Pneumonia & TB

Define Pneumonia?
inflammation of the lung parenchyma (includes alveoli & surrounding tissue in contact w/lungs) most commonly caused by microorganisms

How do you get community-acquired pneumonia?
lower respiratory tract infection with onset in the community or during the first 2 days of hospitalization.

How do you get hospital acquired Pneumonia?
occurs 48 hours or longer after hospital admission and not incubating at time of hospitalization.

3. What is the mechanism responsible for hypoxemia in pneumonia (V/Q mismatch)?
Shunting; b/c it is a gas exchange problem

5. What are the normal pulmonary defense mechanisms against pulmonary infections?
Cilia in airways, macrophages, neutrophils, inflammatory mediators.

6. What are the mechanisms through which pulmonary infections can occur?
a. Aspiration of normal flora of nasopharynx oropharynx.
b. Inhalation of microbes in the air.
c. Hematogenous spread from a primary infection elsewhere in the body.

7. What conditions can compromise pulmonary defense mechanisms?
Cigarette smoking; immuno-compromised patients; protein-calorie malnutrition; chronic respiratory disorders; age.

9. What are the classic findings of bacterial pneumonia?
Sudden fever, shaking chills, SOB, cough productive of purulent sputum rust-colored, pleuritic pain, coarse crackles and rhonchi over lung fields, tactile fremitus, and pleural friction rub. ABGs & CXR—infiltrates

What kind of information does differential blood count diagnostic test yield?
WBC 4.5-10,000, RBC 3.8-5.8 (m) 5.3 (f), Hgb. 13.1-17.2 (m) 16 (f), Hct. 35-50, Neutrophil 35-80, Lymphocytes 18-44, Monocytes 0-10, Eosinophils 0-3, Basophils 0-1, Bands 0-11. Provides information about presence of infection. Provides information about adequacy of hemoglobin for oxygen carrying capacity.

What procedures are most frequently used to make a diagnosis of pneumonia?
History and physical examination; Chest x-ray; gram stain of sputum; sputum culture and sensitivity test; pulse oximetry or ABGs; CBC with differential and routine blood chemistries; blood cultures.

Identify the current core measures in the treatment of pneumonia.
• PN-1:* Oxygen assessment within 24 hours before or after arrival at the hospital
• PN-2: Patients over 65 screened for pneumococcal vaccination and administration before discharge, if indicated
• PN-3a: Blood cultures performed within 24 hours before or 24 hours after hospital arrival for patients who were transferred or admitted to the ICU within 24 hours of hospital arrival.
• PN-3b: Blood cultures performed in the ED before initial antibiotic received in hospital
• PN-4: Adult smoking-cessation advice and counseling provided
• PN-5: Median antibiotic timing, with goal of less than six hours from arrival at the hospital
• PN-6A Initial antibiotic selection for CAP in immunocompetent patients – ICU patients
• PN-6B Initial antibiotic selection for CAP in immunocompetent patients – non-ICU patients
• PN-7: Influenza vaccination

what is Latent TB?
TB bacilli infect the alveoli & immune system fights them and try to destroy them (WBC). Hard tubercles are formed when macrophages attack & surround them then calcify and can remain in person for years

What is Active TB?
when a person has TB and s/s of the disease are present

What type of disorder are Pneumonia and TB?
Restrictive disorders

What do restrictive disorders involve?
Gas exchange problems at alveolar capillary membrane and ventilation problems

Where is the infection located with pneumonia?
Inside the alveoli (air sacs)

What is the body’s response to pneumonia?
Inflammation; alveolar tissue starts leaking fluid (infection) into air sac

What is the pneumonia doing in the alveoli?
taking up air space and causing impaired gas exchange

What do you expect to see in a person with pneumonia?
1. Dyspnea (diff breathing) or SOB 2. Chest pain (d/t inflammation) 3. Cough to get out fluid 4. Fever (low/high)

What are most common causes of Pneumonia?
Bacteria and viruses.

