Practice nursing care for Clients with Infectious Problems of the Lower Respiratory Tract
Infections of the respiratory system range from minor "colds" to life-threatening pneumonias and abscesses. When a respiratory infection occurs at the same time as other respiratory problems, the client's risk for ineffective breathing and need for intervention increases.
DISORDERS OF THE NOSE AND SINUSES
Rhinitis, an inflammation of the nasal mucosa, is the most common problem to affect the nose and sinuses of adults. The cause of the inflammation can be infectious (viral or bacterial) or can result from contact with allergens. Often an allergic rhinitis will make the mucous membranes more susceptible to invasion, and an infection will accompany the allergy. Allergic rhinitis, often called "hay fever" or "allergies," is triggered by hypersensitivity reactions to airborne allergens, especially plant pollens or molds. Some acute episodes are "seasonal" in that they tend to recur at the same time each year; they coincide with the timing of a large environmental exposure and last only a few weeks. Chronic rhinitis, or perennial rhinitis, tends to occur intermittently (with no predictable seasonal pattern) or continuously with exposure to certain allergens such as dust, animal dander, wool, and foods (e.g., seafood). Rhinitis also can occur after excessive use of nose drops or sprays (rhinitis medicamentosa) as a rebound effect causing nasal congestion or after nasal inhalation of cocaine.
Acute viral rhinitis (coryza, or the common cold) is caused by any one of at least 200 viruses. It usually spreads from one person to another by droplets from sneezing or coughing and is most contagious in the first 2 to 3 days after symptoms begin to appear. The condition is self-limiting unless complicated by a bacterial infection such as otitis media, sinusitis, bronchitis, or pneumonia. Complications are most often seen in older adults or immunosuppressed people, especially if they live or work in crowded conditions or in group settings such as a long-term care facility.
In both acute and chronic allergic rhinitis, the presence of the offending substance causes a release of natural biochemicals from basophils and mast cells in the nasal mucosa; this release causes changes in blood vessels. The released biochemicals include histamine, serotonin, bradykinin, and prostaglandins. When these substances bind to blood vessels they induce dilation and increase capillary permeability, causing edema and swelling of the nasal mucosa. The resulting symptoms include headache, nasal irritation, sneezing, nasal congestion, rhinorrhea (watery drainage from the nose), and itchy, watery eyes. Viral or bacterial invasion of the nasal passages causes the same local tissue responses as allergic rhinitis. In addition, the client also may have more systemic manifestations, including a sore, dry throat and, at times, a low-grade fever with chills.
Management of the client with any type of rhinitis includes symptomatic relief and client education. The health care provider prescribes appropriate drag therapy, and the nurse instructs the client as indicated.
DRUG THERAPY. Drags, including antihistamines and decongestants, are commonly given but must be used with caution in the older adult because of side effects such as vertigo, hypertension, urinary retention, and insomnia. Antihistamines prevent the reactive biochemicals released from the mast cells and basophils from binding to sites on blood vessels and tissue receptors. Thus antihistamines prevent local edema and itching. Decongestants work by causing vasoconstriction and, subsequently, by decreasing edema. Antipyretics are administered if fever is present. Antibiotics are not usually prescribed for viral rhinitis because these agents do not kill the offending virus. Rhinitis medicamentosa is treated by decreasing or discontinuing the offending drag.
COMPLEMENTARY AND ALTERNATIVE THERAPY.
Some people are able to decrease the severity of acute viral rhinitis by using complementary and alternative therapy early in the course of the problem. Agents commonly used are Echinacea, large doses of vitamin C, and oral ionic zinc preparations such as ColdEeze. It is not clear how these agents reduce symptom severity or duration of illness, but it is believed they may help increase nonspecific immune function.
SUPPORTIVE THERAPY. The nurse instructs the client about the importance of rest (8 to 10 hours a day) and fluid intake of at least 2000 mL/day (approximately eight glasses) unless other conditions (e.g., congestive heart failure, chronic renal failure) cannot tolerate this amount. Humidification of air helps to relieve congestion; the nurse suggests inhaling steam from a pan of boiled water after removing it from the heat. Hot shower water produces the same effect. The client is instructed to avoid people who are susceptible to infection for 2 to 3 days after symptoms begin. Thorough handwashing is another important precaution, especially after the client blows the nose or sneezes. An uncomplicated cold typically subsides within 7 to 10 days.
The client with recurrent allergic rhinitis can undergo allergy testing to determine the cause. The client may be able to avoid the offending substance to prevent further episodes or undergo desensitization for allergy relief.
Sinusitis is an inflammation of the mucous membranes of one or more of the sinuses. Swelling can obstruct the flow of secretions from the sinuses, which may subsequently become infected. The disorder often accompanies or follows acute or chronic allergic rhinitis. Other conditions contributing to sinusitis include a deviated nasal septum, polyps, tumors, chronically inhaled air pollutants or cocaine, facial trauma, nasotracheal intubation, dental infection, or cystic fibrosis. In chronic sinusitis, the mucous membrane becomes permanently thickened from prolonged or repeated inflammation or infection.
The causative organism in sinus infection is usually Streptococcus pneumoniae, Haerrwphilus influenzae, Diplococcus, or Bacteroides. Anaerobic infections also can cause sinusitis. Sinusitis most often develops in the maxillary and frontal sinuses. Complications include cellulitis, abscess, and meningitis.
Diagnosis is made on the basis of the client's history, signs, and symptoms. Transillumination of the affected sinus is decreased. Other diagnostic tests for sinusitis include sinus x-ray studies, endoscopic examination, and computed tomography (CT) of the sinuses.
The clinical manifestations of sinusitis include nasal swelling and congestion, headache, facial pressure, pain (usually made worse by movement of the head to a dependent position), tenderness on percussion over the involved area, low-grade fever, cough, and purulent or bloody nasal drainage.
NONSURGICAL MANAGEMENT. Treatment for sinusitis includes the use of broad-spectrum antibiotics (e.g., amoxicillin), analgesics for pain and fever (e.g., acetaminophen [Tylenol, Atasol]), decongestants (e.g., phenylephrine [Neo-Synephrine]), steam humidification, hot and wet packs over the sinus area, and nasal saline irrigations. The nurse instructs the client to increase free water intake to more than 10 glasses of water or juice per day unless medically contraindicated. When this treatment plan is not successful, the physician orders an additional evaluation with sinus x-ray films and a CT scan. Surgical intervention may be necessary.
ANTRAL IRRIGATION. Antral irrigation, also known as maxillary antral puncture and lavage, is an outpatient surgical procedure. With the client under local anesthesia, a large-gauge needle is inserted under the inferior turbinate of the nose and into the maxillary sinus on the affected side. Fluid or purulent material from the sinus is withdrawn. The sinus is then irrigated with saline solution, an antibiotic solution, or both.
OTHER SURGICAL PROCEDURES. If antral irrigation is not successful, other surgical procedures may be used to open the sinus cavities in clients with chronic sinusitis. In the Caldwell-Luc procedure, the surgeon makes an incision in the anterior wall of the maxillary sinus (under the upper lip). The infected mucosa in the maxillary sinus is then removed. With the nasal antral window procedure, the surgeon creates an opening in the anterior portion of the inferior turbinate to allow unobstructed drainage through the nares. After either procedure, the client may have difficulty eating for a few days because of pain and swelling.
When the ethmoid sinuses need to be opened, the surgeon uses an external approach for better visibility and preservation of structures. The surgical incision is made along the side of the nose from the middle of the eyebrow (Weber-Ferguson incision).
