The Concept of Infection Pneumonia and Tuberculosis Lecture Updated PDF

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

THE CONCEPT OF INFECTION: PNEUMONIA NR 1250/1610 Victoria Leonetti, 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) What happens when pneumonia occurs? Inflammatory response and Immune response Alveolar capillaries dilate Fluid accumulation in alveoli Fluid leaks into interstitial tissues INFILTRATES and the consolidation 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. A nurse is caring for a patient diagnosed with bacterial pneumonia. The patient asks about the difference between bacterial pneumonia and aspiration pneumonia. Which of the following statements by the nurse is most accurate? A) "Bacterial pneumonia is caused by inhaling bacteria, while aspiration pneumonia is caused by inhaling food, liquids, or vomit into the lungs." B) "Aspiration pneumonia is more severe than bacterial pneumonia because it always leads to abscess formation." C) "Both bacterial pneumonia and aspiration pneumonia require the same treatment, including broad-spectrum antibiotics." A nurse is caring for a patient diagnosed with bacterial pneumonia. The patient asks about the difference between bacterial pneumonia and aspiration pneumonia. Which of the following statements by the nurse is most accurate? A) "Bacterial pneumonia is caused by inhaling bacteria, while aspiration pneumonia is caused by inhaling food, liquids, or vomit into the lungs." B) "Aspiration pneumonia is more severe than bacterial pneumonia because it always leads to abscess formation." C) "Both bacterial pneumonia and aspiration pneumonia require the same treatment, including broad-spectrum antibiotics." 25-50% mortality due to sepsis in which classification of pneumonia? A. Community Acquired (CAP) B. Healthcare-associated (HCAP) C. Hospital acquired (HAP) D. Ventilator associated (VAP) E. Opportunistic 25-50% mortality due to sepsis in which classification of pneumonia? A. Community Acquired (CAP) B. Healthcare-associated (HCAP) C. Hospital acquired (HAP) D. Ventilator associated (VAP) E. Opportunistic  Pathophysiology and Etiology Community Acquired (CAP) Healthcare-associated (HCAP) Long-term care facilities Rehab 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 Which of the following patients is at the highest risk for developing community-acquired pneumonia? A) A 50-year-old male with a history of hypertension B) A 30-year-old female who smokes one pack of cigarettes daily C) A 40-year-old male who exercises regularly D) A 25-year-old female who works in a high-rise office building Which of the following patients is at the highest risk for developing community-acquired pneumonia? A) A 50-year-old male with a history of hypertension B) A 30-year-old female who smokes one pack of cigarettes daily C) A 40-year-old male who exercises regularly D) A 25-year-old female who works in a high-rise office building A nurse is educating a group of nursing students about the most common causes of community-acquired pneumonia (CAP) in adults. Which of the following organisms should the nurse identify as the most frequent causative agent? A) Staphylococcus aureus B) Streptococcus pneumoniae C) Legionella pneumophila D) Haemophilus influenzae A nurse is educating a group of nursing students about the most common causes of community-acquired pneumonia (CAP) in adults. Which of the following organisms should the nurse identify as the most frequent causative agent? A) Staphylococcus aureus B) Streptococcus pneumoniae C) Legionella pneumophila D) Haemophilus influenzae A nurse is teaching a group of nursing students about atypical pneumonia. Which of the following organisms is most commonly associated with atypical pneumonia? A) Streptococcus pneumoniae B) Mycoplasma pneumoniae C) Haemophilus influenzae D) Staphylococcus aureus A nurse is teaching a group of nursing students about atypical pneumonia. Which of the following organisms is most commonly associated with atypical pneumonia? A) Streptococcus pneumoniae B) Mycoplasma pneumoniae C) Haemophilus influenzae D) Staphylococcus aureus An emergency department patient who is a resident of a long-term care facility is diagnosed with pneumonia. How is this pneumonia classified? A. Community acquired B. Hospital acquired C. Healthcare associated D. Ventilator associated An emergency department patient who is a resident of a long-term care facility is diagnosed with pneumonia. How is this pneumonia classified? A. Community acquired B. Hospital acquired C. Healthcare associated D. Ventilator associated  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 infection effect 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  MUST KNOW 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  Clinical Manifestations Bacteremia can spread infection to other tissues Can lead to: Meningitis Endocarditis Peritonitis Increased risk of mortality Entry into the bloodstream Septicemia septic shock A nurse is educating a group of elderly patients about the risk factors for pneumonia. Which of the following