Chapter 27 Lower Respiratory Problems

Question 1

Acute bronchitis is a self-limiting inflammation of the?

Answer 1

bronchi in the lower respiratory tract and a common reason for seeking medical care.

• Most acute bronchial infections are caused by viruses.
• Air pollution, dust, inhalation of chemicals, smoking, chronic sinusitis, and asthma are other triggers of acute bronchitis

Question 2

Acute bronchitis

• most common symptom?
• The presence of colored (e.g., green) sputum is?
• Associated symptoms may include?

Answer 2

• Cough, which is the most common symptom, lasts for up to 3 weeks. Clear, mucoid secretions are often present, although some patients produce purulent sputum.
• The presence of colored (e.g., green) sputum is not a reliable indicator of bacterial infection.
  Associated symptoms include headache, fever, malaise, hoarseness, myalgias, dyspnea, and chest pain

Question 3

Diagnosis of acute bronchitis is based on clinical assessment. Assessment may reveal?

Answer 3

1) normal breath sounds or crackles or wheezes, usually on expiration and with exertion.
2) Consolidation (occurs when fluid accumulates in the lungs), suggestive of pneumonia, is ABSENT with bronchitis.
3) Chest x-rays would be normal and are therefore not indicated unless pneumonia is suspected

Question 4

Acute bronchitis

• The goal in acute bronchitis is to?
• Treatment is?
• Generally antibiotics are not prescribed for treating a viral infection, as they may cause?

Answer 4

• goal to relieve symptoms and prevent pneumonia.
• Treatment is supportive, including cough suppressants, encouraging oral fluid intake, and using a humidifier. β2-agonist (bronchodilator) inhalers are useful for patients with wheezes.
• may cause side effects and promote antibiotic resistance. However, antibiotics may be prescribed for patients with underlying chronic conditions and who have a prolonged infection associated with systemic symptoms.

Question 5

Acute Bronchitis: Patients should be encouraged not to ?

- If the acute bronchitis is due to an influenza virus, treatment with?

Answer 5

• encouraged not to smoke, avoid secondhand smoke, and to frequently wash their hands.
• treatment with antiviral drugs, either zanamivir (Relenza) or oseltamivir (Tamiflu), can be started. These drugs should be initiated within 48 hours of the onset of symptoms

Question 6

Acute bronchitis 5 main points

Answer 6

1) Inflammation of the bronchi
2) 90% are viral
3) Most common symptom- cough
- HA, fever, malaise, hoarseness, dyspnea, CP
3) Normal breaths sounds/ rhonchi
4) Normal CXR

Question 7

Pertussis is a highly contagious infection of the respiratory tract caused by?

• The bacteria attach to the cilia of the respiratory tract and?
• The incidence of pertussis has been steadily increasing in the United States since the 1980s, with the largest increase noted in?
• It is thought that immunity resulting from childhood vaccination with DPT (diphtheria, pertussis, tetanus) may diminish over time, allowing a milder (but still contagious) infection. The Centers for Disease Control and Prevention (CDC) currently recommends that all adults age ___ years and older who have not received a dose of Tdap (tetanus, diphtheria, and pertussis) receive a?

Answer 7

• caused by a gram-negative bacillus, Bordetella pertussis.
• release toxins that damage the cilia, causing inflammation and swelling.
• increase noted in adults.
• age 19 years and older who have not received a dose of Tdap (tetanus, diphtheria, and pertussis) receive a one-time vaccination as soon as possible

Question 8

Clinical manifestations of pertussis occur in stages.

1) The first (catarrhal) stage, occurring within?
2) The second (paroxysmal) stage, from the second to tenth week of infection, is characterized by paroxysms of cough.
3) The final (convalescent) stage lasts?

Answer 8

1) first 2 weeks of infection, manifests as a mild upper respiratory tract infection (URI) with a low-grade or no fever, runny nose, watery eyes, and mild, nonproductive cough
2) second (paroxysmal) stage, from the second to tenth week of infection, is characterized by paroxysms of cough.
3) lasts 2 to 3 weeks and is characterized by less severe cough and weakness

Question 9

The hallmark characteristic of pertussis is?

Answer 9

uncontrollable, violent coughing.

• Inspiration after each cough produces “whooping” sound as patient tries to breathe in air against obstructed glottis. The “whoop” often not present in teens and adults (especially those who have been vaccinated).
• Like acute bronchitis, coughing more frequent at night.
• Vomiting may also occur with coughing.
• Unlike bronchitis, cough with pertussis may last from 6 to 10 weeks

Question 10

• The primary treatment for pertussis is?
• The patient is infectious from the?
• What should NOT be used to treat pertussis?

Answer 10

• tantibiotics, usually macrolides (erythromycin, azithromycin [Zithromax]), to minimize symptoms and prevent spread of the disease.
• infectious from the beginning of the catarrhal stage through the third week after onset of symptoms or until 5 days after antibiotic therapy has been initiated.
• Cough suppressants and antihistamines should not be used, since they are ineffective and may induce coughing episodes. Corticosteroids and bronchodilators are also not useful

Question 11

Pertussis main points

Answer 11

1) Highly contagious
2) Gram negative bacillus
3) Uncontrolled, violent coughing
4) Low-grade or no fever
5) Runny nose, watery eyes
6) ABX to prevent spread/minimize symptoms
7) Cough suppressants, antihistamines-ineffective
8) Vaccine Dtap
- Tetanus, diphtheria, pertussis

Question 12

• Pneumonia is an acute infection of the?
• Until 1936, pneumonia was the leading cause of death in the United States. The discovery of _____ and ____ was pivotal in the treatment of pneumonia.
• Since that time, remarkable progress has been made in the development of ______ to treat pneumonia.
• However, despite newer antimicrobial agents, pneumonia is still associated with significant morbidity and mortality rates. The CDC reports that pneumonia and influenza are the?

Answer 12

• acute infection of the lung parenchyma. Until 1936, pneumonia was the leading cause of death in the United States
• discovery of sulfa drugs and penicillin was pivotal
• development of antibiotics to treat pneumonia
• pneumonia and influenza are the eighth leading cause of death in the United States

Question 13

Pneumonia 4 main points

Answer 13

1) Acute infection
2) Until 1936- leading cause of death
3) Still associated with high morbidity/mortality
4) Community-acquired (CAP) 6th leading cause of death for pts >65

Question 14

Pneumonia Etiology
Normally, the airway distal to the larynx is protected from infection by various defense mechanisms. Mechanisms that create a mechanical barrier to microorganisms entering the tracheobronchial tree include?
- Immune defense mechanisms include secretion of?

Answer 14

• mechanical barrier to microorganisms include air filtration, epiglottis closure over the trachea, cough reflex, mucociliary escalator mechanism, and reflex bronchoconstrictio.
• secretion of immunoglobulins A and G and alveolar macrophages

Question 15

1) Pneumonia is more likely to occur when?
2) Decreased consciousness weakens the?
3) Tracheal intubation bypasses normal?
4) What can also impair the mucociliary mechanism?
5) Chronic diseases can?

Answer 15

1) defense mechanisms become incompetent or are overwhelmed by the virulence or quantity of infectious agents.
2) weakens the cough and epiglottal reflexes, which may allow aspiration of oropharyngeal contents into the lungs. 3) bypasses normal filtration processes and interferes with the cough reflex and mucociliary escalator mechanism.
4) Air pollution, cigarette smoking, viral URIs, and normal changes that occur with aging
5) suppress the immune system’s ability to inhibit bacterial growth

Question 16

Organisms that cause pneumonia reach the lung by three ways:

Answer 16

1. Aspiration of normal flora from the nasopharynx or oropharynx. Many organisms that cause pneumonia are normal inhabitants of the pharynx in healthy adults.
2. Inhalation of microbes present in the air. Examples include Mycoplasma pneumoniae and fungal pneumonias.
3. Hematogenous spread from a primary infection elsewhere in the body. Examples are streptococci and Staphylococcus aureus from infective endocarditis

Question 17

Pneumonia occurs when defense mechanisms are overwhelmed and unable to fight the virus
4 types

Answer 17

1) Community-acquired (CAP)
2) Medical Care-associated (MCAP) – usually 48 hrs post admission
3) Aspiration – abnormal entry from mouth or stomach into lungs – triggers inflammatory response
4) Opportunistic – altered immune system – like HIV, chemo or radiation patients

