copyright © 2007, 2004, 2000, mosby, inc., an affiliate of elsevier inc. all rights reserved....

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Infection: Pneumonia, Influenza, Infection: Pneumonia, Influenza, MeningitisMeningitis

Brunner ch. 23, 64, 70

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Infection Concept Review

• Infection—disease state resulting from the presence of pathogens in the body. May be acute or chronic

• Pathogens—disease-producing microorganisms—bacteria, viruses, fungi, parasites. The presence of these pathogens usually produces an inflammatory response as well.


Course of Infection

• Incubation period—time between entry of pathogen and onset of sx

• Prodromal stage—nonspecific sx, most infectious

• Illness stage—worst sx

• Convalescence—recovery time

• Length of each stage depends on type of infection—may be local or systemic


Chain or Cycle of Infection

• Infectious agent (pathogen)

• Reservoir (place it lives)

• Portal of exit (orifices or breaks)

• Mode of transmission (how it moves)

• Portal of entry (orifices or breaks)

• Susceptible host (stressors)


Defenses Against Infection

• Normal body flora • Body system defenses• Inflammatory response

– Vascular and cellular responses– Formation of exudates– Tissue repair


The Susceptible Host

• Changes in normal body flora• Breakdown in body systems• Flawed inflammatory response• Problems with tissue repair• Stressors


Clinical Appearance of Infection

• Localized– Warmth– Swelling– Redness– Drainage– Pain/tenderness– Restricted movement

• Systemic– Changes in VS– Fatigue– N/V/D– Malaise– Lymphadenopathy– Confusion


Laboratory Data

• WBC (Totals and differentials) Amount elevated usually indicates severity.– “Left shift” (high neutrophils) usually indicates

a severe infection. – Total elevation not seen in viral infections.

May see a “right shift” (high lymphocytes) in some viral infections

• +Cultures and gram stains


Interventions

• Protect clients

• Educate clients

• Maintain own worker health

• Give antimicrobials

• Be aware of S&S of infection

• Practice medical and surgical asepsis


Exemplar # 1: Influenza (205, 221-222, 2122, 2131)

• Acute viral respiratory disease• Caused by different strains of A, B, or C virus• Flu shot is made from 2 A strains and 1 B

strain• Spread by droplet. Incubation 24-72h• A leading cause of morbidity and mortality;

most deaths occur in over 60 age group.


High-risk Groups

• Any age with chronic illness• Residents of long term care• Immunocompromised• Pregnant • Also recommended for 6 mo-5 yrs, over 50• Required for healthcare workers


Manifestations

• Abrupt onset with cough, fever, myalgia, HA, sore throat

• Resolution within 7d unless complications develop. Most common complication is PN

• Convalescent phase may include malaise and hyperactive airways


Collaborative Care

• Relieve sx with mild analgesics and cough meds and prevent pneumonia.

• Antivirals shorten course of illness and inhibit spread of virus to other cells—should be given within 2d of onset of sx or can be given prophylactically.

• Older adults may be hospitalized. Vaccine is less effective in this group.

• Encourage flu vaccine esp. in high-risk groups.• Reactions to vaccine required to be reported.• Pandemics should be planned for by HC agencies.


Exemplar # 2: Pneumonia (PN) p. 554

• Acute inflammation of lung caused by microbial organism

• Leading cause of death in the United States from infectious disease

• Most common type is streptococcal• Causes: aspiration, inhalation of microbes, or

spread thru blood from a primary infection site


QuickTime™ and aYUV420 codec decompressor

are needed to see this picture.

LLL Pneumonia


Risk Factors

• Impaired immunity• Chronic respiratory conditions• Hospitalization (HCPs, respiratory equipment, NG or ET

tubes)• Immobility• Smoking/pollution• Meds that cause respiratory depression • ↓ Cough and epiglottal reflexes• Malnutrition • Pneumonitis


Types of PN

• Community-acquired (CAP)—usually streptococcal. Occurs in community or within 48h after hospitalization

• Hospital-acquired (HAP)—occurs after 48h. Most common are the antibiotic-resistant organisms

• Aspiration—usually streptococcal (normal flora in oropharynx)

• Pneumonia in the Immunocompromised Host (formally Opportunistic)—fungal, PCP, TB


Pathophysiology of Pneumonia

• Organism enters respiratory tract and releases toxins causing inflammation

• In alveoli, serous fluid and mucus are released and bacteria multiply rapidly in the fluid

• Capillaries dilate adding red cells to alveolar fluid along with bacteria, white cells, and fibrin

• Venous blood entering the lungs doesn’t get proper oxygenation leading to hypoxemia

• Lobar involves entire lobe; bronchopneumonia is patchy


Clinical Manifestations

• Common to most– Sudden onset of fever, chills – Tachycardia, tachypnea, orthopnea– Cough productive of purulent sputum unless

dehydration is present. Color of sputum not necessarily indicative of organism

– Pleuritic chest pain– Confusion or stupor in elderly or symptoms may

not be readily apparent


Clinical Manifestations

• Lung examination findings– Dullness to percussion– ↑ Fremitus (vibration)– Usually fine crackles– Bronchial breath sounds—high-pitched and loud,

normally only heard around the trachea. No air exchange in the alveoli causes no vesicular sounds to be heard and the high-pitch sound that is heard is from the tracheobronchial tree and being transmitted to the chest wall.


Diagnostic Tests

• Chest x-ray• CBC, differential• Chemistries (if indicated)• Gram stain and C&S of sputum• Pulse oximetry and/or ABGs• Blood cultures


Most Common Complications

• Pleurisy• Atelectasis• Pleural effusion—purulent fluid in pleural

space. Usually is sterile and reabsorbed in 1 to 2 weeks or may require thoracentesis. Occurs in 40% of cases.

