lower respiratory problems acute bronchitis pneumonia tuberculosis copyright 2/4/2013 michelle...
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ACUTE BRONCHITIS Inflammation of the
bronchi in the lower respiratory tract.
Usually occurs with upper respiratory
tract infection
ACUTE BRONCHITIS
EtiologyMay be viral /bacterial infectionAt risk -- those with impaired immune
defenses/cigarette smokingMarked seasonal incidences
ACUTE BRONCHITISClinical ManifestationsPersistent cough Mildly elevated T, RR, HRBreath sounds
Diagnostic AssessmentHistory/PhysicalCXR – differentiate acute bronchitis/pneumonia
ACUTE BRONCHITISCollaborative Management Treatment is generally supportivea. Fluidsb. Rest c. Anti-inflammatory agentsd. Other Antibiotics
Antitussives Bronchodilators
PNEUMONIA Leading cause of death from an infectious
disease Excess fluid in the lungs resulting in an
inflammatory process Caused by various microbial agenta. Bacterial b. Viral c. Fungal
Incidence/Prevalence US – 4 million cases of pneumonia 8th leading cause of death Highest incidence in older adults and people with
debilitating illness1. Nursing home residents2. Those mechanically vented
PNEUMONIA
PNEUMONIARISK FACTORS1. Older Adult2. Bed rest/prolonged immobility3. Debilitating illness4. Human immunodeficiency virus (HIV)5. Intestinal / gastric feedings 6. Malnutrition
PNEUMONIA
CLASSIFICATION1. Community –Acquired Pneumonia (CAP)2. Hospital –Acquired Pneumonia (HAP)3. Aspiration Pneumonia4. Opportunistic Pneumonia
COMMUNITY-ACQUIRED PNEUMONIA
1. Onset occurs in the community /first 2 days of hospitalization
2. Incidence 3. Smoking, alcoholism, immunosuppressive disease4. Age > 65 years, multiple medical co-morbidities5. Causative organism identified only 50% of the time
HOSPITAL ACQUIRED PNEUMONIA
1. Occurs 48 hrs. or longer after admission2. Bacteria are responsible for the majority of
HAP – Pseudomonas, Staph. Aureus 3. Some causes:a. contaminated respiratory therapy equip. b. endotracheal intubation (VAP) c. general debility
HOSPITAL ACQUIRED PNEUMONIA
• Ventilator –Associated Pneumonia• Nosocomial pneumonia• Associated with endotracheal intubation
/mechanical ventilation• Bacterial Pneumonia• Ventilator Bundle
HOSPITAL ACQUIRED PNEUMONIA
• Methicillin-Resistant Staphylococcus Aureus (MRSA)Specific strains of Staphylococcus are resistant
to all available antibiotics except VancomycinHighly virulent
ASPIRATION PNEUMONIA
1. Aspiration of material from the mouth/stomach into the trachea/lungs
2. Typically occurs in clients with altered consciousness and impaired gag reflex
3. Another risk factor – tube feedings4. Prevention –
OPPORTUNISTIC PNEUMONIA Occurs in client’s with altered immune
response. Highly susceptible to respiratory infections Pneumocystis jiroveca (carinii) – fungal
opportunistic pathogen Affects about 70% of HIV virus infected
individuals Common opportunistic infection
OPPORTUNISTIC PNEUMONIA
At risk: 1. those with immune deficiencies2. severe protein calorie malnutrition3. clients who have received organ transplants4. clients treated with chemotherapy, radiation
therapy
OPPORTUNISTIC PNEUMONIA
Clinical ManifestationsInsidious Tachycardia Fever Non-productive coughTachypnea Dyspnea
TreatmentBactrim – primary agent
BACTERIAL PNEUMONIA
Clinical Manifestations1. Fever 2. Shaking chills3. Productive cough 4. Pleuritic chest pain 5. Crackles on auscultation6. Altered mental status
DIAGNOSTIC STUDIES1. History/physical2. Chest x-ray3. Sputum gram stain, C&S (should be
collected before antibiotic therapy started)
4. CBC 5. Serum electrolyte
PNEUMONIA
Empiric Therapy
Treatment is based on observation and experience without always knowing the exact cause.
BACTERIAL PNEUMONIA
COLLABORATIVE CARE1. Antibiotic therapy –Macrolides recommended a. Zithromax (azithromycin) b. Biaxin (clarithromycin)2. Oxygen therapy 3. Analgesics 4. Antipyretics5. Rest/restrict client’s activity
VIRAL PNEUMONIA
No definitive treatmentAntiviral agentsa. Symmetrel (amantadine)b. Flumadine (rimantadine)
VACCINEInfluenza vaccineo Mainstay of preventiono Recommended annually for clients Pneumoccal Vaccineo Good for a lifetimeo 65yrs and older
COMPLICATIONS
o Usually runs an uncomplicated course.o Complications may include a. pleural effusion b. confusion
NURSING MANAGEMENTa. Assess respiratory statusb. Oxygen therapy – as per MD orderc. Maintain patent airwayd. High-calorie, high –protein foodse. Hydrate f. Administer medications as orderedg. Document findings
TUBERCULOSIS
o Bacterial infection o Caused by Mycobacterium tuberculosiso Communicable diseaseo Primarily affects the lungso Can affect other organs & body structureso Transmitted through airborne dropletso The disease may be an active process or it may
remain dormant
RISK FACTORS* Persons in constant, frequent contact with
untreated/undiagnosed individuals* Abuse IV drugs or alcohol* Homeless persons, residents of inner-city
neighborhoods* Foreign-born immigrants from countries with high
prevalence* Those living in crowded areas -- mental health
facilities, long-term care facilities * Those with immune dysfunction or HIV
PATHOPHYSIOLOGY
a. M. tuberculosis, a gram-positive, acid-fast-bacillus, & a slow-growing organism
b. Transmitted via airborne dropletsc. Bacilli are inhaled & deposit themselves on the
bronchioles/alveolid. Here they may be killed by the host's immune
system, or lie dormant without causing symptoms, or produce primary TB
e. It’s possible for the bacilli to proliferate after a period of dormancy, causing reactivation of TB.