Question 18

Pneumonia patho main points

Answer 18

1) Inflammatory response
- Attraction of neutrophils
- Release of inflammatory mediators
2) Alveoli fill w/ fluid- consolidation
3) Increased mucous production
4) Decreased gas exchange
5) Macrophages in alveoli ingest/remove debris

Question 19

18 Risk Factors for Pneumonia

Answer 19

Risk Factors for Pneumonia
• Abdominal or thoracic surgery
• Age >65 yr
• Air pollution
• Altered consciousness: alcoholism, head injury, seizures, anesthesia, drug overdose, stroke
• Bed rest and prolonged immobility
• Chronic diseases: chronic lung and liver disease, diabetes mellitus, heart disease, cancer, chronic kidney disease
• Debilitating illness
• Exposure to bats, birds, rabbits, farm animals
• Immunosuppressive disease and/or therapy (corticosteroids, cancer chemotherapy, human immunodeficiency virus [HIV] infection, immunosuppressive therapy after organ transplant)
• Inhalation or aspiration of noxious substances
• Intestinal and gastric feedings via nasogastric or nasointestinal tubes
• IV drug use
• Malnutrition
• Recent antibiotic therapy
• Resident of a long-term care facility
• Smoking
• Tracheal intubation (endotracheal intubation, tracheostomy)
• Upper respiratory tract infection

Question 20

Organisms Causing Pneumonia

Community-Acquired Pneumonia

Answer 20

Organisms Causing Pneumonia
Community-Acquired Pneumonia
• Streptococcus pneumoniae*
• Mycoplasma pneumoniae
• Haemophilus influenzae
• Respiratory viruses
• Chlamydophila pneumoniae
• Chlamydophila psittaci
• Coxiella burnettii
• Legionella pneumophila
• Oral anaerobes
• Moraxella catarrhalis
• Staphylococcus aureus
• Pseudomonas aeruginosa
• Enteric aerobic gram-negative bacteria (e.g., Klebsiella species)
• Fungi
• Mycobacterium tuberculosis

Question 21

Organisms Causing Pneumonia

Hospital-Acquired Pneumonia

Answer 21

• Pseudomonas aeruginosa†
• Escherichia coli†
• Klebsiella pneumoniae†
• Acinetobacter species†
• Haemophilus influenzae
• Staphylococcus aureus
• Streptococcus pneumoniae
• Proteus species
• Enterobacter species
• Oral anaerobes

Question 22

Types of Pneumonia

• potential causes of pneumonia.
• Although pneumonia can be classified many different ways (e.g., according to the causative organism), the most widely recognized and clinically effective way is to classify pneumonia as?

Answer 22

• Bacteria, viruses, Mycoplasma organisms, fungi,
• community-acquired or hospital-acquired pneumonia. Classifying pneumonia is important because of the differences in the likely causative organisms and the selection of appropriate antimicrobial therapy

Question 23

Community-acquired pneu­monia (CAP) is an acute infection of the lung occurring in patients who have?
- The decision to treat the patient at home or admit him or her to the hospital is based on several factors such as the?

Answer 23

• not been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms
• patient’s age, vital signs, mental status, presence of co-morbid conditions, and current physiologic condition. Clinicians can use tools such as the CURB-65 scale to supplement clinical judgment

Question 24

Community-Acquired pneumonia treatment

Answer 24

Empiric antibiotic therapy should be started as soon as possible. It is the initiation of treatment before a definitive diagnosis or causative agent is confirmed, and should be started as soon as CAP is suspected. Empiric antibiotic administration is based on experience and knowledge of drugs known to be effective for the most likely causative agent

Question 25

Hospital-acquired pneumonia (HAP), also known as ______ pneumonia, is a pneumonia in a? - VAP pneumonia? - Once the diagnosis of HAP or VAP is made, treatment of pneumonia is initiated based on? - Antibiotic therapy can be? - Both HAP and VAP are associated with?

Answer 25

nosocomial pneumonia - nonintubated patient that begins 48 hours or longer after admission to hospital and was not present at the time of admission. - Ventilator-associated pneumonia (VAP), also a type of HAP, refers to pneumonia that occurs more than 48 hours after endotracheal intubation - based on known risk factors, early versus late onset, and probable organism. - Antibiotic therapy can be adjusted once the results of sputum cultures identify the exact pathogen. - longer hospital stays, increased associated costs, sicker patients, and increased risk of morbidity and mortality

Question 26

1) A major problem in treating pneumonia today is the development of? 2) Primary culprits include? 3) Risk factors for development of MDR pneumonia include? 4) Antibiotic susceptibility tests can identify MDR organisms. The virulence of these organisms can severely limit the?

Answer 26

1) multidrug-resistant (MDR) organisms. 2) methicillin-resistant Staphylococcus aureus and gram-negative bacilli. 3) advanced age, immunosuppression, history of antibiotic use, and prolonged mechanical ventilation. 4) Available and appropriate antimicrobial therapy. MDR organisms also increase the morbidity and mortality risks associated with pneumonia

Question 27

1) Aspiration pneumonia results from the abnormal entry of material from the? 2) Conditions that increase the risk of aspiration include? 3) With loss of consciousness, the?

Answer 27

1) mouth or stomach into the trachea and lungs 2) decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and insertion of nasogastric tubes with or without tube feeding 3) gag and cough reflexes are depressed, and aspiration is more likely to occur

Question 28

Aspiration pneumonia 1) The aspirated material triggers an? 2) most common form of aspiration pneumonia is a?

Answer 28

1) aspirated material (food, water, vomitus, or oropharyngeal secretions) triggers an inflammatory response. 2) primary bacterial infection. Typically, more than one organism is identified on sputum culture, including aerobes and anaerobes, since they both make up the flora of the oropharynx

Question 29

Aspiration pneumonia: 1) Until cultures are completed and results obtained, initial antibiotic therapy is based on an assessment of? 2) For patients who aspirate in hospitals, appropriate antibiotics should include coverage for both? 3) In contrast, aspiration of acidic gastric contents causes?

Answer 29

1) probable causative organism, severity of illness, patient factors (e.g., malnutrition, current use of antibiotic therapy), and ability to treat common community-acquired organisms. 2) gram-negative organisms and MRSA. 3) chemical (noninfectious) pneumonitis, which may not require antibiotic therapy. However, secondary bacterial infection can occur 48 to 72 hours later

Question 30

1) Necrotizing pneumonia is a rare complication of? 2) It is characterized by? 3) Although the exact pathophysiologic mechanisms involved are controversial, causative organisms include? 4) ____ ______commonly occur. 5) Signs and symptoms of necrotizing pneumonia include? 6) Treatment often includes?

Answer 30

1) bacterial lung infection 2) liquefaction and, in some situations, cavitation of lung tissue. This often occurs as a result of community-acquired pneumonia (CAP). 3) Staphylococcus, Klebsiella, and Streptococcus. Lung abscesses commonly occur. 4) Lung abscesses 5) immediate respiratory insufficiency and/or failure, leukopenia, and bleeding into the airways 6) Treatment often includes long-term antibiotic therapy and possible surgery

Question 31

1) Opportunistic pneumonia is inflammation and infection of the lower respiratory tract in? 2) Individuals at risk for opportunistic pneumonia include those with? 3) In addition to the risk of bacterial and viral pneumonia, the immunocompromised person may develop an infection from microorganisms that?

Answer 31

1) immunocompromised patients. 2) altered immune responses. This can include people with severe protein-calorie malnutrition or immunodeficiencies (e.g., human immunodeficiency virus [HIV] infection) and those receiving radiation therapy, chemotherapy, and any immunosuppressive therapy, including long-term corticosteroid therapy. 3) do not normally cause disease, such as Pneumocystis jiroveci (formerly carinii) and cytomegalovirus (CMV)

Question 32

Opportunistic pneumonia 1) P. jiroveci pneumonia (PJP) rarely occurs in the healthy individual but is the most common form of pneumonia in? 2) The onset is slow and subtle with symptoms of? 3) The chest x-ray usually shows? 4) In widespread disease, the lungs have? 5) PJP can be life-threatening, causing? 6) Infection can also spread to other organs, including? 7) Bacterial and viral pneumonias must first be ruled out because of the vague presentation of PJP. Although the causative agent is fungal, PJP does not respond to? 8) Treatment consists of a course of?

