Pneumonia Overview and Clinical Manifestations

Pneumonia

• Inflammation of the lung parenchyma caused by microorganisms
• Upper respiratory tract has decreased defenses, allowing infectious agents to enter the sterile lower respiratory tract
• Inflammatory reaction in the alveoli produces exudate that interferes with gas exchange
• White blood cells migrate to the alveoli, filling the normal air spaces
• Classified by origin: community-acquired, health care-associated, hospital-acquired, ventilator-associated
• Can also occur in immunocompromised clients and from aspiration
• Hospital-acquired pneumonia risk factors include: severe acute or chronic illness, contaminated respiratory tract devices or equipment, hands of healthcare personnel, therapeutic agents that depress the CNS, intubation, NG tubes.

Clinical Manifestations

• Pleuritic chest pain
• Confusion or changes in level of consciousness
• Cough
• Fatigue
• Fever
• Nausea/vomiting
• Shortness of breath
• Specific considerations for older adults include: changes in mental status, fatigue, dehydration, lower body temperature, and concomitant heart failure

Medical Treatment

• Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, and antihistamines
• Antibiotic therapy guided by Gram stain results
• Empiric antibiotic therapy used if etiologic agent is not identified
• Antibiotics are not indicated for viral infections but are used for secondary bacterial infection

Nursing Process: Assessment

• Changes in temperature and pulse
• Amount, odor, and color of secretions
• Frequency and severity of cough
• Degree of tachypnea or shortness of breath
• Changes in physical assessment, especially inspection and auscultation of the chest
• Changes in chest X-ray
• Changes in mental status, fatigue, dehydration, and concomitant heart failure, especially in older adults

Nursing Process: Diagnosis

• Airway clearance
• Activity intolerance
• Fluid and electrolyte imbalance
• Nutrition
• Knowledge deficit

Nursing Process: Planning

• Improving airway patency:
  • Removing secretions: encourage hydration, humidification, coughing techniques, chest physiotherapy, position changes, oxygen therapy
• Promoting fluid intake:
  • Encourage fluid intake to at least 2 L/day
• Maintaining nutrition:
  • Provide nutritionally enriched foods and fluids
• Promoting patient knowledge:
  • Educate on disease process, treatment regimen, and preventive measures
• Monitoring and managing complications:
  • Potential complications include continuing symptoms after initiation of therapy, sepsis and septic shock, respiratory failure, atelectasis, pleural effusion, delirium

Pulmonary Tuberculosis

• Infectious disease primarily affecting the lung parenchyma
• Caused by Mycobacterium tuberculosis
• Worldwide public health problem with rising mortality and morbidity rates
• Transmitted through droplet nuclei expelled by infected individuals when coughing, sneezing, talking, laughing, or singing.
• Not everyone exposed to TB becomes infected, and not everyone infected develops active TB disease
• Latent TB infection is the asymptomatic state, with 10% progressing to active TB disease

Symptoms in Active Pulmonary TB

• Low-grade fever
• Cough (non-productive, mucopurulent, or hemoptysis)
• Night sweats
• Fatigue
• Weight loss

Gerontological Considerations for TB

• Atypical clinical manifestations may be present
• Unusual behavior and altered mental status
• Fever
• Anorexia and weight loss
• No reaction or delayed reaction on TB skin test

Assessment and Diagnostic Findings

• Complete history and physical
• Chest X-ray
• TB skin test (read 48-72 hours after injection)
  • Induration greater than 5 mm significant in those at risk
  • Induration greater than 10 mm significant in normal or mildly impaired immunity
• Sputum smears for acid-fast bacilli
• Sputum culture and sensitivity

Medical Management

• Treatment with chemotherapeutic agents (antituberculosis agents) for 6 to 12 months
• Prolonged treatment duration is necessary to eradicate organisms and prevent relapse
• Resistance to TB medications is a global concern and challenge
• First-line medications include: INH, rifampin, pyrazinamide, and ethambutol

Nursing Process: Assessment for Tuberculosis

• Diagnoses:
  • Airway clearance related to copious tracheobronchial secretions
  • Ineffective individual management of the therapeutic regimen (noncompliance) related to knowledge deficit
  • Activity intolerance related to fatigue, altered nutritional status, and fever

Nursing Process: Interventions for Tuberculosis

• Promoting airway clearance:
  • Encourage hydration, coughing techniques, chest physiotherapy, and position changes
• Advocating adherence to treatment regimen - DOT (directly observed therapy):
  • Ensure clients take medications as prescribed to prevent transmission and drug resistance
• Managing side effects:
  • Monitor and manage adverse side effects (hepatitis, neurologic changes, rash, GI upset)
• Preventing transmission:
  • Implement infection control measures (isolation, proper mask use, hand hygiene)

Discharge Planning for Tuberculosis

• Patient education on:
  • Disease process
  • Treatment regimen
  • Importance of adherence
  • Side effects of medications
  • Preventive measures to avoid transmission (hand hygiene, covering cough)
  • Follow-up appointments and monitoring