28/10/2009 1 PneumoniaPneumonia Dr Ibrahim Bashayreh, RN, PhD.
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Transcript of 28/10/2009 1 PneumoniaPneumonia Dr Ibrahim Bashayreh, RN, PhD.
28/10/2009 1
PneumoniaPneumoniaPneumoniaPneumonia
Dr Ibrahim Bashayreh, RN, PhD.Dr Ibrahim Bashayreh, RN, PhD.Dr Ibrahim Bashayreh, RN, PhD.Dr Ibrahim Bashayreh, RN, PhD.
28/10/2009 2
PneumoniaPneumoniaPneumoniaPneumonia
Acute inflammation of lung (lower Acute inflammation of lung (lower respiratory tract) caused by respiratory tract) caused by microorganism, comes with fever, microorganism, comes with fever, focal chest symptoms, shadowing focal chest symptoms, shadowing on CXRon CXRLeading cause of death until 1936Leading cause of death until 1936Discovery of sulfa drugs and Discovery of sulfa drugs and
penicillinpenicillin
Acute inflammation of lung (lower Acute inflammation of lung (lower respiratory tract) caused by respiratory tract) caused by microorganism, comes with fever, microorganism, comes with fever, focal chest symptoms, shadowing focal chest symptoms, shadowing on CXRon CXRLeading cause of death until 1936Leading cause of death until 1936Discovery of sulfa drugs and Discovery of sulfa drugs and
penicillinpenicillin
28/10/2009 3
Classification Classification Classification Classification Community Acquired PneumoniaCommunity Acquired Pneumonia
Occur within 48 hrs of admission or in Occur within 48 hrs of admission or in patient’s who haven’t been hospitalized in the patient’s who haven’t been hospitalized in the last 2 wkslast 2 wks
Strep pneumonia, mycoplasma pneumonia, Strep pneumonia, mycoplasma pneumonia, influenza A, Haemophilus influenza, and influenza A, Haemophilus influenza, and Legionella are more common pathogensLegionella are more common pathogens
Patients with chronic diseases are more prone Patients with chronic diseases are more prone to Klebsiella and other gram negative to Klebsiella and other gram negative organismsorganisms
Highest incidence in winterHighest incidence in winterSmoking important risk factorSmoking important risk factor
Community Acquired PneumoniaCommunity Acquired PneumoniaOccur within 48 hrs of admission or in Occur within 48 hrs of admission or in
patient’s who haven’t been hospitalized in the patient’s who haven’t been hospitalized in the last 2 wkslast 2 wks
Strep pneumonia, mycoplasma pneumonia, Strep pneumonia, mycoplasma pneumonia, influenza A, Haemophilus influenza, and influenza A, Haemophilus influenza, and Legionella are more common pathogensLegionella are more common pathogens
Patients with chronic diseases are more prone Patients with chronic diseases are more prone to Klebsiella and other gram negative to Klebsiella and other gram negative organismsorganisms
Highest incidence in winterHighest incidence in winterSmoking important risk factorSmoking important risk factor
28/10/2009 4
Types of PneumoniaTypes of PneumoniaTypes of PneumoniaTypes of Pneumonia
Hospital-acquired pneumonia (HAP) (Nasocomial Infection)Hospital-acquired pneumonia (HAP) (Nasocomial Infection)
Develops 2 or more days after admissionDevelops 2 or more days after admission Gram negative bacilli (Klebsiella, Pseudomonas, E coli, Gram negative bacilli (Klebsiella, Pseudomonas, E coli,
Proteus) or Staphylococcus are more common pathogensProteus) or Staphylococcus are more common pathogens Aspiration around an ETT/reduced consciousness or Aspiration around an ETT/reduced consciousness or
difficulty swallowing allows pathogens in the oropharynx to difficulty swallowing allows pathogens in the oropharynx to colonize the lungscolonize the lungs
Ventilator-associated pneumonia (VAP): in patients on Ventilator-associated pneumonia (VAP): in patients on ventilatorsventilators
Aspiation: follows aspiration of gastric contentsAspiation: follows aspiration of gastric contents Immunosuppression: chemotherapy/bone marrow Immunosuppression: chemotherapy/bone marrow
transplant/HIV patients susceptible to fungi and viral transplant/HIV patients susceptible to fungi and viral infections as well as other pathogeninfections as well as other pathogen
Highest mortality rate of nosocomial infectionsHighest mortality rate of nosocomial infections
Hospital-acquired pneumonia (HAP) (Nasocomial Infection)Hospital-acquired pneumonia (HAP) (Nasocomial Infection)