Answer 32

1) people with HIV disease. 2) fever, tachypnea, tachycardia, dyspnea, nonproductive cough, and hypoxemia. 3) diffuse bilateral infiltrates. 4) massive consolidation. 5) acute respiratory failure and death. 6) liver, bone marrow, lymph nodes, spleen, and thyroid. 7) does not respond to antifungal agents. 8) trimethoprim/sulfamethoxazole (Bactrim, Septra) either IV or orally depending on the severity of disease and the patient's response

Question 33

Opportunistic pneumonia 1) Cytomegalovirus CMV, a herpesvirus, can cause? 2) Most CMV infections are? 3) CMV is the most common life-threatening infectious complication after? 4) treatment?

Answer 33

1) viral pneumonia 2) asymptomatic or mild, but severe disease can occur in people with an impaired immune response 3) hematopoietic stem cell transplantation 4) Antiviral medications (e.g., ganciclovir [Cytovene], foscarnet [Foscavir], cidofovir) and high-dose immunoglobulin are used for treatment

Question 34

Pneumonia Pathophysiology Specific pathophysiologic changes related to pneumonia vary according to the offending organism, but the majority of organisms trigger an inflammatory response in the lungs. 1) Inflammation, characterized by an increase in? 2) Normal O2 transport is affected, leading to clinical manifestations of? 3) Consolidation, a feature typical of bacterial pneumonia, occurs when the? 4) Mucus production also increases, which can potentially? 5) Over time and with appropriate antibiotic therapy, what happens?

Answer 34

1) increase in blood flow and vascular permeability, activates neutrophils to engulf and kill the offending organisms. As a result, the inflammatory process attracts more neutrophils, edema of the airways occurs, and fluid leaks from the capillaries and tissues into alveoli. 2) hypoxia (e.g., tachypnea, dyspnea, tachycardia). 3) normally air-filled alveoli become filled with fluid and debris. 4) obstruct airflow and impair gas exchange even further. 5) macrophages lyse and process the debris, lung tissue is allowed to recover, and gas exchange returns to normal. Resolution and healing occur if there are no complications

Question 35

Clinical Manifestations for pneumonia 1) The most common presenting symptoms of pneumonia are? 2) Sputum may appear? 3) Viral pneumonia may initially be seen as?

Answer 35

1) cough, fever, chills, dyspnea, tachypnea, and pleuritic chest pain. The cough may or may not be productive. 2) green, yellow, or even rust colored (bloody). 3) influenza, with respiratory symptoms appearing and/or worsening 12 to 36 hours after onset

Question 36

Clinical manifestations for pneumonia | The older or debilitated patient may not have classic symptoms of pneumonia.

Answer 36

1) Confusion or stupor (possibly related to hypoxia) may be the only finding. 2) Hypothermia, rather than fever, may also be noted with the older patient. 3) Nonspecific clinical manifestations include diaphoresis, anorexia, fatigue, myalgias, and headache

Question 37

Pneumonia: On physical examination, what can be heard when auscultated? 2) If consolidation is present, what is noted? 3) Patients with pleural effusion may exhibit?

Answer 37

1) fine or coarse crackles may be auscultated over the affected region. 2) bronchial breath sounds, egophony (a change in the sound of the voice of the patient), and increased fremitus (vibration of the chest wall produced by vocalization) may be noted. 3) dullness to percussion over the affected area

Question 38

Pneumonia Complications develop more frequently in older individuals and those with underlying chronic diseases. Potential complications include the following:

Answer 38

• Atelectasis (collapsed, airless alveoli) of one or part of one lobe may occur. These areas may clear with effective deep breathing and coughing. • Pleurisy (inflammation of the pleura) may occur. • Pleural effusion (fluid in the pleural space) can occur. In most cases, the effusion is sterile and is reabsorbed in 1 to 2 weeks. Occasionally, effusions require aspiration by thoracentesis. • Bacteremia (bacterial infection in the blood) is more likely to occur in infections with Streptococcus pneumoniae and Haemophilus influenzae. • Pneumothorax can occur when air collects in the pleural space, causing the lungs to collapse. • Meningitis can be caused by Streptococcus pneumoniae. The patient with pneumonia who is disoriented, confused, or drowsy may have a lumbar puncture to evaluate the possibility of meningitis. • Acute respiratory failure is one of the leading causes of death in patients with severe pneumonia. Failure occurs when pneumonia damages the lungs' ability to facilitate the exchange of O2 and CO2 across the alveolar-capillary membrane. • Sepsis/septic shock can occur when bacteria within alveoli enter the bloodstream. Severe sepsis can lead to shock and multisystem organ dysfunction syndrome (MODS) (see Chapter 66). Lung abscess is not a common complication of pneumonia. However, it may occur with pneumonia caused by S. aureus and gram-negative organisms. Empyema, the accumulation of purulent exudate in the pleural cavity, occurs in less than 5% of cases and requires antibiotic therapy and drainage of the exudate by a chest tube or open surgical drainage

Question 39

Clinical manifestations main points for pneumonia

Answer 39

- Cough, fever, shaking, chills, tachypnea, pleurisy cp - Green, yellow or rust colored sputum - COMPLICATIONS * Pleurisy- inflammation in pleural space * Pleural effusion-fluid in pleural space * Atelectasis- collapsed alveoli * Bacteremia- blood infection * Empyema-pus in pleural space * Pericarditis-infection that moves to pericardium * Meningitis * Sepsis * Acute respiratory failure * Pneumothorax- collapsed lung

Question 40

Pneumonia diagnostic assessment

Answer 40

* History and physical examination * Chest x-ray * Gram stain of sputum * Sputum culture and sensitivity test * Pulse oximetry or ABGs (if indicated) * Complete blood count, WBC differential, and routine blood chemistries (if indicated) * Blood cultures (if indicated)

Question 41

Pneumonia Management

Answer 41

* Increased fluid intake (at least 3 L/day) * Balance between activity and rest * O2 therapy (if indicated)

Question 42

Pneumonia Drug Therapy

Answer 42

* Appropriate antibiotic therapy * Antipyretics * Analgesics

Question 43

Pneumonia Diagnostic Studies 1) often provide enough clinical information to make decisions about early treatment. 2) Chest x-ray often shows a typical pattern characteristic of the? 3) This may be used to obtain fluid samples from patients not responding to initial therapy

Answer 43

1) History, physical examination, and chest x-ray often provide enough clinical information to make decisions about early treatment. 2) Chest x-ray often shows a typical pattern characteristic of the infecting organism and is important in the diagnosis of pneumonia. X-ray may also show pleural effusions. 3) A thoracentesis and/or bronchoscopy with washings

Question 44

Pneumonia diagnostic studies: 1) sputum specimen for culture and Gram stain to identify the organism are obtained when and can they be delayed? 2) When are Blood cultures done? 3) Arterial blood gases (ABGs) may be obtained to assess for? 4) Leukocytosis occurs in the majority of patients with?

Answer 44

1) obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained. Delays in antibiotic therapy can increase the risk of morbidity and mortality. 2) Blood cultures are done for patients who are seriously ill. 3) hypoxemia (partial pressure of O2 in arterial blood [PaO2] less than 80 mm Hg), hypercapnia (partial pressure of carbon dioxide in arterial blood [PaCO2] greater than 45 mm Hg), and acidosis (pH <7.35). 4) bacterial pneumonia; the white blood cell (WBC) count is usually greater than 15,000/µL (15 × 109/L) with the presence of bands (immature neutrophils)

Question 45

Pneumonia Interprofessional Care 1) Pneumococcal vaccine is used to prevent? 2) Prompt treatment with the appropriate antibiotic is essential. Antibiotics are highly effective for both? 3) In uncomplicated cases, the patient responds to drug therapy within? 4) Indications of improvement include? 5) A repeat chest x-ray may be obtained in?

