Pneumonia, TB, Lung cancer and Smoking Cessation.pdf

Pneumonia, TB, Lung cancer and Smoking Cessation

Pneumonia - acute inflammation of the lung parenchyma that is most frequently caused by a

microorganism. The lower respiratory system is supposed to be sterile, when defense

mechanisms become incompetent or are overwhelmed by the virulence or quantity of infectious

agents

oOrganisms that cause pneumonia reach the lungs one of 3 ways

Aspiration of normal flora~ many are normal inhabitants of the pharynx in

healthy adults

Inhalation of microbes present in the air

Hematogenous spread from a primary infection elsewhere in the body

(staphylococcus aureus)

oTypes of Pneumonia

Community acquired pneumonia – occurring in the community setting or during

the first 2 days of hospitalization

Hospital acquired, ventilator-associated, and health care-associated pneumonia-

occurs 48 hrs. or longer after admission

Aspiration pneumonia- occurs from abnormal entry of secretions or substances

into the lower airway. Certain conditions increase the risk for aspiration

Decreased LOC (seizures, head injury, stroke, alcohol intake)

Difficulty swallowing

And NG intubation with or without tube feeding.

Opportunistic pneumonia- occur in patients with altered immune responses

(protein calorie malnutrition and/or immunodeficienciencies) and following

treatment with radiation therapy, chemotherapy, and long term corticosteroid

treatment.

oPatho-regardless of type the patho is similar….4 stages

Congestion- after organisms reach the alveoli, outpouring of fluid into the

alveoli. The alveoli multiply in the serous fluid and the infection spreads to

adjacent alveoli. The presence of the fluid in alveoli interferes with gas

exchange.

Red Hepatization- massive dilation of the capillaries and alveoli are filled with

organisms, neutrophils, RBCs and fibrin. Red & granular lungs

Gray Hepatization- blood flow decreases & leukocytes and fibrin consolidate in

the affected part of the lung

Resolution- complete resolution& healing occur

oClinical manifestations onset of symptoms is sudden, including fever, shaking chills, SOB,

cough productive of purulent sputum, and sometimes pleuritic chest pain

IN THE ELDERLY= CONFUSION or stupor (related to hypoxia)

oCOMPLICATIONS- develop more freq. in individuals with underlying chronic disease &

other risk factors

Pleurisy- inflammation of the pleura

Pleural effusion- transudate fluid in the pleural space

Atelectasis- collapsed, airless alveoli

Bacteremia- bacterial infection in the blood

Lung abscess- occurs with pneumonia caused by S. aureus

Empyema- accumulation of purulent exudate in the pleural cavity

Pericarditis

Meningitis- can be caused by S. Pneumoniae (disoriented, confused)

Endocarditis- develops when organisms infect the endocardium and the valves

of the heart.

oDiagnostic studies- history, physical examination, and chest x-ray often provide enough

information to make management decisions without costly laboratory tests.

Sputum culture and gram stain to identify organism before starting antibiotics.

ABGs to assess for hypoxemia, hypercapnia, and acidosis.

Leukocytosis occurs in majority of patients with bacterial pneumonia.

WBC count greater than 15000 with the presence of bands.

oCollaborative care-

Drug therapy- appropriate antibiotic therapy

Nurse monitors changes in fever, sputum purulence, leukocytosis, and

oxygenation

And changes in chest x-ray pattern

No improvements = call to MD for new orders

Nutritional therapy – increased fluid intake

Limited activity and rest

Physical activity needs oxygen

When lung is already stressed with an infection, the respirations/alveoli

cannot keep up the oxygen demand created at the cellular level from

activity

Bronchodilators may be added to open up airways

Antipyretic

Analgesics

Oxygen therapy

Encourage vaccination pg. 550

Ages > 65 yrs. old

2-64 w/ long-term health problems

19-64 who smoke or have asthma

2-64 with lowered resistance to infection

19-64 yr. living in special environments or social settings such as chronic

care facilities.

oCare plan pg. 552-553

Impaired gas exchange related to fluid and exudate accumulation at capillary-

alveolar membrane

Ineffective breathing pattern related to inflammation and pain AEB

Acute pain related to inflammation & ineffective pain management and/or

comfort measures AEB

oExpected outcomes clear breath sounds, normal breathing, no signs of hypoxia, normal

chest x-rays, no complication related ; no complications related to pneumonia

oEvery hospital is expected to treat all patients the same(with these measures)

Blood culture before antibiotic therapy is started

Initiate oxygen therapy

Appropriate antibiotic selection

Antibiotic started within = 4 hours

Offered and administer the pneumonia and flu vaccine

Offered smoking cessation counseling

TUBERCULOSIS- infectious disease caused by mycobacterium tuberculosis usually involves

the lungs but can also affect other areas of the body. TB spreads when the person coughs,

speaks, sneezes and sings.

oEtiology & patho- gram positive acid fast bacillus spread by airborne droplets.

Spread by repeated close contact. ( within 6 inches of the persons mouth)

replicates slowly and spreads via the lymphatic system

Finds favorable areas for growth, upper lings, and kidneys, epiphyses of the

bone, cerebral cortex and adrenal glands.

oClassification

TB infection occurs when bacteria are inhaled but there is an effective immune

response and the bacteria become inactive.

Most people mount immune response to encapsulate these organisms

for the rest of their lives

Prevents primary infection form progressing to disease.

Latent TB infection (LTBI) - not sick b/c organism are inactive and not contagious.

About 10% develop active tb in their lifetime so treatment is important

Reactivation can occur if host defense becomes impaired

TB disease – active bacteria that that multiply and cause clinically active disease.