What is Ventilator-acquired Pneumonia?
When a pt is on a ventilator they are exposed to bacteria or organisms that get into the tube and directly into the patient. Aspiration into lungs.

What is primary problem when dealing with pneumonia?
Gas exchange b/c the space in the alveolar is occupied by secretions instead of air not allowing O2 & CO2 to properly exchange gases

As a RN, what do you do when someone presents with SOB?
Ask why? what’s causing it, is the person’s age taken into consideration

What happens as pt’s get older?
lose compliance in lungs, vital capacity decreases, may not generate fever response (w/infection), may not exchange gases as well as youngsters, immune system is weaker, pneumonia can be killer for older adults!

What age considerations are there for pneumonia?
very young (havn’t acquired immune system), very old (high risk population) b/c immune systems become less effective

What should you consider about the pt?
How long it’s been going on, what are their s/s,

What are the s/s of pneumonia?
Fever (key), shaking chills (fever but cold), cough (body trying to get rid of it), color of sputum (not clear), chest pain (d/t inflammation; Pleuracy)

What are complications of pneumonia?
Pleurisy, Pleural Effusion, Atelactasis, Bacteremia (bacteria in blood), Lung abcess, Emypyema—accumulation of purulent exudate. Pericarditis—spread of the infecting organism from infected pleura to the pericardium. Meningitis can be caused by S. pneumonia. Respiratory Failure, Sepsis

How does Pleurisy affect a pneumonia pt?
pleura stretches and rubs together causing pain, pain = < breathes = < O2 and won't want to cough & deep breathe b/c too painful

What is Pleural Effusion?
transudate fluid in the pleural space

When does your plan of care start?
Once you start seeing the s/s

How do co-morbidities of pneumonia pt affect plan of care?
You need to find out what problems need to be addressed in plan of care ex: D.M, MI, Htn, etc

What underlying problem does pneumonia present?
Oxygen deprovation; impaired gas exchange

What is your concern if your pneumonia pt is a smoker?
Smoke destroys the cilia in the bronchis and impairs ability to expectorate secretions

What would you include into plan of care for smoker with pneumonia?
Smoking cessation

Why would a pneumonia pt have coarse crackles?
B/c they have fluid in alveoli; secretions filling up causing neutrophils/macrophages moving in

Why would a pneumonia pt have rhonchi?
they have increased secretions b/c bronchioles can also get secretions (vibrate in airways)

What does Fremitus mean for pneumonia pt?
vibrations as air passes secretions in chest wall; validates the buildup of secretions in the large airways

What do increased secretions cause for a pneumonia pt?
increases airway resistance and decreases airflow to the alveoli

What does pleural friction rub indicate for pneumonia pt?
this indicates pleuracy; on inspiration and expiration d/t inflammation b/c two tissues are rubbing together

What affect will pneumonia have on VS?
BP can be high d/t stress, HR high b/c O2 is decreased so heart is working harder to deliver O2 to tissues, RR faster b/c pain/hypoxia compensation, Temp high d/t infection, ABGs can tell you if hypo/hyperventilating & oxygenation levels are probably low = gas exchange problem, CBCs = elevated, BG can be high d/t stress

What is plan of care for PNA pt with high BP, high HR, high RR, high temp, hypovent, low O2 sats, elevated CBCs, and high BG level that has pain?
1. Give O2 2. manage pain 3. Give antibiotics for infection 4. Give insulin for high BG levels and make sure to prioritize actions

Why would a PNA pt be getting D5NS at 200ml/hr?
Hydrate pt to loosen secretions so they are able to mobilize and expectorate them

How do PNA pt’s lose volume through insensible losses?
Fever = sweating, Resp distress = volume loss from lungs

Why is a gram stain sputum culture a priority for a PNA pt?
PNA bundle = assess O2, find out organism being treated to give correct antibiotics,

What is significance of getting blood cultures for PNA pt?
To find out if the bacteria (infection) got into the blood = sepsis (very serious) must monitor for this

What do we need to know about Vancomycin?
Nephrotoxic; monitor BUN & creatine, peak & trough after the 3rd dose.