Develops 2 or more days after admissionDevelops 2 or more days after admission Gram negative bacilli (Klebsiella, Pseudomonas, E coli, Gram negative bacilli (Klebsiella, Pseudomonas, E coli,
Proteus) or Staphylococcus are more common pathogensProteus) or Staphylococcus are more common pathogens Aspiration around an ETT/reduced consciousness or Aspiration around an ETT/reduced consciousness or
difficulty swallowing allows pathogens in the oropharynx to difficulty swallowing allows pathogens in the oropharynx to colonize the lungscolonize the lungs
Ventilator-associated pneumonia (VAP): in patients on Ventilator-associated pneumonia (VAP): in patients on ventilatorsventilators
Aspiation: follows aspiration of gastric contentsAspiation: follows aspiration of gastric contents Immunosuppression: chemotherapy/bone marrow Immunosuppression: chemotherapy/bone marrow
transplant/HIV patients susceptible to fungi and viral transplant/HIV patients susceptible to fungi and viral infections as well as other pathogeninfections as well as other pathogen
Highest mortality rate of nosocomial infectionsHighest mortality rate of nosocomial infections
28/10/2009 5
Causes of HAPCauses of HAPCauses of HAPCauses of HAP
PseudomonasPseudomonasEnterobacterEnterobacterS. aureusS. aureusS. pneumoniaeS. pneumoniaeImmunosuppressive therapyImmunosuppressive therapyGeneral debilityGeneral debilityEndotracheal intubationEndotracheal intubation
PseudomonasPseudomonasEnterobacterEnterobacterS. aureusS. aureusS. pneumoniaeS. pneumoniaeImmunosuppressive therapyImmunosuppressive therapyGeneral debilityGeneral debilityEndotracheal intubationEndotracheal intubation
28/10/2009 6
Aging, 65 years or olderAging, 65 years or olderMale Male Children under 2Children under 2Having HIV or AIDSHaving HIV or AIDSIncreased frequency of gram- negative bacilli Increased frequency of gram- negative bacilli (leukemia, diabetes, alcoholism)(leukemia, diabetes, alcoholism)SmokingSmokingBeing around certain chemicalsBeing around certain chemicalsLiving in certain parts of the countryLiving in certain parts of the countryBeing hospitalized in ICU & having ETTBeing hospitalized in ICU & having ETTPollutionPollutionMalnutritionMalnutrition
Aging, 65 years or olderAging, 65 years or olderMale Male Children under 2Children under 2Having HIV or AIDSHaving HIV or AIDSIncreased frequency of gram- negative bacilli Increased frequency of gram- negative bacilli (leukemia, diabetes, alcoholism)(leukemia, diabetes, alcoholism)SmokingSmokingBeing around certain chemicalsBeing around certain chemicalsLiving in certain parts of the countryLiving in certain parts of the countryBeing hospitalized in ICU & having ETTBeing hospitalized in ICU & having ETTPollutionPollutionMalnutritionMalnutrition
28/10/2009 7
Acquisition of OrganismsAcquisition of OrganismsAcquisition of OrganismsAcquisition of Organisms
AspirationAspiration from nasopharynx, from nasopharynx, oropharynxoropharynx
InhalationInhalation of microbes of microbes
Hematogenous spreadHematogenous spread from from primary infection elsewhereprimary infection elsewhere
AspirationAspiration from nasopharynx, from nasopharynx, oropharynxoropharynx
InhalationInhalation of microbes of microbes
Hematogenous spreadHematogenous spread from from primary infection elsewhereprimary infection elsewhere
28/10/2009 8
Signs & Symptoms Signs & Symptoms Signs & Symptoms Signs & Symptoms SymptomsSymptomsDyspneaDyspnea PleurisyPleurisy CoughCough Discolored sputumDiscolored sputum
SignsSigns CyanosisCyanosis TachycardiaTachycardia TachypneaTachypnea Dull percussionDull percussion CrepitusCrepitus Bronchial breath soundsBronchial breath sounds Pleural rubPleural rub Sweating, cold clammy skinSweating, cold clammy skin
Non-respiratory featuresNon-respiratory features Confusion, fatigueConfusion, fatigue Diarrhea, N&V.Diarrhea, N&V.
SymptomsSymptomsDyspneaDyspnea PleurisyPleurisy CoughCough Discolored sputumDiscolored sputum
SignsSigns CyanosisCyanosis TachycardiaTachycardia TachypneaTachypnea Dull percussionDull percussion CrepitusCrepitus Bronchial breath soundsBronchial breath sounds Pleural rubPleural rub Sweating, cold clammy skinSweating, cold clammy skin
Non-respiratory featuresNon-respiratory features Confusion, fatigueConfusion, fatigue Diarrhea, N&V.Diarrhea, N&V.