Answer 45

1) Streptococcus pneumoniae 2) bacterial and mycoplasma pneumonia. 3) 48 to 72 hours 4) decreased temperature, improved breathing, and reduced chest discomfort. Abnormal physical findings can last more than 7 days. 5) 6 to 8 weeks to assess for resolution

Question 46

Pneumonia interprofessional Care 1) In addition to antibiotic therapy, supportive measures are individualized to the patient's needs. These may include? 2) Although cough suppressants, mucolytics, bronchodilators, and corticosteroids are often prescribed as adjunctive therapy, the use of these drugs is controversial. However, they may be prescribed for patients with?

Answer 46

1) O2 therapy to treat hypoxemia, analgesics to relieve chest pain, and antipyretics (e.g., aspirin, acetaminophen) for elevated temperature. 2) underlying chronic conditions.

Question 47

Pneumonia: Individualize rest and activity to each patient's tolerance. Benefits of mobility include?

Answer 47

improved diaphragm movement and chest expansion, mobilization of secretions, and prevention of venous stasis.

Question 48

Pneumonia: Currently, no definitive treatment exists for the majority of viral pneumonias. As identified earlier, care is generally supportive. In most circumstances, viral pneumonia is self-limiting and will often resolve in?

Answer 48

resolve in 3 to 4 days. Antiviral therapy may be used to treat pneumonia caused by influenza (e.g., 504oseltamivir, zanamivir) and a few other viruses (e.g., acyclovir [Zovirax] for herpes simplex virus)

Question 49

Drug therapy for pneumonia: 1) For all types of pneumonia, empiric antibiotic therapy is based on whether the patient has? 2) The prevalence and resistance patterns of MDR pathogens vary among localities and institutions. Therefore the antibiotic regimen must be adapted to? 3) Multiple regimens exist, but all should initially include antibiotics that are effective against?

Answer 49

1) risk factors for MDR organisms. 2) local patterns of antibiotic resistance. 3) both resistant gram-negative and resistant gram-positive organisms

Question 50

Pneumonia: 1) Clinical improvement usually occurs in? 2) Patients who deteriorate or fail to respond to therapy require?

Answer 50

1) 3 to 5 days 2) aggressive reevaluation to assess for noninfectious etiologies, complications, coexisting infectious processes, or pneumonia caused by a drug-resistant pathogen

Question 51

Pneumonia drug therapy: 1) IV antibiotic therapy should be switched to oral therapy as soon as the patient is? 2) Stable patients do not need to be? 3) Total treatment time for patients with CAP should be a minimum of? 4) Longer treatment time may be needed if initial therapy was?

Answer 51

1) hemodynamically stable, is improv­ing clinically, is able to ingest oral medication, and has a functioning gastrointestinal tract. 2) observed in the hospital and can be discharged to home on oral antibiotics. 3) 5 days, and the patient should be afebrile for 48 to 72 hours before stopping treatment. However, you need to emphasize the importance of completing the full course of antibiotic treatment. 4) not active against the identified pathogen or complications occur

Question 52

Pneumonia Nutritional Therapy. 1) Hydration is important in the? 2) Individualize and carefully monitor fluid intake. When is IV administration of fluids and electrolytes necessary? 3) Weight loss may occur in patients with pneumonia because of?

Answer 52

1) supportive treatment of pneumonia to prevent dehydration and to thin and loosen secretions. 2) If the patient is an older adult, has heart failure, or has a known preexisting respiratory condition 3) increased metabolic needs and difficulty eating due to nonspecific abdominal complaints or shortness of breath. Small, frequent meals are easier for dyspneic patients to tolerate. Offer foods high in calories and nutrients

Question 53

Pneumonia diagnostic studies main points

Answer 53

- Hx and physical - CXR, sputum, lab tests * CBC * WBC * Blood cultures * ABGs

Question 54

Pneumonia collaborative care main points

Answer 54

- Vaccinations - ABX therapy for bacterial pneumonia - O2 - Analgesics - Antipyretics for fever control - Cough suppressants - Bronchodilators - Corticosteroids

Question 55

Nursing management for pneumonia main points

Answer 55

- Assessment - Dx – impaired gas exchange, ineffective breathing, pain - Health promotion

Question 56

Pneumonia Subjective Data: Important Health Information 1) Past health history: 2) Medications: 3) Surgery or other treatments:

Answer 56

1) Past health history: Lung cancer, COPD, diabetes mellitus, chronic debilitating disease, malnutrition, altered consciousness, immunosuppression, exposure to chemical toxins, dust, or allergens 2) Medications: Antibiotics, corticosteroids, chemotherapy, or any immunosuppressants 3) Surgery or other treatments: Recent abdominal or thoracic surgery, splenectomy, endotracheal intubation, or any surgery with general anesthesia. Tube feedings

Question 57

Pneumonia Functional Health Patterns 1) Health perception–health management: 2) Nutritional-metabolic: 3) Activity-exercise: 4) Cognitive-perceptual:

Answer 57

1) Health perception–health management: Cigarette smoking, alcoholism; recent upper respiratory tract infection, malaise 2) Nutritional-metabolic: Anorexia, nausea, vomiting. Chills 3) Activity-exercise: Prolonged bed rest or immobility. Fatigue, weakness. Dyspnea, cough (productive or nonproductive). Nasal congestion 4) Cognitive-perceptual: Pain with breathing, chest pain, sore throat, headache, abdominal pain, muscle aches

Question 58

Pneumonia Objective Data | General

Answer 58

Fever, restlessness or lethargy. Splinting of affected area

Question 59

Pneumonia Objective data: Respiratory

Answer 59

Tachypnea, pharyngitis, asymmetric chest movements or retraction, decreased excursion, nasal flaring. Use of accessory muscles (neck, abdomen). Crackles, friction rub on auscultation, dullness on percussion over consolidated areas, increased tactile fremitus on palpation. Pink, rusty, purulent, green, yellow, or white sputum (amount may be scant to copious)

Question 60

Pneumonia objective data: Cardiovascular

Answer 60

Tachycardia

Question 61

Pneumonia objective data: Neurologic

Answer 61

Changes in mental status, ranging from confusion to delirium

Question 62

Pneumonia objective data: Possible Diagnostic Findings

Answer 62

1) Leukocytosis. 2) Abnormal ABGs with ↓ or normal PaO2, ↓ or normal PaCO2, and ↑ or normal pH initially, and later ↓ PaO2, ↑ PaCO2, and ↓ pH 3) Positive sputum on Gram stain and culture. 4) Patchy or diffuse infiltrates, abscesses, pleural effusion, or pneumothorax on chest x-ray

Question 63

Nursing diagnoses for the patient with pneumonia may include, but are not limited to, the following:

Answer 63

* Impaired gas exchange related to fluid and exudate accumulation within the alveoli and surrounding lung tissue * Ineffective breathing pattern related to inflammation and chest discomfort * Acute pain (chest) related to inflammation and ineffective pain management and/or comfort measures * Activity intolerance related to chest discomfort, inflammation, shortness of breath, generalized weakness

Question 64

Pneumonia Planning | The overall goals are that the patient with pneumonia will have?

Answer 64

(1) clear breath sounds (2) normal breathing patterns (3) no signs of hypoxia (4) normal chest x-ray (5) normal white blood cell (WBC) count (6) absence of complications related to pneumonia

Question 65

Pneumonia Health Promotion. 1) To reduce the risk of pneumonia, teach individuals to practice good health habits, such as frequent? 2) Avoidance of cigarette smoke is one of the most important health-promoting behaviors. If possible, avoid exposure to people with? 3) Encourage those at risk for pneumonia (e.g., chronically ill, older adult) to obtain both? 4) What are priority interventions?

Answer 65

1) hand washing, proper nutrition, adequate rest, regular exercise, and coughing or sneezing into the elbow rather than hands. 2) URIs. If a URI occurs, it requires prompt attention with supportive measures (e.g., rest, fluids). If symptoms persist for longer than 7 days, the person should seek medical care. 3) influenza and pneumococcal vaccines 4) Identifying patients at risk and taking measures to prevent pneumonia are priority interventions

Question 66

Pneumonia Health promotion: 1) In the acute care setting, place the patient with altered consciousness in? 2) In the ICU, strict adherence to all aspects of the?

