MS Exam #1 Review

Intro to Med-Surg Review Exam #1

​Professional Nursing Practice

• American Nurses Association Social Policy statement (2010): Nursing is “the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.”

• The World Health Organization (WHO, 2006) defines health in the preamble to its constitution: “state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity.”

Wellness

• Wellness: has been defined as equivalent to health

• Hood (2018): wellness has four components:

  • Capacity to perform to the best of ability

  • Ability to adjust and adapt to varying situations

  • Reported feeling of well-being

  • Feeling that “everything is together” and harmonious

​Maslow's Hierarchy of Needs

​Changing Patterns of Disease and Wellness

• Chronic disease account for 7 out of 10 leading causes of death (CDC, 2019)

• Cardiovascular, cancer, diabetes, chronic lung disease

• Nearly half of all adults have one diagnosed chronic condition

• 60 million have two or more chronic diseases (CDC, 2019)

​Evidence Based Practice

• Best practices derived from valid and reliable research studies

• Take into consideration the health care setting, patient preferences and values, and clinical judgment

• Identify and evaluate current literature and research and incorporate these findings into patient care (Melnyk & Fineout-Overholt, 2018)

• Evidence-Based Practice Bundles measurably improve patient outcomes

Health Promotion

• Best practices derived from valid and reliable research studies

• Take into consideration the health care setting, patient preferences and values, and clinical judgment

• Identify and evaluate current literature and research and incorporate these findings into patient care (Melnyk & Fineout-Overholt, 2018)

• Evidence-Based Practice Bundles measurably improve patient outcomes

Health Promotion and Technology

• Best practices derived from valid and reliable research studies

• Take into consideration the health care setting, patient preferences and values, and clinical judgment

• Identify and evaluate current literature and research and incorporate these findings into patient care (Melnyk & Fineout-Overholt, 2018)

• Evidence-Based Practice Bundles measurably improve patient outcomes

Pain

• Defined as “unpleasant sensory, emotional experience with actual or potential tissue damage”

• Personal and subjective experience

• Patient is the most reliable indicator of pain and essential component of pain assessment

• Most common reason for seeking health care

Types of Pain

• Acute pain: Differs from chronic by duration

  • Result of tissue damage; surgery; trauma

• Chronic pain: Can be time limited or last a lifetime

• Cancer

• Noncancer: peripheral neuropathy, back pain, osteoarthritis

• Breakthrough pain: chronic pain with acute exacerbations

• Nociceptive (physiologic) pain

  • Tissue injury

• Neuropathic (pathophysiologic) pain

• Damage to the peripheral or central nervous system

• Refer to Table 9-2

Multiple Select

Which are considered a tool for pain measurement?

• Numeric Rating

• Wong–Baker FACES

• Verbal descriptor

• Visual Analog

• Acuity Score

Multiple Choice

The nurse is caring for a patient who has been hospitalized on several occasions for lower abdominal pain related to Crohn's disease. How may this chronic pain be identified?

• It is attributable to a specific cause

• It is prolonged in duration

• It occurs rapidly and subsides with treatment

• It is separate from any central or peripheral pathology

Match

Match the following

• Pain receptors sensitive to noxious stimuli

• Nonsteroidal agents that decrease inflamation

• The only commercially available transdermal opioid medication

• Significantly increases a person's response to pain

• Chemicals known to inhibit the transmission or perception of pain

Nociceptors

NSAIDs

Fentanyl

Anxiety

Endorphins

• Nociceptors

• NSAIDs

• Fentanyl

• Anxiety

• Endorphins

Match

Match the following

• This substance, released in response to painful stimuli, causes vasodilation

• An inactive substance given in place of pain medication

• Medication administered directly into the subarachnoid space and cerebrospinal fluid

• Transcutaneous stimulation of ono-pain receptors in the same area of an injury

• Term used to describe a pain's rhythm

Histamine

Placebo

Epidural

TENS

Waning

• Histamine

• Placebo

• Epidural

• TENS

• Waning

​Nursing Process Framework

• Identify goals for pain management

• Establish nurse–patient relationship, teaching

• Provide physical care

• Manage anxiety related to pain

• Evaluate pain management strategies

​Adverse Effects of Analgesic Agents

• Respiratory depression

• Sedation

• Nausea, vomiting

• Constipation

• Pruritis

Drag and Drop

Pain can be defined according to its ​

Placeholder

, location and ​

Placeholder

Drag these tiles and drop them in the correct blank above

duration

etiology

complexity

nurse perception

Open Ended

Seven factors that directly influence a person's response to pain:

Open Ended

Identify seven factors a nurse needs to consider for complete pain assessment

Multiple Choice

A patient slipped and fell on the floor in the hospital room, causing a back injury, and the patient now reports pain. How will the nurse determine the pain is characteristic of acute pain?

