TEST 2 MOD 10 WINKS Flashcards
Difference between Health care associated vs. community acquired
Community-acquired pneumonia (CAP):
Acute infection in patients who have not been hospitalized or lived in a long-term care facility within 14 days of the onset of symptoms
Hospital-acquired pneumonia (HAP):
Occurring 48 hours or longer after admission and not incubating at time of hospitalization
also known asnosocomial pneumonia
Once the diagnosis of CAP, HAP, or VAP is made, treatment is started based on known risk factors, early versus late onset, presentation, underlying medical conditions, hemodynamic stability, and the likely causative pathogen.
Empiric antibiotic therapy,the initiation of treatment before a definitive diagnosis or causative agent is confirmed, should be started as soon as pneumonia is suspected. Empiric antibiotic therapy is based on the knowledge of drugs known to be effective for the likely cause. Antibiotic therapy can be adjusted once the results of sputum cultures identify the exact pathogen.
Pneumonia Prevention
Pneumococcal conjugate vaccine (PCV13, Prevnar 13): Protects against 13 types of pneumococcal bacteria
All adults ≥ 65
Adults with certain medical conditions. Single dose
Pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23): Protects against 13 types of pneumococcal bacteria
All adults ≥ 65
Adults with certain medical conditions, conditions that increase infection risk, smokers, those with asthma
Single dose. May receive 1-2 additional doses
Nursing management of Pneumonia
Prevention for at-risk patients (The older adult or chronically ill patient may have a prolonged period of convalescence.)
Elevate head of bed 30 to 45 degrees for patients
with feeding tube
Aspiration precautions (Place the patient with altered consciousness in positions (e.g., side-lying, upright) that will prevent or minimize the risk for aspiration)
Assist immobile patients with turning and deep breathing (Turn and reposition patients at least every 2 hours to promote adequate lung expansion and mobilization of secretions. Encourage and assist with ambulation and positioning into a chair.)
Emphasize need to take course of medication(s).
Teach drug–drug interactions.
Medications administered
Antibiotics
Bronchodilators
Expectorants
Specimen collection
Respiratory assessment, pulse oximetry
Oxygen therapy
Hydration
Nutritional support
Breathing exercises
Early ambulation
Basic concepts of medical management in regards to Pneumonia
Antibiotic therapy
Oxygen for hypoxemia
Analgesics for chest pain
Antipyretics
Bronchodilators
Expectorants
Fluid intake at least 3 L per day
Caloric intake at least 1500 per day
In uncomplicated cases, the patient responds to drug therapy within 48 to 72 hours. Signs of improvement include decreased temperature, improved breathing, and reduced chest discomfort. Abnormal physical findings can last more than 7 days. A repeat chest x-ray may be done in 6 to 8 weeks to assess for resolution.
Currently, no definitive treatment exists for most viral pneumonias. Care is generally supportive. In most circumstances, viral pneumonia is self-limiting and will often resolve in 3 to 4 days. Antiviral therapy may be used to treat pneumonia caused by influenza (e.g., oseltamivir, zanamivir) or a few other viruses (e.g., acyclovir [Zovirax] for herpes simplex virus).
Hydration is important in the supportive treatment of pneumonia to prevent dehydration and to thin and loosen secretions.
Weight loss may occur in patients with pneumonia because of increased metabolic needs and difficulty eating due to shortness of breath or nonspecific abdominal symptoms. Small, frequent meals are easier for dyspneic patients to tolerate. Offer foods high in calories and nutrients.
Clinical manifestations of Pneumonia
Sudden onset of fever
Shaking chills
Shortness of breath
Cough productive of purulent sputum
Pleuritic chest pain
Adventitious breath sounds
The older or debilitated patient may not have classic symptoms of pneumonia. Confusion or stupor (possibly related to hypoxia) may be the only finding. Hypothermia, rather than fever, also may be seen in the older adult.
Nursing diagnoses of Pneumonia
Impaired gas exchange
Impaired breathing
Fluid imbalance
Hyperthermia
Activity intolerance
Nursing evaluation of Pneumonia
Assess for signs of pneumonia and respiratory distress which will require immediate intervention. Physical assessment consists of: auscultating lung sounds, obtaining vital signs (to include pulse oximetry), and skin assessment for the client’s overall respiratory health.
fever or sometimes low body temperature, an increased respiratory rate, low blood pressure, a fast heart rate, or a low oxygen saturation, which is the amount of oxygen in the blood as indicated by either pulse oximetry or blood gas analysis.