28/10/2009 9
Clinical ManifestationsClinical Manifestations Clinical ManifestationsClinical Manifestations
CAP symptomsCAP symptomsSudden onset of feverSudden onset of feverChillsChillsCough productive of purulent Cough productive of purulent
sputumsputumPleuritic chest painPleuritic chest pain
CAP symptomsCAP symptomsSudden onset of feverSudden onset of feverChillsChillsCough productive of purulent Cough productive of purulent
sputumsputumPleuritic chest painPleuritic chest pain
28/10/2009 10
Pathophysiology: Pathophysiology: Pneumococcal PneumoniaPneumococcal Pneumonia
Pathophysiology: Pathophysiology: Pneumococcal PneumoniaPneumococcal Pneumonia
Congestion from outpouring of Congestion from outpouring of fluid into alveoli fluid into alveoli Microorganisms multiply and Microorganisms multiply and
spread infection, interfering with spread infection, interfering with lung functionlung function
Congestion from outpouring of Congestion from outpouring of fluid into alveoli fluid into alveoli Microorganisms multiply and Microorganisms multiply and
spread infection, interfering with spread infection, interfering with lung functionlung function
28/10/2009 11
Pathophysiology: Pathophysiology: Pneumococcal PneumoniaPneumococcal Pneumonia Pathophysiology: Pathophysiology: Pneumococcal PneumoniaPneumococcal Pneumonia
Red hepatizationRed hepatizationMassive dilation of capillariesMassive dilation of capillariesAlveoli fill with organisms, Alveoli fill with organisms,
neutrophils, RBCs, and fibrinneutrophils, RBCs, and fibrinCauses lungs to appear red and Causes lungs to appear red and
granular, similar to livergranular, similar to liver
Red hepatizationRed hepatizationMassive dilation of capillariesMassive dilation of capillariesAlveoli fill with organisms, Alveoli fill with organisms,
neutrophils, RBCs, and fibrinneutrophils, RBCs, and fibrinCauses lungs to appear red and Causes lungs to appear red and
granular, similar to livergranular, similar to liver
28/10/2009 12
ComplicationsComplicationsComplicationsComplications
Pleurisy (pain with breathing)Pleurisy (pain with breathing)
Pleural effusionPleural effusionUsually is sterile and reabsorbed in 1-2 Usually is sterile and reabsorbed in 1-2
weeks or requires thoracentesisweeks or requires thoracentesis
AtelectasisAtelectasisUsually clears with cough and deep Usually clears with cough and deep
breathingbreathing
Pleurisy (pain with breathing)Pleurisy (pain with breathing)
Pleural effusionPleural effusionUsually is sterile and reabsorbed in 1-2 Usually is sterile and reabsorbed in 1-2
weeks or requires thoracentesisweeks or requires thoracentesis
AtelectasisAtelectasisUsually clears with cough and deep Usually clears with cough and deep
breathingbreathing
28/10/2009 13
ComplicationsComplicationsComplicationsComplications
Delayed resolutionDelayed resolutionPersistent infection seen on x-ray as Persistent infection seen on x-ray as
residual consolidationresidual consolidation
Lung abscess (pus-containing lesions)Lung abscess (pus-containing lesions)Empyema (purulent exudate in pleural Empyema (purulent exudate in pleural cavity)cavity)Requires antibiotics and drainage of Requires antibiotics and drainage of
exudateexudate
Delayed resolutionDelayed resolutionPersistent infection seen on x-ray as Persistent infection seen on x-ray as
residual consolidationresidual consolidation
Lung abscess (pus-containing lesions)Lung abscess (pus-containing lesions)Empyema (purulent exudate in pleural Empyema (purulent exudate in pleural cavity)cavity)Requires antibiotics and drainage of Requires antibiotics and drainage of
exudateexudate
28/10/2009 14
ComplicationsComplicationsComplicationsComplications
PericarditisPericarditisFrom spread of microorganismFrom spread of microorganism
ArthritisArthritisSystemic spread of organismSystemic spread of organismExudate can be aspiratedExudate can be aspirated
MeningitisMeningitisPatient who is disoriented, confused, or Patient who is disoriented, confused, or
somnolent should have lumbar puncture somnolent should have lumbar puncture to evaluate meningitisto evaluate meningitis
PericarditisPericarditisFrom spread of microorganismFrom spread of microorganism
ArthritisArthritisSystemic spread of organismSystemic spread of organismExudate can be aspiratedExudate can be aspirated
MeningitisMeningitisPatient who is disoriented, confused, or Patient who is disoriented, confused, or
somnolent should have lumbar puncture somnolent should have lumbar puncture to evaluate meningitisto evaluate meningitis
28/10/2009 15
ComplicationsComplicationsComplicationsComplications
EndocarditisEndocarditisMicroorganisms attack endocardium and Microorganisms attack endocardium and
heart valvesheart valvesManifestations similar to bacterial Manifestations similar to bacterial
endocarditisendocarditis
EndocarditisEndocarditisMicroorganisms attack endocardium and Microorganisms attack endocardium and
heart valvesheart valvesManifestations similar to bacterial Manifestations similar to bacterial
endocarditisendocarditis
28/10/2009 16
Diagnostic TestsDiagnostic Tests Diagnostic TestsDiagnostic Tests
HistoryHistory
Physical examPhysical exam
Chest x-rayChest x-ray
Gram stain of sputumGram stain of sputum
Sputum culture and sensitivitySputum culture and sensitivity
Pulse oximetry or ABGsPulse oximetry or ABGs
CBC, differential, chemsCBC, differential, chems
Blood culturesBlood cultures
HistoryHistory
Physical examPhysical exam
Chest x-rayChest x-ray
Gram stain of sputumGram stain of sputum