• It does not respond well to treatment

• It is associated with a specific injury

• It serves no useful purpose

• It responds well to placebos

Multiple Choice

The patient develops respiratory depression after the nurse administers fentanyl for pain. Which medication can the nurse anticipate administering to counteract the effects of the fentanyl?

• Nalbuphine hydrochloride

• Morphine

• Naloxone

• Lidocaine

Match

Match the following

• Normal blood pH

• Average daily urinary output for an adult

• Cardiac effects of hyperkalemia usually present at this level

• The most common buffer system in the body

• Helps regulate calcium levels

7.35-7.45

1.5 L

8 mEq/L

bicarbonate-carbonic

Vitamin D

• 7.35-7.45

• 1.5 L

• 8 mEq/L

• bicarbonate-carbonic

• Vitamin D

Fluid and Electrolyte Balance

• Osmosis—the diffusion of water caused by fluid and solute concentration gradients

• Movement of fluid through capillary walls depends on

  • Hydrostatic pressure: exerted on walls of blood vessels

  • Osmotic pressure: exerted by protein in plasma

• Direction of fluid movement depends on differences of  hydrostatic pressure and osmotic pressure

• Nursing role: anticipate, identify, and respond to possible imbalances

​F/E Balance

• Osmosis: area of low solute concentration to area of high solute concentration

• Diffusion: solutes move from area of higher concentration to one of lower concentration

• Filtration: movement of water, solutes occurs from area of high hydrostatic pressure to area of low hydrostatic pressure 

• Active transport: Sodium–potassium pump

• Maintains higher concentration of extracellular sodium, intracellular potassium

Fluid Gain and Loss

Gain

• Healthy people gain fluids by drinking and eating

• Daily I&O of water are equal

Loss

• Kidney: urine output of 1mL/kg/hr

• Skin loss: sensible due to sweating and insensible due to fever, exercise, and burns

• Lungs: 300 mL everyday, greater with increased respirations

• GI tract: large losses due to diarrhea and fistulas

Homeostatic Mechanisms

• Kidney
  Renin–Angiotensin–Aldosterone System

• Antidiuretic Hormone

• Osmoreceptors

• Natriuretic Peptides

• Heart and Blood Vessels

• Lung

• Pituitary

• Adrenal

• Parathyroid

• Baroreceptors

Gerontologic Considerations

• Clinical manifestations of imbalance may be subtle

• Fluid deficit may cause delirium

• Decreased cardiac reserve

• Reduced renal function

• Dehydration is common

• Age-related thinning of the skin and loss of strength and elasticity

​Fluid Volume Deficit

• May occur alone or in combination with other imbalances

• Loss of extracellular fluid exceeds intake ratio of water

  • Electrolytes lost in same proportion as they exist in normal body fluids

• Dehydration

  • Not the same as FVD

  • Loss of water alone, with increased serum sodium levels

​Causes of Fluid Volume Deficit (FVD)

• Abnormal fluid losses

  • Vomiting, diarrhea, sweating, GI suctioning

• Decreased intake

  • Nausea, lack of access to fluids

• Third-space fluid shifts

  • Due to burns, ascites

• Additional causes

  • Diabetes insipidus, adrenal insufficiency, hemorrhage

• CAN DEVELOP RAPIDLY

Management of FVD

• Oral route is preferred

• IV for acute or severe losses

• Types of Solutions

  • Isotonic

  • Hypotonic

  • Hypertonic

  • Colloid

• Refer to Table 10-5

​Nursing Management

• I&O at least every 8 hours, sometimes hourly

• Daily weight

  • The most reliable indicator of fluid status

• Vital signs closely monitored

• Skin and tongue turgor, mucosa, urine output, mental status

• Measures to minimize fluid loss

• Administration of oral fluids

• Administration of parenteral fluids

​Fluid Volume Excess (FVE)

• Expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF

• Secondary to an increase in the total‐body sodium content

• Due to fluid overload or diminished homeostatic mechanisms

• Heart failure, kidney injury, cirrhosis of liver

• Contributing factors: Consumption of excessive amounts of table salt or other sodium salts

• Excessive administration of sodium-containing fluids

Management of FVE

• Diuretics

• Dialysis

• Nutritional

• Dietary restrictions of sodium
  I&O and daily weights; assess  lung sounds, edema, etc