Viral pneumonia
Cytomegalovirus(CMV)
Fungal pneumonia
P. jirovecipneumonia (PJP
Pathology of Pneumonia
Almost all pathogens trigger an inflammatory response in the lungs. Inflammation, characterized by an increase in blood flow and vascular permeability, activates neutrophils to engulf and kill the offending pathogens. As a result, the inflammatory process attracts more neutrophils, edema of the airways occurs, and fluid leaks from the capillaries and tissues into alveoli. Normal O2transport is affected, leading to manifestations of hypoxia (e.g., tachypnea, dyspnea, tachycardia).
Dx tests that indicate presence of pneumonia
CBC: Leukocytosis (an elevated white blood cell (WBC) count, typically above 11.0x10^9/L)
ABG: Initially: Normal or decreased PaO2, mild respiratory alkalosis
Later: Decreased PaO2, respiratory acidosis
Sputum is positive on gram stain culture
Abnormal chest xray
What feature is typical of BACTERIAL pneumonia
Pulmonary consolidation (pneumonia) describes the presence of exudate in the airways and alveoli, usually as a result of infection.
PH Normal Range
7.35-7.45
PaO2 Normal Range
Amount of oxygen dissolved in arterial blood 80-100 mm Hg
SaO2 Normal Range
Arterial oxygen saturation 95-100%
PaCO2 Normal Range
amount of carbon dioxide dissolved in arterial blood 35-45 mm/Hg
HCO3 Normal Range
amount of bicarb in the bloodstream 22-26 mEq/liter
Measures to promote adherence with TB medications
Directly observed therapy (DOT)
Noncompliance is major factor in multidrug resistance and treatment failures.
Requires watching patient swallow drugs
Preferred to ensure adherence
when is a TB skin test positive
Induration refers to the thickening and hardening of soft tissues of the body, specifically the skin, and is the result of an inflammatory process caused by various triggering factors. Indurated areas commonly appear on the hands and face
The tuberculin skin test (TST) (Mantoux test) using purified protein derivative (PPD) is the standard method to screen people forM. tuberculosis. The test is given by injecting 0.1 mL of PPD intradermally on the ventral surface of the forearm. The test is read by inspection and palpation 48 to 72 hours later for the presence or absence of induration. Induration, a palpable, raised, hardened area or swelling (not redness) at the injection site means the person has been exposed to TB and has developed antibodies. Antibody formation occurs 2 to 12 weeks after initial exposure to the bacteria.
Intradermal administration of tuberculin
Positive reactions
> 5 mm—immunocompromised patients, people with close personal contact to infected person
> 10 mm—recent immigrants from areas with increased TB incidence, IV drug users, residents or employees of prisons, SNFs, homeless shelters
> 15 mm—no known risk factors
Two-step testing for individuals who will be tested periodically
TB 3 =
TB, clinically active
Positive bacteriologic studies or both a significant reaction to TST and clinical or x-ray evidence of current disease
Tb 5=
TB suspect
Diagnosis pending
TB 4 =
TB, but not clinically active
History of previous episode of TB or abnormal, stable x-ray findings in a person with a positive reaction to TST. Negative bacteriologic studies if done. No clinical or x-ray evidence of current disease.
TB 0 =
No TB exposure
No history of exposure, negative tuberculin skin test (TST)
TB 1 =
TB exposure, no infection
History of exposure, negative TST
TB 2 =
Latent TB infection, no disease
Positive TST, negative bacteriologic studies, no x-ray findings compatible with TB, no clinical evidence of TB
TB is caused by
Mycobacterium tuberculosis
TB is spread by
airborne droplets when infected person
Coughs
Speaks
Sneezes
Sings
Spread
Inhaled bacilli pass down bronchial system and implant themselves on bronchioles or alveoli.
Multiply with no initial resistance
Clinical manifestations of pneumonia
Symptoms of pulmonary TB usually do not develop until 2 to 3 weeks after infection or reactivation. The primary manifestation is an initial dry cough that often becomes productive with mucoid or mucopurulent sputum.Tired, weight loss
Acute symptoms feel like to flu. Dyspnea is a late symptom that may signify considerable pulmonary disease or a pleural effusion. Hemoptysis, which occurs in less than 10% of patients with TB, is also a late symptom.