ENDOSCOPIC SINUS SURGERY. Endoscopic sinus surgery has become a revolutionary method of diagnosing and treating sinus disorders. Direct inspection of the sinuses through a sinus endoscope is an improved surgical procedure for refractory sinus disorders. Completed with the client under general anesthesia in an outpatient surgical center, the procedure takes only minutes. The client goes home the same day and can return to work in 4 to 5 days. The nasal mucosa may take up to 4 to 6 weeks to heal. The nurse instructs the client in the frequent use of saline nasal sprays to prevent intranasal and sinus crusting and to promote healing.
DISORDERS OF THE ORAL PHARYNX AND TONSILS
Pharyngitis or "sore throat," is a common
inflammation of the mucous membranes of the
pharynx, and it accounts for more than 15 million
office visits each year in the
Acute pharyngitis has multiple causes. The most common bacterial organism causing pharyngitis is group A beta-hemolytic Streptococcus, but most adult cases are caused by a virus. The incidence of streptococcal infection rises between late fall and spring, especially in colder climates.
The client with pharyngitis experiences soreness and dryness in the throat, pain, pain on swallowing (odynophagia), difficulty in swallowing (dysphagia), and fever. Viral and bacterial pharyngitis are often difficult to differentiate on physical assessment. When inspecting the mucous membranes of a throat infected with virus or bacteria, the nurse may note a mild to severe hyperemia (redness) with or without enlarged erythematous tonsils and with or without exudate. The client is asked about nasal discharge, which can vary from thin and watery to thick and purulent. Enlarged cervical lymph nodes may be present in either viral or bacterial pharyngitis. With a parapharyngeal (or tonsillar) abscess, the client may have a characteristic "hot potato" voice, a thickened voice of poor quality.
Clinical studies indicate that streptococcal or other bacterial infections are more often associated with enlarged erythematous tonsils, exudate, purulent nasal discharge, and cervical lymph node enlargement.. Viral pharyngitis is communicable for 2 to 3 days; symptoms usually subside within 3 to 10 days after onset. The disease is usually self-limiting.
Bacterial pharyngitis, such as group A streptococcal infection, can lead to dangerous medical complications. The two most serious complications, acute glomerulonephritis and rheumatic fever carditis, occur in 1% to 3% of cases. Acute glomerulonephritis generally occurs 7 to 10 days after the acute infection, and rheumatic fever may develop 3 to 5 weeks after an acute streptococcal infection.
Throat cultures are important in distinguishing a viral infection from a group A beta-hemolytic streptococcal infection. However, the results are not entirely accurate. False-negative cultures can occur, some of which are due to incorrect throat culture technique. In such cases the microorganisms are not uniformly distributed throughout the pharynx. To obtain a specimen, the nurse rubs a cotton swab first over the right tonsillar area, across the right arch to the uvula, and then across left arch to the left tonsillar area. The cotton swab is streaked on a blood agar plate, which is then incubated for 24 to 48 hours.
There are many types of rapid tests and screens for group A beta-hemolytic streptococcal antigen. These tests vary in specificity and sensitivity and cost about the same as a culture and sensitivity, but the results are available more quickly than with standard cultures. Two of the most efficient tests are the Gen-Probe and the OIA (Optical Immunoassay).
A complete blood count is performed when the client's condition is severe or does not improve. The client may exhibit extremely high temperatures, lethargy, or signs and symptoms of complications. A complete blood count may indicate other causes of pharyngitis.
When obtaining a history, the nurse inquires about the client's recent contacts (within the last 10 days) with people who have been ill. Of particular importance is whether the client has recently been ill with symptoms of a cold or upper respiratory tract infection. Documenting previous streptococcal infections is essential. The nurse also documents a history of rheumatic fever, valvular heart disease, streptococcal infections, or penicillin allergy. Because diphtheria (Corynebacterium diphtheriae) can cause pharyngitis, the nurse asks about and documents whether the client has had a diphtheria immunization.
Most sore throats in adults are viral and do not require antibiotic therapy. The treatment plan includes rest, increased fluid intake, humidification of the air, analgesics for pain, warm saline throat gargles, and throat lozenges containing mild anesthetics.
The management of bacterial pharyngitis involves the use of antibiotics and the same supportive care provided for viral pharyngitis. For a streptococcal infection, an oral penicillin or cephalosporin is prescribed. Erythromycin is the alternative if the client is allergic to penicillin. The nurse counsels the client on the importance of completing the entire antibiotic prescription, even if symptoms subside. If the client cannot tolerate the medication, the nurse notifies the physician so the antibiotic regimen can be changed. If compliance is a concern or the client cannot swallow pills, 1.2 million units of long-acting benzathine penicillin can be administered intramuscularly in a single dose to eradicate the organism.
The client should be re-evaluated if there is no improvement in 3 days or if symptoms are still present after the antibiotic course is completed. One cause of persistent bacterial pharyngitis is a positive human immunodeficiency virus (HIV) status with immunosuppression. Any client who fails to respond to the appropriate therapy should be considered for HIV testing (Leiner, 2000).
A rare complication of pharyngitis in adults is infection of the epiglottis and supraglottic structures (epiglottitis). The epiglottis is a flaplike structure that closes over the trachea during swallowing to prevent aspiration. An inflamed epiglottis can partially or completely obstruct the airway and is considered a medical emergency. The client with pharyngitis who begins to have stridor or other symptoms of airway obstruction should be evaluated immediately by a health care provider in a setting in which intubation or a tracheostomy can be performed quickly and safely.
The nurse teaches the proper procedure for obtaining an oral temperature reading. This reading should be taken in the morning and in the evening until the infection resolves. The client is not contagious after 24 hours of antibiotic therapy. Family members or significant others who experience a sore throat should be evaluated, and a throat culture may be indicated.
Tonsillitis is an inflammation and infection of the tonsils and lymphatic tissue, which are located on each side of the oropharynx (where the palatine, or faucial, tonsils are located). The tonsils are lymphatic tissue shaped like a small almond. Each tonsil is covered by a mucous membrane and has small valleys (crypts) across the surface. Tonsils filter microorganisms, thus protecting the respiratory and gastrointestinal tracts.
Tonsillitis is a contagious airborne infection. Acute or chronic tonsillitis can occur in any age-group, but children are affected most often. The infection is usually more severe when it occurs in adolescents or adults.
The acute form of tonsillitis usually lasts 7 to 10 days and is usually caused by a bacterial organism. The most common organism is Streptococcus. Other bacterial pathogens include Staphylococcus aureus, Haemophilus influenzae, and Pneumococcus. Viruses may also cause tonsillitis. Chronic tonsillitis usually results from either an unresolved acute infection or recurrent infections.
Diagnostic studies are performed to rule out other causes of the sore throat and fever (e.g., acute pharyngitis). A complete blood count, throat culture and sensitivity (C&S) studies, monospot test and, if respiratory symptoms are present, chest x-ray studies may be ordered for a client with suspected tonsillitis. The white blood cell count is elevated in bacterial infections. Throat C&S studies identify the causative bacterial organism and direct the choice of drug therapy.
The health care provider orders systemic antibiotics (usually penicillin or erythromycin) for 7 to 10 days. Warm saline throat gargles, analgesics, antipyretics, and lozenges with topical anesthetic ingredients may provide symptomatic relief.
Indications for surgical intervention include recurrent acute infections or chronic infections that have not responded to antibiotic therapy, a peritonsillar abscess, and infected hypertrophy of the tonsils or adenoids that obstructs the airway. The indication for surgery becomes stronger with repeated group A beta-hemolytic streptococcal infections. In general, surgery is not indicated if the client is experiencing an acute tonsillar infection (except with an acute peritonsillar abscess) or has a blood dyscrasia such as aplastic anemia, hemophilia, or leukemia.
