pneumonia readings and ppt Flashcards
what are the 4 major classifications of pneumonia
hospital acquired P
community acquired P
aspiration P
pneumonia in immunocompromiszed
what is pneumonia
- Pneumonia = inflm of lung parenchyma, caused by various micro-organisms (bacteria, mycobacteria, chlamydiae, fungi, parasites, viruses, etc.)
- Pneumonitis is more general term for this
how is community acquired P defined
• Occurs in community setting or first 48hrs of hospitalization/institutionalization
! agents that cause CAP
most commonly: Streptococcus pneumoniae, Haemophilus Influenzae, Legionella pneumophila Pseudomonas aeruginosa and other gram negative rods (etiology known in 50% of cases)
less common:
mycoplasma penumonia
viral pneumonia eg cytomegalovirus, influenza etc
chlamydial pneumonia
what is the most common cause of CAP
• Steptococcus pneumoniae
often follows recent resp illness
who does mycoplasma pneumonia often occur in
kids and YA.
what is the most common cause of pneumonia in infants and kids?
is this common in adults?
• Viruses most common cause of pneumonia in infants + children (uncommon as cause of CAP in adults)
if pt is immunomised what is often cause of pneum
cytomegalovirus
ppt suggests Pneumocystis pneumonia (PCP) and other fungal pneumonias
hospital acquired pneumonia aka nosocomial pneum. how is this defined?
how lethal and common is it?
which form in partic is most lethal?
- = onset of symptoms >48hrs post hospitalization
- 2nd most common + most lethal nosocomial infect
• Ventilator-assocaited pneumonia (VAP) = type assoc with intubation + mechanical ventilation; 24-76% mortality
common causes of HAP
• HAP often involves organisms not found in CAP, such as enteric gram –ve bacilli and S. Aureus enterobacter species, E Coli, H. Influenzae, Klebsiella species, proteus, Serratia marcenscens, P. aerouginosa, MRSA, S. Pneumoniae
t or f a pt with HAP is often colonized with only one organism
false. often multiple
if pt has MRSA what type of precautions are used
contact
usual presentation of HAP
• Usual presentation of HAP: new pulmonary infiltrate on CXR combined with signs of infection (fever, resp synotms, purulent sputum, and/or leukocytosis)
o Cough, sputum production, low-grade fever, general malaise common
o Gram negative organisms characterized by destruction of lung structure, consolidation, and bacteremia
o In pt that is debilitated or dehydrated: minimal or no sputum production, pleural effusions, tachycardia, high fevers
what kind of organisms often cause pneumonia in immunocompromized host
acquired from orgs w low virulence
what is aspiration pneumonia and what is the most common form
• d/t entry of endogenous or exogenous substances in to lower airway
• Most common form = bacterial infection with bacteria that normally reside in URT
other substances can also cause
what can cause pt to get aspiration pneumonia
• Substances can also be: gastric contents, exogenous chemical contents, irritating gases impair lung defenses, cause inflm changes, lead to bacterial growth + pneumonia
what is more common lobar or bronchopneumonia
bronchopneumonia
mnfts of pneumonia (they vary depending on cause)
predominant symptoms
predominant symptoms
• Headache, low grade fever, pleuritic pain, myalgia, rash, pharyngitis (all are most common)
- Possible URT (sore throat, nasal congestion)
- Onset may be gradual and nonspecific
- Mucoid or mucopurulent sputum after a few days
- Orthopnea
- Poor appetite
- Diaphoresis
- Tires easily
- Rusty, blood-tinged sputum with pneumococcal + others
can you diagnose the type of pneumonia based on symptoms alone
• Specific type of P cannot be diagnosed on mnfts alone
symptoms of severe pneumonia
cheeks are flushed
lips and nail beds show central cyanosis (hypoxemia)
what might the only signs of pneumonia be in pt with COPD
• Purulent sputum or slight changes in resp symptoms may be only changes for individual with COPD
what signs might pt have who is immunocompromised
• Those who are immunocompromised may show fever, crackles, physical findings indicating consolidation of lungs (inc tactile fremitus, percussion dullness, egophony, bronchial breath sounds…d/t sound being transmitted better through dense tissue)
imp??