Answer 66

1) positions (e.g., side-lying, upright) that will prevent or minimize the risk of aspiration. Turn and reposition the patient at least every 2 hours to facilitate adequate lung expansion and mobilization of secretions. Encourage and assist with ambulation and positioning into a chair. 2) ventilator bundle, a group of interventions aimed at reducing the risk of VAP, has been shown to significantly reduce VAP

Question 67

Pneumonia Health promotion 1) For the patient who has difficulty swallowing and needs assistance in eating, drinking, and taking medication to prevent aspiration, elevate the? 2) Assess for ____before giving food or fluids. 3) Patients who have orogastric or nasogastric tubes are at risk for aspiration pneumonia. Although feeding tubes are small, any interruption in the integrity of the lower esophageal sphincter can allow? 4) To prevent aspiration?

Answer 67

1) patient's head-of-bed to at least 30 degrees and have the patient sit up for all meals. 2) Assess for a gag reflex before giving food or fluids. 3) reflux of gastric contents. 4) elevate the head of the bed to at least 30 degrees and monitor gastric residual volumes

Question 68

Pneumonia health promotion: 1) Patients with impaired mobility from any cause need assistance with? 2) Observe the patient's skin and all pressure points for any evidence of? 3) How to reduce the incidence of pneumonia in postoperative patients? 4) Treat pain to a?

Answer 68

1) turning and moving as well as encouragement to breathe deeply at frequent intervals. 2) redness or breakdown, especially the sacrum and coccyx. 3) Early mobilization, the use of an incentive spirometer, and twice-daily oral hygiene with chlorhexidine swabs 4) comfort level that permits the patient to deep breathe and cough but yet remain awake and alert and achieve optimum mobility

Question 69

Pneumonia health promotion: 1) Practice strict medical asepsis and adherence to infection control guidelines to reduce the incidence of? 2) Staff and visitors should wash their hands on entering and leaving the patient's room. Staff must wash or use sanitizing hand gel? 3) Use strict sterile aseptic technique when? 4) Avoid inappropriate use of antibiotics to prevent?

Answer 69

1) health care–associated infection (HAI). 2) before and after providing care and on removing gloves. 3) suctioning the patient's trachea, and use caution when handling ventilator circuits, tracheostomy tubing, and nebulizer circuits that can become contaminated from patient secretions. 4) development of drug-resistant organisms

Question 70

Pneumonia Acute Care. 1) Although many patients with pneumonia are treated on an outpatient basis, the nursing care plan for a patient with pneumonia applies to? 2) Essential nursing care for patients with pneumonia includes? 3) Along with physical assessment (including pulse oximetry monitoring), prompt? 4) What measures are part of the nursing management? 5) Collaborate with?

Answer 70

1) both individuals at home and in-hospital patients. 2) monitoring physical assessment parameters, providing treatment, and monitoring the patient's response to treatment. 3) collection of specimens and initiation of antibiotics are critical. 4) O2 therapy, hydration, nutritional support, breathing exercises, early ambulation, and therapeutic positioning 5) respiratory therapists for assistance in monitoring the patient's condition and with physical therapy for postural drainage and chest percussion

Question 71

Pneumonia Ambulatory Care. 1) Teach the patient about the importance of taking every dose of the? 2) Instruct the patient to drink plenty of? 3) What may help the patient breathe easier? 4) Tell patients that it may be several weeks before their? 5) Explain that a follow-up chest x-ray may be done in? 6) A prolonged period of convalescence may be necessary for?

Answer 71

1) prescribed antibiotic, any drug-drug and food-drug interactions for the prescribed antibiotic, and the need for adequate rest to facilitate recovery. 2) liquids (at least 6 to 10 glasses/day, unless contraindicated) and to avoid alcohol and smoking. 3) A cool mist humidifier or warm bath 4) usual vigor and sense of well-being return. 5) 6 to 8 weeks to evaluate resolution of pneumonia. 6) older adult or chronically ill patient.

Question 72

Pneumonia Evaluation

Answer 72

The expected outcomes are that the patient with pneumonia will have • Effective respiratory rate, rhythm, and depth of respirations • Lungs clear to auscultation

Question 73

TB Main points

Answer 73

- Infectious- leading cause of death in HIV pts - Spread person to person via droplets - MDR-TB??? Multi-drug resistant - Clinical manifestations- * 2-3 weeks after infection- fever, malaise anorexia, unexplained weight loss, low-grade fevers and night sweats - Hemoptysis- <10%- late symptom

Question 74

Tuberculosis 1) Tuberculosis (TB) is an infectious disease caused by? 2) It usually involves the? 3) The CDC reports that more than 2 billion people (one third of the world's population) are infected with TB. It is the leading cause of mortality in patients with? 4) The incidence of TB worldwide declined until the mid-1980s when HIV disease emerged. The major factors contributing to the resurgence of TB were? 5) Although the prevalence of TB has increased in Europe, it has steadily declined in the United States since?

Answer 74

1) Mycobacterium tuberculosis. 2) lungs, but any organ can be infected, including brain, kidneys, and bones. 3) HIV infection. 4) (1) high rates of TB among patients with HIV infection and (2) the emergence of MDR strains of M. tuberculosis. 5) reaching a resurgence peak in 1992

Question 75

1) TB occurs disproportionately in the? 2) People most at risk include the? 3) Immunosuppression from any etiology (e.g., HIV infection, malignancy, long-term corticosteroid use) increases the?

Answer 75

1) poor, underserved, and minorities. 2) homeless, residents of inner-city neighborhoods, foreign-born people, those living or working in institutions (long-term care facilities, prisons, shelters, hospitals), IV injecting drug users, poor people, and those with poor access to health care. 3) risk of active TB infection

Question 76

TB: 1) Once a strain of M. tuberculosis develops resistance to two of the most potent first-line antituberculous drugs (e.g., isoniazid [INH], rifampin [Rifadin]), it is defined as? 2) Extensively drug-resistant TB (XDR-TB) occurs when the organism is? 3) Resistance results from several problems, including?

Answer 76

1) multidrug-resistant tuberculosis (MDR-TB) 2) resistant to any of the fluoroquinolones plus any injectable antibiotic agent. 3) incorrect prescribing, lack of public health case management, and patient nonadherence to the prescribed regimen

Question 77

Etiology and Pathophysiology 1) M. tuberculosis is a gram-positive, acid-fast bacillus (AFB) that is usually spread from person to person via? 2) A process of evaporation leaves small droplet nuclei, 1 to 5 µm in size, suspended in the air for? 3) These bacteria are then inhaled by another person. TB is not highly infectious, as transmission usually requires? 4) The disease cannot be spread by?

Answer 77

1) airborne particles expectorated when breathing, talking, singing, sneezing, and coughing. 2) minutes to hours. 3) close, frequent, or prolonged exposure. 4) touching, sharing food utensils, kissing, or any other type of physical contact

Question 78

TB: - Factors that influence the likelihood of transmission include? - Once inhaled, these small particles lodge in?

Answer 78

(1) number of organisms expelled into the air (2) concentration of organisms (small spaces with limited ventilation would mean higher concentration) (3) length of time of exposure (4) immune system of the exposed person. - bronchioles and alveoli. A local inflammatory reaction occurs, and the focus of infection is established. This is called the Ghon lesion or focus, which represents a calcified TB granuloma, the hallmark of a primary TB infection. The formation of a granuloma is a defense mechanism aimed at walling off the infection and preventing further spread. Replication of the bacillus is inhibited and the infection is stopped.

Question 79

1) Most immunocompetent adults infected with TB are able to completely kill the mycobacteria. Some people contain the mycobacteria in a nonreplicating dormant state. Of these individuals, ____% develop active TB infection when the bacteria begin to multiply months or years later. 2) M. tuberculosis is aerophilic (O2 loving) and thus has an affinity for the lungs. However, the infection can spread via the?

Answer 79

1) 5% to 10% 2) lymphatic system and find favorable environments for growth in other organs, including the cerebral cortex, spine, epiphyses of the bone, and adrenal glands.

Question 80

Classification Several systems can be used to classify TB. The American Thoracic Society classifies TB based on development of the disease. TB can also be classified according to?

Answer 80

(1) its presentation (primary, latent, or reactivated) | (2) whether it is pulmonary or extrapulmonary

Question 81

Primary TB infection occurs when the bacteria are?

Answer 81

inhaled and initiate an inflammatory reaction. The majority of people mount effective immune responses to encapsulate these organisms for the rest of their lives, preventing primary infection from progressing to disease.

