1. Infection: Pneumonia, Influenza, Meningitis
Brunner ch. 23, 64, 70

2. Infection Concept Review
Infection—disease state resulting from the presence of pathogens in the body. May be acute or chronic
Pathogens—disease-producing microorganisms—bacteria, viruses, fungi, parasites. The presence of these pathogens usually produces an inflammatory response as well.

3. Course of Infection
Incubation period—time between entry of pathogen and onset of sx
Prodromal stage—nonspecific sx, most infectious
Illness stage—worst sx
Convalescence—recovery time
Length of each stage depends on type of infection—may be local or systemic

4. Chain or Cycle of Infection
Infectious agent (pathogen)
Reservoir (place it lives)
Portal of exit (orifices or breaks)
Mode of transmission (how it moves)
Portal of entry (orifices or breaks)
Susceptible host (stressors)

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

6. The Susceptible Host Changes in normal body flora
Breakdown in body systems
Flawed inflammatory response
Problems with tissue repair
Stressors

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

8. Laboratory Data
WBC (Totals and differentials) Amount elevated usually indicates severity.
“Left shift” (high neutrophils) usually indicates a severe infection.
Total elevation not seen in viral infections. May see a “right shift” (high lymphocytes) in some viral infections
+Cultures and gram stains

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

10. Exemplar # 1: Influenza (205, 221-222, 2122, 2131)
Acute viral respiratory disease
Caused by different strains of A, B, or C virus
Flu shot is made from 2 A strains and 1 B strain
Spread by droplet. Incubation 24-72h
A leading cause of morbidity and mortality; most deaths occur in over 60 age group.

11. High-risk Groups Any age with chronic illness
Residents of long term care
Immunocompromised
Pregnant
Also recommended for 6 mo-5 yrs, over 50
Required for healthcare workers

12. Manifestations
Abrupt onset with cough, fever, myalgia, HA, sore throat
Resolution within 7d unless complications develop. Most common complication is PN
Convalescent phase may include malaise and hyperactive airways

13. Collaborative Care
Relieve sx with mild analgesics and cough meds and prevent pneumonia.
Antivirals shorten course of illness and inhibit spread of virus to other cells—should be given within 2d of onset of sx or can be given prophylactically.
Older adults may be hospitalized. Vaccine is less effective in this group.
Encourage flu vaccine esp. in high-risk groups.
Reactions to vaccine required to be reported.
Pandemics should be planned for by HC agencies.

14. Exemplar # 2: Pneumonia (PN) p. 554
Acute inflammation of lung caused by microbial organism
Leading cause of death in the United States from infectious disease
Most common type is streptococcal
Causes: aspiration, inhalation of microbes, or spread thru blood from a primary infection site

15. LLL Pneumonia

16. Risk Factors Impaired immunity Chronic respiratory conditions
Hospitalization (HCPs, respiratory equipment, NG or ET tubes)
Immobility
Smoking/pollution
Meds that cause respiratory depression
↓ Cough and epiglottal reflexes
Malnutrition
Pneumonitis

17. Types of PN
Community-acquired (CAP)—usually streptococcal. Occurs in community or within 48h after hospitalization
Hospital-acquired (HAP)—occurs after 48h. Most common are the antibiotic-resistant organisms
Aspiration—usually streptococcal (normal flora in oropharynx)
Pneumonia in the Immunocompromised Host (formally Opportunistic)—fungal, PCP, TB

18. Pathophysiology of Pneumonia
Organism enters respiratory tract and releases toxins causing inflammation
In alveoli, serous fluid and mucus are released and bacteria multiply rapidly in the fluid
Capillaries dilate adding red cells to alveolar fluid along with bacteria, white cells, and fibrin
Venous blood entering the lungs doesn’t get proper oxygenation leading to hypoxemia
Lobar involves entire lobe; bronchopneumonia is patchy

19. Clinical Manifestations
Common to most
Sudden onset of fever, chills
Tachycardia, tachypnea, orthopnea
Cough productive of purulent sputum unless dehydration is present. Color of sputum not necessarily indicative of organism
Pleuritic chest pain
Confusion or stupor in elderly or symptoms may not be readily apparent

20. Clinical Manifestations
Lung examination findings
Dullness to percussion
↑ Fremitus (vibration)
Usually fine crackles
Bronchial breath sounds—high-pitched and loud, normally only heard around the trachea. No air exchange in the alveoli causes no vesicular sounds to be heard and the high-pitch sound that is heard is from the tracheobronchial tree and being transmitted to the chest wall.