• Monitor responses to medications—diuretics and parenteral fluids

• Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions

• Monitor, avoid sources of excessive sodium, including medications 

• Promote rest

Multiple Select

Which laboratory findings does the nurse determine are consistent with HYPOvolemia in a female patient? (SATA)

• Hematocrit level of >47%

• BUN/Creatinine ratio of >12.1

• Urine specific gravity of 1.027

• Urine osmolality of >450

• Urine positive for blood

Multiple Choice

A patient with mild fluid volume excess is prescribed a diuretic that blocks sodium reabsorption in the distal tubule. Which diuretic does the nurse anticipate administering to this patient?

• Bumetanide

• Torasemide

• Hydrochlorothiazide

• Furosemide

Multiple Choice

In a patient with excess fluid volume, hyponatremia is treated by restricting fluids to how many milliliters in 24 hours?

• 400

• 600

• 800

• 1200

​Operative Nursing

• Preoperative phase: begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed

• Intraoperative phase: begins when the patient is transferred onto the OR bed and ends with admission to the PACU (postanesthesia care unit)

• Postoperative phase: begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home

​Surgical Classification

• Facilitating a diagnosis, a cure, or repair

• Reconstructive, cosmetic, or palliative

• Rehabilitative

• Based upon the degree of urgency involved: emergent, urgent, required, elective, and optional

Patient Education

• Deep breathing, coughing, incentive spirometry

• Mobility, active body movement

• Pain management

• Cognitive coping strategies

• Instruction for patients undergoing ambulatory surgery

Preadmission Testing

• Initiates the nursing assessment process

• Admission data: demographics, health history, other information pertinent to the surgical procedure

• Verifies completion of preoperative diagnostic testing according to patient’s needs

• Begins discharge planning by assessing patient’s need for postoperative transportation and care

Medications That Potentially Affect Surgical Experience

vAnticoagulants

vAnticonvulsant medications

vThyroid hormone

vOpioids

vOver-the-counter and herbals

vCorticosteroids

vDiuretics

vPhenothiazines

vTranquilizers

vInsulin

vAntibiotics

​Gerentologic Considerations

• Cardiac reserves are lower

• Renal and hepatic functions are depressed

• Gastrointestinal activity is likely to be reduced

• Respiratory compromise

• Decreased subcutaneous fat; more susceptible to temperature changes

• May need more time and multiple education formats to understand and retain what is communicated

Special Considerations During Preoperative Period

• Patients with obesity

  • extremely susceptible to infection

  • makes the patient more at risk for poor healing

• Patients with disabilities

  • appropriate assistive devices

  • modification in pre-op education

  • may not be able to communicate pain or discomfort

• Patients undergoing ambulatory surgery

  • need for anticipation of needs due to short stay

• Patients undergoing emergency surgery

  • no time for proper education or assessment of needs

Informed Consent

• Should be in writing before nonemergent surgery

• Legal mandate

• Surgeon must explain the procedure, benefits, risks, complications, etc.

• Nurse clarifies information and witnesses signature

• Consent is valid ONLY when signed before administering psychoactive premedication

• Consent accompanies patient to OR

​Members of the Surgical Team

• Patient

• Anesthesiologist (physician) or certified registered nurse anesthetist (CRNA)

• Surgeon

• Nurses

• Surgical technicians

• Registered nurse first assistants (RNFAs) or certified surgical technologists (assistants)

Multiple Choice

The Circulating Nurse is responsible for monitoring ____?

• the patient's family

• the recovery room

• the surgical team

• all surgery rooms

Multiple Choice

The on-call perioperative team is called for an emergent surgery to be performed as soon as they arrive. Which surgical procedure is considered urgent?

• appendectomy

• exploratory laparotomy

• repair of multiple stab wounds

• face-life

Multiple Choice

A patient is scheduled for a reduction mammoplasty. Which classification of surgery does the nurse document on the perioperative document?

• Urgent

• Optional

• Recquired

• Reconstructive

Multiple Choice

A patient is scheduled for a surgical procedure. For which surgical procedure will the nurse prepare an informed consent form for the surgeon to sign?