The most common surgical procedure to remove the tonsils is dissection and snare. The adenoids are removed with an adenoid curette or adenotome. Recently, laser tonsillectomy has been showing good success with decreased postoperative discomfort compared to standard surgery. A tonsillectomy and adenoidectomy (T&A) is usually performed with the client under general anesthesia. Postoperatively, the nurse focuses care on assessing for airway clearance, providing pain relief, and monitoring for excessive bleeding.
Peritonsillar abscess (РТА), or quinsy, is a complication of acute tonsillitis. The acute infection spreads from the tonsil to the surrounding peritonsillar tissue, which forms an abscess. РТА is one of the most common abscesses of the head and neck area. The common cause is group A beta-hemolytic streptococcus. Anaerobic organisms also may be the cause.
Signs of infection are pronounced at the physical examination. Pus forms behind the tonsil and causes a marked asymmetric swelling and deviation of the uvula. The client may experience drooling, severe throat pain that may radiate to the ear, a voice change, and difficulty swallowing because of the swelling. He or she may also have a tonic contraction of the muscles of chewing (trismus) and complain of breathing difficulties.
The nurse instructs about comfort measures (e.g., warm saline gargles or irrigations, ice collar, analgesics) and the importance of completing the antibiotic regimen. The client should improve in 24 to 48 hours. Outpatient management using percutaneous needle aspiration and antibiotic therapy may be needed. Hospitalization is required when the airway is in jeopardy or when the infection does not respond to antibiotic therapy. Incision and drainage (I&D) of the abscess and additional antibiotic therapy may be indicated. A tonsillectomy may be performed to prevent recurrence.
DISORDERS OF THE LARYNX AND LUNGS
Laryngitis is an inflammation of the mucous membranes lining the larynx and may or may not include edema of the vocal cords. It is commonly associated with upper respiratory tract infections, and it can be a solitary problem or a symptom of a related disease process. Causes include exposure to irritating inhalants and pollutants (chemical agents, tobacco, alcohol, and smoke), overuse of the voice, inhalation of volatile gases (e.g., glue, paint thinner, and butane), or intubation.
The nurse assesses the client for acute hoarseness, dry cough, and dysphagia. Complete but temporary voice loss (aphonia) also may occur. A laryngeal examination is performed to assist in the diagnosis. A laryngeal mirror is used to examine the larynx and to differentiate inflammation, polyps, edema, or tumor. The physician may order an x-ray study, computed tomography (CT) scan, or fiberoptic laryngoscopic examination. Most clients are referred to an ear, nose, and throat (ENT) specialist for any suspected disorder other than acute laryngitis.
Nursing management is aimed toward symptom relief and prevention. Treatment consists of voice rest, steam inhalations, increased fluid intake, and topical throat lozenges. The physician may order antibiotic therapy and bronchodilators when sinusitis, bronchitis, or a bacterial upper respiratory tract infection is also present. The nurse informs the client and family about immediate acute care therapies, infection prevention, and the avoidance of alcohol, tobacco, and pollutants.
Preventive therapy is aimed toward increasing the client's and family's awareness of the hazards of tobacco and alcohol use. The nurse also emphasizes the activities that place an added strain on the larynx, such as singing, cheering, public speaking, heavy lifting, and whispering. Speech therapy is often the treatment of choice for vocal cord injuries and should be implemented for any voice disorder. For recurrent bouts of laryngitis, further medical and speech therapy evaluation are necessary.
How to prevent laryngitis? Steps:
1. Don't yell or scream. Try not to talk or yell in a way that hurts your voice. A humidifier that puts more water into the air may also help keep your throat from drying out. Also, never smoke and try not to be around people who are smoking.
2. Stay hydrated. Drink a lot of water each day for about 3 hours and eat watery foods like fruit and vegetables. Fluids help thin the mucus in your throat, preventing the need to clear it.
3. Keep away from sick people. Many cases of laryngitis are caused by infection, so practice good hygiene by washing your hands frequently, taking a shower everyday, washing your hair and cleaning your face.
4. Keep away from alcohol and caffeine. These beverages dry out your lungs, making you clear your throat more, increasing your chance for getting laryngitis.
Influenza, or the "flu," is a highly contagious, acute viral respiratory infection that can occur in adults of all ages. Epidemics are common and lead to complications of pneumonia or death, especially in older adults or debilitated or immuno-compromised clients. Hospitalization may be required. Influenza may be caused by one of several viruses, which are usually referred to as A, B, and C.
The client with influenza usually has a severe headache, muscle aches, fever, chills, fatigue, weakness, and anorexia. Clinical manifestations associated with the respiratory system, such as a sore throat, cough, and rhinorrhea (watery discharge from the nose), generally follow the initial symptoms for a week or more. Most clients continue to experience general malaise for 1 to 2 weeks after the acute episode has resolved.
Traditional antibiotic therapy is ineffective against viral infections. Antiviral agents may be effective for the prevention and treatment of some types of influenza. Amantadine (Symmetrel) and rimantadine (Flumadine) have been effective in the prevention and treatment of influenza A. Ribavirin (Vira-zole) has been used for severe influenza B. Newer antivirals include zanamivir (Relenza), which is administered as a nasal spray, and oseltamivir (Tamiflu), which is taken orally. Both of these antivirals inhibit the enzyme neuraminidase and are effective in shortening the duration of influenza if taken within 24 to 48 hours after the onset of symptoms. Both agents are approved for preventive use.
The nurse recommends that the client remain in bed for several days and drink large amounts of fluids unless contraindicated by some other physical condition such as chronic renal failure or congestive heart failure. Saline gargles may ease sore throat pain. Antihistamines may be ordered to reduce the rhinorrhea. Other supportive and comfort measures are the same as those for acute rhinitis.
During the past two decades vaccinations for the prevention of influenza have been developed and widely administered. With advanced refinement of the vaccine, allergic reaction is rare. The vaccine is altered every year on the basis of specific viral strains that are likely to pose a problem during the influenza season (i.e., late fall and winter). It is highly recommended that persons older than 50 years of age, those with chronic illness or immune compromise, those living in institutions, and health care personnel providing direct care to clients receive the vaccine each year, typically during October or November (Centers for Disease Control and Prevention [CDC], 2000).
Pneumonia is an inflammatory process that results in edema of lung tissue and movement of fluid into the alveoli, causing hypoxemia. It can be caused by infectious or noninfectious irritating agents, such as inhaled fumes or aspirated food or fluids. Pneumonias are classified as community acquired or hospital acquired (nosocomial). In the past, antibiotics could reduce the mortality from pneumonia. However, the recent emergence of new or resistant organisms has made pneumonia a more serious problem.
The inflammation in pneumonia occurs in the interstitial spaces, the alveoli, and often the bronchioles. The process begins when pathogens successfully penetrate the airway mucus and multiply in the alveolar spaces. To do this, they must survive the lung's many defenses against microbial invasion. Fluid and exudate forms as the organisms multiply, and other evidence of inflammation becomes apparent. White blood cells migrate into the alveoli and cause thickening of the alveolar wall. Red blood cells and fibrin move into the alveoli. Fluid fills the alveoli, which protects the organisms from phagocytosis and facilitates the movement of organisms to other alveoli. As a result, the infection spreads. If the invading organisms obtain access to the bloodstream, septicemia results; if the infection extends into the pleural cavity, empyema results.
