Pneumonia and Tuberculosis

Pneumonia & Tuberculosis

• Influenza affects both upper and lower respiratory systems
• Common types of influenza are A and B
• Influenza symptoms include headache, fever, chills, myalgia, cough, and sore throat lasting up to 7 days
• A complication of influenza is pneumonia
• Pneumonia is the inflammation of the lung parenchyma caused by various organisms
• Pneumonia involves fluid in the alveoli and excess fluid in the lungs affecting ventilation and diffusion
• Pneumonia can be an opportunistic infection
• Causes of pneumonia include infectious and non-infectious factors
• Types of pneumonia are lower (lobar) pneumonia and bronchopneumonia (in bronchioles), which is more common than lobar pneumonia
• Tuberculosis (TB) is an infectious disease primarily affecting the lung parenchyma, starting in the lungs
• TB can be asymptomatic
• TB skin tests are important for diagnosis
• N-95 masks should be worn to prevent spread
• Mycobacterium tuberculosis bacilli are the causative agent, Gram-positive and acid-fast
• TB spreads via airborne droplets
• TB primarily affects the lungs but can involve lymph, kidney, adrenal, bone/joint, meningeal, and peritoneal sites
• Primary TB infection is transmitted person-to-person through inhalation of infected, aerosolized sputum from coughing or sneezing
• Immunity usually develops within a few weeks after initial infection
• 90% with normal immune systems never develop clinical or radiologic evidence of TB
• If the immune system fails to control primary TB infection, necrosis and cavitation of lung tissue occurs, leading to severe destruction without treatment
• Reactivation of TB occurs if re-exposed, renewing dormant tubercle bacilli
• 60% of new TB infections may be caused by reactivation
• Risk factors for TB include low-grade fever, productive cough with possible hemoptysis, night sweats, weight loss without dieting, and fatigue
• TB is assessed and diagnosed using acid-fast bacillus smear, TB Gold, T-spot TB test, sputum culture, and chest X-ray to identify lung cavities
• TB skin tests also used in assessment

Influenza Patient Teaching

• The goal is to relieve symptoms and initiate early treatment with antiviral agents if present
• Antiviral agents should be administer within 48 hours; consult a doctor if past 48 hours
• Type A specific antiviral agents include oral Rimantadine (Flumadine) and Amantadine (Symmetrel)
• Antiviral agents for both Type A and B include oral Oseltamivir (Tamiflu), nasal or oral inhaled Zanamivir (Relenza), and oral or inhaled Ribavirin (Virazole)
• Annual flu vaccines are recommended, especially for high-risk groups
• Hand hygiene, covering coughs/sneezes, and avoiding close contact with sick individuals is important
• Adequate rest, hydration, and symptomatic treatment with OTC medications are recommended
• Medical attention should be sought if difficulty breathing, persistent fever, or worsening symptoms occur

Pneumonia Risk Factors, Patient Teaching, and Vulnerable Populations

• Risk factors for pneumonia include conditions producing mucus or bronchial obstruction that interfere with normal lung drainage, such as cancer, cigarette smoking, and chronic obstructive pulmonary disease
• Additional risk factors include smoking, prolonged immobility, shallow breathing patterns, and altered pulmonary defense mechanisms
• Elderly are more susceptible to severe illness, hypoxia, and confusion
• COPD, immunosuppression (e.g., organ transplant or chemo patients), heart disease, renal failure, and diabetes are risk factors
• Patients in supine positioning that cannot protect their airway may develop aspiration pneumonia via NG tube
• Antibiotic therapy in very ill people makes the oropharynx prone to colonization by gram-negative bacteria
• General anesthetics, sedatives, or opioid preparations can promote respiratory depression, leading to pooling of bronchial secretions and pneumonia
• Patient teaching includes taking medications on time, home care instructions, rest, 2-3L fluid intake to mobilize secretions, and completing antibiotics
• Patients should call provider if they experiencing shortness of breath, smoking cessation resources, getting flu vaccines, incentive spirometry, promote coughing, and repositioning to prevent aspiration is important
• Oral hygiene should be promoted, frequent checks of tube placement, elevate head of bed 30 degrees, and strict hand hygiene and gloves
• Vulnerable populations include the elderly (especially those in nursing homes or retirement communities), immunocompromised individuals, post-surgical patients, and people with lung disease
• Management of pneumonia in bacterial cases includes oxygen therapy and antibiotics
• Support includes elevating the head of the bed, teaching, fluids, and encouraging coughing
• Management of pneumonia in viral cases entail oxygen, antivirals, and support
• Bronchodilators, mucolytics, and increased fluid intake may be needed
• Preventative care includes pneumococcal vaccination