statements indicates a correct understanding of the risk factors for pneumonia? A) "As long as I don't smoke, I won't get pneumonia." B) "I am at higher risk for pneumonia because of my age and chronic lung disease." C) "Only people with weakened immune systems need to worry about pneumonia." D) "Getting vaccinated against the flu doesn't affect my risk for pneumonia." A nurse is educating a group of elderly patients about the risk factors for pneumonia. Which of the following statements indicates a correct understanding of the risk factors for pneumonia? A) "As long as I don't smoke, I won't get pneumonia." B) "I am at higher risk for pneumonia because of my age and chronic lung disease." C) "Only people with weakened immune systems need to worry about pneumonia." D) "Getting vaccinated against the flu doesn't affect my risk for pneumonia." A nurse is assessing a patient who is suspected of having pneumonia. Which of the following clinical manifestations would the nurse expect to find? A) Bradycardia and clear lung sounds B) Sudden onset of high fever, chills, and productive cough with purulent sputum C) Gradual onset of fatigue, headache, and non-productive cough D) Abdominal pain and jaundice A nurse is assessing a patient who is suspected of having pneumonia. Which of the following clinical manifestations would the nurse expect to find? A) Bradycardia and clear lung sounds B) Sudden onset of high fever, chills, and productive cough with purulent sputum C) Gradual onset of fatigue, headache, and non-productive cough D) Abdominal pain and jaundice  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: Chest Xray NORMAL PNEUMONIA  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 are written by the 92%. provider. Place the Encourage the patient to perform actions in the incentive spirometry. correct order of Administer acetaminophen for a priority. fever of 102°F (39°C).  Apply oxygen to maintain SpO₂ > The nurse is caring 92%. for a patient with Collect a sputum sample for pneumonia. The culture. following orders are written by the Administer IV antibiotics. provider. Place the Administer acetaminophen for a actions in the fever of 102°F (39°C). correct order of Encourage the patient to perform priority. incentive spirometry. The Concept of NR 1250/1610 Infection: Victoria Leonetti, MSN, RN Nursing Care of the Patient with Tuberculosis Course Student Learning Outcomes 01 02 03 04 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: Chain of Infection 1. Etiologic Agent – Mycobacterium tuberculosis 2. Reservoir – Human 3. Portal of Exit – Aerosolization 4. Mode of Transportation – Cough, sneeze 5. Portal of Entry – Inhalation 6. Susceptible Host – Human  Chronic infectious disease Recurrent Caused by mycobacterium Tuberculosis- tuberculosis Slender, rod-shaped organism- bacilli Waxy outer capsule resists destruction overview, Slow growing pathophysiolo 2-12 weeks to illicit an immune response Acid-fast bacilli (AFB) gy & etiology Primary site for infection- lungs (can “seed” into other organs) REPORTABLE DISEASE! Public health concern Epidemiology- Active Tuberculosis Cases in Ohio: 2022 Not very common! Lake = 0 cases Cuyahoga = 27 cases Summit = 5 cases Geagua = 0 Cases Ashtabula = 1 Cases Ohio 2019 Cases = 150 Pathophysiology & Etiology  Caused by Mycobacterium tuberculosis  Aerosolization of the bacilli enters the lung, implants into an alveolus or respiratory bronchiole, multiples and initiates an inflammatory response.  Phagocytic cells (neutrophils and macrophages) engulf the bacteria, isolating, preventing the spread.  A granulomatous lesion is called a tubercle is formed.  After 2-12 weeks, a cellular immune response can be elicited with a TB skin test.  If you have an adequate immune response, scar tissue will form around the tubercle and bacteria will remain enclosed.  Dormant (Latent) TB Bacteria temporarily inactive, but not dead Pathophysiolog Individual infected, but not sick and no y & Etiology symptoms If you have an inadequate immune response, the tubercle may rupture and spread the bacteria.  Active TB Unable to encapsulate the tubercle Infectious Severe disease—erosion/cavitation of lung tissue  W ! Active TB N O Exposed & Infectious O K Shows clinical manifestations D T Unable to encapsule the tubercle E NE Dormant (Latent) TB Classificatio Exposed & noninfectious No clinical manifestations ns Strong Immune system Reactivation TB You have latent TB but becomes active later in life due to weaken immune system Due to age, disease (HIV, immunosuppressive diseases), or use of immunosuppressive drugs  An older adult client experiencing a cough, hemoptysis, night sweats, anorexia, and weakness reports being told of having TB when younger. Which reason should the nurse suspect is responsible for the client’s current symptoms? A. Skeletal tuberculosis B. Reactivation tuberculosis C. New-onset tuberculosis D. Dormant tuberculosis  An older adult client experiencing a cough, hemoptysis, night sweats, anorexia, and weakness reports being told of having TB when younger. Which reason should the nurse suspect