Name of alternative screening test for TB
Interferon-γ (INF-γ) release assays (IGRAs) are another screening tool for TB. IGRAs are blood tests that detect INF-γ release from T cells in response toM. tuberculosis. Examples of IGRAs include QuantiFERON-TB Gold In-Tube test (QFT-GIT) and the T-SPOT.TB test. Test results are available in a few hours
Describe the diagnostic test for bacteriologic pneumonia
Stained sputum smears examined for acid-fast bacilli
Required for diagnosis
On different days, three consecutive sputum samples
Culture is the gold standard for diagnosing TB. Three consecutive sputum specimens are needed, each collected at 8- to 24-hour intervals, with at least 1 early morning specimen. The initial test involves a microscopic examination of stained sputum smears for AFB. A definitive diagnosis of TB requires mycobacterial growth, which can take up to 6 weeks. Treatment is needed pending the culture results for patients in whom suspicion of TB is high. Samples for other suspected TB sites can be collected from gastric washings, cerebrospinal fluid (CSF), or fluid from an effusion or abscess.
Chest x-ray: Although the chest x-ray findings 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 upper lobe infiltrates, cavitary infiltrates, lymph node involvement, and pleural and/or pericardial effusion. Other diseases, such as sarcoidosis, can mimic the appearance of TB.
What are the four drugs used for TB patients
isoniazid, rifampin (lofantin) dyes pee orange, pyrazinamide, and ethambutol
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 only 1 drug is needed.
in people with Active disease
Four drugs are used in initial phase for maximum effectiveness. Treatment is aggressive to combat resistant strains of TB. Liver function should be monitored.
Whats the name of the TB vaccine that may cause a permanently positive TB test
Bacille Calmette-Guérin (BCG) vaccine
What would you do with a pt that has to be admitted that has TB
Airborne infection isolationrefers to isolation of patients infected with organisms spread by the airborne route. Patients are in a single-occupancy room with negative pressure and airflow of 6 to 12 exchanges per hour. High-efficiency particulate air (HEPA) masks are worn whenever entering the patient’s room.
If patients need to be out of the negative-pressure room, they must wear a standard isolation mask to prevent exposure to others.
T/F: Pts cannot leave the hospital until their TB is gone
F: 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 monthly intervals until 2 consecutive specimens are negative on culture.Negative cultures are needed to declare the patient not infectious. Also overall improvement in patient condition, and improvement on chest x-ray
What would you teach your TB pt when being discharged home
Cover you mouth with you cough/sneeze. Throw tissues in bag. Keep window open in room alone. Stay away from public places. Try to be outdoors as much as possible.
Medications for acute exacerbations of asthma
know action
indications
side effects
nursing considerations
how to evaluate effectiveness
maintenance medications of asthma
know action
indications
side effects
nursing considerations
how to evaluate effectiveness
maintenance medications of COPD
Inhaled corticosteroids (ICS)
Mech/Action: suppress airway inflammation by activating anti-inflammatory genes, switching off inflammatory gene expression, and inhibiting inflammatory cells. Suppress immune response, Reduce bronchial hyperresponsiveness, Decrease mucous production
Side effects: a sore mouth or throat, a hoarse or croaky voice, a cough, oral thrush
Don’t use for an acute attack, Have the patient use decongestant drops before using the inhaled steroid to facilitate penetration of the drug if nasal congestion is a problem. Have the patient rinse the mouth after using the inhaler because this will help to decrease systemic absorption and decrease GI upset and nausea.
Ex: Beclomethasone (Qvar MDI), Budesonide, (Pulmicort Turbuhaler)
Fluticasone (Flovent),
Instruct patient to rinse mouth after use
CAN BE USED ALONE W/ COPD: Long-Acting β-Adrenergic agonists (LABA)
Salmeterol (Serevent Dry Powder Inhaler)
Fometerol (DPI, nebulizer)
Arformoterol (Brovana): Nebulizer
FOR COPD ONLY: Long-acting anticholinergic bronchodilators
Tiotropium (Spiriva): (Dry Powder Inhaler)
know action
indications
side effects
nursing considerations
how to evaluate effectiveness
Medications for acute exacerbations of COPD
know action
indications
side effects
nursing considerations
how to evaluate effectiveness
Clinical manifestations of asthma
The characteristic manifestations are wheezing, cough, dyspnea, and chest tightness after exposure to a risk factor or trigger.In asthma, the airways become narrower than usual because of bronchospasm, edema, and mucus. As a result, it takes longer for the air to move out of the bronchioles (airflow obstruction). This causes the characteristic wheezing, air trapping, and hyperinflation of the lungs. As a result, expiration may be prolonged.
