unit3 noninfectious 7q Flashcards
● Excess fluid in the lungs resulting from an inflammatory process
● Inflammation triggered by many infectious organisms and by inhalation of irritating
agents
● Develops when the immune system cannot overcome the invading organisms
Pneumonia
Common types of Pneumonia-
● Community acquired
● Hospital acquired
● Ventilator associated
● Healthcare associated
RF for Pneumonia-
● Older adult
● Chronic health problems
● Recent exposure to respiratory viral or flu infections
● Limited mobility
● Uses tobacco or alcohol
● Presence of gram-negative colonization of the mouth, throat, and stomach
● Altered LOC
● Aspiration
● Presence of artificial tubes
● Poor nutritional status
● Immunocompromised status
● Mechanical ventilation
CM of Pneumonia-
**● Chest discomfort
**● Dyspnea
**● Increased respiratory rate
**● Fever with or without chills
**● Cough
● Fatigue
● Confusion
**● Hypoxemia
**● Purulent, blood-tinged, or rust-colored sputum
● Lungs- crackes, wheezing, diminished
● Headache
● Rapid, weak pulse may indicate hypoxemia, dehydration, impending sepsis, or shock
● Hypotension- result of vasodilation and dehydration
What might be different in the older adult with Pneumonia?
Acute confusion with hypoxia
○ Most common manifestation in older adults rather than fever or cough, may-be
absent
What is the nursing intervention with the highest priority when taking care of a patient with pneumonia?
● Encourage deep breathing exercises and controlled coughing
What diagnostic tests may be ordered for Pneumonia?
● Pulse oximetry
● ABG
● CXR
● Sputum culture
● CBC
What interventions should be included when caring for a client with pneumonia?
● Oxygen therapy
● Monitor pulse oximetry
● Cough and deep breath Q2H
● Incentive spirometry
● Adequate hydration- helps with secretions
● Assess fluid status- I&O, assess oral mucous membranes and skin turgor
● Drug therapy- anti-infectives and bronchodilators
What discharge teaching should be included for a patient to prevent further pneumonia?
● Continue breathing exercises
● Healthy balanced diet
● Avoid crowded public areas
● Annual flu vaccine
● Pneumococcal vaccine
Pneumonia Prevention-
● Avoid RF
● Annual flu vaccine
● Pneumococcal vaccine
● Avoid crowded public areas during flu and holiday seasons
● Handwashing
● If limited mobility, caught, turn, and move about as much as possible, and perform deep
breathing exercises
● Clean respiratory equipment
● Avoid indoor pollutants
● Stop smoking
● Rest and eat a healthy, balanced diet
● Drink 3 L of fluids each day (unless fluid restriction)
● Highly communicable
● Mycobacterium tuberculosis
● Transmitted via aerosolization
Pulmonary Tuberculosis-
What is correct about TB?
● Exposure to TB does not frequently lead to an active TB infection
RF for TB-
● Those in constant, frequent contact with an untreated person
● Those who have decreased immune function
○ Ex- HIV, taking immunosuppressants
● Individuals who live in crowded areas
○ Ex- Long term care, prison, homeless shelters
● Individuals who don’t have access to health care
● Individuals from countries with a higher incidence of TB
CM of TB-
● Progressive fatigue and lethargy
● Nausea and anorexia
● Weight loss
● Irregular menses
● Low-grade fever
● Night sweats may occur
● Cough with mucopurulent sputum, may be streaked with blood
● Chest tightness, dull aching chest pan may occur with the cough
● Dullness with percussion over-involved lung fields
● Auscultation of lung fields may have bronchial sounds, wheezing or crackles
TB Diagnostic Assessment-
● NAA test- Rapid test
● QuantiFERON-TB- Test with results in 24 hours
● Sputum culture of M. Tuberculosis confirms the diagnosis
○ Required 1-4 weeks to determine + or - results
○ Obtained after drugs are started to determine therapy effectiveness
● Tuberculin (Mantoux) Test-
○ Screening tool
○ Positive reaction does not mean that active disease is present but indicates
exposure to TB or the presence of inactive (dormant) disease
● CXR- Detect active TB or old, healed lesions