Pneumonia Signs & Symptoms in Older Adults

• Classic pneumonia symptoms in the elderly include confusion, fatigue, weakness, decreased appetite, anorexia, worsening of chronic conditions, and rapid respirations
• Other classic symptoms include acute onset fever, chills, cough (purulent or rust-colored sputum), pleuritic chest pain, discomfort when laying down, and bronchial breath sounds (crackles, rales) with possible pleural effusion
• Atypical presentation includes gradual onset symptoms, HA, sore throat, aches, fatigue, nausea, vomiting, diarrhea, dry cough, and rales, often seen in viral or mycoplasma pneumonia

Tuberculosis Risk Factors and Patient Teaching

• Risk factors include constant, frequent contact with infected individuals especially in crowded/impoverished/lower socioeconomic areas
• Additional include immunocompromised states, institutionalization, substance abuse, immigration, and healthcare work
• Patient education include avoiding sick people, adhering to prescribed medication regimens (long-term, expensive), practicing infection control, seeking treatment and follow-up, wear a mask
• TB medications last about 6 months

Tuberculosis Direct Observation Therapy & Preventative Therapy

• Direct observation therapy ensures patients take medications, addresses compliance challenges, and uses clinics, mobile centers, or health department
• Preventative measures include avoiding the flu and sick people, enforcing infection control, focusing on those in close quarters, masks and testing partners/spouses

Tuberculosis Skin Test

• A subdermal (intradermal) injection is given, watching for a reaction, feeling for a bump
• A reaction >5mm is positive for immunocompromised patients (HIV/transplant), those with recent contact with active TB, or with nodular/fibrotic changes on chest X-ray
• A reaction >10mm is positive for high-risk people (healthcare workers, recent immigrants, children 4 years old, IV drug users)
• A reaction >15mm is positive for low-risk people

Asthma & COPD

• Asthma is a chronic inflammatory disorder of the airway, managed to slow progression
• Asthma involves the body's response to irritants/allergies
• Asthma signs and symptoms include breathlessness, chest tightening, wheezing, dyspnea, cough, tachycardia, and pale/wet skin
• Asthma symptoms are caused by reversible airflow obstruction, inflammation and bronchoconstriction
• Asthma is caused by immune-mediated airway inflammation
• Physical assessment reveals dyspnea, wheezing, cough and gas exchange via arterial blood gases
• Pulmonary function tests (PFTs) measure airflow
• Chest x-ray CXR to evaluate underlying disorders, pneumonia/bronchitis (COPDs)
• CO2 levels initially decrease, then increase, causing drowsiness
• Lung function tests: Forced Expiratory Volume in 1 second (FEV1) measures air exhaled in 1 second
• Forced Vital Capacity (FVC) measures the largest amount of air after deep breath
• Peak Expiratory Flow (PEF) measures maximal exhale rate during exhalation

Exercise Induced Asthma

• Body adapts poorly to the environment during exercise
• Bronchospasm is secondary to loss of heat/water in lungs
• Starts during or after exercise, peaks in 5-10 mins, resolves in 20-30 mins
• Beta-2 agonists are inhaled before exercise
• Cromolyn inhaled 15 mins before exercise

Status Asthmaticus

• Labored breathing, prolonged exhalation, engorged neck veins, wheezing, accessory muscle use
• Goals: relieve airway obstruction, hypoxemia, normalize lung function
• Initial therapy: oxygen, nebulized high-dose SABA, nebulized ipratropium, systemic glucocorticoid (IV)
• Increasing PaCO2 levels indicate worsening condition

Chronic Obstructive Pulmonary Disease

• Preventable/treatable, slowly progressive respiratory disease of airflow obstruction
• Involves the airways/pulmonary parenchyma

Emphysema

• Alveoli do not stretch
• Results in loss of lung elasticity; hyperinflation of lungs

Chronic Bronchitis

• Chronic inflammation/mucus in bronchi/bronchioles; vasodilation; mucosal edema; congestion, bronchospasms.