Question 82

Latent TB infection (LTBI) occurs in a person who does not have active TB disease. 1) People with LTBI have a? 2) These individuals can? 3) What can precipitate the reactivation of LTBI?

Answer 82

1) positive skin test but are asymptomatic. 2) These individuals cannot transmit the TB bacteria to others but can develop active TB disease at some point. 3) Immunosuppression, diabetes mellitus, poor nutrition, aging, pregnancy, stress, and chronic disease

Question 83

TB: 1) If the initial immune response is not adequate, the body cannot contain the organisms. As a result, the bacteria? 2) What is primary TB? 3) Individuals co-infected with HIV are at greatest risk for? 4) Post-primary TB, or reactivation TB, is defined as? 5) If the site of TB is pulmonary or laryngeal, the individual is considered?

Answer 83

1) replicate and active TB disease results. 2) When active disease develops within the first 2 years of infection, it is termed primary TB. 3) developing active TB. 4) TB disease occurring 2 or more years after the initial infection. 5) infectious and can transmit the disease to others.

Question 84

Clinical Manifestations of TB 1) Symptoms of pulmonary TB usually do not develop until? 2) The characteristic pulmonary manifestation is an? 3) Active TB disease may initially manifest with constitutional symptoms such as? 4) Dyspnea is a late symptom that may signify? 5) Hemoptysis occurs?

Answer 84

1) 2 to 3 weeks after infection or reactivation. 2) initial dry cough that frequently becomes productive with mucoid or mucopurulent sputum. 3) fatigue, malaise, anorexia, unexplained weight loss, low-grade fevers, and night sweats. 4) considerable pulmonary disease or a pleural effusion. 5) in less than 10% of patients with TB, is also a late symptom.

Question 85

Clinical manifestations of TB: 1) Sometimes TB has a more acute, sudden presentation. The patient may have a? 2) Auscultation of the lungs may be?

Answer 85

1) high fever, chills, generalized flu-like symptoms, pleuritic pain, and a productive cough. 2) normal or reveal crackles, and/or adventitious (such as bronchial) breath sounds

Question 86

Clinical manifestations of TB: 1) Immunosuppressed (e.g., HIV-infected) people and older adults are? 2) In patients with HIV, classic manifestations of TB such as fever, cough, and weight loss may be wrongly attributed to? 3) Clinical manifestations of respiratory problems in patients with HIV must be carefully investigated to determine the cause. A change in cognitive function may be the only initial presenting sign of TB in?

Answer 86

1) less likely to have fever and other signs of an infection. 2) P. jiroveci pneumonia (PJP) or other HIV-associated opportunistic diseases. 3) an older person

Question 87

1) The clinical manifestations of extrapulmonary TB depend on? - For example, renal TB can cause? - Bone and joint TB may cause? - TB meningitis may cause?

Answer 87

1) the organs infected. - renal TB: dysuria and hematuria - Bone and joint TB: severe pain - Headaches, vomiting, and lymphadenopathy may be present with TB meningitis.

Question 88

TB: 1) Diagnostic tests 2) Complications

Answer 88

1) Diagnostic tests - TB skin test - CXR, bacterial studies- sputum smears 2) Complications - Can heal if treated correctly - Severe pulmonary damage if treated poorly - TB in central nervous system- meningitis - Abdominal TB- peritonitis - Bacteria travels through the blood stream

Question 89

Complications of TB 1) Appropriately treated pulmonary TB typically heals without complications, except for? 2) Significant pulmonary damage, although rare, can occur in patients who are?

Answer 89

1) scarring and residual cavitation within the lung. | 2) poorly treated or who do not respond to TB treatment.

Question 90

- Miliary TB is the widespread dissemination of the mycobacterium. The bacteria are spread via? - The infection is characterized by a large amount of? - It can occur as a result of? - Clinical manifestations of miliary TB slowly progress over a period of days, weeks, or even months. Symptoms vary depending on the organs that are affected. What is present and what may also occur?

Answer 90

- bloodstream to several distant organs. - large amount of TB bacilli and may be fatal if left untreated. - primary disease or reactivation of latent infection. - Fever, cough, and lymphadenopathy are present. Hepatomegaly and splenomegaly may also occur

Question 91

Pleural TB, a specific type of extrapulmonary TB, can result from either primary disease or reactivation of a latent infection. 1) What manifestations are common? 2) A pleural effusion is caused by? 3) Empyema is less common than effusion but may occur from? 4) Diagnosis is confirmed b?

Answer 91

1) Chest pain, fever, cough, and presence of a unilateral pleural effusion are common. 2) bacteria in the pleural space, which trigger an inflammatory reaction and a pleural exudate of protein-rich fluid. 3) may occur from large numbers of tubercular organisms in the pleural space. 4) AFB cultures and a pleural biopsy.

Question 92

TB Complications: Because TB can infect organs throughout the body, various acute and long-term complications can result. 1) TB in the spine (Pott's disease) can lead to? 2) Central nervous system TB can cause? 3) Abdominal TB can lead to? 4) What may also be affected?

Answer 92

1) (Pott's disease) can lead to destruction of the intervertebral disc and adjacent vertebrae. 2) Central nervous system TB can cause severe bacterial meningitis. 3) Abdominal TB can lead to peritonitis, especially in HIV-positive patients. 4) The kidneys, adrenal glands, lymph nodes, and urogenital tract may also be affected.

Question 93

Diagnostic Studies Tuberculin Skin Test. 1) The tuberculin skin test (TST) (Mantoux test) using purified protein derivative (PPD) is the standard method to screen people for M. tuberculosis. The test is administered by injecting? 2) The test is read by? 3) Induration, a palpable, raised, hardened area or swelling (not redness) at the injection site means? 4) The indurated area (if present) is measured and recorded in millimeters. Based on the size of the induration and the risk factors, an interpretation is made according to standards for determining a positive test reaction. Because the immunocompromised patient may have a decreased response to TST, what size induration is considered positive?

Answer 93

1) 0.1 mL of PPD intradermally on the ventral surface of the forearm. 2) inspection and palpation 48 to 72 hours later for the presence or absence of induration. 3) the person has been exposed to TB and has developed antibodies. (Antibody formation occurs 2 to 12 weeks after initial exposure to the bacteria.) 4) smaller induration reactions (5 mm or larger) are considered positive

Question 94

Tuberculin Skin Test 1) Some people who were previously infected with TB may have a waning immune response to the TST, resulting in? 2) However, repeating the TST may stimulate (boost) the body's ability to react to tuberculin in future tests. A positive reaction to a subsequent test could then be misinterpreted as a new infection, rather than the result of the boosted reaction to an old infection. To prevent misinterpretation in future testing, a?

Answer 94

1) a false negative result. 2) two-step testing process is recommended for initial testing for health care workers (who get repeated testing) and for individuals who have a decreased response to allergens. A previously negative two-step TST ensures that any future positive results can be accurately interpreted as being caused by a new infection

Question 95

TB Diagnostic tests: Interferon-γ Release Assays. 1) Interferon-γ (INF-gamma) release assays (IGRAs) provide another screening tool for TB. IGRAs are? 2) IGRAs offer several advantages over the TST in that they? 3) Current guidelines suggest that both tests are viable options and that selection should be based on context and reasons for testing. Neither IGRAs nor TST can distinguish between?

Answer 95

1) blood tests that detect INF-gamma release from T cells in response to Mycobacterium tuberculosis. Examples of IGRAs include QuantiFERON-TB test and the T-SPOT.TB test. Test results are available in a few hours. 2) require only one patient visit, are not subject to reader bias, have no booster phenomenon, and are not affected by prior bacillus Calmette-Guérin (BCG) vaccination. The cost of an IGRA is substantially higher than the TST. 3) LTBI and active TB infection. LTBI can only be diagnosed by excluding active TB

Question 96

TB Chest X-ray. 1) Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely on chest x-ray findings. The chest x-ray may appear normal in a patient with TB. Findings suggestive of TB include? 2) Other diseases, such as sarcoidosis, can?

Answer 96

1) upper lobe infiltrates, cavitary infiltrates, lymph node involvement, and pleural and/or pericardial effusion. 2) Other diseases, such as sarcoidosis, can mimic the appearance of TB

Question 97

TB Bacteriologic Studies. 1) Three consecutive sputum specimens obtained on different days are sent for smear and culture. The initial testing involves a microscopic examination of stained sputum smears for AFB. However, the definitive diagnosis of TB requires the? 2) Treatment is warranted pending the culture results for patients in whom clinical suspicion of TB is high. Samples for other suspected TB sites can be collected from?