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

22. Most Common Complications
Pleurisy
Atelectasis
Pleural effusion—purulent fluid in pleural space. Usually is sterile and reabsorbed in 1 to 2 weeks or may require thoracentesis. Occurs in 40% of cases.
Sepsis
Shock and respiratory failure (delayed or inadequate tx or at risk populations)

23. Atelectasis

24. Pleural Effusion

25. Collaborative Care Assess ability to treat at home.
HCP should check with Case Management to see if patient meets inpatient criteria.
Ultimately, HCP can decide, but hospital may not get paid for inpatient stay.

26. Collaborative Care Antibiotic therapy (only if bacterial)
Oxygen for hypoxemia
Analgesics for chest pain
Antitussives for cough
Antipyretics for fever
May need nebulizer treatments
Fluid intake at least 3 L per day
Caloric intake at least 1500 per day (high calorie fluids if severe anorexia is present)

27. Commonly Used Antibiotics
Penicillins—amoxicillin, penicillin-G
Cephalosporins—Ancef, Rocephin
Methicillin resistant—vancomycin, linzeloid
Fluoroquinolone—Cipro (tendonitis)
Levofloxacin—Levaquin (“)
Macrolides—azithromycin, erythromycin
Antivirals—Tamiflu, Relenza
Antifungals—v
Anti-TB—isoniazid + rifampin

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

29. Nursing Diagnoses Impaired gas exchange Ineffective breathing pattern
Ineffective airway clearance
Impaired tissue perfusion
Acute pain
Imbalanced nutrition: Less than body requirements
Activity intolerance
Deficient fluid volume
Deficient knowledge

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

31. Nursing Management
Admission history, med list, and physical assessment
Identify risk factors
Labs and radiology
Monitor O2 status and oxygen therapy
Monitor effects of respiratory therapy
HOB elevated
Promote C&DB and use of IS
Monitor IV fluids and encourage po fluids
Administer and evaluate antibiotic therapy
Balance rest and activity
Evaluate activity tolerance
Monitor for changes in status

32. Patient Education Causes
Individual risk factors and how to minimize risk such as stopping smoking
Managing symptoms
Importance of med therapy
S & S to report
Keeping FU appts
May need to teach IV antibiotic therapy
Vaccines

33. Evaluation Dyspnea not present SpO2 ≥ 95
Free of adventitious breath sounds
Clears sputum from airway
Reports pain control
Verbalizes causal factors
Adequate fluid and caloric intake
Performs activities of daily living

34. Developmental Issues
Very young and very old are more susceptible to the complications of PN and influenza. Both can become ill very quickly and mortality rates are generally higher
Both groups also become dehydrated quicker than adults.
Remember that elderly may have atypical symptoms.
Children have shorter, straighter passageways in their respiratory system, making spread of infectious organisms more rapid.

35. Cultural and Socioeconomic Issues
Be sensitive to another cultures need to treat infections with alternative therapies and healers: herbal, acupuncture, hot-cold, prayer, charms, etc.
Be aware that $ play an important role today with limited access to health care and expense of prescriptions. HCPs should try to be sensitive to what they prescribe.

36. Exemplar #3: Meningitis (1950-2)
Inflammation of the lining around the brain and spinal cord
Caused by bacteria or virus
80% are caused by the bacteria Streptococcus pneumoniae and Neisseria meningitides
Viral infections are usually caused by mumps, herpes, or mosquitoes or other insects.

37. Risk Factors Pneumonia Otitis media Mastoiditis URI AIDS Lyme Disease
Smoking
Immunosuppression
Crowded living conditions
Facial trauma
Invasive procedures

38. Pathophysiology Bacteria enters bloodstream
Crosses blood-brain barrier
Invades CSF
Inflammation occurs
IICP results

39. Complications Vision and hearing impairments Seizures Hydrocephalus
Paralysis
Septic shock
Brain damage

40. Manifestations Fever HA Nuchal rigidity Photophobia Hemorrhagic rash
Confusion, irritability, lethargy, decreased LOC
+Kernig’s sign—flexed hip and knee cannot be extended
+Brudzinski sign—neck flexion causes flexion of the hips and knees

41. Diagnostics CT or MRI to detect brain shift LP with evaluation of CSF
Blood cultures

42. Preventative Management
Hib vaccine has almost eradicated Hemophilus influenza, a past major cause of meningitis in children.
Meningococcal vaccine should be given to all college-bound adolescents, especially those planning on living in dorms.
People who have close contact with meningitis should get Rocephin.

43. Medical Management
IV antibiotic therapy usually with Vancomycin and a cephalosporin such as Rocephin.
Decadron steroid therapy decreases swelling and inflammation
Antiseizure meds if indicated
Contact precautions

44. Nursing Management VS and O2 sat Neuro checks Low lights
Administration of meds (antibiotics, antiseizure, antipyretics, analgesics)
Seizure precautions
Monitor IV therapy and fluid status
Maintain isolation precautions
Prevent complications from decreased mobility
Family support