Asthma Patient Teaching

• Goals: control symptoms, keep from getting worse
• Identify/avoid triggers (allergens, smoke, cold air), monitor peak flow, adhere to medications, SMOKE CESSATION
• Breathing exercises, regular exercise, realistic goals (strenghtens the lungs)
• Emergency management: asthma plan, what to do when sick, always have inhaler, teach use of inhalers
• Asthma and COPD teachings are similar
• Encase pillow, mattress, box spring in allergen-impermeable covers
• Wash bedding/stuffed animals weekly in hot water
• Remove carpeting from bedroom, avoid sleeping/lying on upholstered furniture, keep indoor humidity below 50%

Prevention of Exacerbation

• When symptoms start picking up! Avoid known triggers, vaccinations (flu, pneumonia), use inhalers correctly
• Short-acting (SABA): Bronchodilator FOR ASTHMA ATTACK
• Long-lasting beta-adrenergic agonist (LABA); cholinergic antagonist; corticosteroids; relieves bronchoconstriction
• Long-acting (LABA): corticosteroid; short-acting beta-adrenergic agonist (SABA); cholinergic antagonist; TO PREVENT THE ASTHMA ATTACK FROM HAPPENING
• Can be for more than just asthma (bronchodilator & inhaled LABA) anti-inflammatories; leukotriene antagonist

Patient Teaching for Respiratory Meds

• If taking glucocorticoid (steroid, decreases inflammation) & a bronchodilator (opens airways), always give the bronchodilator first
• To open up the lungs and so the corticosteroid can go in and do its job, everyday, preferably in the AM
• Inhaled (cause thrush/oral candidates); if prescribed, 2 puffs, then wait 1 minute, exhale; inhale slowly, hold breath, exhale; wash out mouth after glucocorticoid
• Uses spacer if needed; wash out mouth because of risk of fungus infection, yeast infection in mouth

COPD

• Destruction of the walls of the alveoli, worn out the alveoli and can't push oxygen back out (air gets trapped in lungs; hyperinflated lung); loss of lung therapy; hyperinflation of the lung

Bronchitis

• Inflammation creating excess mucus / blocks the airway; Vasodilation → mucosal edema → congestion/ bronchospasms; airway blocked and too narrow; diaphragm → trampoline, curved & bouncy; can't breathe
• Patient Teaching: Stop smoking & secondhand too!
• Breathing exercises (pursed-lip breathing, medication (similar to the asthma patient), oxygen therapy (don't smoke around your oxygen, tank has to be upright, portable oxygen)
• Avoid irritants, pulmonary rehabilitation (respiratory therapists will do exercises to secretions out of their lungs.); bronchodilator first, then steroid; teach patient how to use metered dose inhalers Causes
• Anxiety; self-care deficits (range of motions to prevent atrophy, occupational therapy)
• Lack of knowledge; imbalanced nutrition (high protein, multivitamin supplements); activity intolerance; impaired gas exchange (desired O2 sat 88-92%)
• Ineffective airway clearance: controlled coughing (move secretions around); physiotherapy; hydration (prevent infections in secretions)

Nursing Assessment Findings

• Tripoding, accessory muscles, pink puffers, wheezing in lungs, barrel chest (from hyperinflation), arms and legs thin, eating is difficult from using up all energy to breathe (trouble with nutrition), easily fatigued, frequent respiratory infections, cor pulmonale, thin in appearance, digital clubbing

COPD Complications

• Hypoxemia & acidosis; respiratory infections; right-sided heart failure; cardiac dysrhythmias

Elderly Patients

• Elderly patients with COPD and risk for pneumonia
• Mucus from inflammation; can have an infection (common), chest x-rays are important; increased risk due to decreased lung elasticity, impaired ciliary function, and poor mucus clearance

COPD Exacerbation - Nursing Interventions

• Breathing exercises, SABA, nebulizer mask, sit them up, tripod if needed, let them hug the pillow, (respiratory therapy), hydrate them (because they are at risk with pneumonia)