Answer 97

1) demonstration of tubercle bacilli bacteriologically by sputum culture, which can take up to 8 weeks. 2) gastric washings, cerebrospinal fluid (CSF), or fluid from an effusion or abscess

Question 98

TB Interprofessional Care 1) Most patients with TB are treated on an outpatient basis. Many people can continue to work and maintain their lifestyles with few changes. Patients with sputum smear–positive TB are generally considered infectious for the? 2) Advise these patients to restrict? 3) Remind them of the importance of good handwashing and oral hygiene. Hospitalization may be needed for the severely ill or debilitated. The mainstay of TB treatment is?

Answer 98

1) first 2 weeks after starting treatment. 2) restrict visitors and avoid travel on public transportation and trips to public places. 3) drug therapy. Promoting and monitoring adherence are critical for treatment to be successful

Question 99

Pulmonary Tuberculosis | Diagnostic Assessment

Answer 99

* History and physical examination * Tuberculin skin test (TST) * QuantiFERON-TB test * Chest x-ray * Bacteriologic studies * Sputum smear for acid-fast bacilli (AFB) * Sputum culture

Question 100

Pulmonary Tuberculosis | Management

Answer 100

* Long-term treatment with antimicrobial drugs * Follow-up AFB smears, cultures, and chest x-rays * Follow-up care involving community health care workers and social workers

Question 101

Drug Therapy Active TB Disease. 1) Because of the growing prevalence of MDR-TB, it is important to manage the patient with active TB aggressively. Drug therapy is divided into two phases: 2) In most circumstances the treatment regimen for patients with previously untreated TB consists of a 2-month initial phase with four drugs? 3) If drug susceptibility test results indicate that the bacteria are susceptible to all drugs, ethambutol may be discontinued. If pyrazinamide cannot be included in the initial phase (because of liver disease, pregnancy, etc.), the? 4) If the patient develops a toxic reaction to the primary drugs, other drugs can be used, including rifabutin and rifapentine (Priftin). Treatment for drug-resistant TB is guided by? 5) MDR-TB therapy typically includes a fluoroquinolone and an injectable antibiotic. Bedaquiline (Sirturo), a relatively new drug, is used in combination with other drugs to treat MDR-TB. It works by inhibiting an?

Answer 101

1) initial and continuation. 2) isoniazid, rifampin, pyrazinamide, and ethambutol 3) remaining three drugs are used for the initial phase. 4) sensitivity testing. 5) enzyme needed for M. tuberculosis to replicate.

Question 102

TB: 1) Directly observed therapy (DOT) involves providing the? 2) To ensure adherence, it is the preferred strategy for all patients with TB, especially for those at risk for nonadherence. Nonadherence is a major factor in the? 3) Many individuals do not adhere to the treatment program in spite of understanding the disease process and value of treatment. DOT is an expensive but essential public health measure. The risk for reactivation of TB and MDR-TB is increased in patients who?

Answer 102

1) antituberculosis drugs directly to patients and watching as they swallow the medications. 2) emergence of multidrug resistance and treatment failures. 3) do not complete the full course of therapy. In many areas, the public health nurse administers DOT at a clinic site.

Question 103

TB: 1) When DOT is not used, fixed-dose combination drugs may enhance adherence. Combinations of isoniazid and rifampin (Rifamate) and of isoniazid, rifampin, and pyrazinamide (Rifater) are available to simplify therapy. The therapy for people with HIV follows the same therapy options. However, alternative regimens that include once-weekly isoniazid plus rifapentine continuation dosing in any HIV-infected patient and twice-weekly isoniazid plus rifampin or rifabutin should not be used if CD4+ counts are less than ____ 2) HCPs must also be alert for possible drug interactions between?

Answer 103

1) should not be used if CD4+ counts are less than 100/µL. | 2) antiretrovirals (used to treat HIV) and rifamycins

Question 104

TB: 1) Teaching patients about the adverse effects of these drugs and when to seek prompt medical attention is critical. The major side effect of isoniazid, rifampin, and pyrazinamide is? 2) Baseline liver function tests (LFTs) are done at the?

Answer 104

1) nonviral hepatitis. | 2) start of treatment and monitored closely (e.g., every 2 to 4 weeks), if results are abnormal.

Question 105

Latent Tuberculosis Infection. 1) In people with LTBI, drug therapy helps prevent a TB infection from developing into active TB disease. Because a person with LTBI has fewer bacteria, treatment is much easier. Usually it involves the use of? 2) The standard treatment regimen for LTBI is 9 months of daily isoniazid. It is an effective and inexpensive drug that the patient can take orally. The 9-month regimen is more effective, but adherence issues may make a 6-month regimen preferable. For HIV patients and those with fibrotic lesions on chest x-ray, what is given? 3) An alternative 3-month regimen of isoniazid and rifapentine may be used for otherwise healthy patients who are not presumed to be infected with drug-resistant bacilli. Four-month therapy with rifampin may be indicated if the patient is resistant to? 4) Because of severe liver injury and deaths, the CDC does not recommend the combination of?

Answer 105

1) only one drug that is needed 2) isoniazid is given for 9 months 3) resistant to isoniazid. 4) rifampin and pyrazinamide for treatment of LTBI

Question 106

TB: Bacille-Calmette-Guerin Vaccine. 1) Bacille-Calmette-Guerin (BCG) vaccine is a live, attenuated strain of Mycobacterium bovis. The vaccine is given to infants in parts of the world with a high prevalence of TB. In the United States it is typically not recommended because of the low risk of infection, the vaccine's variable effectiveness against adult pulmonary TB, and potential interference with TB skin test reactivity. The BCG vaccination can result in a false-positive TST. IGRA results are not affected. The BCG vaccine should be considered only for select individuals who meet specific criteria (e.g., health care workers who are continually exposed to patients with MDR-TB and when infection control precautions are not successful).

Answer 106

- vaccine is given to infants where high prevalence of TB, not in US - result in false-positive TST, IGRA results not affected - considered only for individuals who meet criteria (e.g., health care workers who are continually exposed to patients with MDR-TB and when infection control precautions are not successful)

Question 107

Nursing Management: Tuberculosis Nursing Assessment 1) Ask the patient about a previous history of? 2) Obtain a social and occupational history to determine? 3) Assess the patient for what s/s? 4) If the patient has a productive cough, when should you get a sputum specimen?

Answer 107

1) TB, chronic illness, or any immunosuppressive medications. 2) risk factors for transmission of TB. 3) productive cough, night sweats, temperature elevation, weight loss, pleuritic chest pain, and abnormal lung sounds. 4) early morning is the ideal time to collect sputum specimens for an AFB smear

Question 108

Nursing Diagnoses | Nursing diagnoses for the patient with TB may include, but are not limited to, the following:

Answer 108

* Ineffective breathing pattern related to decreased lung capacity * Ineffective airway clearance related to increased secretions, fatigue, and decreased lung capacity * Risk for infection (spread of infection to others) related to cough and sputum production, lack of knowledge of disease process, and social/economic circumstances * Noncompliance and ineffective health management related to lack of knowledge of disease process, lack of motivation, long-term nature of treatment, and lack of resources

Question 109

Planning | The overall goals are that the patient with TB will

Answer 109

(1) comply with the therapeutic regimen (2) have no recurrence of disease (3) have normal pulmonary function (4) take appropriate measures to prevent the spread of the disease

Question 110

TB Health Promotion 1) The ultimate goal is to? 2) Screening programs in known risk groups are of value in detecting individuals with TB. Treatment of LTBI reduces the? 3) The person with a positive TST should have a? 4) Individuals with a diagnosis of TB must be? 5) Programs to address the social determinants of TB are necessary to decrease transmission of TB. Reducing HIV infection, poverty, overcrowded living conditions, malnutrition, smoking, and drug and alcohol abuse can help minimize TB infection rates. Improving access to?

Answer 110

1) eradicate TB worldwide. 2) number of TB carriers in the community. 3) chest x-ray to assess for active TB disease. 4) reported to the public health authorities for identification and assessment of contacts and risk to the community. 5) health care and education is also important.