• Sepsis• Shock and respiratory failure (delayed or

inadequate tx or at risk populations)


Atelectasis


Pleural Effusion


Collaborative Care

– Assess ability to treat at home.– HCP should check with Case Management to see if

patient meets inpatient criteria.– Ultimately, HCP can decide, but hospital may not

get paid for inpatient stay.


Collaborative Care

• Antibiotic therapy (only if bacterial)• Oxygen for hypoxemia• Analgesics for chest pain• Antitussives for cough• Antipyretics for fever• May need nebulizer treatments• Fluid intake at least 3 L per day• Caloric intake at least 1500 per day (high

calorie fluids if severe anorexia is present)


Commonly Used Antibiotics

• Penicillins—amoxicillin, penicillin-G• Cephalosporins—Ancef, Rocephin• Methicillin resistant—vancomycin, linzeloid• Fluoroquinolone—Cipro (tendonitis)• Levofloxacin—Levaquin (“)• Macrolides—azithromycin, erythromycin• Antivirals—Tamiflu, Relenza• Antifungals—v • Anti-TB—isoniazid + rifampin


Preventative Care

• Influenza drugs and influenza vaccine• Pneumococcal vaccine indicated for those at risk:

• Chronic illness such as heart disease, lung disease, or diabetes mellitus, or asplenia

• Recovering from severe illness• 65 or older• In long-term care facility or other environments that

may increase risk


Nursing Diagnoses

• Impaired gas exchange• Ineffective breathing pattern• Ineffective airway clearance• Impaired tissue perfusion• Acute pain• Imbalanced nutrition: Less than body requirements• Activity intolerance• Deficient fluid volume• Deficient knowledge


Planning: Outcome Criteria

• Clear breath sounds• Normal breathing patterns• No signs of hypoxia• Normal chest x-ray• No complications related to pneumonia


Nursing Management• Admission history, med list, and physical assessment• Identify risk factors• Labs and radiology• Monitor O2 status and oxygen therapy• Monitor effects of respiratory therapy• HOB elevated• Promote C&DB and use of IS• Monitor IV fluids and encourage po fluids• Administer and evaluate antibiotic therapy• Balance rest and activity• Evaluate activity tolerance• Monitor for changes in status


Patient Education

• Causes• Individual risk factors and how to minimize risk such

as stopping smoking• Managing symptoms• Importance of med therapy• S & S to report• Keeping FU appts• May need to teach IV antibiotic therapy• Vaccines


Evaluation

• Dyspnea not present• SpO2 ≥ 95• Free of adventitious breath sounds• Clears sputum from airway• Reports pain control• Verbalizes causal factors• Adequate fluid and caloric intake• Performs activities of daily living


Developmental Issues• Very young and very old are more susceptible to

the complications of PN and influenza. Both can become ill very quickly and mortality rates are generally higher

• Both groups also become dehydrated quicker than adults.

• Remember that elderly may have atypical symptoms.

• Children have shorter, straighter passageways in their respiratory system, making spread of infectious organisms more rapid.


Cultural and Socioeconomic Issues

• Be sensitive to another cultures need to treat infections with alternative therapies and healers: herbal, acupuncture, hot-cold, prayer, charms, etc.

• Be aware that $ play an important role today with limited access to health care and expense of prescriptions. HCPs should try to be sensitive to what they prescribe.


Exemplar #3: Meningitis (1950-2)

• Inflammation of the lining around the brain and spinal cord

• Caused by bacteria or virus• 80% are caused by the bacteria Streptococcus

pneumoniae and Neisseria meningitides• Viral infections are usually caused by mumps,

herpes, or mosquitoes or other insects.


Risk Factors

• Pneumonia• Otitis media• Mastoiditis• URI• AIDS• Lyme Disease• Smoking • Immunosuppression• Crowded living conditions• Facial trauma• Invasive procedures


Pathophysiology

• Bacteria enters bloodstream• Crosses blood-brain barrier• Invades CSF• Inflammation occurs• IICP results


Complications

• Vision and hearing impairments• Seizures• Hydrocephalus• Paralysis• Septic shock• Brain damage


Manifestations

• Fever• HA• Nuchal rigidity• Photophobia• Hemorrhagic rash• Confusion, irritability, lethargy, decreased LOC• +Kernig’s sign—flexed hip and knee cannot be extended• +Brudzinski sign—neck flexion causes flexion of the hips

and knees


Diagnostics

• CT or MRI to detect brain shift• LP with evaluation of CSF• Blood cultures


Preventative Management

• Hib vaccine has almost eradicated Hemophilus influenza, a past major cause of meningitis in children.

• Meningococcal vaccine should be given to all college-bound adolescents, especially those planning on living in dorms.

• People who have close contact with meningitis should get Rocephin.


Medical Management

• IV antibiotic therapy usually with Vancomycin and a cephalosporin such as Rocephin.

• Decadron steroid therapy decreases swelling and inflammation

• Antiseizure meds if indicated• Contact precautions


Nursing Management

• VS and O2 sat• Neuro checks• Low lights• Administration of meds (antibiotics, antiseizure,

antipyretics, analgesics)• Seizure precautions• Monitor IV therapy and fluid status• Maintain isolation precautions• Prevent complications from decreased mobility• Family support

copyright © 2007, 2004, 2000, mosby, inc., an affiliate of elsevier inc. all rights reserved....

Documents