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
Pulmonary TB Interventions-
● Combination drug therapy is most effective method of treatment and preventing transmission
● First Line-
○ Isoniazid (INH_
○ Rifampin (RIF)
■ Can stain skin and cause body secretions to have a red/orange color
■ Rifampin may reduce the effectiveness of oral contraceptives and that an additional method of contraception should be used
○ Pyrazinamide (PZA)
■ Added for the first 2 months to shorten therapy from 6-12 months to 6
months
■ Increase fluids as it can increase risk of gout
○ Ethambutol (EMB)
■ Increase fluids as it can increase risk of gout
○ All these drugs can affect liver function
■ Avoid all alcohol
■ Report any dark urine or yellow changes in skin color
Nausea very common
■ Take medications at night
● Chronic bronchitis- Blue bloaters- chronic exposure to irritants or smoking; retaining CO2
○ Inflammation, congestion, mucosal edema, bronchial spasm
○ Airways, NOT alveoli
○ CM- Cyanosis, obesity, crackles and wheezes, peripheral edema
COPD
CM of COPD
Cyanosis,
Obesity,
Crackles and wheezes,
Peripheral edema
COPD
● Pink puffers- Emphysema- trying to get rid of CO2
○ Alveoli
○ Chronic smoking, bad air
○ CM- pursed lip breathing, barrel chest, decreased breath sounds and ecessary
muscles used, barrel chest, hyperinflation of the lungs
CM of Emphysema
pursed lip breathing,
barrel chest,
decreased breath sounds and
necessary
muscles used, ,
hyperinflation of the lungs