Question 111

Acute Care for TB Patients admitted to the emergency department or directly to the nursing unit with respiratory symptoms should be assessed for the possibility of TB. Those strongly suspected of having TB should

Answer 111

(1) be placed on airborne isolation (2) receive a medical workup, including chest x-ray, sputum smear, and culture (3) receive appropriate drug therapy. - Airborne infection isolation is indicated for the patient with pulmonary or laryngeal TB until the patient is noninfectious.

Question 112

Acute Care for TB Airborne infection isolation refers to isolation of patients infected with organisms spread by the airborne route. It requires a?

Answer 112

single-occupancy room with negative pressure and airflow of 6 to 12 exchanges per hour.

Question 113

Acute care for TB High-efficiency particulate air (HEPA) masks are worn whenever entering the patient's room. These masks are highly effective at protecting from small particles 5 µm or less in diameter. Because there are many different types of HEPA masks currently available, health care professionals should be “fit tested” each time a different brand or model of mask is used to ensure proper mask size. Otherwise, the CDC recommends that?

Answer 113

yearly mask “fit testing” is acceptable.20 To be effective, the mask must be molded to fit tightly around the nose and mouth.

Question 114

Acute care for TB 1) Teach patients to cover the nose and mouth with paper tissues every time they cough, sneeze, or produce sputum. The tissues should be? 2) Emphasize careful hand washing after handling sputum and soiled tissues. If patients need to be out of the negative-pressure room, they must wear a? 3) Identify and screen close contacts of the person with TB. Anyone testing positive for TB infection will undergo further evaluation and needs to be treated for?

Answer 114

1) tissues should be thrown into a paper bag and disposed of with the trash or flushed down the toilet. 2) standard isolation mask to prevent exposure to others. Minimize prolonged visitation to other parts of the hospital. 3) either LTBI or active TB disease.

Question 115

Ambulatory Care for TB 1) Patients who respond clinically are discharged home (even with positive cultures) if their household contacts have already been exposed and the patient is not posing a risk to others. A sputum specimen for AFB smear and culture should be obtained at a minimum of? 2) More frequent AFB smears may be useful to assess the?

Answer 115

1) monthly intervals until two consecutive specimens are negative on culture. 2) early response to treatment and provide an indication of infectious­ness. Negative cultures are needed to declare the patient not infectious.

Question 116

Ambulatory Care for TB | Teach the patient how to minimize exposure to close contacts and household members.

Answer 116

- Homes well ventilated, especially areas where infected person spends time. - While still infectious, patient should sleep alone - spend as much time as possible outdoors - minimize time in congregate settings or on public transportation.

Question 117

Ambulatory Care for TB Teach the patient and caregiver about adherence with the prescribed regimen. This is important, since most treatment failures occur because?

Answer 117

- patient neglects to take the drug, discontinues it prematurely, or takes it irregularly. - Strategies to improve adherence to drug therapy include teaching and counseling, reminder systems, incentives or rewards, contracts, and DOT.

Question 118

Ambulatory Care for TB Notification of the public health department is required. 1) The public health nurse is responsible for? 2) If adherence is an issue, the public health agency may be responsible for DOT. Most individuals can be considered adequately treated when?

Answer 118

1) follow-up on household contacts and assessment of the patient for adherence. 2) the therapy regimen has been completed and there is evidence of negative cultures, clinical improvement, and improvement on chest x-ray

Question 119

Ambulatory Care for TB 1) Because about 5% of individuals experience relapses, teach the patient to recognize the symptoms that indicate recurrence of TB. If these symptoms occur, the patient should? 2) Instruct the patient about certain factors that could reactivate TB, such as? 3) In some situations it is necessary to put the patient on anti-TB therapy. Because smoking is associated with poor outcomes in TB, patients should be?

Answer 119

1) seek immediate medical attention. 2) immunosuppressive therapy, malignancy, and prolonged debilitating illness. If the patient experiences any of these events, the HCP must be told so that TB can be closely monitored for reactivation. 3) encouraged to quit. Provide patients with teaching and resources to help them stop smoking.

Question 120

Evaluation. | The expected outcomes are that the patient with TB will have

Answer 120

* Resolution of the disease * Normal pulmonary function * Absence of any complications * No further transmission of TB

Question 121

Drug Therapy for Tuberculosis (TB) | Drug: rifampin (Rifadin)

Answer 121

Hepatitis, thrombocytopenia, orange discoloration of bodily fluids (sputum, urine, sweat, tears)

Question 122

For TB if a patient has difficulty of compliance for meds due to homelessness or other factors what should the nurse do?

Answer 122

Call social worker so the patient can keep taking the medications

Question 123

Collaborative care for TB main points

Answer 123

- Treat on out-patient basis - Nursing management * Assess for s/s * Health promotion- screening programs * Tb mask fit test * Follow prescribed regimen - Drug therapy- * Some medications are taken any where from 3-9 months

Question 124

Atypical mycobacteria - varieties - what does it cause?

Answer 124

- 30 varieties | - Doesn’t cause TB but pulmonary infections

Question 125

Atypical Mycobacteria 1) There are more than 30 varieties of acid-fast mycobacteria that do not cause TB but can cause? 2) Pulmonary disease is indistinguishable from TB clinically and radiologically but can be differentiated by? 3) Atypical mycobacteria are not airborne and not transmitted by droplets. They can be found in? 4) Mycobacterium avium complex (MAC), found in? 5) Only a small number of people exposed to the organism actually develop MAC lung disease. People who are? 6) Treatment is?

Answer 125

1) pulmonary disease, lymphadenitis, skin or soft tissue disease, or disseminated disease 2) bacteriologic culture. 3) tap water, soil, bird feces, and house dust. 4) aerosols generated from baths, hot spas, and swimming pools, is one cause of atypical mycobacteria pulmonary infection. 5) immunosuppressed (e.g., HIV/AIDS) or have chronic pulmonary disease are most susceptible. 6) similar to that for TB.

Question 126

``` Lung cancer Etiology Patho- Clinical manifestations- Diagnostic studies- Collaborative care- ```

Answer 126

- Etiology-80-90% from smoking - Patho- tumors arise from mutated epithelial cells - Clinical manifestations-non-specific/appear late - Diagnostic studies- CXR, CT/PET scan, MRI,labs - Collaborative care- * Surgery * Radiation * chemotherapy

Question 127

Pulmonary fungal infections

Answer 127

- Inhalation of spores | - Valley fever

Question 128

Lung abscess

Answer 128

Necrosis of lung tissue/cxr/atb therapy

Question 129

Nursing Management ofLung Cancer

Answer 129

- Assessment- anxiety level - Nursing DX * Ineffective airway clearance * Anxiety * Self-management * Ineffective breathing pattern * Impaired gas exchange - Health promotion- QUIT SMOKING!!

Question 130

Chest trauma 1) Pneumothorax- 2) Hemothorax- 3) Fractured ribs 4) Flail chest- - Chest surgeries

Answer 130

1) Pneumothorax-air enters pleural cavity 2) Hemothorax- blood enters pleural cavity 3) Fractured ribs 4) Flail chest-fx of several consecutive ribs in two or more separate places - Chest surgeries * Pre-op care * Thoracotomy-lateral incision * Post-op care

Question 131

Restrictive Respiratory Disorders 1) Pleural effusion- 2) Empyema- 3) Pleurisy- 4) Atelectasis- 5) Pulmonary fibrosis/sarcoidosis- 6) Pulmonary edema- 7) Pulmonary embolism- 8) Pulmonary hypertension- 9) Cor Pulmonary- 10) Lung transplant

Answer 131

1) Pleural effusion- fluid buildup 2) Empyema- pus in the pleural space/ pneumonia 3) Pleurisy-inflammation 4) Atelectasis-collapsed, airless alveoli 5) Pulmonary fibrosis/sarcoidosis-interstital lung disease 6) Pulmonary edema-fluid in alveoli/interstitial spaces 7) Pulmonary embolism-pulmonary artery blockage * 10% die within first hour/ 90% come from DVT’s 8) Pulmonary hypertension-elevated pulmonary artery pressure-sob/fatigue 9) Cor Pulmonary-enlargement of right ventricle- common cause COPD 10) Lung transplant