When is PNA considered hospital acquired?
if you got PNA 48hrs after being admitted into a hospital

What is our tx for PNA pt’s gas exchange problem?
O2; start low then keep increasing until the pt’s ABGs start getting better

What diagnostic study will tell you a PNA pt has infiltrates?

After you place PNA pt on O2, what should you be working on next?
mobilizing secretions and treating the infection

What can happen if the PNA pt’s RR is as high as 60 bpm?
the pt is going to get tired of working so hard to breathe and ABGs should show he is heading toward Resp Failure

If the PNA pt is in Respiratory Failure, what should you be planning for?

Why would a PNA pt who is getting worse become disoriented & combative?
Due to hypoxia (low O2)

Would a BiPap machine help this PNA pt?
NO, b/c Bipap helps to open airways and PNA is more of a gas exchange problem at alveoli

How will we treat PNA?
put on correct antibiotics to treat infection

How will you evaluate if Vancomycin is working for your PNA pt?
WBCs should go down, Fever should go down, HR go down, RR less labored, ABGs should show increased oxygenation so all s/s should get better or go away

What does TB do to a pt’s lungs?
forms granulomas in the lungs which are irreversible and decreases area for gas exchange to occur

What kind of disorder is TB?
Restrictive disorder; gas exchange problem

What is TB?
A communicable infectious disease that must be reported to public health department

What causes TB?
Mycobaterium tuberculosis organism is of most concern

How is TB spread?
airborne; person to person through cough/sneeze/expelling air with Active TB; usually occurs after 1-2 months of exposure to someone within close proximity

What do you do if you think a pt comes in with s/s of TB?
Put them in negative pressure isolation room; want to ventilate the organism into the air which minimizes concentration of organism. Close confined quarters increases risk of getting TB

What kind of precautions should you use when managing a TB pt?
N95 mask; needs to be specially fitted so it seals nose/mouth completely.

What is most important measure of preventing spread of TB?
Adequate ventilation and covering mouth when coughing/sneezing, etc.

What are early symptoms of Active TB?
Wgt loss, fever, night sweats, chills, loss of appetite, coughing >3wks, weakness/fatigue, hemoptysis (TB or cancer), chest pain

How do you diagnose TB?
with skin test (Mantu test); PPD injected under FA and examined 48-72 hrs later

How do you diagnose Active TB?
S/S, pt’s history, CXR (lesions), sputum culture (acid fast)

What is treatment of TB?
Pt education is essential; taking 3 meds for 6-9 mths

What are the meds used to treat TB?
INH, Rifampin, EMB, or PZA. Most are toxic to the liver, do not take with alcohol

What are side effects of INH?
eye infection; neuritis, take vit B6 with this to reduce eye problems and toxic to liver (NO alcohol)

What are side effects of Rifampin?
all secretions will turn orange; toxic to liver can result in hepatitis; NO alcohol!

What are side effects of EMB?
optic neuritis; can go blind; take vit B6. Skin rash

What are side effects of PZA?
toxic to liver; No alcohol, Hyperuricemia, GI distress

When are TB pt’s usually no longer contagious?
After taking meds for 2 wks; after taking 3 negative sputum cultures can be taken out of isolation/discharged

Why is it important for pt’s to take meds as prescribed and for the entire time?
bacteria can become resistant

Which drug can be given to pt’s with latent TB or are in close contact with infected pt’s?

What is the TB vaccine?
BCG; prevents spread of TB w/in the body but DOESN’T prevent initial infections

Can Latent TB become Active?
Yes, if a person becomes immunocompromised, the bacteria can come out and attack organs in the body and become active

Can a person w/latent TB spread it?
No, as long as their immune system is strong it will contain the bacilli.