High risk groups- immunosuppress and diabetes mellitus.

oClinical manifestations- early stages usually symptom free.

LTBI = positive skin tests but asymptomatic

Active TB disease – fatigue, malaise, anorexia, unexplained weight loss, low-

grade fevers, and night sweats.

Pulmonary manifestation = freq. cough and mucoid or mucopurulent sputum.

Dyspnea is unusual.

Hemoptysis is usually associated with more advanced cases.

oComplications

Military TB- lg # of organisms invade the blood stream and spread to all organs;

involvement includes CNS, bone/joint tissue, kidneys, adrenals, lymph nodes,

genital tracts; hepatomegaly , splenomegaly, and lymphadenopathy may be

present.

Pleural effusion and empyema- inflammatory reaction in the pleural space.

TB pneumonia- large amount of bacilli discharging from granulomas into lung or

lymph nodes

Patient can easily transmit TB

Other organ involvement- involvement of the CNS with inflammation of the

meninges. Other organisms that may include the bone, joints, kidneys, adrenal

glands, lymph nodes and genital tracts.

oDiagnostic studies-

Tuberculin skin test using PPD. before admin. Ask patient if they received BCG

vaccination which could produce a positive result (ask for date of vaccination).

Admin0.1ml of PPD intradermal on dorsal surface of forearm

Test is read 48-72 hours later for the presence or absence of induration

(raised area)

Pg. 515 table 26-11

oGreater than (>) 15 mm induration = positive in people who are

at low risk

o> 10mm= positive for recent immigrants, injecting drug users,

residents and employees of high risk congregate settings,

mycobacteriology lab personnel, and persons w/ clinical

conditions (diabetes, ESRD)

o>5 mm = positive in HIV, recent contact with TB, Fibrotic lesions,

organ transplants, immunosuppressed (taking prednisone)

Chest x-ray – can be suggestive, but not usable for diagnosis

Bacteriologic and other studies- AFB test.

3 SMEARS ON 3 DIFFERENT DAYS

QuantiFERON-TB (QFT)- rapid diagnostic test. Blood test.

oCollaborative care- many treated on an outpatient basis.

Patients strongly suspected- placed on isolation, and receive immediate work-up

Airborne isolation for pulmonary and laryngeal TB

Nurse wears HEPA mask

Close home contacts encouraged to use precautions

Table 28-11 pg. 555 & TABLE 28-12 PG. 556

Primary treatment is DRUG THERAPY

Compliance is critical for treatment to be successful.

Initial phase= 4 drug for a 6 month regimen OR 2 month for patients

previously untreated for TB

DOT- direct observation therapy involves providing the antituberculosis

drugs directly to the patients and watching as they swallow the

medications.

Best way to assure adherence to regimen.

Necessary lab study follow-up throughout treatment. (LFTs)

oExpected outcomes- complete resolution of disease, normal pulmonary function,

absence of complications, and No transmission of TB.

LUNG CANCERS- leading cause of cancer related deaths in the US.

oETILOGY- smoking is the most important risk factor. Risk is directly related to total

exposure to tobacco smoke. Another risk is inhaled carcinogens (i.e. Asbestos, radon, air

pollution, etc.)

oPatho- the patho is not well understood; thought to arise from bronchial epithelial cells

Growly slowly, takes 8-10 years for a tumor to reach 1 cm in size (smallest lesion

detectable on x-ray)

Lung cancer has a preference for the upper lobes

Table 28-16 pg. 562

Lung cancers metastasize primarily by direct extension of lymph system and

blood.

Non-small cell lung cancer – 80%

Small lung cell-20 % (very aggressive and always considered systemic)

Common sites for metastatic growth: liver, brain, bine, lymph nodes, and

adrenal glands.

oCLINICAL MANIFESTATIONS- Nonspecific, and clinically silent for majority of its course.

SYMPTOMS MAY BE MASKED BY CHRONIC SMOKERS COUGH OR LUNG DISEASE

Later manifestations- anorexia, fatigue, weight loss, and vomiting. Sometime

hoarseness will also develop.

oDiagnostic studies- Chest x-ray initially to identify a lung mass or infiltrate. (atelectasis or

pneumonia)

Ct scan identifies location and extent of mass

Sputum cystologic study

Bronchoscopy

CT scan

MRI, PET

Pg. 563 table 28-17

oCollaborative Care- surgical therapy, radiation therapy, chemotherapy, biologic &

targeted therapy, airway stenting, cryotherapy

Discuss smoking cessation

oEVALUATION/ Goals-

Adequate breathing patterns

Minimal to no pain

Realistic attitude towards prognosis.

Tobacco cessation- every healthcare worker is responsible for identifying tobacco users and

providing them with information on ways to stop the use of tobacco. A combination of nicotine

replacement products, meds, behavioral approaches and support is believed to be most effective

in Long-term tobacco cessation.

oTable 12-4 pg. 171, agents….Nicotine gum, lozenge, patch, nasal spray, and inhaler. Non

nicotine- Zyban, Chantix, Aventyl, catapres

oTable 12-5 pg. 172

5 A’S~ ask, advise, assess, assist, arrange

5 R’S (UNWILLING TO QUIT) relevance, risks, rewards, roadblocks, repetition

EBP- as little as 3 mins teaching, makes a difference

Successful motivational interviewing

Listen rather than tell

Adjust to, rather than oppose, patient resistance

Express empathy through reflective listening

Focus on the positive

Gently persuade

Focus on patients strengths

Avoid argument and confrontation.

Help patient recognize the gap- where they are and where they wanna

be.

oSee also power point

Students also viewed