Sputum culture and sensitivitySputum culture and sensitivity
Pulse oximetry or ABGsPulse oximetry or ABGs
CBC, differential, chemsCBC, differential, chems
Blood culturesBlood cultures
28/10/2009 17
Collaborative CareCollaborative CareCollaborative CareCollaborative Care
Antibiotic therapyAntibiotic therapy
Oxygen for hypoxemiaOxygen for hypoxemia
Analgesics for chest painAnalgesics for chest pain
AntipyreticsAntipyretics
Influenza drugsInfluenza drugs
Influenza vaccineInfluenza vaccine
Fluid intake at least 3 L per dayFluid intake at least 3 L per day
Caloric intake at least 1500 per dayCaloric intake at least 1500 per day
Antibiotic therapyAntibiotic therapy
Oxygen for hypoxemiaOxygen for hypoxemia
Analgesics for chest painAnalgesics for chest pain
AntipyreticsAntipyretics
Influenza drugsInfluenza drugs
Influenza vaccineInfluenza vaccine
Fluid intake at least 3 L per dayFluid intake at least 3 L per day
Caloric intake at least 1500 per dayCaloric intake at least 1500 per day
28/10/2009 18
Collaborative CareCollaborative CareCollaborative CareCollaborative Care
Pneumococcal vaccinePneumococcal vaccineIndicated for those at riskIndicated for those at risk
Chronic illness such as heart and lung Chronic illness such as heart and lung disease, diabetes mellitusdisease, diabetes mellitus
Recovering from severe illnessRecovering from severe illness65 or older65 or olderIn long-term care facilityIn long-term care facility
Pneumococcal vaccinePneumococcal vaccineIndicated for those at riskIndicated for those at risk
Chronic illness such as heart and lung Chronic illness such as heart and lung disease, diabetes mellitusdisease, diabetes mellitus
Recovering from severe illnessRecovering from severe illness65 or older65 or olderIn long-term care facilityIn long-term care facility
28/10/2009 19
Nursing AssessmentNursing Assessment Nursing AssessmentNursing Assessment
History of Predisposing/Risk FactorsHistory of Predisposing/Risk Factors
Lung cancerLung cancerCOPDCOPDDiabetes mellitusDiabetes mellitusDebilitating diseaseDebilitating diseaseMalnutritionMalnutrition
History of Predisposing/Risk FactorsHistory of Predisposing/Risk Factors
Lung cancerLung cancerCOPDCOPDDiabetes mellitusDiabetes mellitusDebilitating diseaseDebilitating diseaseMalnutritionMalnutrition
28/10/2009 20
Nursing AssessmentNursing Assessment Nursing AssessmentNursing AssessmentHistory of Predisposing/Risk FactorsHistory of Predisposing/Risk Factors
AIDSAIDSUse of antibiotics, corticosteroids, Use of antibiotics, corticosteroids,
chemotherapy, immunosuppressantschemotherapy, immunosuppressantsRecent abdominal or thoracic Recent abdominal or thoracic
surgerysurgerySmoking, alcoholism, respiratory Smoking, alcoholism, respiratory
infections infections Prolonged bed restProlonged bed rest
History of Predisposing/Risk FactorsHistory of Predisposing/Risk FactorsAIDSAIDSUse of antibiotics, corticosteroids, Use of antibiotics, corticosteroids,
chemotherapy, immunosuppressantschemotherapy, immunosuppressantsRecent abdominal or thoracic Recent abdominal or thoracic
surgerysurgerySmoking, alcoholism, respiratory Smoking, alcoholism, respiratory
infections infections Prolonged bed restProlonged bed rest
28/10/2009 21
Nursing AssessmentNursing Assessment Nursing AssessmentNursing Assessment
Clinical ManifestationsClinical ManifestationsDyspneaDyspneaNasal congestionNasal congestionPain with breathingPain with breathingSore throatSore throatMuscle achesMuscle achesFeverFever
Clinical ManifestationsClinical ManifestationsDyspneaDyspneaNasal congestionNasal congestionPain with breathingPain with breathingSore throatSore throatMuscle achesMuscle achesFeverFever
28/10/2009 22
Nursing AssessmentNursing AssessmentNursing AssessmentNursing Assessment
Clinical ManifestationsClinical ManifestationsRestlessness or lethargyRestlessness or lethargySplinting affected areaSplinting affected areaTachypneaTachypneaAsymmetric chest movementsAsymmetric chest movementsUse of accessory musclesUse of accessory musclesCracklesCracklesGreen or yellow sputumGreen or yellow sputum
Clinical ManifestationsClinical ManifestationsRestlessness or lethargyRestlessness or lethargySplinting affected areaSplinting affected areaTachypneaTachypneaAsymmetric chest movementsAsymmetric chest movementsUse of accessory musclesUse of accessory musclesCracklesCracklesGreen or yellow sputumGreen or yellow sputum
28/10/2009 23
Nursing AssessmentNursing Assessment Nursing AssessmentNursing Assessment
Clinical ManifestationsClinical ManifestationsTachycardiaTachycardiaChanges in mental Changes in mental
statusstatusLeukocytosisLeukocytosisAbnormal ABGsAbnormal ABGsPleural effusionPleural effusionPneumothorax on CXRPneumothorax on CXR
Clinical ManifestationsClinical ManifestationsTachycardiaTachycardiaChanges in mental Changes in mental
statusstatusLeukocytosisLeukocytosisAbnormal ABGsAbnormal ABGsPleural effusionPleural effusionPneumothorax on CXRPneumothorax on CXR
28/10/2009 24
Nursing DiagnosesNursing Diagnoses Nursing DiagnosesNursing Diagnoses
Ineffective breathing patternIneffective breathing pattern
Ineffective airway clearanceIneffective airway clearance
Acute painAcute pain
Imbalanced nutrition: less than body Imbalanced nutrition: less than body requirementsrequirements
Activity intoleranceActivity intolerance
Ineffective breathing patternIneffective breathing pattern
Ineffective airway clearanceIneffective airway clearance
Acute painAcute pain
Imbalanced nutrition: less than body Imbalanced nutrition: less than body requirementsrequirements
