Enlex RN Review - Day 19
Introduction
- Welcome to the 19th day of 90-day Enlex RN review session.
- Comprehensive explanation and dissection of 2,000 Enlex questions.
- Free classes, subscribe and activate notifications.
- Visit StankX Coaching for tailored assistance.
Overview of Today's Session
- Focus: Nursing management for aspiration pneumonia and infectious pneumonia.
Aspiration Pneumonia
Definition
- Serious condition where oral/stomach contents are inhaled into lungs, leading to pneumonia.
- Prevalent among the elderly and individuals with certain medical conditions.
Underlying Causes and Mechanisms
- Oropharyngeal Dysphasia: Difficulty swallowing.
- Lack of Protective Airway Reflexes: Swallowing/coughing reflexes may be lost post-surgery or due to altered consciousness.
- Neurological Conditions: Seizures, stroke, multiple sclerosis, dementia, Parkinson’s disease, Myasthenia Gravis.
- Gastrointestinal Issues: Strictures, diverticula, tracheoesophageal fistula, acid reflux, hiatal hernia.
- Severity Factors: Dependent on the volume and type of content aspirated (e.g., gastric acid, bacteria, vegetable oil).
Pathogens Involved
- Streptococcus pneumoniae
- Haemophilus influenzae
- Staphylococcus aureus
- Gram-negative bacteria
Manifestations
- Increase in Heart Rate: Tachycardia
- Fever: Elevated body temperature.
- Shortness of Breath: Difficulty in breathing due to inflammation and fluid in the lungs.
- Cough: Body's attempt to clear aspirated substance.
- Rapid Breathing: Compensate for reduced oxygen intake.
- Cyanosis: Bluish discoloration of skin, especially around lips/fingertips, indicating hypoxemia.
- Decreased Breath Sounds: Fluid or pus in lungs.
- Crackles: Indicative of fluid in small airways.
- Pleural Friction Rub: Inflammation sound in lungs.
- Percussion Dullness: Fluid/solid material in lungs.
- Thick Pus-filled Mucus: Indicates significant infection.
Diagnostic Tests
- Chest X-ray: Key tool; shows consolidation and abnormalities over time.
Treatment Steps
- Clearing Blocked Airway: Use of suctioning and manual removal.
- Antibiotic Therapy: Address bacterial infections.
- Laryngoscopy/Bronchoscopy: Assess and clear airways.
- Oxygen Therapy: Administration and potential mechanical ventilation.
- Fluid Volume Replacement: Stabilize blood pressure during shock.
- Correction of Acidosis: Manage respiratory acidosis.
Nursing Care
- Assess/Maintain Patent Airway: Clear airway and monitor continuous pulse oximetry.
- Monitor for Infection Signs: Fever, foul-smelling sputum, lung congestion.
- Evaluate Level of Consciousness and Gag Reflex: Determine swallowing ability and aspiration risk.
- Elevate Head of Bed: Prevent aspiration in patients with decreased consciousness.
- Screen for Dysphagia: Use bedside assessment and make referrals if needed.
- Tube Feeding Safety Practices: Correct tube placement, slow feeding administration.
Infectious Pneumonia
Types and Pathogens
- Community-Acquired Pneumonia (CAP): Streptococcus pneumoniae, Haemophilus influenzae, Aerobic Gram-negative bacteria, Staphylococcus aureus.
- Hospital-Acquired Pneumonia (HAP): Gram-negative rods, Staphylococcus aureus (including MRSA).
- Atypical Pneumonia: Mycoplasma pneumoniae, Legionella species, Influenza A and B, RSV.
Risk Factors
- CAP: Altered mental status, smoking, alcohol, hypoxemia, toxic inhalations, pulmonary edema, uremia, malnutrition, immunocompromised conditions.
- HAP: Recent hospitalization, living in long-term care facilities, intravenous antimicrobial therapy, chemotherapy, wound care.
Manifestations of Pneumonia
- General: Fatigue, productive cough, pleuritic chest pain, dyspnea, use of accessory muscles, tachycardia.
- Diagnostic Tests: Chest X-ray, sputum analysis, blood cultures.
Treatment and Nursing Interventions
- Antibiotics: Empiric therapy initially, tailored according to culture results.
- Oxygen Therapy: Monitor oxygen levels, humidify at >4L/min, cautious administration for COPD patients.
- Early Ambulation: Shorten hospital stay, improve recovery.
- Vaccination Status: Ensure influenza and pneumococcal vaccines.
- Smoking Cessation and Respiratory Hygiene: Prevent recurrence and spread of infection.
Complications
- Pleural Effusion: Fluid buildup between lungs and chest wall.
- Shock: Persistent low blood pressure due to sepsis.
- Empyema: Collection of pus in pleural cavity.
- Superinfections: Pericarditis, bacteremia, meningitis.
- Delirium: Acute confusion, marker of severe infection.
- Atelectasis: Lung collapse due to mucus plugging.
Patient Education
- Antibiotic Compliance: Prevent resistance.
- Fatigue and Gradual Activity Increase: Post-recovery care.
- Lung Clearing Exercises: Enhance lung function.
- Follow-up Chest X-ray: Reassess lung clearance.
- Vaccination and Preventive Measures: Enhance immunity.
- Hand Hygiene and Avoiding Close Contact: Prevent spread.
Conclusion
- Regular assessment, administration of antibiotics, respiratory support, and patient education are crucial.
- Encourage caregiver involvement and ensure adherence to treatments and follow-up appointments.
Next topic will be posted in the thumbnail. Thank you for attending.