The fibrin and edema of inflammation stiffen the lung, causing decreased lung compliance and a decline in the vital capacity (VC) of the lung. Decreased production of surfactant further reduces compliance and leads to atelectasis (alveolar collapse). Some of the venous blood coming into the lungs passes through the underventilated area. This unoxygenated blood then travels to the left side of the heart. As a result, arterial oxygen tension falls, causing hypoxemia (insufficient oxygen in the blood).
Systemically, fever results from the infection. The client may develop shaking chills. Hypoxemia and an increase in metabolic demand cause tachypnea with tachycardia. Blood pressure may fall as a result of peripheral vasodilation and dehydration. Cardiac function may be compromised by hypoxemia and enhanced metabolism. Congestive heart failure or shock may result, and cardiac irritability may be enhanced because of inadequate tissue oxygenation, thus causing dysrhythmias.
Pneumonia may occur as either lobar pneumonia, with consolidation (solidification, lack of air spaces) in a segment or an entire lobe of the lung, or as bronchopneumonia, with diffusely scattered patches around the bronchi. The extent of lung involvement after microbial invasion depends on the defenses of the host. Bacteria can multiply quickly in a person whose immune system is compromised. Tissue necrosis results when multiplying organisms form an abscess that perforates the bronchial wall.
In general, individuals develop pneumonia when their defense mechanisms are unable to combat the virulence of the invading organisms. Organisms from the environment, invasive devices, equipment and supplies, staff, or other people can invade the body. Pneumonia can be caused by bacteria, viruses, mycoplasmas, fungi, rickettsiae, protozoa, or helminths (worms). Noninfectious causes of pneumonia include inhalation of toxic gases, chemicals, or smoke or the aspiration of water, food, fluid, and vomitus.
Prevention is aimed at immunizing against the causative agent when possible and reducing the other risks for infection or exposure.
are different types of the pneumoniae organism, the most common being 6B,
The nurse follows strict handwashing and aseptic techniques to avoid the spread of organisms. Respiratory therapy equipment is well maintained and is decontaminated or changed as recommended. Sterile water rather than tap water is used in gastrointestinal tubes, and aspiration precautions are initiated as indicated.
The concept map on addresses assessment and nursing care issues related to clients who have pneumonia.
In preparing to obtain a history from the client who may have pneumonia, the nurse considers risk factors consistent with infection. Information may be obtained from a family member or significant other if the client is too dyspneic.
The nurse documents data regarding age; living, work, or school environment; diet, exercise, and sleep routines; swallowing problems; nasogastrointestional tube; tobacco and alcohol use; past and current use of medications; and history of drug addiction or intravenous (IV) drug use. The client is asked about past illnesses, particularly those with a respiratory origin, and whether the client has been exposed to influenza or pneumonia or has experienced a recent viral episode. In addition, the nurse notes a history of any rashes, insect bites, or exposure to animals.
If the client has chronic respiratory problems, the nurse asks whether respiratory equipment is used in the home. It is essential to determine whether the client's housecleaning is adequate to prevent infection. The client is asked about inoculations with influenza or pneumococcal vaccine.
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
The nurse first observes the general appearance of the client, who may present with flushed cheeks, bright eyes, and an anxious expression. He or she may have chest or pleuritic pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, dyspnea, tachypnea, and sputum production. Severe chest muscle weakness also may be present from sustained coughing.
The client's breathing pattern, position, and use of accessory muscles are observed. The acutely compromised client is uncomfortable in a lying position and sits upright, balancing with the hands. The nurse assesses the client's cough and the amount, color, consistency, and odor of sputum produced for diagnostic clues about the offending pathogen.
Crackles are heard on auscultation when there is fluid in interstitial and alveolar areas. Wheezing may be heard as a result of inflammation and exudate in the airways. Bronchial breath sounds are heard over areas of density or consolidation. Tactile fremitus is increased over areas of pneumonia, and percussion is dulled in these areas. Chest expansion may be diminished or unequal on inspiration.
In evaluating vital signs, the nurse compares the results with baseline values. The client with pneumonia is likely to be hypotensive with orthostatic changes. A rapid, weak pulse may indicate hypoxemia, dehydration, or impending shock.
The nurse also inspects the skin for a rash, which may occur with Mycoplasma infection, cytomegalovirus infection (CMV), or Rocky Mountain spotted fever.
The client with pneumonia experiences pain, fatigue, and dyspnea, all of which promote anxiety. Anxiety is assessed by looking at facial expressions and the general tenseness of the facial and shoulder muscles. The nurse listens to the client carefully and uses a calm, slow approach to assessment. Because of airway obstruction and muscle fatigue, the client with dyspnea speaks in broken sentences. The nurse gauges the length of the interview on the degree of dyspnea or breathing discomfort.
Sputum is obtained and examined by Gram stain, culture, and sensitivity testing. A sputum sample is easily obtained from a client who can cough into a specimen container. Extremely ill clients may require nasotracheal suctioning or suctioning via a tracheostomy or endotracheal tube. In these situations, a sputum specimen is obtained via a sputum trap while suctioning. However, the responsible organism is not identified approximately 50% of the time. Sensitivity testing determines how resistant or sensitive the organism is to various anti-infective agents.
A complete blood count (CBC) is obtained to identify leukocytosis (an elevated white blood count), which is a common finding except in older adults. Blood cultures may be performed to determine whether the organism has invaded the bloodstream. An assessment for HIV may be performed. Urine may be examined for hematuria, pyuria, and the presence of protein, which may occur in the septic client with pneumonia.
Arterial blood gases (ABGs) determine baseline levels of arterial oxygen and carbon dioxide and help identify a need for supplemental oxygen. Serum electrolyte, blood urea nitrogen (BUN), and creatinine levels also are assessed. An increased BUN value may occur as a result of increased catab-olism and a diminished glomerular filtration rate. Electrolyte changes occur with dehydration, especially hypernatremia, as a result of fever and decreased fluid intake.
In general, pneumonia appears on chest x-ray films as an area of increased density. It may involve a lung segment, a lobe, one lung, or both lungs. In the older adult, the chest x-ray film is essential for early diagnosis of pneumonia because symptoms are often vague.
* Normal X-Ray
OTHER DIAGNOSTIC ASSESSMENT
The nurse uses pulse oximetry to assess for hypoxemia. The physician may order invasive tests such as transtracheal aspiration, bronchoscopy, or direct needle aspiration of the lung to obtain lower airway specimens in selected clients. Thoracentesis is most often used in clients who have an accompanying pleural effusion.
COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
The following are common nursing diagnoses for clients with pneumonia:
1. Impaired Gas Exchange related to the effects of alveolar capillary membrane changes
2. Ineffective Airway Clearance related to the effects of infection, excessive tracheobronchial secretions, fatigue and decreased energy, chest discomfort, and muscle weakness
A common collaborative problem for the client with pneumonia is Potential for Sepsis related to an infectious organism.
ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
In addition to the common nursing diagnoses and collaborative problem, clients with pneumonia may have one or more of the following:
• Acute Pain related to the effects of inflammation of parietal pleura, coughing
• Hyperthermia related to an increased metabolic rate, dehydration
• Deficient Fluid Volume related to fever, infection, and increased metabolic rate
• Disturbed Sleep Pattern related to pain, dyspnea, and unfamiliar environment (hospitalization)
• Potential for Pleural Effusion related to spread of the infection
Planning and Implementation
IMPAIRED GAS EXCHANGE
PLANNING: EXPECTED OUTCOMES. The client with pneumonia is expected to attain or maintain the partial pressure of arterial oxygen and carbon dioxide (Pao2 and Paco2, respectively) and oxygen saturation values within baseline ranges.