Activity intoleranceActivity intolerance
28/10/2009 25
PlanningPlanning PlanningPlanning
Goals: Patient will haveGoals: Patient will haveClear breath soundsClear breath soundsNormal breathing patternsNormal breathing patternsNo signs of hypoxiaNo signs of hypoxiaNormal chest x-rayNormal chest x-rayNo complications related to pneumoniaNo complications related to pneumonia
Goals: Patient will haveGoals: Patient will haveClear breath soundsClear breath soundsNormal breathing patternsNormal breathing patternsNo signs of hypoxiaNo signs of hypoxiaNormal chest x-rayNormal chest x-rayNo complications related to pneumoniaNo complications related to pneumonia
28/10/2009 26
Nursing ImplementationNursing ImplementationNursing ImplementationNursing Implementation
Teach nutrition, hygiene, rest, regular Teach nutrition, hygiene, rest, regular exercise to maintain natural resistanceexercise to maintain natural resistance
Prompt treatment of URIsPrompt treatment of URIs
Teach nutrition, hygiene, rest, regular Teach nutrition, hygiene, rest, regular exercise to maintain natural resistanceexercise to maintain natural resistance
Prompt treatment of URIsPrompt treatment of URIs
28/10/2009 27
Nursing ImplementationNursing ImplementationNursing ImplementationNursing Implementation
Encourage those at risk to obtain Encourage those at risk to obtain influenza and pneumococcal influenza and pneumococcal vaccinationsvaccinations
Reposition patient q2hReposition patient q2h
Assist patients at risk for aspiration Assist patients at risk for aspiration with eating, drinking, and taking medswith eating, drinking, and taking meds
Encourage those at risk to obtain Encourage those at risk to obtain influenza and pneumococcal influenza and pneumococcal vaccinationsvaccinations
Reposition patient q2hReposition patient q2h
Assist patients at risk for aspiration Assist patients at risk for aspiration with eating, drinking, and taking medswith eating, drinking, and taking meds
28/10/2009 28
Nursing ImplementationNursing ImplementationNursing ImplementationNursing Implementation
Assist immobile patients with turning Assist immobile patients with turning and deep breathingand deep breathing
Strict asepsisStrict asepsis
Emphasize need to take course of Emphasize need to take course of medication(s)medication(s)
Teach drug-drug interactionsTeach drug-drug interactions
Assist immobile patients with turning Assist immobile patients with turning and deep breathingand deep breathing
Strict asepsisStrict asepsis
Emphasize need to take course of Emphasize need to take course of medication(s)medication(s)
Teach drug-drug interactionsTeach drug-drug interactions
28/10/2009 29
EvaluationEvaluationEvaluationEvaluation
Dyspnea not presentDyspnea not present
SpOSpO22 >> 95 95
Free of adventitious breath soundsFree of adventitious breath sounds
Clears sputum from airwayClears sputum from airway
Dyspnea not presentDyspnea not present
SpOSpO22 >> 95 95
Free of adventitious breath soundsFree of adventitious breath sounds
Clears sputum from airwayClears sputum from airway
28/10/2009 30
EvaluationEvaluationEvaluationEvaluation
Reports pain controlledReports pain controlled
Verbalizes causal factorsVerbalizes causal factors
Adequate fluid and caloric intakeAdequate fluid and caloric intake
Performs ADLsPerforms ADLs
Reports pain controlledReports pain controlled
Verbalizes causal factorsVerbalizes causal factors
Adequate fluid and caloric intakeAdequate fluid and caloric intake
Performs ADLsPerforms ADLs
28/10/2009 31
TuberculosisTuberculosisTuberculosisTuberculosisFamous people who have had TB
Fredric Chopin*Eleanor Roosevelt*Nelson MandelaRingo StarrTom JonesTina Turner
*Died of TB
28/10/2009 32
What is tuberculosis (TB)?What is tuberculosis (TB)?What is tuberculosis (TB)?What is tuberculosis (TB)?Disease caused by bacteria called Disease caused by bacteria called Mycobacterium tuberculosisMycobacterium tuberculosisChronic bacterial infectionChronic bacterial infectionWas once the leading cause of death in USWas once the leading cause of death in USThe number of cases declined in the 1940’s The number of cases declined in the 1940’s when drugs were developed to treat TBwhen drugs were developed to treat TBTB is still a problem worldwideTB is still a problem worldwide8 million people develop TB yearly8 million people develop TB yearly3 million die3 million die
Disease caused by bacteria called Disease caused by bacteria called Mycobacterium tuberculosisMycobacterium tuberculosisChronic bacterial infectionChronic bacterial infectionWas once the leading cause of death in USWas once the leading cause of death in USThe number of cases declined in the 1940’s The number of cases declined in the 1940’s when drugs were developed to treat TBwhen drugs were developed to treat TBTB is still a problem worldwideTB is still a problem worldwide8 million people develop TB yearly8 million people develop TB yearly3 million die3 million die
28/10/2009 33
TuberculosisTuberculosisTuberculosisTuberculosis
5-10%5-10% become become activeactiveOnly Only contagiouscontagious when activewhen activePrimarily affect Primarily affect lungslungs but… but…KidneysKidneysLiverLiverBrainBrainBoneBone
5-10%5-10% become become activeactiveOnly Only contagiouscontagious when activewhen activePrimarily affect Primarily affect lungslungs but… but…KidneysKidneysLiverLiverBrainBrainBoneBone
28/10/2009 34
How is TB spread?How is TB spread?How is TB spread?How is TB spread?