• An open reduction of a fracture

• An insertion of an intravenous catheter

• Irrigation of the external ear canal

• Urethral catheterization

​Adverse Effects of Surgery and Anesthesia

• Allergic reactions, drug toxicity or reactions

• Cardiac dysrhythmias

• CNS changes, oversedation, undersedation

• Trauma: laryngeal, oral, nerve, skin, including burns

• Hypotension

• Thrombosis

• Refer to Chart 15-2

​Gerontologic Considerations

v Older adult patients are at higher risk for complications from anesthesia and surgery compared to younger adult patients due to several factors:

o Age-related cardiovascular and pulmonary changes

o Decreased tissue elasticity (lung and cardiovascular systems) and reduced lean tissue mass

o Decreases the rate at which the liver can inactivate many anesthetic agents

o Decreased kidney function slows the elimination of waste products and anesthetic agents

o Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms

Preventing Infection

• Surgical environment

  • Unrestricted zone: street clothes allowed

  • Semirestricted zone: scrub clothes and caps

  • Restricted zone: scrub clothes, shoe covers, caps, and masks

• Surgical asepsis

• Environmental controls

• Refer to Figure 15-3

Basic Guidelines for Surgical Asepsis

• All materials in contact with the surgical wound or used within the sterile field must be sterile

• Gowns considered sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff

• Sterile drapes are used to create a sterile field. Only top of draped tables are considered sterile

• Items dispensed by methods to preserve sterility

• Movements of surgical team are from sterile to sterile, from unsterile to unsterile only

​Guidelines continued

• Movement at least 1-foot distance from sterile field must be maintained

• When sterile barrier is breached, area is considered contaminated

• Every sterile field is constantly maintained, monitored

• Items of doubtful sterility considered unsterile

• Sterile fields prepared as close to time of use

• The routine administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections

Fill in the Blank

When lasers are being used in the perioperative setting, ______ should be clearly posted to alert personnel.

Fill in the Blank

A patient is in stage I: beginning anesthesia. The circulating nurse should be sure that a ______ is provided.

Multiple Choice

The patient is having a repair of a vaginal prolapse. Which position will the nurse place the patient in?

• Left lateral Sims'

• Prone position

• Lithotomy position

• Trendelenburg

Multiple Choice

A patient is having a surgical procedure that requires the patient to be in prone position. Which is an expected patient outcome?

• The patient will not experience anxiety during the preoperative phase

• The patient will not experience signs of an allergic reaction

• The patient remains free of perioperative positioning injury

• The patient will not experience signs and symptoms of infection

• Monitoring, modifying physical environment

• Safety measures (grounding of equipment, restraints, not leaving a sedated patient)

• Verification, accessibility of blood

• Patient identification

• Correct informed consent

• Verification of records of health history, exam

• Results of diagnostic tests

• Allergies (include latex allergy)

Protecting the Patient from Injury

Multiple Choice

Through which route are inhaled general anesthetics primarily eliminated?

• kedneys

• liver

• lung

• skin

Postanesthesia Care

• Postanesthesia Care Unit (PACU)

  • Phase I

    Immediate recovery

• Intensive nursing care

• Patient transitions to an inpatient nursing unit or phase II PACU

• Phase II

  Prepared for transfer to an inpatient nursing unit, an extended care setting, or discharge

Nursing Management in PACU

• Provide care for patient until patient has recovered from effects of anesthesia

  • Return to cognitive baseline

  • Clear airway

  • Controlled nausea and vomiting

  • Stable vital signs

• Vital to perform frequent skilled assessment of patient

Responsibilities of PACU Nurse

• Review pertinent information, baseline assessment upon admission to unit

• Assess airway, level of consciousness, cardiac, respiratory, wound, and pain

• Check drainage tubes, monitoring lines, IV fluids, and medications
  Assess vital signs at the time of arrival to PACU and repeated per institution protocol

• Administration of postoperative analgesia

• Transfer report to another unit or discharge patient to home, continuing or transitional care, refer to Charts  16-1 and 16-3

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of hypoxemia and hypercapnia.

Outpatient Surgery and Direct Discharge

• Discharge planning, discharge assessment

• Provide written, verbal instructions regarding follow-up care, complications, wound care, activity, medications, diet

• Give prescriptions, contact information

  • Discuss actions to take if complications occur

• Give instructions to patient, responsible adult who will accompany patient

• Patients are not to drive home or be discharged to home alone

  • Sedation, anesthesia may cloud memory, judgment, affect decision-making ability 

Nursing Management Post-Op

• Assessment

  • Respiratory

    • maintain a patent airway

    • suction if needed (if vomiting, turn to their side)