INTERVENTIONS. Interventions to treat and manage impaired gas exchange are similar to those for the client with chronic obstructive pulmonary disease (COPD) or asthma. In pneumonia, oxygen is the gas exchange most affected; therefore hypoxemia is the primary problem. Carbon dioxide retention is not as common in pneumonia as it is, for example, in chronic emphysema.
Incentive spirometry, also referred to as sustained maximal inspiration, is a type of bronchial hygiene used in pneumonia. The objective is to improve inspiratory muscle performance and prevent or reverse atelectasis (alveolar collapse). The nurse instructs the client to exhale fully, place the mouthpiece in the mouth, and take a long, slow, deep breath for 3 to 5 seconds. The nurse evaluates the client's technique and records the volume of air inspired. The client performs 5 to 10 breaths per session every hour while awake.
INEFFECTIVE AIRWAY CLEARANCE
PLANNING: EXPECTED OUTCOMES. The client with pneumonia is expected to have auscultated breath sounds in the expected range.
INTERVENTIONS. For the client with pneumonia, interventions for the treatment and management of ineffective airway clearance are similar to those for COPD or asthma. Because of fatigue, muscle weakness, chest discomfort, and excessive secretions, the client with pneumonia often has difficulty clearing secretions. The nurse helps the client to cough and deep breathe at least every 2 hours. The alert client may use an incentive spirometer to facilitate deep breathing and stimulate coughing. Chest physiotherapy (CPT or chest PT), which was once thought to be useful for clearing secretions in pneumonia, is no longer recommended for uncomplicated pneumonia. Dehydration should be avoided, but there is no evidence that hydration helps to clear secretions. Adequate hydration may help to thin secretions and make them easier to remove. To ensure adequate hydration when fever and tachypnea are present, the nurse monitors intake and output.
The physician prescribes bronchodilators, especially beta-2 agonists, when bronchospasm is part of the disease process. These are usually administered initially by aerosol nebulizer and then by metered dose inhaler. In general, inhaled steroid preparations are not used with acute pneumonia except when the client also has bronchial asthma or respiratory failure.
POTENTIAL FOR SEPSIS
PLANNING: EXPECTED OUTCOMES. The client with pneumonia is expected to be free of the invading organism and return to a prepneumonia health status.
INTERVENTIONS. The key to the effective treatment of pneumonia is identification and eradication of the organism causing the infection. Anti-infectives are given for all types of pneumonias except those caused by viruses. The physician prescribes anti-infective therapy depending on the organism suspected or identified, whether the pneumonia is community acquired or hospital acquired, and whether there are other contributing factors. Treatment is often initiated based on presenting clinical manifestations and prior experience, and it may be continued if the specific organism is not identified.
The client may be able to switch from IV to oral therapy in 2 or 3 days depending on the response (e.g., stable clinical condition, afebrile). The course of anti-infective therapy varies with the characteristics of the drug and the organism(s) involved and generally ranges from a low of 5 days for a client with uncomplicated community-acquired pneumonia to up to 21 days for an immunocompromised client.
For pneumonia resulting from aspiration of food or stomach contents, interventions are focused on preventing lung damage and treating the infection. Aspiration of acidic substances (e.g., vomitus or stomach contents) can cause widespread inflammation and lead to complications such as acute respiratory distress syndrome (ARDS) and permanent lung damage. Thus steroids and nonsteroidal anti-inflammatory agents are used in conjunction with antibiotics to reduce the inflammatory response.
The client needs to continue the anti-infective medications as prescribed by the physician or primary care provider. The nurse reinforces, clarifies, and provides additional information to the client and family as indicated. Completion of the entire medication regimen is stressed.
The most important aspect of education for the client and family is the avoidance of upper respiratory tract infections and viruses. The client is instructed to avoid crowds (especially in the fall and winter, when viruses are prevalent), persons who have a cold or flu, and exposure to irritants such as smoke. An annual influenza vaccine is recommended, and the pneumococcal vaccine is currently recommended once every 5 years (possibly more often in some high-risk cases). A balanced diet and adequate fluid intake are essential.
The nurse reviews all medication with the client and family and emphasizes completing anti-infective therapy. The client is instructed to notify the physician if chills, fever, persistent cough, dyspnea, wheezing, hemoptysis, increased sputum production, chest discomfort, or increasing fatigue recurs or if symptoms fail to resolve. The nurse emphasizes the importance of getting plenty of rest and gradually increasing exercise.
HOME CARE MANAGEMENT
structural changes are needed in the home. If the home consists of more than one story, the client may
prefer to stay on the first floor for a few weeks, because stair climbing may increase fatigue and dyspnea.
The prolonged convalescent phase of the disease process, particularly in the older client, can be frustrating and perhaps depressing. Fatigue, weakness, and a residual cough can last for weeks. Some clients fear they will never return to a "normal" level of functioning. It is important that the nurse prepare the client for the course of disease and offer reassurance so that complete recovery will occur. Initially after discharge, a home care nursing assessment may be beneficial.
HEALTH CARE RESOURCES
Clients who smoke are taught that smoking is a risk factor for pneumonia. The nurse provides information on smoking cessation classes through the American Lung Association (ALA) and American Cancer Society. The physician or nurse practitioner may prescribe nicotine patches. The client is warned of the danger of myocardial infarction if smoking is continued while using the patches. The client should be enrolled in a smoking cessation program to assist in the nicotine withdrawal process in conjunction with nicotine patches. The nurse also can give the client information booklets on pneumonia provided by the ALA. A client who has not already been vaccinated against influenza or pneumococcal pneumonia is encouraged to take this preventive measure when the pneumonia has resolved.
The nurse evaluates the care of the client with pneumonia on the basis of the identified nursing diagnoses and collaborative problems. The expected outcomes are that the client:
• Attains and/or maintains a Pao2, Paco2, and oxygen saturation values within expected ranges
• Has optimal breath sounds, either clear lungs in all lobes on auscultation or, minimally, improved breath sounds
• Is free of the invading organism
• Returns to his or her prepneumonia health status
was the leading cause of death in the
Tuberculosis is caused by a group of organisms Mycobacterium tuberculosis, M. bovis, M. africanum and a few other rarer subtypes. Tuberculosis usually appears as a lung (pulmonary) infection. However, it may infect other organs in the body. Recently, antibiotic-resistant strains of tuberculosis have appeared. With increasing numbers of immunocompromised individuals with AIDS, and homeless people without medical care, tuberculosis is seen more frequently today. (Image courtesy of the Centers for Disease Control and Prevention.)
ТВ is a highly communicable disease caused by Mycobacterium tuberculosis. The tubercle bacillus is transmitted via aerosolization (i.e., an airborne route). When an infected person coughs, laughs, sneezes, whistles, or sings, droplet nuclei are produced, become airborne, and may be inhaled by others. The tubercle bacillus multiplies freely when it reaches a susceptible site (bronchi or alveoli). An exudative response occurs, causing a nonspecific pneumonitis. With the development of acquired immunity, further multiplication of bacilli is controlled in most initial lesions. The lesions typically resolve and leave little or no residual. However, a small percentage of individuals who are initially infected will acquire the disease (5% to 15%). The greatest risk for acquiring the disease for the non-HIV-infected person is during the first 2 years after infection.
Cell-mediated immunity develops 2 to 10 weeks after infection and is manifested by a significant reaction to a tuberculin test. A primary infection may be microscopic in size and may never appear on an x-ray film. The process of infection occurs in the following order:
• The granulomatous inflammation created by the tubercle bacillus in the lung becomes surrounded by collagen, fibroblasts, and lymphocytes.
• Caseation necrosis (necrotic tissue being turned into a granular mass) occurs in the center of the lesion. If this area becomes evident on x-ray, it is called a Ghon tubercle, or the primary lesion.