Through the air from person to Through the air from person to person by coughingperson by coughingUsually attacks lungsUsually attacks lungsTwo stagesTwo stagesLatent TBLatent TB
asymptomatic and not contagiousasymptomatic and not contagious can take medication to prevent development of can take medication to prevent development of
diseasediseaseActive TB DiseaseActive TB Disease
May spread to othersMay spread to othersMay have abnormal chest x-rayMay have abnormal chest x-rayUsually have positive skin testUsually have positive skin test
Through the air from person to Through the air from person to person by coughingperson by coughingUsually attacks lungsUsually attacks lungsTwo stagesTwo stagesLatent TBLatent TB
asymptomatic and not contagiousasymptomatic and not contagious can take medication to prevent development of can take medication to prevent development of
diseasediseaseActive TB DiseaseActive TB Disease
May spread to othersMay spread to othersMay have abnormal chest x-rayMay have abnormal chest x-rayUsually have positive skin testUsually have positive skin test
28/10/2009 35
Symptoms of TBSymptoms of TBSymptoms of TBSymptoms of TB
ChillsChills
FeverFever
Weakness or fatigueWeakness or fatigue
Sweating while sleeping, Night sweatsSweating while sleeping, Night sweats
Cough that lasts longer than 2 weeksCough that lasts longer than 2 weeks
Pain in chestPain in chest
Coughing up blood or sputumCoughing up blood or sputum
ChillsChills
FeverFever
Weakness or fatigueWeakness or fatigue
Sweating while sleeping, Night sweatsSweating while sleeping, Night sweats
Cough that lasts longer than 2 weeksCough that lasts longer than 2 weeks
Pain in chestPain in chest
Coughing up blood or sputumCoughing up blood or sputum
28/10/2009 36
Risk FactorsRisk FactorsRisk FactorsRisk Factors
Close contact with someone who is infected Close contact with someone who is infected with TBwith TBTraveling to a country where TB is commonTraveling to a country where TB is commonForeign-born individuals and minorities Foreign-born individuals and minorities have a higher incidence of developing TBhave a higher incidence of developing TB2002: 50% of US cases were in foreign-2002: 50% of US cases were in foreign-
born individuals.born individuals.2002: 80% of all US TB cases were in 2002: 80% of all US TB cases were in
ethnic and racial minorities.ethnic and racial minorities.
Close contact with someone who is infected Close contact with someone who is infected with TBwith TBTraveling to a country where TB is commonTraveling to a country where TB is commonForeign-born individuals and minorities Foreign-born individuals and minorities have a higher incidence of developing TBhave a higher incidence of developing TB2002: 50% of US cases were in foreign-2002: 50% of US cases were in foreign-
born individuals.born individuals.2002: 80% of all US TB cases were in 2002: 80% of all US TB cases were in
ethnic and racial minorities.ethnic and racial minorities.
28/10/2009 37
Risk FactorsRisk FactorsRisk FactorsRisk Factors
ImmunocompromiseImmunocompromiseSubstance abuseSubstance abuseIndigent (POVERTY)Indigent (POVERTY)Living in overcrowded, substandard housingLiving in overcrowded, substandard housingHealth care workers performing high risk Health care workers performing high risk activitiesactivities
ImmunocompromiseImmunocompromiseSubstance abuseSubstance abuseIndigent (POVERTY)Indigent (POVERTY)Living in overcrowded, substandard housingLiving in overcrowded, substandard housingHealth care workers performing high risk Health care workers performing high risk activitiesactivities
28/10/2009 38
Multi-drug resistant TB (MDR TB)Multi-drug resistant TB (MDR TB)Multi-drug resistant TB (MDR TB)Multi-drug resistant TB (MDR TB)
Bacteria become resistant to antibioticsBacteria become resistant to antibioticsArose from improper use of antibiotics in the Arose from improper use of antibiotics in the treatment of TBtreatment of TBTreatment of one case can cost up to $1.3 millionTreatment of one case can cost up to $1.3 million45 states and Washington, DC have confirmed cases 45 states and Washington, DC have confirmed cases of MDR TB of MDR TB Treatment is difficult and costlyTreatment is difficult and costlyCan develop from not taking proper course of Can develop from not taking proper course of antibiotics for TBantibiotics for TBMDR TB can be spread by an infected personMDR TB can be spread by an infected person
Bacteria become resistant to antibioticsBacteria become resistant to antibioticsArose from improper use of antibiotics in the Arose from improper use of antibiotics in the treatment of TBtreatment of TBTreatment of one case can cost up to $1.3 millionTreatment of one case can cost up to $1.3 million45 states and Washington, DC have confirmed cases 45 states and Washington, DC have confirmed cases of MDR TB of MDR TB Treatment is difficult and costlyTreatment is difficult and costlyCan develop from not taking proper course of Can develop from not taking proper course of antibiotics for TBantibiotics for TBMDR TB can be spread by an infected personMDR TB can be spread by an infected person
28/10/2009 39
How to protect yourselfHow to protect yourselfHow to protect yourselfHow to protect yourself
BCG vaccine for TB is given in many countriesBCG vaccine for TB is given in many countries
Not recommended for healthcare workers Not recommended for healthcare workers unless a high percentage of patients are unless a high percentage of patients are infected with MDR TBinfected with MDR TB
PPD test if exposure is suspectedPPD test if exposure is suspected
USE proper PPE when in contact with patients USE proper PPE when in contact with patients who may have TBwho may have TB
BCG vaccine for TB is given in many countriesBCG vaccine for TB is given in many countries