What can untreated TB do to a person?
Damages lung tissue; which can be seen in CXR

Can TB go systemic?
YES, it can spread to other tissues/organs; kidneys, spinal fluid, brain, etc. Not limited to lungs

What are risk factors for TB?
Have HIV, had TB w/in 2 yrs, Being immunocompromised, young/old, traveling outside of US or areas high incidence of TB, D.M. pt’s, alcohol/drug abuse, not completing course of tx

What are high risk populations?
young/old, homeless, people w/out good access to healthcare, prisons, SNF’s, traveling out of country w/higher incidence of dz, people w/weak immune systems, African americans,

What is preferred method of screening for TB?
TB skin test or CXR. Mantoux test; positive if the induration is >10, looks red and feels hard.

How will a pt’s Mantu test come back if they received the BCG vaccine?
Positive, so they will need to get a CXR done and look at medical history

What additional info will you get from pt before interpreting the Mantu test?
did they get BCG vaccine? have they been exposed? does she drink/use drugs, get a history

Is drinking alcohol frequently a concern for someone who has latent or active TB?
YES, b/c drugs are toxic to the liver and alcohol is contraindicated and could decrease their immune system

What is important to include when managing a pt who may have latent or active TB?
Educating pt on importance of reducing risk of spreading it, taking meds completely for 6-9 mths, importance of nutrition, not smoking/drinking, SE of meds, etc

What would confirm a pt does have TB?
CXR, 3 acid fast sputum cultures to show presence of bacilli

How long after tx is the pt no longer contagious?
2 wks after taking meds and after 3 negative acid fast sputum cultures are they allowed out of isolation/discharged

What does RN have to do if their pt is positive for TB according to the CDC?
Report it. Further follow up: CXR, medical hx, assess for s/s, sputum culture, refer to healthcare provider for further evaluation, educate pt’s about importance of following tx

What should you consider for a PPD of 6?
A PPD induration greater than 5 mm is considered positive for persons with, or at risk for, HIV infection; those who have had close, recent contact with someone who has infectious tuberculosis; or persons who have chest x-ray (CXR) that show old, healed TB.

What should you consider for a PPD of 11?
A PPD induration greater than 10 mm is considered positive for foreign-born persons from high-prevalence countries; IV drug users, medically underserved, low-income populations; residents of long-term care facilities; people with chronic illnesses; and all children and adolescents.

What should you consider for a PPD of 16?
A PPD induration greater than 15 mm is considered positive for all other persons not mentioned in above questions.

What does a positive skin test tell you?
This means the person’s body was infected with TB bacteria. Additional tests are needed to determine if the person has latent TB infection or active TB disease. A health care worker will then provide treatment as needed.

What do TB blood tests tell you?
TB blood tests (also called interferon-gamma release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB. An IGRA measures how strong a person’s immune system reacts to TB bacteria by testing the person’s blood in a laboratory.

What IGRA’s are used in US and what do they tell you?
1. QuantiFERON®-TB Gold In-Tube test (QFT-GIT) 2. T-SPOT®.TB test (T-Spot) Positive IGRA: This means that the person has been infected with TB bacteria.

Can latent TB become active TB disease?
Yes, if the person’s immune system gets weaker they are at risk for active TB.

According to the CDC, if a person has a positive PPD, what subsequent steps are necessary?
• Medical history,
• Physical examination,
• Test for TB infection (TB skin test or TB blood test),
• Chest radiograph (X-ray), and
• Appropriate laboratory tests; acid fast sputum culture

What teaching given to + skin test per Case study?
a. Teach that TB is a communicable disease and can be spread to others. All persons exposed should be screened and potentially treated.
b. Promoting adherence to treatment regimen (may last up to 9 -12 months). Importance of compliance with medication regime to avoid resistant organisms and spread of organisms outside the lungs to other body tissues. Medications should be taken on an empty stomach for better absorption. She should be taught the side effects of the medications and foods to avoid eating (tyramine and histamine containing items). Avoid alcohol because of high potential for hepatotoxic effects with medications.
c. Promote activity and good nutrition to maintain a healthy immune system.
d. Prevent transmission of TB to others. Cover mouth and nose when coughing. Dispose of tissues appropriately. Good hand hygiene.

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