PNA Flashcards
PNA Pathophysiology
Inflammatory process —> production of alveoli exudate: decreased O2 diffusion —> migration of WBC to alveoli: decrease O2 diffusion —> decreased ventilation (bronchi edema, secretions): decreased alveolar O2 tension
Ventilation/ perfusion mismatch
Oxygen available but cannot reach the capillaries causing blood to leave pulmonary circulation poorly oxygenated
PNA risk factors (10)
- immunosuppressive (older adults)
- shallow breathing (OA)
- weak cough reflex (OA)
- immobility (stroke, frail)
- mucus and bronchial obstruction
- smoking
- NPO, NG/ET tubes
- supine position
- respiratory depression]
- antibiotic therapy
Community-acquired PNA: CAP
- acquired within the community
- diagnosis less than 48h of hospital admission and does not meet criteria for HCAP
Health care-associated PNA: HCAP (what is it and the factors)
Diagnosis less than 48 hours after admission with any of the following factors:
- acute care hospital for more than 2 days within 90 days of diagnosis
- nursing home or long term care facility
- recent IV antibiotic therapy, chemotherapy, or wound care within 30 days preceding current diagnosis
- hospital or hemodialysis clinic
Usual cause of HCAP, how hard is it to treat, what kind of antibiotics?
- usually caused by MDR pathogen (MRSA)
- difficult to treat due to antibiotic resistance
- special antibiotics needed (different from CAP)
Hospital acquired PNA: HAP
- occurrence more than 48 hours of hospital admission
- no clinical manifestations at time of admission
Predisposing factors to HAP (4)
- impaired defenses, comorbidities
- malnutrition, immobility
- CNS depression with hypoventilation (stroke, respiratory failure)
- NG tubes, prolonged antibiotic course
HAP Presentation
- CXR: new pulmonary infiltrate
- evidence of infection: Fever, respiratory symptoms, purulent sputum, leukocytosis
- may evolve to consolidation: solidification of tissues
- mediastinal shift: deviation of mediastinal structure towards one side of the chest cavity, indicating severe asymmetry of intrathoracic pressures (***REQUIRES EMERGENCY INTERVENTIONS: THORACOTOMY W/ DRAINAGE)
Ventilator-associated PNA: VAP
- type of HAP
- more than 48 hours after endotracheal tube intubation
Prevention of VAP
- HOB 30-45 degrees
- daily assess readiness to extubate
- PUD prophylaxis (peptic ulcer disease)
- DVT prophylaxis
- daily oral care with chlorhexidine
Aspiration PNA (most common aspiration, other aspirations, where it occurs, what causes the PNA)
- most common aspiration: bacteria from upper airways
- other types of aspiration: gastric contents, exogenous chemicals
- may occur in the community or hospital
- inflammatory changes lead to bacteria growth —> PNA
PNA Diagnosis
- H&P
- CXR
- blood and sputum culture —> only for sever disease, all inpatients empirically treated diet MRS or pseudo
PPSV Vaccination
- one time: all patients 65 or older, adult with chronic diseases or smoking
- second dose: All 65 year old adults who received first dose more than 5 years ago
PCV13 and PPSV23
Pharmacological therapy: antibiotics for bacterial PNA
- mono therapy or combination
- IV to PO when patients are stable
What does a stable PNA patient look like?