dx of pneumonia
• Hx, px, CXR
• Blood culture
• Sputum examination
o To take this, have pt rinse mouth with water (to get rid of normal flora), breathe deeply several times, cough deeply, expectorate into sterile container
• Can use more invasive procedures – take sputum from nasotracheal or orotracheal suctioning by sputum trap or bronchoscopy (usually with more severe cases)
what is primary tx for pneumonia
• Abx (according to results of gram stain)
pt has CAP how likely is it the etiologic agent is known? consequence
what is key tx measure for CAP pt
only known in 50% of cases.–>empiracl therapy (educated guess in absence of info)
• Prompt admin (within 4-8hrs) of anx in CAP patients is key
how long is pt usually treated for
• Recommended duration of tx for pneumococcal pneumonia is 72hrs after pt becomes afebrile; other kinds typically treated 1-2wks after afebrile
if pt has viral pneumonia when are abx used
• Abx used with viral resp infection ONLY when 2ndry bacterial infection
pt has viral pneumonia how are they treated?
what meds are they given?
what are concerns and how are they addressed?
when are they given 02?
which resp support meas are used?
o Hydration important! (d/t insensible loss form tachypnea + fever)
o Antipyretics
o Antitussives
o Warm, moist inhalations for bronchial irritations
o Antihistamines – sneezing + rhinorrhea
o Nasal decongestants as sleep aid (but not prolonged – risk for rebound congestion!)
o Pt on bedrest until signs of clearing
o O2 if hypoxemia develops
o Resp support measures: High O2, endotracheal intubation, mechanical ventilation
what might older adult w pneumonia present with
- Less likely to exhibit classic symptoms (cough, chest pain, sputum, fever) – may be masked or absent
- Onset may look like: General deterioration, weakness, abdominal symptoms, anorexia, confusion, tachycardia, tachypnea …diagnosis more unlikely
- some s/s are misleading: Abnormal lung sounds may be d/t microatelectasis that occurs with aging (d/t immobility, dec lung volumes, etc)
what is pneumonia often hard to differentiate with in elderly and what can be done about this
• May need to CXR to differentiate between pneumonia + CHF
pneumonia in o adult is harder to treat and has inc mortality rate. what supportive meas are given/recommended
o Watch for fluid overload with hydration o Supplemental O2 o Deep breathing, coughing o Frequent position changes o Early ambulation
• Pneumococcal and flu vaccines recommended
what are complications to watch for in pneumonia pt
• Shock, pleural effusion, superifecitons, pericarditis, and otitis media
when can atelectasis and pleural effusion occur
how common is pleural effusion in bacterial pneumonia?
interventions?
o Can occur at any stage of P
parapneumonic e=plerual effusoon occurs in 40% of bact P cases
CXR, thoracentesis, chest tube, 4-6wks of Abx to sterilize empyema cavity
who is at risk of superinfection and how do their symptoms progress?
how are meds changed?