is responsible for the client’s current symptoms? A. Skeletal tuberculosis B. Reactivation tuberculosis C. New-onset tuberculosis D. Dormant tuberculosis  Immigrants, foreign-born (in the U.S.) HIV/AIDS Individuals with altered immune function Risk Factors Homelessness, homeless shelters Prison, detention facilities Overcrowded institutions, poor living conditions Poverty (no access to healthcare, poor sanitation) The nurse suspects that a client is at risk for tuberculosis. Which risk factor should the nurse assess in this client? Select all that apply. A. Being an immigrant to the United States B. Sharing clothes with an infected individual C. Having a compromised immune system D. Using injection drugs E. Living in a poorly ventilated environment The nurse suspects that a client is at risk for tuberculosis. Which risk factor should the nurse assess in this client? Select all that apply. A. Being an immigrant to the United States B. Sharing clothes with an infected individual C. Having a compromised immune system D. Using injection drugs E. Living in a poorly ventilated environment A nurse is assessing a patient for risk factors related to tuberculosis (TB). Which of the following factors is the greatest risk for developing active TB?  A) History of asthma B) Recent travel to a country with high TB incidence C) Family history of diabetes D) Occupation as a school teacher A nurse is assessing a patient for risk factors related to tuberculosis (TB). Which of the following factors is the greatest risk for developing active TB?  A) History of asthma B) Recent travel to a country with high TB incidence C) Family history of diabetes D) Occupation as a school teacher  MUST KNOW Asymptomatic in early stages, initial infection Fever (typically low grade) Night sweats Clinical Dry cough, progressing to hemoptysis (blood- Manifestation tinged sputum) Weight loss s Fatigue Cough, pleuritic chest pain Dyspnea (shortness of breath) Prevention and Diagnostic Tests  PPD Skin Test, TST, Mantoux test  Intradermal- read 48-72 hours  Measure INDURATION  >15mm is positive in ALL people  Redness NOT indicative of positive test A nurse is evaluating A. Redness measuring the results of a 16 mm tuberculin skin test (TST) 48 hours after it B. Induration was administered. Which of the following measuring 16 mm findings would indicate a positive test result in C. Induration a healthy adult with no measuring 5 mm known risk factors for tuberculosis? D. Redness and induration measuring 3 mm A nurse is evaluating A. Redness measuring the results of a 16 mm tuberculin skin test (TST) 48 hours after it B. Induration was administered. Which of the following measuring 16 mm findings would indicate a positive test result in C. Induration a healthy adult with no measuring 5 mm known risk factors for tuberculosis? D. Redness and induration measuring 3 mm  A positive TB test does not indicate active disease Prevention Sputum and chest x-rays are routinely used and Diagnostic Special procedures and PPE should be used when obtaining Tests sputum specimen Occasionally, endotracheal suctioning, bronchoscopy, or gastric lavage is necessary to obtain a specimen  O W T KN U S Sputum smear AFB M positive (active TB) Prevention Rapid indicator of the tubercle bacillus and At least 3 specimens needed, Diagnostic 8-24 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) A client has a 6-mm area that is slightly red and soft to the touch at the site of a PPD (Mantoux) test. Which finding should the nurse document for this client? A. Positive response B. Indeterminate response C. Positive response if the client had an abnormal chest x-ray D. Negative response A client has a 6-mm area that is slightly red and soft to the touch at the site of a PPD (Mantoux) test. Which finding should the nurse document for this client? A. Positive response B. Indeterminate response C. Positive response if the client had an abnormal chest x-ray D. Negative response 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 **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 and pyrazinamide 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) Helps with adherence Used for noncompliant patients Example: Active TB (ODH.OHIO.GOV) 1st month- rifampin, isoniazid,  If underlying HIV ethambutol and pyrazinamide  7th month- rifampin, isoniazid 2nd month- rifampin, isoniazid,  8th month- rifampin, isoniazid ethambutol and pyrazinamide  9th month- rifampin, isoniazid 3rd month- rifampin, isoniazid 4th month- rifampin, isoniazid 5th month- rifampin, isoniazid 6th month- rifampin, isoniazid Collaboration: Pharmacologic Therapy LATENT TB  Isoniazid—for 6-9 months  You do not have TB disease and cannot spread TB to others.  This medicine will help you PREVENT getting TB disease.  Rifampin for 4 months if indicated  Monitoring/surveillance for manifestations  Must know Clinical improvement has been Collaboration: demonstrated TB No Longer Considered On medications for at least 2 weeks Infectious When: Three (3) consecutive AFB smears are negative 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