Test 3

• Risk Factors for TB

  • Homeless
  • Populations that are crowded
  • IV injecting drug users
  • Poverty, poor access to health care
  • Immunosuppression
  • Living or working in institutions (hospitals/prisons)
• Signs/Symptoms of TB


  • Take 2-3 weeks to develop symptoms
  • Initial symptoms - dry cough that becomes productive, fatigue, malaise, anorexia and weight loss
  • Low-grade fever, night sweats - is what normally brings the patient in
  • Late symptoms - dyspnea and hemoptysis (blood tinge sputum)
• Diagnostic Tests for TB

  • Mantoux test - inspecting the site for induration 48-72 hours
  • Chest x-ray - cannot make diagnosis solely on X-ray, may appear normal in a patient with TB
  • Sputum culture - NAAT sputum culture is the gold standard for diagnosing TB
• Positive TB test (Mantoux test)

  Low risk individuals - greater than or equal to 15mm induration

  High risk (immigrants, diabetes, IV drug users) - greater than 10mm induration

  Immunocompromised (HIV, recent contact with TB, taking 15mg/day prednisone) - 5mm induration or greater
• Nursing Education for TB

  • Most patients treated outpatient
  • Patients are infectious for first 2 weeks after starting treatment if sputum positive for TB
  • Restricted visitors, limited public exposure, hand hygiene
  • Airborne isolation - single-occupancy room with 6-12 airflow exchanges/hour
  • Healthcare workers wear high-efficiency particulate air (HEPA) mask
  • Teach patients to prevent spread by cover nose and mouth with tissue when coughing, sneezing, or producing sputum, dispose in trash or flush. Hand washing after handling sputum-soiled tissues
  • Patients wear regular mask if outside of negative-pressure room
  • They may go home even if cultures are positive
  • They will need monthly sputum cultures, if they have two consecutive negative cultures then they are noninfectious
  • You will have to notify public health department if positive TB
• Treatment for TB


  • Initial 8wks-3months 4 drugs - Isoniazid, rifampin, pyrazinamide and ethambutol
  • Continuation - 18 weeks 2 drugs - Isoniazid and Rifampin
  • Rifampin causes a reddish/yellow urine, this is normal
• TB Vaccine


  Bacille-Calmette-Guerin (BCG) vaccine - it's live strain of mycobacterium bovis. It's given to infants in parts of world with high prevalence TB. The vaccine can result in a false TB screening test.
• Pneumonia


  Infection of any of the lung structures
• Signs/Symptoms of Pneumonia


  • Cough - productive or nonproductive
  • Green, yellow, or rust-colored sputum
  • Fever, chills
  • Dyspnea, tachypnea
  • Pleuritic chest pain
  • Older or debilitated patients - confusion or stupor (hard to arouse), hypothermia
• Physical Examination Findings for Pneumonia


  • Fine or coarse crackles
  • With consolidation - bronchial breath sounds, egophony (E to A), increased fremitus
  • With pleural effusion - dullness to percussion
• Complications of Pneumonia


  • Atelectasis - collapse of the alveoli
  • Pleural effusion - fluid buildup
  • Elderly complications - Sepsis
• Diagnostic Tests for Pneumonia


  • History and physical
  • Chest x-ray - infiltrates/consolidation
  • May need a thoracentesis and/or bronchoscopy
  • O2 stat - want above 90%
  • ABGs - measuring level of CO2
  • Sputum gram statin C&S - do culture prior to starting antibiotics
  • Blood cultures - to rule out sepsis
  • CBC - monitoring
• Treatment for Pneumonia


  • Outpatient treatment - (Mycin)

  Inpatient - Fluroquinolones (Floxacin) or B-Lactam plus macrolides, vancomycin

  Response to treatment generally occurs within 48-72 hrs (2-3 days) - you will see decreased temperature, improved breathing, decreased chest discomfort

  Repeat CXR 6-8 weeks

  If no improvement - may be wrong antibiotic or may be multiple comorbidities that inhibit healing
• Supportive Care for Pneumonia