Not recommended for healthcare workers Not recommended for healthcare workers unless a high percentage of patients are unless a high percentage of patients are infected with MDR TBinfected with MDR TB
PPD test if exposure is suspectedPPD test if exposure is suspected
USE proper PPE when in contact with patients USE proper PPE when in contact with patients who may have TBwho may have TB
28/10/2009 40
PPD Skin Test Procedure PPD Skin Test Procedure PPD Skin Test Procedure PPD Skin Test Procedure
Intradermal administration of PPD Intradermal administration of PPD L forearmL forearm
Must be “read” between 48 and 72 hoursMust be “read” between 48 and 72 hours
To accurately “read”To accurately “read”Visual inspection for erythemaVisual inspection for erythemaTactile inspection to monitor size of Tactile inspection to monitor size of
indurationinduration10 mm or > area of 10 mm or > area of indurationinduration
Consider positive and must be referred Consider positive and must be referred
Intradermal administration of PPD Intradermal administration of PPD L forearmL forearm
Must be “read” between 48 and 72 hoursMust be “read” between 48 and 72 hours
To accurately “read”To accurately “read”Visual inspection for erythemaVisual inspection for erythemaTactile inspection to monitor size of Tactile inspection to monitor size of
indurationinduration10 mm or > area of 10 mm or > area of indurationinduration
Consider positive and must be referred Consider positive and must be referred
28/10/2009 41
TuberculosisTuberculosisTuberculosisTuberculosis
Diagnostic examsDiagnostic examsPPD PPD Mantoux skin testMantoux skin test > 10mm in diameter> 10mm in diameter indurationinduration Indicates: Indicates:
LatentLatent TB TB ReadRead
48-72 after 48-72 after Intradermal: 15-degreesIntradermal: 15-degrees Do not rubDo not rub
Diagnostic examsDiagnostic examsPPD PPD Mantoux skin testMantoux skin test > 10mm in diameter> 10mm in diameter indurationinduration Indicates: Indicates:
LatentLatent TB TB ReadRead
48-72 after 48-72 after Intradermal: 15-degreesIntradermal: 15-degrees Do not rubDo not rub
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Confirmation of DiseaseConfirmation of DiseaseConfirmation of DiseaseConfirmation of Disease
Positive reaction does not Positive reaction does not necessarily mean active disease.necessarily mean active disease.May indicate exposure to TBMay indicate exposure to TB
Diagnosis confirmed by: Diagnosis confirmed by: Positive smear for AFB andPositive smear for AFB andSputum culture of Sputum culture of
Mycobacterium tuberculosis Mycobacterium tuberculosis
Positive reaction does not Positive reaction does not necessarily mean active disease.necessarily mean active disease.May indicate exposure to TBMay indicate exposure to TB
Diagnosis confirmed by: Diagnosis confirmed by: Positive smear for AFB andPositive smear for AFB andSputum culture of Sputum culture of
Mycobacterium tuberculosis Mycobacterium tuberculosis
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InterventionsInterventions InterventionsInterventions
Combination drug Combination drug therapytherapyIsoniazidIsoniazidRifampicinRifampicinPyrazinamidePyrazinamideEthambutol or Ethambutol or
streptomycin streptomycin
Combination drug Combination drug therapytherapyIsoniazidIsoniazidRifampicinRifampicinPyrazinamidePyrazinamideEthambutol or Ethambutol or
streptomycin streptomycin
EducationEducationMust follow Must follow
exact drug exact drug regimenregimen
Proper Proper nutritionnutritionReverse weight Reverse weight
loss and lethargy loss and lethargy
About disease About disease
EducationEducationMust follow Must follow
exact drug exact drug regimenregimen
Proper Proper nutritionnutritionReverse weight Reverse weight
loss and lethargy loss and lethargy
About disease About disease
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Tuberculosis TreatmentTuberculosis TreatmentTuberculosis TreatmentTuberculosis Treatment
INHINH Isonicotinyl Hydrazine Isonicotinyl Hydrazine Isoniazid Isoniazid Toxic to the Toxic to the liverliver
RifampicinRifampicin Turns urine redTurns urine red
StreptomycinStreptomycin Causes 8th cranial nerve Causes 8th cranial nerve
damagedamage Acoustic nerveAcoustic nerve
INHINH Isonicotinyl Hydrazine Isonicotinyl Hydrazine Isoniazid Isoniazid Toxic to the Toxic to the liverliver
RifampicinRifampicin Turns urine redTurns urine red
StreptomycinStreptomycin Causes 8th cranial nerve Causes 8th cranial nerve
damagedamage Acoustic nerveAcoustic nerve
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CLASSIFICATIONCLASSIFICATIONCLASSIFICATIONCLASSIFICATION
Class 0—no exposureClass 0—no exposure
Class 1—exposure, no infectionClass 1—exposure, no infection
Class 2—latent infection; no disease (positive Class 2—latent infection; no disease (positive PPD but no evidence of active TBPPD but no evidence of active TB
Class 3—disease; clinically activeClass 3—disease; clinically active
Class 4—disease; not clinically activeClass 4—disease; not clinically active
Class 5—suspected disease; diagnosis Class 5—suspected disease; diagnosis pendingpending
Class 0—no exposureClass 0—no exposure
Class 1—exposure, no infectionClass 1—exposure, no infection
Class 2—latent infection; no disease (positive Class 2—latent infection; no disease (positive PPD but no evidence of active TBPPD but no evidence of active TB
Class 3—disease; clinically activeClass 3—disease; clinically active
Class 4—disease; not clinically activeClass 4—disease; not clinically active
Class 5—suspected disease; diagnosis Class 5—suspected disease; diagnosis pendingpending
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MEDICAL MANAGEMENTMEDICAL MANAGEMENTMEDICAL MANAGEMENTMEDICAL MANAGEMENT
Treated with chemotherapeutic agents for 6-12 Treated with chemotherapeutic agents for 6-12 monthsmonths
Resistance increasing. May be Resistance increasing. May be primary, primary, secondary, secondary, oror multidrug resistant. multidrug resistant.