Areas of caseation then undergo resorption, hyaline degeneration, and fibrosis. These necrotic areas may calcify (calcification) or liquefy (liquefaction). If liquefaction occurs, the liquid material empties into a bronchus, and the evacuated area becomes a cavity (cavitation). Bacilli continue to grow in the necrotic cavity wall and spread via the tracheobronchial lymph nodes into new areas of the lung.
A lesion also may progress by direct extension if bacilli multiply rapidly with marked exudative response to the inflammation. These lesions may extend through the pleura, which results in tuberculous pleural effusion with a small number of organisms. Pericardial effusions also may occur.
Miliary or hematogenous ТВ occurs when a large number of organisms enter the bloodstream and the disease spreads throughout the body. Many tiny, discrete nodules scattered throughout the lung are seen on the chest x-ray film. The brain, meninges, liver, kidney, or bone marrow are commonly involved as a result of spread through the blood.
Initial infection is seen more often in the middle or lower lobes of the lung. The regional lymph nodes, particularly the hilar and paratracheal nodes, are commonly involved. There is usually an asymptomatic interval after the primary infection that lasts for years or decades—before clinical symptoms develop. An infected individual is not infectious to others until symptoms of disease occur.
Secondary ТВ occurs in a previously infected person and is a reactivation (sometimes inaccurately termed a reinfection) of the primary disease. Reactivation is more likely whenever defenses are lowered, which may be part of the reason why older adults are susceptible to the development of ТВ. The upper lobes are the most common site of reactivation and are referred to as Simon's foci.
The organism M. tuberculosis is a nonmoving, slow-growing, nonsporulating, acid-fast rod. The bacillus is transmitted via aerosolization.
The people most commonly infected are those having repeated close contact with an infectious person who has not yet been diagnosed with ТВ. The risk of transmission is greatly reduced after the infectious person has received the proper medication for 2 to 3 weeks and after clinical signs of improvement are seen (including the reduction of acid-fast bacilli [AFB] in the sputum).
Іnсіаепсе & Prevalence
Figures for 1981 reveal that ТВ accounted for only 0.8% of
deaths in the
• In constant, frequent contact with an untreated individual
• With immune dysfunction or HIV
• Living in crowded areas such as long-term care facilities, prisons, and mental health facilities
• Who are older, homeless, and minorities
• Who abuse IV drugs or alcohol
• From a lower socioeconomic group
are foreign immigrants (especially from
Early detection of tuberculosis (ТВ) depends on subjective findings rather than the presentation of symptoms. ТВ has an insidious onset, and many clients are not aware of symptoms until the disease is well advanced. A diagnosis of ТВ should be considered for a persistent cough or other symptoms compatible with ТВ, such as weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills.
A thorough history includes an assessment of past exposure to ТВ. The nurse inquires about the client's country of origin and travel to foreign countries in which there is a high incidence of ТВ. It is important to note the results of any previous tests for ТВ. In addition, the client is asked whether he or she has had a bacille Calmette-Guerin (BCG) vaccine. The BCG vaccine contains attenuated tubercle bacilli and is given routinely in many foreign countries to produce increased resistance to ТВ. Anyone who has received a BCG vaccine within the previous 10 years will have a somewhat positive skin test that can complicate interpretation. The size of the skin response usually decreases each year after vaccination. These clients should be evaluated for ТВ with a chest x-ray film. The effectiveness of the BCG vaccine in preventing ТВ is controversial and not recommended by the Centers for Disease Control and Prevention (CDC).
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
The client with ТВ usually has progressive fatigue, lethargy, nausea, anorexia, weight loss, irregular menses, and a low-grade fever, which may have been present for weeks or months. Fever also may be accompanied by night sweats. The client finally notices a cough and the production of mucoid and mucopurulent sputum, which is occasionally streaked with blood. Chest tightness and a dull, aching chest pain may accompany the cough.
Physical examination of the chest does not provide conclusive evidence of ТВ. The nurse may hear dullness with percussion over involved parenchymal areas, bronchial breath sounds, crackles, and increased transmission of spoken or whispered sounds. Partial obstruction of a bronchus because of endobronchial disease or compression by lymph nodes may produce localized wheezing.
A diagnosis of ТВ is suggested by the clinical manifestations and a positive smear for acid-fast bacillus. Sputum is obtained, smeared on a slide, and stained with a dye (usually fuchsin). After the slide has dried, it is treated with an acid alcohol to remove the stain. The ТВ bacillus does not destain with this procedure and remains red. The acid-fast bacillus test is not specific for ТВ (other mycobacterium are also acid-fast) but is used as a quick method to determine whether ТВ treatment and precautions should be started until more definitive testing can be completed.
Sputum culture of Mycobacterium tuberculosis confirms the diagnosis. Traditionally, these cultures are slow-growing, with weeks required to determine a positive or negative result. Some newer techniques (BACTEC) promote faster culture growth in a liquid rather than a solid culture environment and allow the microorganism to be identified in 1 to 3 weeks instead of 4 to 6 weeks. Three samples are usually obtained for an acid-fast smear. After medications are started, sputum samples are obtained again to determine the effectiveness of therapy. Most clients have negative cultures after 3 months of treatment.
The polymerase chain reaction (PCR) assay is performed for rapid identification of mycobacteria in selected situations. This process allows amplification of mycobacterial genetic material (deoxyribonucleic acid [DNA]) and identification of mycobacteria within hours instead of days to weeks. This test allows for earlier diagnosis of ТВ. Although highly accurate, the high cost and limited availability of PCR currently prohibit its widespread use as a screening or diagnostic tool for ТВ.
tuberculin test (Mantoux test) is the most reliable
determinant of ТВ infection. A small amount (0.1 mL)
of intermediate-strength purified protein derivative (PPD) containing 5 tuberculin units is given intradermally
in the forearm. An area of induration (not
Yearly screening is recommended for anyone at greater risk of coming into contact with persons infected with ТВ. Screening is particularly important for foreign-born persons and migrant workers. Participation in screening programs can be enhanced when such programs are delivered in a culturally sensitive and nonthreatening manner.
Once a person's skin test is positive, a chest x-ray study is essential to rule out clinically active ТВ or to detect old, healed lesions. Caseation and inflammation may be seen on the x-ray film if the disease is active. Routine, repeat skin tests and chest x-ray studies are no longer recommended. Clients are instructed to seek medical attention if they experience symptoms suggestive of ТВ.
The radiographic presentation in HIV-infected clients may be unusual. In such cases the chest x-ray may be normal or may show infiltrates in any lung zone, which are often associated with hilar lymph node enlargement.
· This x-ray shows a single lesion (pulmonary nodule) in the upper right lung (seen as a light area on the left side of the picture). The nodule has distinct borders (well-defined) and is uniform in density. Tuberculosis (TB) and other diseases can cause this type of lesion.
· This CT scan shows a single lesion (pulmonary nodule) in the left lung. This nodule is seen as the light circle in the upper portion of the dark area on the left side of the picture. A normal lung would look completely black in a CT scan.
Combination drug therapy is the most effective method of treating tuberculosis (ТВ) and preventing transmission. Increasing the number of clients with ТВ who complete curative therapy is a major focus for Healthy People 2010. Active ТВ is treated with a combination of drags to which the organism is susceptible. Therapy is continued until the disease is under control. The use of multiple-drag regimens destroys organisms as quickly as possible and minimizes the emergence of drag-resistant organisms. Current therapy uses isoniazid (INH) and rifampin throughout the therapy; pyrazinamide is added for the first 2 months. This protocol shortens the therapy for most clients from 6 to 12 months to 6 months. Ethambutol and streptomycin are often added to the treatment regimen as the fourth drag. Additional therapies under investigation for treatment of ТВ include aerosolized interferon-gamma and thalidomide (Synovir, Thalomidtl).
