Infection: Pneumonia and Influenza

1. Infection: Pneumonia and Influenza Lewis ch. 27, 28

2. Objectives (pp.5-6) • The Infection concept will be reviewed in this presentation. • Pneumonia and influenza are the exemplars for the Infection concept and are included in this presentation.

3. 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.

4. 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

5. 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)

6. Defenses Against Infection • Normal body flora • Body system defenses • Inflammatory response • Vascular and cellular responses • Formation of exudates • Tissue repair

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

8. Localized Warmth Swelling Redness Drainage Pain/tenderness Restricted movement Systemic Changes in VS Fatigue N/V/D Malaise Lymphadenopathy Confusion Clinical Appearance of Infection

9. 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

10. Interventions • Protect clients • Educate clients • Maintain own worker health • Give antimicrobials • Be aware of S&S of infection • Practice medical and surgical asepsis

11. Exemplar # 1: Influenza p. 538 • Caused by different strains of A or B virus • A leading cause of morbidity and mortality; most deaths occur in over 60 age group • Most could be prevented with vaccination-need new one each year. Inactivated in >50 and live, attenuated in younger groups • Table 27-3, p. 539 shows hi-risk groups and those who could transmit to them

12. 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

13. 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 • Encourage flu and PN vaccines esp. in high-risk groups

14. Exemplar # 2: Pneumonia (PN) p. 561 • Acute inflammation of lung caused by microbial organism • Leading cause of death in the United States from infectious disease • Most common type is pneumococcal (strep) • Causes: aspiration, inhalation of microbes, or spread thru blood from a primary infection site

15. LLL Pneumonia

16. Risk Factors • Impaired immunity • ↓ Cough and epiglottal reflexes • Impaired mucociliary mechanism by pollutants, infection, intubation • Malnutrition • Increased presence of bacteria in leukemia, diabetes, alcoholism

17. Types of PN • Community-acquired (CAP)—usually pneumococcal • Hospital-acquired • Aspiration • Opportunistic (fungal, PCP)

18. Pathophysiology of Pneumococcal Pneumonia • Strep enters respiratory tract and releases toxins causing inflammation • In alveoli, serous fluid is released and bacteria multiply rapidly in the fluid • Capillaries dilate adding red cells to alveolar fluid along with bacteria, white cells, and fibrin (red hepatization) • Consolidation of white cells and fibrin in one part of lung (gray hepatization) • Resolution

19. Clinical Manifestations • CAP symptoms • Sudden onset of fever (atypical-gradual) • Chills • Cough productive of purulent sputum (atypical-dry cough) • Pleuritic chest pain • Confusion or stupor in elderly/debilitated

20. Clinical Manifestations • Lung examination findings • Dullness to percussion • ↑ Fremitus • Bronchial breath sounds • Crackles

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

22. Most Common Complications • Pleurisy—pain with inflammation • Atelectasis—partial or full(partial may clear with C&DB) • Pleural effusion—fluid in pleural space. Usually is sterile and reabsorbed in 1 to 2 weeks or may require thoracentesis. Occurs in 40% of cases. • Bacteremia (sepsis)

23. Atelectasis

24. Pleural Effusion

25. Other Complications • Pericarditis and Endocarditis • Spread of microorganism to heart • Meningitis • Patient with pneumonia who is disoriented, confused, or somnolent should have lumbar puncture

26. Collaborative Care • Three-step approach to treatment • Assess ability to treat at home • Calculate Pneumonia Severity Index (PSI) Table 28-3, p. 562 • Clinician decision for inpatient or outpatient

27. Collaborative Care • Antibiotic therapy • Oxygen for hypoxemia • Analgesics for chest pain • Antipyretics for fever • May need nebulizer treatments • Fluid intake at least 3 L per day • Caloric intake at least 1500 per day

28. Collaborative Care • Influenza drugs and influenza vaccine • Pneumococcal vaccine indicated for those at risk: • Chronic illness such as heart and lung disease, diabetes mellitus • Recovering from severe illness • 65 or older • In long-term care facility

29. Nursing Assessment on Admission: Subjective Info • Lung cancer • COPD • Diabetes mellitus • Debilitating disease • Malnutrition • AIDS

30. History cont’d • Use of antibiotics, corticosteroids, chemotherapy, immunosuppressants • Recent abdominal or thoracic surgery • Smoking • Alcoholism • Respiratory infections

31. History cont’d • Prolonged bed rest • Dyspnea • Nasal congestion • Pain with breathing • Sore throat • Myalgias • Fever • Restlessness

32. Objective Nursing Assessment • Splinting affected area • Tachypnea • Asymmetric chest movements • Use of accessory muscles • Crackles • Green or yellow sputum • Tachycardia

33. Nursing Assessment • Changes in mental status • Leukocytosis • Abnormal ABGs • Pleural effusion • Pneumothorax (total atelectasis) on x-ray

34. Analysis of Info: Formulating Nursing Diagnoses • Ineffective breathing pattern • Ineffective airway clearance • Acute pain • Imbalanced nutrition: Less than body requirements • Activity intolerance • Deficient fluid volume

35. Planning: Outcome Criteria • Clear breath sounds • Normal breathing patterns • No signs of hypoxia • Normal chest x-ray • No complications related to pneumonia

36. Interventions & Rationales • Maintain ongoing respiratory assessment: to prevent complications • Prompt treatment of URIs: to prevent spread • Increase fluid volume: to liquefy secretions and prevent dehydration • Strict asepsis: to prevent spread • Monitor and control pain: to promote increased activity

37. Interventions & Rationales • Initiate and maintain oxygen supplementation: to improve oxygen status • Assist patients with turning and deep breathing, IS, and ambulation q2h: mobilize secretions • HOB up/overbed table positioned: improves oxygen status • Assist patients at risk for aspiration with eating, drinking, taking meds: to prevent aspiration and subsequent pneumonia

38. Interventions & Rationales • Emphasize need to take course of medication(s): to ensure effective tx of current infection and prevent resistant strains from developing • Teach drug–drug, drug-food interactions: to ensure drug is as effective as possible • Encourage those at risk to obtain influenza and pneumococcal vaccinations and other preventative techniques: to prevent recurrence • Teach nutrition, hygiene, rest, regular exercise: to maintain natural resistance

39. 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

40. 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.

41. 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.

42. Comparison of Nursing Care • Remember the concept of infection: regardless of where the infection is or what organism causes it, people have the same general manifestations: fever, malaise, myalgia, and sometimes elevated labs for systemic; and redness, swelling, and pain for localized infections. • We do treat viruses consistently with antivirals and other infections with other antimicrobials. • Nursing care is very similar: provide supportive care for symptoms, give meds, promote health, and do teaching.