  • Oxygen for hypoxemia
  • Analgesics for chest pain
  • Antipyretics for fever
• Nursing Interventions for Pneumonia

  • Monitoring for impaired gas exchange
  • Auscultate breath sounds
  • Monitor rate, rhythm, depth, and effort of respirations to determine respiratory status
  • Monitor for increased restlessness, anxiety and air hunger to detect increasing hypoxemia
  • Position the patient with head of bed elevated, in a semi-Fowler's position
  • Monitor patient's ability to cough effectively to promote secretion removal - cough/deep breathe
  • Use pulse oximetry to monitor oxygen saturation (should be 90% or greater)
  • Administer supplemental O2 as ordered to promote adequate oxygenation
  • Administer prescribed antibiotics
  • To prevent aspiration pneumonia - elevated head of bed 30 degrees and have sit up for all meals
  • Semi-conscious or unconscious patient in side lying position
  • Early mobilization
  • Cough and deep breathe, incentive spirometry
• Evaluation Criteria for Pneumonia

  • Effective respiratory rate, rhythm, and depth of respirations
  • Lungs clear to auscultation
  • Absence of infection
  • Decrease in WBC
  • O2 saturation above 90%
• Signs/Symptoms of COPD


  • Fatigue
  • Weight loss/anorexia
  • Prolonged expiratory phase - leads to barrel chest
  • Decreased breath sounds, wheezing
  • Barrel chest
  • Tripod position - help with air exchange
  • Pursed-lip breathing
  • Bluish-red color of skin due to polycythemia and cyanosis
• COPD Complications


  • Pulmonary hypertension

  Cor Pulmonale (right-sided heart failure) - late manifestation
• Diagnostic Tests for COPD

  • Chest x-ray - large pulmonary vessels for HF

  Echocardiogram - Right sided heart enlargement for HF

  Increased BNP

  Spirometry confirms dx of COPD - FEV1 less than 70% is a high indicator that COPD is present

  Serum antitrypsin levels - genetic link

  6 minute walk test to less than 88% to qualify for supplemental O2

  ABGs looking at CO2 and oxygen saturation levels
• Treatment for COPD


  • Bronchodilators - relax smooth muscle in the airway, improve ventilation of the lungs, decrease dyspnea and increase FEV1

  B2 Adrenergic agonists - Albuterol - short acting know side effects

  Anticholinergics - Ipratropium (Atrovent), Tiotropium (Spiriva) - know side effects
• Nursing Interventions for COPD

  • Keep O2 saturation above 90%

  Humidification and Nebulization - used because O2 has a drying effect on the mucosa and secretions

  3 Complications of oxygen therapy - combustion (no smoking), CO2 narcosis, hypoxic drive administer O2 carefully

  Pursed lip breathing - prolongs expiration to reduce bronchial collapse and air trapping

  Diaphragmatic breathing - use of diaphragm instead of accessory muscles to achieve maximum inhalation and slow respiratory rate

  Airway clearance techniques - often used with other treatments (bronchodilator) - loosens mucus to clear with coughing

  Effective coughing or huff coughing - conserves energy, reduces fatigue, and facilitates removal of secretions
• Nutritional Therapy for COPD

  • Malnutrition in COPD due to the body is trying to compensate for poor oxygen exchange

  Decrease dyspnea and conserve energy by - rest at least 30 minutes before eating, avoiding exercise for 1 hour before and after eating, use bronchodilator before meals to help open up airway

  Diet - high-calorie, high-protein, eat 5-6 meals to avoid bloating and early satiety, water between meals

  Avoid - foods that require excess chewing, exercises, and treatments 1 hour before and after eating, gas-forming foods because it will increase fullness
• Activity for COPD


  • Ambulate/walking is important

  Exercise training leads to energy conservation - in upper extremities, it may improve muscle function and reduce dyspnea

  Modify ADLS to conserve energy - hair care, shaving, showering (make adjustments)

  Give O2 during activities of hygiene

  Walk 15-20 minutes a day at least 3x a week with gradual increases everyday

  Exercise-induced dyspnea should return to baseline within 5 minutes after exercise