Strict adherence to the prescribed drug regimen is crucial to suppressing the disease. Thus the nurse's major role is teaching the client about drug therapy. Accurate information provided in multiple formats (e.g., pamphlets, videos, drug schedule worksheets) can be valuable in client education. The nurse recognizes that the anxious client may not absorb information well. The nurse repeats the information and obtains the assistance of available family members. The client is asked to describe the treatment regimen and major side effects for which to call the health care agency and physician.
ТВ is often treated outside the acute care setting, with the client convalescing in the home setting. Airborne precautions are not necessary in this setting because family members have already been exposed; however, all members of the household need to undergo ТВ testing. The nurse instructs the client to cover the mouth and nose when coughing or sneezing, to confine used tissues to plastic bags, and to wear a mask when in contact with crowds until the medication is effective in suppressing the infection.
The client is informed that sputum needs to be examined every 2 to 4 weeks once drug therapy is initiated. When the results of three sputum cultures are negative, the client is considered to be no longer infectious and can usually return to former employment. The nurse reminds the client to avoid excessive exposure to silicone or dust because these substances can cause further lung damage.
The hospitalized client with active ТВ is placed under airborne precautions in a well-ventilated room. The room should have at least six exchanges of fresh air per minute and should be ventilated to the outside if possible. All health care workers wear a N95 or high-efficiency particulate air (HEPA) respirator when caring for the client. When there is risk of hand and clothing contamination, standard precautions are implemented by using appropriate barrier protection (i.e., gowns and gloves). Thorough handwashing is performed before and after client care. Precautions are discontinued when the client is no longer considered infectious.
Nausea related to the medications may be prevented by taking the daily dose at bedtime. Antiemetics may also prevent this symptom. The client with ТВ is instructed about the need for adequate nutrition and a well-balanced diet to promote healing. An increased intake of foods that are rich in iron, protein, and vitamin С is recommended. The nurse consults the nutritionist for specialized needs.
The client with ТВ may be frightened by changes in physical stamina and also faces concerns about the prognosis of the disease. The nurse is realistic in offering a positive outlook for the client who complies with the medication regimen and suggests that fatigue will diminish as the treatment progresses. With current resistant strains of ТВ, the nurse must emphasize that noncompliance with the medication regimen could lead to an infection that is difficult to treat or has total drag resistance.
The client is instructed to follow the drag regimen exactly as prescribed and always to have a supply of medication on hand. The nurse stresses the side effects and ways of minimizing them to ensure compliance. The client is reminded that the disease is usually no longer communicable after the medication has been taken for 2 to 3 consecutive weeks and clinical improvement is seen. However, the prescribed medication must be continued for 6 months or longer as ordered. Directly observed therapy (DOT), in which the nurse watches the client swallow the medications, may be indicated in some situations. This practice contributes to more treatment successes, fewer relapses, and less drag resistance.
The client who has experienced weight loss and severe lethargy should gradually resume his or her usual activities. Proper nutrition must be maintained to prevent a recurrence of infection.
To help with concerns about the contagious aspect of the infection, the nurse provides information about ТВ. A key to preventing transmission is identifying those in close contact with the infected person so they can be tested and treated as necessary. Public health professionals have an important role in this aspect of care. Identified contacts are assessed with a ТВ test and possibly a chest x-ray examination to determine infection. Multiple-drag therapy may be indicated. In addition, certain high-risk contacts receive prophylactic therapy, usually with isoniazid (INH).
HOME CARE MANAGEMENT
Most clients with ТВ are managed outside the hospital. However, clients may be diagnosed with ТВ while in the hospital if pneumonia is suspected or other possible complications exist. Discharge may be delayed if the living situation is considered high risk or if noncompliance is likely. The nurse consults with the social service worker in the hospital or the community health nursing agency to ensure that the client is discharged to the appropriate environment with continued supervision.
HEALTH CARE RESOURCES
The nurse instructs the client to receive follow-up care by a physician for at least 1 year during active treatment. The American Lung Association (ALA), an organization that uses volunteers, can provide free information about the disease and its treatment. In addition, Alcoholics Anonymous and other health care resources for clients with alcoholism are available if needed. The nurse assists the client who uses drags to locate an appropriate drag treatment program.
A lung abscess is a localized area of lung destruction caused by liquefaction necrosis, which is usually related to pyo-genic bacteria. Clients with this problem often have a history of pneumonia, possibly complicated by the aspiration of oropharyngeal contents or proximal obstruction as a result of a tumor or foreign body. Other causes of aspiration leading to abscess include alcoholism that causes loss of consciousness, seizure disorders or other neurologic deficits, and swallowing disorders. An obstruction of a bronchus may cause a necrotizing process in the lung that eventually becomes an abscess.
Multiple abscesses and cavities commonly form in clients with tuberculosis (ТВ) or fungal infections of the lung. Immunosuppressed clients, such as those receiving chemotherapy or those with a disease such as leukemia or AIDS, are particularly susceptible to fungal infections. The most common organisms are anaerobic bacteria, Staphylococcus or other gram-positive organism, or gram-negative or opportunistic infections such as fungi.
As a result of the widespread availability of antibiotics, the incidence of lung abscesses has dramatically reduced. Similarly, mortality has reduced. The elderly, immunocompromised, malnourished, debilitated and of course those who do not have access to antibiotics are particularly susceptible and have the worst prognosis. Particularly due to increased number of immunocompromised (secondary to HIV / AIDS and iatrogenic immunosuppression) the rate has once more increased.
Lung abscesses are divided according to their duration into acute (< 6 weeks) and chronic (> 6 weeks) . Presentation is usually non-specific and generally similar to a non-cavitating chest infection. Symptoms include fever, cough and shortness of breath. Peripheral abscesses may also cause pleuritic chest pain.
If chronic, symptoms are more indolent and include weight loss and constitutional symptoms. In some cases erosion into a bronchial vessel may result in sudden and potentially massive life threatening haemoptysis.
It is convenient to divide lung abscesses into primary and secondary as they differ not only in aetiology, but also microbiology and prognosis.
A primary abscess is one which develops as a result of primary infection of the lung. They most commonly arise from aspiration, necrotising pneumonia or chronic pneumonia, e.g. pulmonary tuberculosis.
In patients who develop abscesses as a result of aspiration, mixed infections are most common, including anaerobes.
Some organisms are particularly prone to causes significant necrotising pneumonia resulting in cavitation and abscess formation. These include:
· Staphylococcus aureus
· Klebsiella sp - Klebsiella pneumonia
· Pseudomonas sp
· Proteus sp
In immunocompromised patients additional organisms may also be implicated including:
· Candida albicans - pulmonary candidiasis
· Legionella micdadei & Legionella pneumophila
· Pneumocystis carinii (uncommon) - pneumocystis jirovecii pneumonia
A secondary abscess is one which develops as a result of another condition. Examples include:
* bronchial obstruction: bronchogenic carcinoma, inhaled foreign body
* haematogeneous spread: bacterial endocarditis, IVDU
* direct extension from adjacent infection: mediastinum, subphrenic
Also sometimes grouped with secondary abscesses are colonisation of pre-existing cavities with organisms.
As aspiration is the most common cause of pulmonary abscesses it is no surprise that the superior segment of the right lower lobe is the most common site of infection.