COPD Patient Teaching

• Includes preventing thrush when they take their inhaler
• Rinse mouth after corticosteroids and use spacer with MDIs as needed
• Post-procedure care following Bronchoscopy:

Bronchoscopy

• Visualization of the bronchioles (look for cancer, mucus plug): The purposes of diagnostic bronchoscopy are (1) to visualize tissues and determine the nature, location, and extent of the pathologic process; (2) to collect secretions for analysis and to obtain a tissue sample for diagnosis; (3) to determine whether a tumor can be resected surgically; and (4) to diagnose sources of hemoptysis
• How to take care of patient: Patient is NPO until cough reflex returns; make sure they have gag reflex back; after, offer ice chips & eventually fluids; assess for confusion & lethargy
• Monitory respiratory status; coughing is normal (blood sputum normal as long as it's not a lot) Fever & shortness of breath
• Fever and bloody sputum are expected in the first 24 hours and report bleeding & shortness of breath

Hematology and Anemias

• Liver produces prothrombin and blood clotting (platelets respond first, clotting factors take over)
• Spleen: white pulp; filled with WBC: major site for antibody production; Red pulp: sinuses store RBCs and platelets; Marginal Pulp: contains end of many arteries
• Anemias: decrease in RBCs; number, size, or hemoglobin content
• Causes of anemias: blood loss (trauma/critical care related); hemolysis (destruction of blood cells); bone marrow dysfunction; deficiency of substances essential for RBC formation and malnutrition

Red Blood Cell Formation

• Begins in the BONE MARROW; RBCs mature in the blood; healthy development requires: healthy bone marrow, erythropoietin (essential for blood to mature); iron; b12 and folate

Anemias - Types, causes, Nursing interventions, Patient education

• Symptoms of anemia: fatigue; faintness (passing out); pallor (pale); anorexia (loss of appetite); poor wound healing (poor circulation/ RBCs carrying oxygen); poor gas exchange (oxygen & hemoglobin); C/O cold; Pica (eating stuff that's not food); exhausted but cant sleep at night; can resemble other things.
• Iron deficiency: decreased production of RBC; iron stores depleted first, then hemoglobin stores; most common nutritional deficiency & cause of nutrition-related anemia; not enough intake of iron; more common in women
• Metabolic function of Iron
• Uptake & distribution: uptake into mucosal cells in small intestine; stored mucosal cells; binds to Transferrin (helps transfer)
• Utilization & storage: taken up by cells of the bone marrow; taken up by the liver and other tissues; taken up by muscle
• Causes: results from an imbalance in iron uptake and iron demand; pregnancy (blood volume expansion); infancy & childhood; chronic blood loss
• Consequences: microcytic (smaller), hypochromic (not enough) anemia
• Education & prevention:
• Nutrition: can both prevent & treat; assist in seelcting appropriate options (red meat, supplements, dark leafy veggies, potatos); refer dietary counseling if special consideration
• Medication: oral supplement (best on an empty stomach/ 2 hours after meal, because will slow down absorption if taken with food); parenteral supplement make sure to educate on importance of repeated doses that they have to keep coming back)
• Bone marrow aspiration (most accurate); blood tests

Vitamin B12 Deficiency

• Decreased production of RBCs; poor intake of foods containing B12; GI disorders
• CM: pallor, jaundice, glossitis; fatigue, weight loss, paresthesia (numbness & tingling of fingers and toes).

Folic acid deficiency

• Can't make new cells w/o folic acid
• Is essential factor for DNA synthesis; absorbed early in the segment of the small intestine; stored in body as Folate (keeps it in its storage container)
• Caused by: malnutrition; alcoholism (they're drinking instead of eating)
• Megaloblastic anemia
• Can increase risk for colorectal cancer & atherosclerosis
• Assessment: serum folate diagnostic (will pick up every folate is not reliable, is very sensitive; smooth glossy tongue (glossitis)
• Treatment: replacement is the key; choice of treatment is determined by cause
• Dietary teaching; medication oral & parenteral;
• Supplemental folic acid might become or are pregnant.
• Sickle Cell anemia: platelets deformed (look like boomerang), get stuck in places, banks up blood flow (no oxygen; have pain), manage pain (a lot of pain medicine), hydrate them (keeps blood flowing), oxygen, blood transfusion; can cause tissue hypoxia (bc of obstruction of blood flow & oxygen)

