The Concept of Infection: Pneumonia and Tuberculosis PDF

THE CONCEPT OF INFECTION: PNEUMONIA NR 1250/1610 Victoria Leonetti, MSN, RN Emily Raddell, MSN, RN  Course Student Learning Outcomes 1 2 3 4 Provide safe, Demonstrate Relate the impact Explain pa...

THE CONCEPT OF INFECTION: PNEUMONIA NR 1250/1610 Victoria Leonetti, MSN, RN Emily Raddell, MSN, RN  Course Student Learning Outcomes 1 2 3 4 Provide safe, Demonstrate Relate the impact Explain patient-centered, intermediate of quality management of evidence-based levels of critical improvement care concepts for nursing care thinking & clinical measures to adult patients guided by the reasoning to improved patient Caritas provide quality care philosophy patient care The Concept of Infection: The Chain of Infection  Overview and Pathophysiology Inflammation of the lung parenchyma (the respiratory bronchioles and alveoli) as a result of infection. What types of pathogens can invade the lungs and cause pneumonia? Answer: bacteria, viruses, fungi, protozoa What pathogen causes roughly 50% of pneumonia cases? Answer: streptococcus pneumoniae Disorders can affect the lower respiratory system: Affect ability to ventilate Affect respiration Affect ability to maintain airways Pathophysiology and Etiology What happens when pneumonia occurs? Organisms enter the lungs: Inhaled Through bloodstream from infection elsewhere Aspiration Organisms colonize alveoli Initiate inflammatory, immune response Inflammation, vascular congestion, edema Infectious debris, exudate fill alveoli -Fluid accumulation -Fluid leakage -INFILTRATES (substance denser than air- fluid, pus) -Consolidation (solidification of lung tissue)  Infectious Bacteria, viruses, fungi, protozoa Noninfectious Pathophysiolo Aspiration of gastric contents Inhalation of toxic or irritating gases gy and Bacterial pathogens Etiology Usually in one or more lobes of single lung Viruses Bronchopneumonia Typically a mild disease pattern Aspiration Chemical injury- lower pH material of GI tract can cause a severe inflammatory response  Pathophysiology and Etiology – Bacterial Bacterial pathogens will circulate around in the bloodstream leading to the lungs, where they damage cells. Those damage cells will cause cellular debris and mucus which can cause airway obstruction. Usually in one or more lobes of single lung, a pattern termed unilateral lobar pneumonia.  Pathophysiology and Etiology – Viral Viruses frequently enter through the upper respiratory tract. Infiltrating the alveoli nearest the bronchi of one or both lungs. They invade the cells, replicate, and burst out forcefully, killing the cells and sending out debris. They rapidly invade adjacent areas, distributing themselves in a scattered patchy pattern referred to as bronchopneumonia. Typically, a mild disease pattern Pathophysiology and Etiology – Aspiration Aspiration of food, emesis, gastric reflux, or hydrocarbons causes a chemical injury and an inflammatory response. Materials with a lower pH causes more inflammation, which sets the stage for bacterial invasion. Pathophysiology and Etiology Community Acquired (CAP) Healthcare-associated (HCAP) Hospital acquired (HAP) Ventilator associated (VAP) Opportunistic Primarily in immunocompromised patients (AIDS) Immunosuppressive or cytotoxic drugs for cancer  Etiology- Community Acquired Pneumonia Acute bacterial Spread via Complications pneumonia Pneumococcal Individual to Pleuritis pneumonia individual via droplets Pleural effusion (streptococcus Aspiration of resident Lung abscess pneumoniae) bacteria Empyema Causes about 50% of community acquired pneumonia leading to hospital admission Resides in the upper respiratory tract of up to 70% of adults  Etiology- Primary Atypical Pneumonia Patchy inflammatory Mycoplasma changes in alveolar Typically, mild disease Highly contagious pneumoniae septum, interstitial course tissue of lung Presentation, course Exudate and Outbreaks in Oftentimes referred differ from other consolidation of lung crowded settings to as “walking bacterial tissue not found Young adults- college pneumonia” pneumonias students and military recruits Resembles viral pneumonia  Etiology- Viral Pneumonia Typically, a mild Lung involvement Common disease that often is limited to the Occurs in organisms are affects older alveolar septum community influenza and adults, people and interstitial epidemics adenovirus with chronic spaces conditions May present with Headache, fever, Sudden or flu-like symptoms fatigue, malaise, gradual onset and dry cough muscle aches  Etiology- Opportunistic Pneumonia May present with abrupt onset, with SIGNIFICANT Pneumocystis jiroveci Patchy involvement fever, tachypnea, At risk: RESPIRATORY pneumonia throughout lungs shortness of breath, DISTRESS and dry nonproductive Caused by a common People with AIDS Causes alveoli to cough. parasite/fungi found Those with significant thicken and become worldwide called immunocompromise edematous Pneumocystis jiroveci Alveoli fill with foamy Immunity is usually and protein-rich fluid universal, except in Gas exchange is those severely impaired immunocompromised  Aspiration pneumonia Aspiration of gastric contents Chemical and bacterial pneumonia Etiology- Risk Factors Aspiration Emergency surgery or obstetrical procedures Depressed cough and gag reflex Pneumonia Impaired swallowing Low pH of gastric contents severe inflammatory response Pulmonary edema, and respiratory failure may occur Common complications Abscesses Bronchiectasis (chronic dilation of bronchi and bronchioles) Gangrene of pulmonary tissues  Risk Factors Altered immunity, Frequent Alcohol or drug Altered level of Age compromised exposure to use consciousness immune system cigarette smoke Infants, young HIV/AIDS, cancer Smoking injures Alcohol Why? children, older patients, organ in airway tissue interferes with adults