The classical appearance of a pulmonary abscess is a cavity containing an air-fluid level. In general abscesses are round in shape, and appear similar in both frontal and lateral projections. Additionally all margins are equally well seen, although adjacent consolidation may make assessment of this difficult. These features are helpful in distinguishing a pulmonary abscess from an empyema (see empyema vs pulmonary abscess)
CT is the most sensitive and specific imaging modality to diagnose a lung abscess. Contrast should be administered, as this enables the identification of the abscess margins, which can otherwise blend with surrounding consolidated lung.
Abscesses vary in size, and are generally rounded in shape. The may contain only fluid or have an air-fluid level. Typically there is surrounding consolidation, although with treatment the cavity will persist longer than consolidation.
The wall of the abscess is typically thick and the luminal surface irregular.
Bronchial vessels and bronchi can be traced as far as the wall of the abscess, whereupon they are truncated.
Ultrasound does not play a routine role in the assessment of lung abscesses as any aerated intervening lung will prevent visualisation. Peripheral abscesses abutting the pleura or with only compressed or consolidated lung may however be visible, and should not be mistaken for an empyema. Consolidated lung may mimic a fluid collection with low level echoes.
Treatment and prognosis
Lung abscesses are usually managed with prolonged antibiotics and physiotherapy with postural drainage. Bronchoscopy may be beneficial in establishing bronchial patency to improve drainage. In cases that are refractory to conservative management, or those complicated by haemoptysis, empyema or suspected malignancy, surgical resection is the 'traditional' definitive treatment. Percutaneous drainage under CT guidance has also been advocated in selected cases. Larger abscesses (> 4cm in diameter) are less likely to be cured with medical management only and have a higher mortality irrespective of treatment.
Complications of surgery or percutaneous drainage include :
· bronchoplueral fistula
· haemorrhage (from chest wall or from lung)
Despite treatment abscesses continue to have high mortality (15-20%). This is particularly the case in nosocomial infections, which account for the majority of deaths, presumably due to the combined effect of pre-existent illness and higher prevalence virulent of antibiotic resistant strains, particularly P aeruginosa (mortality rate of 83%), S aureus (50%) and Klebsiella pneumoniae (44%) 6.
The nurse notes any recent history of influenza, pneumonia, febrile illness, cough, and foul-smelling sputum production. The client is asked about the color and odor of the sputum and about any pleuritic chest pain (a stabbing pain, especially when taking a deep breath). The client is often febrile, pale, fatigued, and cachectic. Decreased breath sounds may be noted on auscultation, and there is dullness on percussion in the involved area. Bronchial breath sounds and crackles are often heard over the site of the lesion. The health care professional orders a chest x-ray examination and sputum samples to assist in the diagnosis.
The nursing diagnoses and interventions identified for the client with pneumonia also apply to the client with a lung abscess. Medical treatment is directed toward antibiotics and drainage of the abscess. The physician may prescribe more than one antibiotic. The nurse provides frequent mouth care and observes for oral overgrowth of Candida albicans.
Empyema is a collection of pus in the pleural space. The most common cause of empyema is a pulmonary infection, lung abscess, or infected pleural effusion. Pneumonia or a lung abscess can spread across the pleura, or obstruction of the lymph nodes can cause a retrograde flood of infected lymph into the pleural space. In addition, a liver abscess or abscess under the diaphragm can spread through the diaphragm's lymphatic system into the lung area. Thoracic surgery and chest trauma are common predisposing conditions in which bacteria are introduced directly into the pleural space. Blood from trauma may accumulate in the pleural space, and incomplete drainage of this blood promotes bacterial growth.
Empyemas are usually the complication of another underlying abnormality, and thus demographics will follow those of the primary cause e.g. pneumonia, sub-diaphragmatic abscess, oesophageal perforation etc..
Patients with HIV / AIDS are more likely to have pneumonia, and in turn are more likely to develop an empyema, which may occur in over 5% of cases of pneumonia.
Clinical signs and symptoms in isolation are non-specific, and mimic pulmonary infection of any compartment, with fever and increased white cell count being common. In the setting of a pleural collection, consolidation and infective symptoms, imaging alone is unable to exclude infection, and thoracocentesis with microbiological assessment is required. Presence of gas locules within the collection or thickened enhancing pleural margins are strongly indicative of infection (see below).
Additionally the presumptive diagnosis can be made if the fluid pH is < 7.0 or the fluid has glucose level < 40mg/dL.
Offending organisms vary somewhat according to the age at which the empyema develops and the underlying abnormality / primary site of infection. For parapneumonic empyemas most frequent organisms are:
· childhood – Pneumococcus
· adults - penicillin-resistant staphylococcus, gram-negative bacteria, anaerobic bacteria : usually polymicrobial
In the setting of trauma or thoracic surgery staphylococcus aureus is usually involved.
Can resemble a pleural effusion and can mimic a peripheral pulmonary abscess, although a number of features usually enable distinction between the two (see empyema vs lung abscess). Pleural fluid is typically unilateral or markedly asymmetric. Generally empyemas form an obtuse angle with the chest wall, and due to their lenticular shape are much larger in one projection (e.g. frontal) compared to the orthogonal projection (e.g. lateral). The lenticular shape (bi-convex) is also suggestive of the diagnosis, as transudative / sterile pleural effusions tend to be cresentic in shape (i.e concave towards the lung, see empyema vs pleural effusion).
Treatment and prognosis
Prompt evacuation of the infected fluid along with appropriate antibiotics is the mainstay of treatment, and will not only improve survival but also hopefully prevent the formation of a fibrothorax.
Evacuation may be performed with percutaneous chest tube placement often with administration of fibrinolytic agent (e.g. streptokinase or urokinase 8) into the pleural space to break down septations. Alternatively video-assisted thoracic surgery (VATS), open decortication, or even Clagett thoracotomy may be performed. VATS is increasingly thought to lead to faster resolution with lower morbidity and reduced cost.
Important history findings include recent febrile illness (including pneumonia), chest pain, dyspnea, cough, and trauma. The nurse documents the character of the sputum. Chest wall motion may be reduced on physical assessment. If a pleural effusion is present, fremitus may be decreased or absent on palpation, percussion may sound flat, and breath sounds are decreased on auscultation. With compression of lung tissue near or next to the effusion, auscultation abnormalities include bronchial breath sounds, egophony, and whispered pectoriloquy.
Some clients experience fever, chills, night sweats, and weight loss. If there is cardiorespiratory compromise, the client may be hypotensive because of a mediastinal deviation. The PMI (point of maximal impulse) may be displaced on cardiac palpation.
The health care provider orders a chest x-ray examination and obtains a sample of the pleural fluid via thoracentesis for help in making the diagnosis. Empyema fluid is thick, opaque, exudative, and intensely foul smelling. The pleural fluid is sent to the laboratory and is analyzed for color, red blood cell count, white blood cell count and differential, glucose and protein levels, lactate dehydrogenase (LDH), and pH. Gram stains, acid-fast stains, and cytology studies are also performed. A protein concentration higher than 3 g/100 mL indicates an exudative process.
Therapy for empyema is focused on emptying the empyema cavity, reexpanding the lung, and controlling the infection. The physician usually treats the client with antibiotics appropriate for the isolated pathogen. In addition, closed-chest drainage is used to promote lung expansion. The physician places one or more chest tubes in the lower parts of the empyema sac. Underwater seal drainage is used without suction initially, but suction may be added if the lung fails to expand with gravity drainage alone. The physician removes the tube when the lung is fully expanded and the infectious process is under control. Open thoracotomy and removal of a portion of the pleura may be needed for thick pus or marked pleural thickening. Nursing considerations are the same as those for clients with a pleural effusion, pneumothorax, or infection.