TUBERCULOSIS
Contraction of TB typically requires close, repeated contact over a long period of time
CLINICAL MANIFESTATIONS
Early stages the client may be symptom free• Active disease: 1. Fatigue2. Low-grade fever / night sweats3. Anorexia / weight loss4. Persistent cough 5. Chest tightness, & dull, aching chest pain may
accompany the cough
TUBERCULIN SKIN TESTING
Mantoux test - PPD (purified protein derivative)* Gold standard for screening * Most reliable determinant of TB infection* Skin test should be read 48-72 hrs. after PPD
administration* A positive test is determined by the size of the area
of induration (hardened & raised area)
MANTOUX TEST
MANTOUX TEST (cont’d)* A positive reaction indicates the presence of a
tuberculosis infection* Does not show whether the infection is inactive
(dormant) disease or active.* Immunosuppressed clients or those with HIV-
infection with a induration reaction 5mm or greater are considered positive
TUBERCULOSIS* An area of induration
measuring 10mm or more in diameter, 48-72 hours after injection, indicates the individual has been exposed to TB
QuantiFERON-TB Gold
New test for detection of TBTest is an enzyme-linked immunosorbent
assay (ELISA)Detects the release of interferon-gamma by
WBC’S when the blood of a pt. with TB is incubated.
Results of the test are available in less than 24 hr.
DIAGNOSTIC ASSESSMENT
Chest x-ray Sputum cultures –most accurate means of
making a diagnosis.a. (3) consecutive sputum specimens on three
different days are obtained for C&S b. A positive sputum culture of tubercle bacilli
confirms the diagnosis
VACCINE
Immunization with bacille Calmette-Guerin (BCG) is still given to prevent TB in many parts of the world.
Given to children in high prevalence areas in developing countries
BCG vaccination can result in a positive reaction on TST
COLLABORATIVE CARE
Most client's are treated on an outpatient basis1. Hospitalization used for – severely ill,
debilited, & those who experience adverse drug reactions
2. Mainstay of TB treatment – Drug Therapy
TUBERCULOSIS
What is multidrug – resistant TB?
Resistance develops to at least two or more anti-TB drugs
Standard therapy has been revised
TUBERCULOSIS
Treatment consist of a combination of at least 4 drugs
Reason for the combination therapy a. Increase therapeutic effectiveness b. Decrease the development of resistant strains of M. tuberculosis
TUBERCULOSIS
FIRST LINE DRUGS1. Isoniazid (INH)2. Rifampin (Rifadin)3. Ethambutol
(Myambutol)4. Streptomycin5. Pyrazinamide
DRUG THERAPY
* Length of time medication must be taken 6/12 months
* Strict adherence to the drug regimen is crucial to suppress the disease
* Non-compliance is a major factor in the emergence of MDR - TB
DRUG THERAPY
Isoniazid- (INH)First drug of choice for TB prophylaxisAdverse effects Administer pyridoxine (vitamin B6) Hepatitis – hepatotoxic
DRUG THERAPY
Rifampin (Rifadin)Used in combination with INH and other antitubercular medsCan cause hepatitis, flu-like symptoms Causes body fluids – turn red/orange.Monitor liver function studies, renal studies for evidence of toxicity
DRUG THERAPY
Pyrazinamide (Tebrazid)Used with INH and RifampinToxic to the liver Monitor liver function
DRUG THERAPY
Ethambutol (Myambutol)Toxic effect Early signs Baseline visual exam prior to therapySchedule periodic eye exams
DRUG THERAPY
StreptomycinAminoglycoside antibiotic2 drawbacks *must be given parenterally * has toxic effect on the kidneysMonitor u/o, weight, renal function studies Ototoxicity
NURSING INTERVENTIONS
1. Hospitalization2. Respirator masks used when entering the client’s
room3. Instruct client to cough into tissues & wear a mask
when leaving the hospital room4. Monitor the client’s respiratory status, breath
sounds, O2 saturation & document
NURSING INTERVENTIONS
5. Administer medications as ordered by MD 6. Encourage high-protein & high CHO foods7. Monitor laboratory results periodically -- (liver
function test)8. Educate the client about strict compliance with
medications9. Inform client about adverse effects of medications10. Encourage close follow-up