    • keep head of bead elevated 15-30 degrees

  • Pain

  • Mental status/LOC

  • General discomfort

Maintain Cardiovascular Stability

• Monitor all indicators of cardiovascular status

• Assess all IV lines

• Potential for hypotension, shock

• Potential for hemorrhage

• Potential for hypertension, arrhythmias

• Refer to Table 16-1

​Indicators of Hypovolemic Shock or Hemorrhage

• Cool, moist skin

• Rapid respirations

• Cyanosis

• Rapid, weak, thread pulse

• Decreasing pulse pressure

• Pallor

• Low blood pressure

• Concentrated urine

Preventing Complications

• Provide healing environment

• Absorb drainage

• Splint or immobilize

• Protect

• Promote homeostasis

• Promote patient’s physical and mental comfort

Purpose of Post-Op Drains

• First-intention wound healing

• Second-intention wound healing

• Factors that affect wound healing

• Refer to Chart 16-5 and Table 16-3
  

Wound Healing

​Structures of the Upper Respiratory Tract

• Nose: passageway for air to pass to and from the lungs (Figure 17-1)

• Paranasal Sinuses (Figure 17-2)

  • Frontal

  • Ethmoid

  • Sphenoid

  • Maxillary

• Pharynx, Tonsils, Adenoids

  • Nasal

  • Oral

  • Laryngeal
    

Structures continued

• Larynx

  • Epiglottis

  • Glottis

  • Thyroid cartilage

  • Cricoid cartilage

  • Arytenoid cartilages

  • Vocal cords

• Trachea

​Structures of the Lower Respiratory Tract

• Two lungs, five lobes

  • Left: upper and lower

  • Right: upper, middle, and lower

• Pleura

• Mediastinum

• Bronchi and bronchioles

• Alveoli

​Functions of the Respiratory System

• Oxygen transport

• Respiration

• Ventilation

• Air pressure variances

• Airway resistance

• Compliance

• Lung volumes and capacities (Table 17-1)

• Pulmonary diffusion and perfusion

• Ventilation and perfusion balance and imbalance (Chart 17-2)

• Gas exchange

o

​Gas Exchange

• Gas Exchanges

  • Partial pressure of gases

  • Oxyhemoglobin dissociation curve

  • Carbon dioxide transport

• Neurologic control of ventilation

​Management of Upper Respiratory Infections

• Most common cause for illness, reason for seeking health care and absences from school and work

• May be minor, acute, chronic, severe, or life threatening

• Treated in community settings: doctor offices, urgent care clinics, long-term care facilities, or self-care at home

• Early detection of signs and symptoms and appropriate interventions can avoid unnecessary complications

• Patient teaching focus on prevention and health promotion

• Special considerations for older adults: Refer to Chart 18-1

Epistaxis

• Hemorrhage from the nose

• Anterior septum, most common site

• Serious problem, may result in airway compromise or significant blood loss

• Risk factors, refer to Chart 18-5
  

Management of Epistaxis

• Identify cause and location

• Pinch soft portion of nose for 5 to 10 minutes, patient sits upright (lean head forward to prevent aspiration or obstruction of airway)

• Phenylephrine spray, vasoconstriction

• Cauterize with silver nitrate or electrocautery

• Gauze packing or balloon-inflated catheter inserted into nasal cavity for 3 to 4 days

• Antibiotic therapy 

• If bleeding does not stop in 15 minutes, seek medical attention
  

​Potential Complications and Collaborative Problems

• Airway obstruction

• Hemorrhage

• Sepsis

• Meningitis or brain abscess

• Nuchal rigidity
  Medicamentosa

• Acute otitis media

• Trismus

• Dysphagia

• Aphonia

• Cellulitis

• Gargles for sore throat

• Use alternative communication

• Encourage liquids and use of room vaporizers or steam inhalation to keep secretions loose and moist for easier expectoration

• Rest

• Elevate head

• Ice collar to reduce inflammation and bleeding

• Hot packs to reduce congestion

• Analgesics for pain

• Topical anesthetics

• Monitor for severe complications

Nursing Management of URIs

​Evaluation of Patient with URI

• Maintenance of patent airway

• Expresses relief of pain

• Able to communicate needs

• Evidence of positive hydration

• Free of signs and symptoms

• Absence of complications

​Patient Education

• Prevention of upper airway infections

• Emphasize frequent hand washing

• When to contact health care provider

• Need to complete antibiotic treatment regimen

• Annual influenza vaccine for those at risk

Laryngectomy

• Health history

• Physical, psychosocial, and spiritual  assessment

• Nutrition, BMI, albumin, glucose, electrolytes

• Literacy, hearing, and vision; may impact  communication after surgery

• Coping skills and available support systems for patient and family after surgery