Sickle Cell Anemia Common Triggers

• Hypoxia; dehydration; infections; venous stasis; pregnancy; alcohol consumption; high altitudes; low temp; strenuous exercise; stress; anesthesia
• Care of pt in crisis: Treatment
• PAIN MANAGEMENT (higher doses of narcotic meds), hydration (to push cells through & dilute them), oxygen (helps with hypoxia), transfusion (replacing blood)
• Prevent infection
• DRUG THERAPY: morphine & hydromorphone (for pain, but watch for respiratory depression/respirations!); hydroxyurea (droxia); decreases sickling in body priority interventions, assessment findings
• CMS: PAIN!, CV changes (heart overworking to compensate); priapism (extended erection); skin changes (itchy, red/ inflammation); abdominal changes (nausea/vomiting, cramps, difficulty eating); kidney & urinary changes; musculoskeletal changes (lack of o2 to muscles causes weakness & atrophy); CNS changes (numbness/tingling, nerve pain, confused) ● Neutropenia
• Lack of WBC's (neutrophils= fight off infection/ first line of defense, get sick more often since not enough WBCs to fight off infection); usually caused by medications; cancer; bacterial infection; immunologic disorder (will suppress neutrophil count)
• 2000 mm3; protection gone; common cold could kill you
• Keep patients isolated, wear mask, wash hands isolated from large crowds to prevent infection (steamed food over raw salads bc it can be contaminated), be careful if injured since your body can't heal properly; reverse contact precautions.
• Risk factors: chemo; elderly; HIV; immunosuppressant

Anemia Nursing Intervention and Patient Teaching

• If hemoglobin and hematocrit is too low, give transfusion; give meds as ordered to reverse it; try to reverse the problem; replace it; teach to take meds; take iron on empty stomach
• Blood transfusions- management of reactions, procedure for administration of:

Blood Transfusions

• 30 minutes from blood bank to patient (make sure have IV ready and check functionality!!)
• do it with another RN there needs to be 2 nurses!
• patient identification,
• use filter tubing from the blood bank, hang with patient for 15 minutes (don't leave alone)
• check vitals (making sure they're not having a reaction, fluid overload, allergic reaction, blood not matching.)
• 4 hours to run the transfusion Homologous transfusions- somebody's blood

Transfusions

• Autologous transfusion- self transfusion
• Packed RBCs- 2 to 4 hours; 200 to 250ml
• O(-)- universal donor
• TRANSFUSION- Febrile non hemolytic transfusion reaction
• TRANSFUSION nursing actions

1. Stop the transfusion 2)Initiate sodium chloride with IV tubing
2. Save the blood bag and tubing with remaining blood

Oncology

• Cancer Screening Education:
  • Mammogram: annually for women over 40
  • clinical breast exam- annually for women over 40 every 12 years for women 20 to 39 years
  • Fetal occult blood stool: Recommended annually for adults 45-75
  • Digitial rectal exam- adults 50 to 70 gene testing history for breast cancer, colon cancer
  • HPV: Varisil vaccine from 10-25 years old for cervical cancer

Chemotherapy

• Patient Teaching,Complications, Management Of Side Effects:
  • Chemotherapy is a cancer drug that kills off cell by killing mutated cells Normal cell mostly affected are-
  • Skin Hair Tissues spermatocytes, blood forming cell

PATIENT Teaching

• Complications
• Eat bland food that doesnt irritate the gil tract
• Medicate with anti-nausea medication Complications: Skin breakdown if it gets into the tissue
• Anemia Neutropenia thrombocytopenia alopecia, hair loss, nausea in the gil tract
• Management: Private room, sanitation, dont reuse itemsLimit healthcare providers coming in and change dressings

Overview of influenza, pneumonia, and tuberculosis. Discusses the symptoms, causes, and prevention of pneumonia. Covers types of pneumonia along with tuberculosis (TB) including symptoms, diagnosis, and prevention.