Primary—Primary—resistance to one of first line drugs in resistance to one of first line drugs in those who have not had prior treatmentthose who have not had prior treatment
Secondary—Secondary—resistance to one or more anti-TB resistance to one or more anti-TB
drugs in patientsdrugs in patients undergoing txundergoing tx
Multidrug resistance—Multidrug resistance—resistance to two agents, resistance to two agents, INH and Rifampicin.INH and Rifampicin.
Treated with chemotherapeutic agents for 6-12 Treated with chemotherapeutic agents for 6-12 monthsmonths
Resistance increasing. May be Resistance increasing. May be primary, primary, secondary, secondary, oror multidrug resistant. multidrug resistant.
Primary—Primary—resistance to one of first line drugs in resistance to one of first line drugs in those who have not had prior treatmentthose who have not had prior treatment
Secondary—Secondary—resistance to one or more anti-TB resistance to one or more anti-TB
drugs in patientsdrugs in patients undergoing txundergoing tx
Multidrug resistance—Multidrug resistance—resistance to two agents, resistance to two agents, INH and Rifampicin.INH and Rifampicin.
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TuberculosisTuberculosisTuberculosisTuberculosis
ComplicationsComplications
PleurisyPleurisy
PericarditisPericarditis
MeningitisMeningitis
Bone infectionsBone infections
MalnutritionMalnutrition
Drug-toxicityDrug-toxicity
ComplicationsComplications
PleurisyPleurisy
PericarditisPericarditis
MeningitisMeningitis
Bone infectionsBone infections
MalnutritionMalnutrition
Drug-toxicityDrug-toxicity
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TuberculosisTuberculosisTuberculosisTuberculosis
Nursing DxNursing Dx
Impaired gas exchangeImpaired gas exchange
Ineffective airway clearanceIneffective airway clearance
AnxietyAnxiety
Knowledge deficitKnowledge deficit
Alt. nutritionAlt. nutrition
Nursing DxNursing Dx
Impaired gas exchangeImpaired gas exchange
Ineffective airway clearanceIneffective airway clearance
AnxietyAnxiety
Knowledge deficitKnowledge deficit
Alt. nutritionAlt. nutrition
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TuberculosisTuberculosisTuberculosisTuberculosisPreventative measuresPreventative measures
CleanClean well well ventilatedventilated living areas living areas
Resp. isolation Resp. isolation
Vaccine?Vaccine?BCGBCGDoes not prevent TBDoes not prevent TBCauses a + PPDCauses a + PPD
If exposed takeIf exposed takeINHINH
Preventative measuresPreventative measures
CleanClean well well ventilatedventilated living areas living areas
Resp. isolation Resp. isolation
Vaccine?Vaccine?BCGBCGDoes not prevent TBDoes not prevent TBCauses a + PPDCauses a + PPD
If exposed takeIf exposed takeINHINH
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Tuberculosis SummaryTuberculosis SummaryTuberculosis SummaryTuberculosis Summary
Chronic bacterial infection Chronic bacterial infection spread through the airspread through the air
Fever, chills, sweating while sleeping, Fever, chills, sweating while sleeping, persistent cough, coughing up blood persistent cough, coughing up blood or sputumor sputumMulti-drug-resistant tuberculosis Multi-drug-resistant tuberculosis MDR TBMDR TBUse proper PPE and get PPD test if Use proper PPE and get PPD test if exposedexposed
Chronic bacterial infection Chronic bacterial infection spread through the airspread through the air
Fever, chills, sweating while sleeping, Fever, chills, sweating while sleeping, persistent cough, coughing up blood persistent cough, coughing up blood or sputumor sputumMulti-drug-resistant tuberculosis Multi-drug-resistant tuberculosis MDR TBMDR TBUse proper PPE and get PPD test if Use proper PPE and get PPD test if exposedexposed