- May occur w/ large doses of abx such as penicillin or combo tx or those two receive numerous courses + treatments with abx
- Pt improves with tx at first, then subsequently see rise in temp + inc cough, inc fremitus, adventitois breath sounds evidence that pneumonia has spread + superinfeciton is likely
- Abx discontinued or changed
what are warning signs of possible pneumonia
• Fever, chills, night sweats in patient with resp symptoms = warning signs of possible P
what does your resp assessment tell you about pneumonia
what skin issue might they present with
• Resp assessment shows pleuritic-type pain, fatigue, tachypnea 25-45, use of accessory muslces with breathing, bradycardia or tachycardia, coughing, purulent sputum
HoTN
may have rash or pharyngitis
• LOTARP of chest pain
what symptoms to look for in elderly
• Elderly: look for unusual behavior, altered mental status, dehydration, excessive fatique, cocomitant heart failure
nursing dx (not on outcomes)
- Ineffective airway clearance r/t copious tracheobronchial secretions
- Activity intolerance r/t impaired resp fx
- Risk for deficient fluid vol r/t fever + rapid resp rate
- Imbalnced nutrition
- Deficient knowledge about treatment regimen + preventative health measures
how to improve a/w patency
o Removing secretions important b/c interferes with gas exchange + slow recovery
o Encourage hydration (2-3L/d) to thin + loosen secretions
o Humidification (loosened secretions) – high-humidity facemask to do this + relieve tracheobronchial irritation
o Coughing
o Lung expansion maneuvers such as DB w/ incentive spirometer can induce cough
o Chest physiotherapy (percussion + postural drainage) important for mobilizing secretions
o After each position change, pt encouraged to DB + cough if too weak, nurse may need to remove mucus by nasotracheal suctioning
o O2 therapy
how to promote rest and conserve energy
• Promoting rest and conserving energy – rest + avoid over-exertion b/c will worse symptoms; position changes, semi-fowler position
why is fluid intake so imp? how much is nec
• Promoting fluid intake– inc resp rate of pt with P d/t increased workload imposed by laboured breathing + fever inc in insensible loss need 2-3L of water/d
also helps to loosen/thin secretions
why does P pt need help maint nutrtion
• Maintaining nutrition– those with SOB + fatigue often have reduced appetite; nutritional shakes, Gatorade etc may be helpful
what might confusion indicate in pneumonia pt
o Confusion: changes in mental status with P are poor prognostic signs; r/t hypoxemia, fever, dehydration, sleep dep, developing sepsis…or may be d/t underlying illness
who is most at risk of chlamydial pneumonia?
what symptoms do you see
- Most often seen in newborns up to 12wks b/c contracted in mother’s vagina during birth
- Gradual onset w nasal congestion + sharp cough
- Failure to gain back birth weight
- Tachypnea, weezing, rales
now begin notes from ppt
which diagnostics are used for pneumonia
Chest x-ray CBC, look for elevated WBC’s and leukocytes in particular ESR Blood cultures Sputum sample for C&S ABG’s Oxygen saturation
what is a poor indicator of pneumonia or prognosis in elderly
NOTE: Breath sounds are difficult indicators for pneumonia in elderly
what can cause aspiration pneumonia for kids
hydrocarbons-eg floor polish
lipids
newborns born >____hr after rupture of membranes and those who aspirated ____ or ___ ar at inc risk of pneumonia.
who should have a workup to see if infected
newborns born >___24_hr after rupture of membranes and those who aspirated __meconium__ or _amnitoic fluid__
should have a workup to see if infected if born after >24hr of waters being broken so prophylactic Abx can be given
other than the usual resp findings what is a concern with the dev of an infection like pneumonia
with some strains the fever gets so high so quickly it can lead to seizure
tx of child (this was specifically for pneumococcal pneumonia but well generalize it
o Abx
o Strength conservation important (as difficulty breathing)
o Fluids, antipyretics
o Frequent repositioning
o Humidified O2 for laboured breathing + prevent hypoxemia
o Chest physio
o Coughing encouraged so secretions don’t pool and cause more infection
how does lipid pneumonia work?
can you use Abx?
- d/t aspiration of oily or lipidic substances
- Less common than in past – children not given castor or cod liver oil as were before
- Now most likely d/t aspiration of peanuts or popcorn
- Lung lipases act on oil inflammatory response fibrosis of bronchi or alveoli 2ndry infection develops
- Abx useless unless has 2ndry infection
what is hydrocarbon penum d/t
how does kid present?
• D/t furniture polish, keyboard cleaner, turpentine, kesosine, insect sprays w/ hydrocarbon bases
- On assessment, child who swallows this will present with GI symptoms, then drowsy + develop cough (as vapors from stomach rise and are inhaled)
- Bronchial edema occurs resps become shallow, inc in rate, dyspnea
- Inc percussion sounds as air trapped beyond point of inflm or breath sounds may diminish
- Possible emphysema (pocketing air in alveoli) + rupture pneumothorax + atelectasis
treatment of hydrocarbon pneumonia
o Parent should not induce vomiting b/c risk of aspiration from this – phone poison control
o Nasogastric lavage done by professional to remove substance
o Child usually admitted for short time to ensure resps are stabilizing
o Asess for signs of CNS intoxication (drowsiness, etc)
o Cool, moist air + supplemental O2
o This kind of P is slow to resolve – child will be ill for some time