Potential Problems

• Respiratory distress

• Hemorrhage

• Infection

• Wound breakdown

• Aspiration

• Tracheostomal stenosis

Nursing Interventions

• Preoperative teaching

• Reduce anxiety

• Maintain patent airway, control secretions

• Support alternative communication

• Promote adequate nutrition and hydration

• Promote positive body image, self-esteem

• Monitor for potential complications

• Self-care management; homecare (Chart 18-7)

​Atelectasis

• Closure or collapse of alveoli

• Acute or chronic

• Most common is acute atelectasis, which occurs in the postoperative setting

• Symptoms: insidious, increasing dyspnea, cough, and sputum production

• Acute: tachycardia, tachypnea, pleural pain, and central cyanosis if large areas of the lung are affected

• Chronic: similar to acute, pulmonary infection may be present

Assessment and Diagnosis

• Characterized by increased work of breathing and hypoxemia

• Decreased breath sounds and crackles over the affected area

• Chest x-ray may suggest a diagnosis of atelectasis before clinical symptoms appear

• Pulse oximetry (SpO2) may demonstrate a low saturation of hemoglobin with oxygen (less than 90%)

Nursing Interventions

• Prevention

  Frequent turning

  • Early mobilization

  • Strategies to expand lungs and manage secretions

  • Incentive spirometer

  • Voluntary deep breathing

  • Secretion management

  • Pressurized metered-dose inhaler

Management

• Improve ventilation and remove secretions

• First‐line measures:

  • Frequent turning, early ambulation, lung volume expansion maneuvers and coughing

• Multidisciplinary: ICOUGH (see Chart 19‐3)

• PEEP, CPAB, bronchoscopy

• CPT

• Endotracheal intubation and mechanical ventilation

• Thoracentesis to relieve compression

​Inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses

​Heart failure
Diabetes
Alcoholism
COPD
AIDS

Influenza

Cystic fibrosis

• ​Community setting or within first 48 hours post hospitalization

• Rate of infection increases with age

• S. Pneumoniae is the most common cause among adults

• Viral origin in infants and children

​​Community-Acquired
Pneumonia

• ​Often caused by multidrug‐resistant organisms

• Early diagnosis and treatment are critical

​​Health-Care Associated Pneumonia

Hospital-Acquired Pneumonia

• Develops 48 hours or more after hospitalization

• Subtype of health care–associated pneumonia

• Potential for infection from many sources

• High mortality rate

• Colonization by multiple organisms due to overuse of antimicrobial agents

• Pleural effusion, high fever, and tachycardia

• Common with debilitated, dehydrated patients with minimal sputum production

• ​Received mechanical ventilation for at least 48 hours

• Prevention is key

• VAP bundles (Chart 19-6)

Ventilator-Associated Pneumonia

• ​Common agents include pneumocystis, fungi, and tuberculosis

• Receiving immunosuppressive agents, history of immunosuppressive condition

• Subtle onset with progressive dyspnea, fever, and nonproductive cough

​Assessment and Diagnosis of Pneumonia

• History

• Physical exam

• Chest x-ray

• Blood culture

• Sputum examination

• Bronchoscopy may be used for acute severe infection

​Medical Management of Pneumonia

• Administration of the appropriate antibiotic as determined by the results of a culture and sensitivity

• Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, and antihistamines

• Antibiotics not indicated for viral infections but are used for secondary bacterial infection

• Refer to Table 19-3

• Gerontologic considerations

Tuberculosis

• Mycobacterium tuberculosis bacillus (TB)

• 10 million people with TB worldwide and 9,105 cases in the United States (2017)

• Spreads by airborne transmission through droplets then moves to other parts of the body such as the kidneys, bones, and cerebral cortex.

• Granulomas and Ghon tubercule

• Risk factors for TB, refer to Chart 19-10

• Low‐grade fever

• Cough; nonproductive or mucopurulent; hemoptysis

• Night sweats, fatigue, weight loss

​Assessment and Diagnostic Findings for TB

• History and physical

• TB skin test; Mantoux method: See Figure 19-3

• Significant versus nonsignificant reactions

• TB blood tests

  • Quantiferon Gold

• Sputum culture

• Sputum testing

Medical Management of TB

• Treated for 6 to 12 months

• Drug resistance is primary concern

• Initiate treatment with four or more medications

• Complete all therapy

• Initial treatment phase (8 weeks)

• Continuation phase (4 to 7 months)

• Table 19-4