Transcript OXGENATION DEFICITS

LOWER RESPIRATORY
PROBLEMS
Acute Bronchitis
Pneumonia
Tuberculosis
Copyright 2/4/2013
Michelle Gardner
ACUTE BRONCHITIS
Inflammation of the
bronchi in the lower
respiratory tract.
Usually occurs with
upper respiratory
tract infection
ACUTE BRONCHITIS
Etiology
May be viral /bacterial infection
At risk -- those with impaired immune
defenses/cigarette smoking
Marked seasonal incidences
ACUTE BRONCHITIS
Clinical Manifestations
Persistent cough
Mildly elevated T, RR, HR
Breath sounds
Diagnostic Assessment
History/Physical
CXR – differentiate acute bronchitis/pneumonia
ACUTE BRONCHITIS
Collaborative Management

a.
b.
c.
d.
Treatment is generally supportive
Fluids
Rest
Anti-inflammatory agents
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 agent
a. Bacterial
b. Viral
c. Fungal
PNEUMONIA
Incidence/Prevalence
 US – 4 million cases of pneumonia
 8th leading cause of death
 Highest incidence in older adults and people with
debilitating illness
1. Nursing home residents
2. Those mechanically vented
PNEUMONIA
PNEUMONIA
RISK FACTORS
1.
2.
3.
4.
5.
6.
Older Adult
Bed rest/prolonged immobility
Debilitating illness
Human immunodeficiency virus (HIV)
Intestinal / gastric feedings
Malnutrition
PNEUMONIA
CLASSIFICATION
1. Community –Acquired Pneumonia (CAP)
2. Hospital –Acquired Pneumonia (HAP)
3. Aspiration Pneumonia
4. Opportunistic Pneumonia
COMMUNITY-ACQUIRED
PNEUMONIA
1. Onset occurs in the community /first 2 days of
hospitalization
2. Incidence
3. Smoking, alcoholism, immunosuppressive disease
4. Age > 65 years, multiple medical co-morbidities
5. Causative organism identified only 50% of the time
HOSPITAL ACQUIRED PNEUMONIA
1. Occurs 48 hrs. or longer after admission
2. 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 Vancomycin
Highly 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 feedings
4. 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 deficiencies
2. severe protein calorie malnutrition
3. clients who have received organ transplants
4. clients treated with chemotherapy, radiation
therapy
OPPORTUNISTIC PNEUMONIA
Clinical Manifestations
Insidious
Tachycardia
Fever
Non-productive cough
Tachypnea
Dyspnea
Treatment
Bactrim – primary agent
BACTERIAL PNEUMONIA
Clinical Manifestations
1. Fever
2. Shaking chills
3. Productive cough
4. Pleuritic chest pain
5. Crackles on auscultation
6. Altered mental status
VIRAL PNEUMONIA
Clinical Manifestations
1. Fever
2. Dry non-productive cough
3. Chills
4. Malaise
DIAGNOSTIC STUDIES
1. History/physical
2. Chest x-ray
3. 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 CARE
1.
2.
3.
4.
5.
Antibiotic therapy –Macrolides recommended
a. Zithromax (azithromycin)
b. Biaxin (clarithromycin)
Oxygen therapy
Analgesics
Antipyretics
Rest/restrict client’s activity
VIRAL PNEUMONIA
No definitive treatment
Antiviral agents
a. Symmetrel (amantadine)
b. Flumadine (rimantadine)
VACCINE
Influenza vaccine
o Mainstay of prevention
o Recommended annually for clients
Pneumoccal Vaccine
o Good for a lifetime
o 65yrs and older
COMPLICATIONS
o Usually runs an uncomplicated course.
o Complications may include
a. pleural effusion
b. confusion
NURSING MANAGEMENT
a.
b.
c.
d.
e.
f.
g.
Assess respiratory status
Oxygen therapy – as per MD order
Maintain patent airway
High-calorie, high –protein foods
Hydrate
Administer medications as ordered
Document findings
PULMONARY
TUBERCULOSIS
TUBERCULOSIS
o
o
o
o
o
o
o
Bacterial infection
Caused by Mycobacterium tuberculosis
Communicable disease
Primarily affects the lungs
Can affect other organs & body structures
Transmitted through airborne droplets
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-fastbacillus, & a slow-growing organism
b. Transmitted via airborne droplets
c. Bacilli are inhaled & deposit themselves on the
bronchioles/alveoli
d. 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. Fatigue
2. Low-grade fever / night sweats
3. Anorexia / weight loss
4. 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 HIVinfection with a induration reaction 5mm or greater
are considered positive
TUBERCULOSIS
* An area of induration
measuring 10mm or
more in diameter, 4872 hours after
injection, indicates the
individual has been
exposed to TB
QuantiFERON-TB Gold
New test for detection of TB
Test 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 basis
1. 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 antiTB 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 DRUGS
1. Isoniazid (INH)
2. Rifampin (Rifadin)
3. Ethambutol
(Myambutol)
4. Streptomycin
5. 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 prophylaxis
 Adverse effects
 Administer pyridoxine (vitamin B6)
 Hepatitis – hepatotoxic
DRUG THERAPY
Rifampin (Rifadin)
 Used in combination with INH and other
antitubercular meds
 Can 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 Rifampin
 Toxic to the liver
 Monitor liver function
DRUG THERAPY
Ethambutol (Myambutol)
 Toxic effect
 Early signs
 Baseline visual exam prior to therapy
 Schedule periodic eye exams
DRUG THERAPY
Streptomycin
 Aminoglycoside antibiotic
 2 drawbacks
*must be given parenterally
* has toxic effect on the kidneys
 Monitor u/o, weight, renal function studies
 Ototoxicity
NURSING INTERVENTIONS
1. Hospitalization
2. Respirator masks used when entering the client’s
room
3. Instruct client to cough into tissues & wear a mask
when leaving the hospital room
4. 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 foods
7. Monitor laboratory results periodically -- (liver
function test)
8. Educate the client about strict compliance with
medications
9. Inform client about adverse effects of medications
10. Encourage close follow-up
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