transplants can decreases macrophage cilia action action Hyperplasia of Injection drug bronchial use- increased epithelium cells risk of The chemical in bloodstream cigarettes have spread of a numbing effect infection on the cough reflex Increased production of mucus  Prevention Identify vulnerable populations Instituting preventative strategies and measures to reduce the mortality and morbidity associated with the condition. Early identification of infecting organism -Why? VACCINES Pneumococcal vaccine single dose gives lifetime immunity One-time revaccination Immunosuppressed individuals Adults >65 years old who were immunized >5 years previously and before the age of 65  Clinical Manifestations Productive cough, purulent sputum Dyspnea, crackles Fever & chills Excessive mucous in lungs production Hemoptysis (coughing up blood) Chest pain Headache, fatigue, (pleuritic) sharp, Confusion muscle pains, localized diminished appetite  Bacteremia can spread infection to other tissues Can lead to: Meningitis Clinical Endocarditis Manifestations Peritonitis Increased risk of mortality Entry into the bloodstream Septicemia septic shock  Diagnostic Tests Complete blood Computed Sputum gram Sputum culture count (CBC) Chest x-ray tomography (CT stain and sensitivity with WBC scan) differential Determine Used when Gram positive Secretion Look for “left extent, chest x-ray or gram must be from shift”- pattern of lung not diagnostic negative? lower increased involvement Can provide a Antibiotic respiratory circulating Fluid, more detailed therapy tract! immature infiltrates, image of directed to leukocytes consolidated pulmonary that organism lung tissue tissue Atelectasis can be seen (areas of alveolar collapse)  Diagnostic Tests Arterial Blood Gas Pulse oximetry Bronchoscopy Procalcitonin levels (ABG) May indicate Evaluate gas May be done to Serum biomarker impaired alveolar exchange obtain sputum Helps distinguish gas exchange Arterial partial specimen bacterial infection pressure of oxygen Remove secretions from other causes of (Pa02) of less than from the bronchial infection or 75-80 mmHg tree inflammation indicates impaired Helps guide gas exchange or antibiotic therapy in alveolar ventilation treating pneumonia 15mm is positive in ALL people  Redness NOT indicative of positive test Prevention and Diagnostic Tests  A positive TB test does not indicate active disease  Sputum and chest x-rays are routinely used  Special procedures and PPE should be used when obtaining sputum specimen  Occasionally, endotracheal suctioning, bronchoscopy, or gastric lavage is necessary to obtain a specimen  Sputum smear AFB positive (active TB) Prevention Rapid indicator of the tubercle bacillus and At least 3 specimens needed, 8-24 Diagnostic hours apart One sputum Sputum Culture should be an early Tests morning specimen confirmatory diagnosis of infection with M. tuberculosis Time consuming: 4-8 weeks for detection (slow growing) Collaboration: Diagnostic Tests  Chest X-Ray  Dense lesions (apical, upper lobe), cavity formation  Interferon-gamma release assays (IGRA)  “QuantiFERON-TB test” or “T-Spot test”  Can be used on those who have received the tuberculosis vaccine  Used for those unable to return to have TST read  Nucleic Acid Amplification (NAA)  Amplifies DNA/RNA segments to rapidly identify the microorganisms in a specimen  Can detect M. tuberculosis in hours **CULTURE remains GOLD STANDARD for laboratory confirmation of tuberculosis**  Provide Spread patient and through the family air- person Collaboratio education to person TB n: transmission Airborne reduced by isolation- direct “negative sunlight/ pressure”; Prevention & ultraviolet HEPA filter light Place mask Precautions on patient if N95 masks leaving room Keep patient door closed Collaboration: Pharmacologic Therapy  Antibiotics are used to prevent and treat tuberculosis infection  Goals of the pharmacologic treatment of tuberculosis are the following: 1. To make the disease noncommunicable to others 2. To reduce symptoms of the disease 3. To effect a cure in the shortest possible time  Collaboration: Pharmacologic Therapy Isoniazid Rifampin Ethambutol Pyrazinamide A first-line drug for Inhibits RNA Bacteriostatic drug Inferences with treating ACTIVE syntheses which that reduces the bacteria's ability to TB. prevents bacteria development of synthesis fatty Helps eradicate from forming resistance to the acids dormant Used in bactericidal fist- Can causes tuberculosis bacilli combination with line agent. hepatotoxicity Can causes isoniazid due to Inhibits RNA peripheral resists develops syntheses neuropathy rapidly Can causes optic (Vitamin B-6 & Can causes body neuritis pyridoxine can fluids to turn red help) (sweat, urine, saliva, tears) Collaboration: Pharmacologic Therapy ACTIVE TB First 2 months: rifampin, isoniazid, ethambutol, pyrazinamide, rifabutin, and rifapentine After 2 months for at least additional 4-6 months: rifampin and isoniazid Longer for patients with underlying HIV, usually 9 months Increase compliance: Rifatar: combination drug (rifampin, isoniazid & pyrazinamide) Directly Observed Therapy (DOT) Collaboration: Pharmacologic Therapy LATENT TB  Isoniazid—for 6-9 months  Rifampin for 4 months if indicated  Monitoring/surveillance for manifestations  Clinical improvement has Collaboratio been demonstrated n: TB No Longer On medications for at Considered least 2 weeks Infectious When: Three (3) consecutive AFB smears are negative  Ineffective breathing pattern Ineffective airway Common TB clearance nursing Activity intolerance, fatigue Diagnoses Imbalanced nutrition, less than body requirements Ineffective health maintenance, noncompliance Resources  CDC website  https://www.cdc.gov/tb/ (This a very good, comprehensive overview of the disease process and treatment protocols)  Ohio Department of Health website