Clinical manifestations of COPD
Inability to expire air is a main characteristic of COPD.The main site of the airflow limitation is in the smaller airways. As the peripheral airways become obstructed, air is progressivelytrapped during expiration. The volume of residual air becomes greatly increased in severe COPD as alveolar attachments (similar to rubber bands) to small airways are destroyed. As air is trapped in the lungs, the chest hyperexpands and becomes barrel shaped, because the respiratory muscles are not able to function effectively. The residual air, combined with the loss of elastic recoil, makes passive expiration of air difficult. The patient is now trying to breathe in when the lungs are in an “overinflated” state. Thus, the patient becomes dyspneic with limited exercise capacity. Typically, the patient does not have problems with hypoxemia at rest until late in the disease.
how to use and significance of peak flow meter readings
(red, yellow, green zones)
Interventions/techniques for dyspnea and airway clearance for asthma
Interventions/techniques for dyspnea and airway clearance for COPD
Lifestyle modifications to help control symptoms of COPD
The effect of oxygen therapy on COPD
Nursing diagnoses for COPD
Nursing diagnoses for asthma
Nursing evaluation for asthma
Nursing evaluation for COPD
Difference between COPD and asthma
Asthma: REVERSIBLE airflow limitation or bronchial hyperresponsiveness. Inability to get air in
COPD: PROGRESSIVE airflow limitation that is part of a chronic inflammatory response such as bronchitis or emphysema. Inability to get air out.
Define status asthmaticus
most extreme form of an acute asthma attack. It is characterized by hypoxia, hypercapnia, and acute respiratory failure. The patient is unresponsive to treatment with bronchodilators and corticosteroids. The patient may have chest tightness, a severely marked increase in shortness of breath, or suddenly be unable to speak. Hypotension, bradycardia, and respiratory and/or cardiac arrest may occur if we do not recognize that the patient’s condition is getting worse.
Long term complications of COPD include
COPD exacerbation
Cor pulmonale
Pulmonary hypertension
Acute respiratory failure
Pulmonary heart disease, also known as cor pulmonale, is the enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance or high blood pressure in the lungs. Chronic pulmonary heart disease usually results in right ventricular hypertrophy, whereas acute pulmonary heart disease usually results in dilatation.
ABG results that indicates asthma
Normal between exacerbations
Exacerbations: May have respiratory alkalosis early, respiratory acidosis if prolonged or severe
ABG results that indicates COPD
Hypoxemia, low-normal pH
Compensated respiratory acidosis
PH normal values
7.35-7.45
CO2 normal values
35-45
PO2 normal values
80-100
HCO3 normal values
22-26
O2 SAT
95-100%
Pulmonary function test results that indicates COPD
Total lung capacity and residual volume increased
FEV1 decreased
FEV1/FVC ratio decreased (<70%)
Pulmonary function test results that indicates asthma
Total lung capacity and residual volume increased
FEV1 decreased or normal
FEV1/FVC ratio normal to decreased
Define Total lung capacity
Maximum volume of air that lungs can contain
Define Residual volume
Amount of air remaining in lungs after forced expiration. This is the air available for gas exchange.
FEV1: Forced Expiratory Volume
Amount of air exhaled quickly and forcefully in 1st second after maximum inspiration
Define
Forced Vital Capacity (FVC)
Amount of air that can be quickly and forcefully exhaled after maximum inspiration
FEV1/FVC ratio
Helpful in differentiating obstructive and restrictive problems
Treatment during an acute exacerbation (Asthma and COPD)
- Short-acting Muscarinic Antagonists (SAMA) Ipratropium (Atrovent HFA): Nebulizer, MDI. Block action of acetylcholine. Usually used in combination with a SABA. Most common side effect is dry mouth)
- Corticosteroids (systemic)
Methylprednisolone (Solu-Medrol; IV/Oral)
Prednisone (Oral)
Suppress immune response
Reduce bronchial hyperresponsiveness
Decrease mucous production
Numerous side effects (fluid retention, HTN, confusion, mood swings, GI upset, weight gain, fat deposits in abdomen, face, back, neck. Long-term effects: osteoporosis, adrenal insufficiency, hyperlipidemia, hepatic issues)
What are the daily “controller” medications for asthma and COPD?
Inhaled corticosteroids (ICS)
Beclomethasone (Qvar MDI)
Budesonide (Pulmicort Turbuhaler)
Fluticasone (Flovent)
Suppress immune response
Reduce bronchial hyperresponsiveness
Decrease mucous production
Instruct patient to rinse mouth after use
FOR ASTHMA ONLY IF USED WITH ABOVE, CAN BE USED ALONE W/ COPD: Long-Acting β-Adrenergic agonists (LABA)
Salmeterol (Serevent Dry Powder Inhaler)
Fometerol (DPI, nebulizer)
Arformoterol (Brovana): Nebulizer
FOR COPD ONLY: Long-acting anticholinergic bronchodilators
Tiotropium (Spiriva): (Dry Powder Inhaler)