T < 100 HR <100 RR < 24 SBP> 90 O2 Sat > 90%
Other therapies for PNA (5)
- symptoms support
- O2 PRN
- pulse ox
- IV fluids
- ABGs monitoring
Gerontological considerations for PNA
- increased mortality
- classic symptoms may not be present (chest pain, fever, sputum, leukocytosis)
- onset symptoms: confusion, weakness, increased HR, increased RR, abd upset
- abnormal breath sounds misleading: decreased at bases, atelectasis, crackles from CHF
PNA Complications (4)
- resp failure
- sepsis and septic shock
- aspiration
- pleural effusion: empyema: accumulation of thick purulent fluid; thoracentesis: removal of fluid; chest tube: drainage of fluids, empyema
Nursing process assessment (7)
- early detection
- pleuritic pain
- fatigue
- tachypnea
- use of accessory muscles
- sputum
- changes in temp (may be slight in gero patients)
Nursing process: diagnosis
- ineffective airway clearance r/try copious secretions
- impaired gas exchange r/t copious secretions
- fatigue/activity intolerance r/t impaired resp function
- imbalanced nutrition: less than body requirements
- risk for deficient fluid volume r/t fever and tachypnea
Nursing process interventions (patency) (6)
-improving patency —> hydration and humidification of secretions, lung expansion, effective directed cough, chest pt, O2 therapy, administer prescribed antibiotics and other meds
Nursing process interventions (administer ___, promote ____ and ____, maintain or improve ____, promote ___, prevent and manage complications: ___, ___, ___, ____, ____)
- administer antibiotics for bacterial PNA
- promote rest
- promote fluid intake (at least 2L/day unless contraindicated)
- maintain or improve nutritional status
- promote knowledge: disease and healing
- prevent and manage complications: assess labs, VS, response to antibiotic treatment, CXR, LOC
PNA prevention for post surgical patients
Incentive spirometry —> keeps lungs active during bed rest which lowers the risk of PNA
Quick risk assessment for sepsis assessment (10 signs of infection)
- increased RR
- increased HR
- low BP
- low output
- ALOC
- decreased O2 sat
- high/low WBC
- high neutrophils
- high/low temp
- high/low bowel sounds
qSOFA score
- 2 or 3 means increased risk of mortality or extended ICU stay
- serum lactate > 2 suggests hypoperfusion
- SBP < 100
- RR >22
- any change in LOC
Nursing process: intervention (pt ed) (7)
- antibiotic treatment and side effects
- breathing exercise (IS w/ goal)
- follow up with PCP
- smoking cessation
- home care PRN
- eval of adherence to therapy
- NUTRITION (protein, iron, vitamins)
PNA complications: aspiration
Inhalation of foreign material
Risk factors of aspiration (6)
- seizure
- brain injury, stroke
- ALOC
- flat body positioning
- swallowing disorders
- cardiac arrest
Aspiration prevention: Absent reflexes
- HOB 30-45
- avoid sedation
- swallowing eval-speech therapist
- soft diet, small bites
- chin tucked, head turned when swallowing
- oral suctioning with minimal pharyngeal stimulation
- patients with ET and feeding tube: cuff pressure 20-30 cm H2O
Aspiration Prevention: feeding tubes
- feeding only after placement verifications: CXR!!!!
- verify exit mark
Aspiration prevention: delayed stomach emptying (causes, how to prevent aspiration)
- obstruction, increased secretions, paralytic ileus, ascites, peritonitis, opioid side effects
- verify NG tube, G tube residual volume; notify HCP PRN
PNA complications: pleural effusion. What is transudate? what is exudate?
- pleural space fluid collection: secondary disease
- PNA, HF, lung tumors, PE
- transudate: plasma from pulmonary capillaries (HF)
- exudate: fluid extravasacation to pleural space (inflammation or tumors)
Pleural effusion (what to treat, how to treat)
- treat underlying cause: PNA, HF, tumors
- thoracentesis: collection of fluid by suction
- chest tube for continued fluid drainage: suction to restore negative pressure of thoracic cavity
Pleurodesis
Chemical irritant instilled in pleural space resulting decrease in pleural space and reaccumulation of fluid
PleureX Catheter
Outpatient management
Pleuroperitoneal shunt
Manual pump from pleural space into peritoneal space
PNA complications: Empyema (what is it, where is it, how long is the treatment, how to manage, pt teaching about ____)
- accumulation of thick, purulent fluid within pleural space
- loculated (walled off)
- drainage
- antibiotic treatment: 4-6 weeks
- lung expanding breathing exercises: IS with goal
- patient teaching about treatment and meds
