risk of aspiration
why is turning a pneumonia patient every two hours important?
to facilitate adequate lung expansion and mobilization of secretions
what technique is used when suctioning a trach
sterile aseptic technique
how to use an incentive spirometer
- put the mouthpiece in your mouth and close your lips tightly around it
- inhale slowly and deeply through the mouthpiece to raise the indicator
- when you cannot inhale any longer, remove the mouthpiece and hold your breath for at least 3 seconds.
- exhale normally
