hello everyone Welcome to our live enlex RN review session so if you're new here we are currently progressing through day 19th of our 90-day free encl review series and we are going to cover a wide variety of nursing subjects and we'll be dissecting 2,000 enlex questions with Comprehensive explanation so I want you to spread the news to your friends preparing for the enlex our classes are entirely costree so don't forget to subscribe and activate notifications to stay updated on our latest content and for more information refer to the description box below and we do appreciate your feedback so feel free to share your thoughts or questions in the comments and we'll gladly offer further clarification on any topics now guys we are also offering the enlex review course through our website so please check out our website at www.st Co ankx coaching.com for tailored assistants and the program emphasizes enjoyable studying we're offering engaging lectures and a vast pool of 3,000 nlex to questions and you are going to be able to explore to our 10hour animated video course and 100 hours of prep time so you can also utilize our OnDemand video library and practice with M exams to boost your confidence and you can gain six-month full access with over 200 ngn test questions for comprehensive preparation so study it your convenience with our flexible platform and stanos andx coaching provides continuous support throughout your journey so today guys we are going to focus on nursing management for the aspiration pneumonia and infectious pneumonia so let's delve into it now let's identify First what this condition is well the aspiration pneumonia is a very much serious medical condition and uh it can occur uh when the oral or stomach contents are inhaled into the lungs which can lead to the pneumonia and this is a condition that is particularly prevalent among the elderly and those with certain medical conditions and it can really POS a serious health risk to these age uh to these group of people now let's first understand the underlying causes and also the mechanisms of the aspiration pneumonia so here we go uh we'll start first with Oro fenial dysphasia so what is this this is the difficulty in swallowing and this is quite common in the elderly and is a major risk factor again this is the most common type of problem especially in the elderly and this will really uh complicate at into aspiration pneumonia now there's also that lack of protective Airway reflexes for example like the swallowing or the coughing reflexes sometimes these can be lost and um for example if the person will probably go into a surgical procedure or let's say once they have completed their U surgical procedure any diagnostic test requiring uh general anesthesia then definitely they are prone to having this kind of issue now these reflexes can also be determined or it can be impaired due to so many reasons right and so with uh altered Consciousness this is going to be one of those um alcohol drug overdose is another one and for those people that have seizure disorders or it could be stroke or they might have some form of head injury and I have said earlier about anesthesia and for those people that might have some brain mass and um severe illness or let's say swallowing problems can also lead to that now if there is like a procedure let's say uh intubation or let's say pting in or creation of a tracheostomy or endoscopy these can also lead to that U loss of protective Airway now in some cases wherein there is going to be a neurological IC condition so these are the following that can also lead to the aspiration pneumonia such as the seizures uh for those people that may have had stroke in the past uh and also multiple sclerosis uh for those people that are Elderly with dementia uh could be Parkinson's disease or meia grais these can also contribute significantly to the risk of aspiration pneumonia now for those uh uh women that are in their uh childbearing age um they could probably undergo some sort of OB statc procedures uh that will require anesthesia or let's say lithotomy position then they are also going to be at risk all right now let's go into another uh factors here well of course if there are any issues with the gastrointestinal tract uh for example maybe it's aagil issues like strictures or diverticula or it could be trache Sagal fistula or acid reflux maybe hiatal hernia or let's say intestinal obstruction or abdominal distension and also the presence of a tube feeding okay or could be the postpyloric tube feedings these can also predispose the patient into developing the aspiration pneumonia now there's also that um severity that is going to be dependent on the amount let's say the volume that has been inhaled or that has been aspirated by the patient and this can lead to different kinds of problems in this uh type of disorder okay so for example if the person had aspirated stomach contents well we know what's in there right so the gastro the gastric acid or the hydrochloric acid can lead to the development of a chemical pneumonitis while if they are inhaling or aspirating um the bacteria in the oringal uh part then they are going to possibly develop that bacterial pneumonia because of the amount of bacteria that is present in the oral cavity and we also have probably some inhalation or aspiration of vegetable oil this can lead into lipoid type of pneumonia and uh could be inhalation or let's say aspiration of some foreign bodies and this can also trigger the acute uh respiratory emergency and can also lead to a bacterial type of pneumonia now guys I really want you to uh refamiliarizing pathogens that are going to be involved in um the aspiration ponia so so we have here the streptococus pneumonia we also have the hemophilus influenza uh we have the staus orius and the gram negative bacteria so these are those organisms that can potentially uh also lead to aspiration pneumonia now let's move right ahead with identifying the different manifestations of this patient with the aspiration pneumonia so there are several signs and symptoms that can give us clues in order for us to uh make sure that we are planning the care plan and also we are reporting these assessment findings to the medical provider now one of those signs and symptoms is the increase in the heart rate of course takic cardia is going to be one right and the person will also develop fever wherein there is now elevation of the body temperature as it's trying to fight off the bacteria or any harmful substances that may have entered the lungs and so this is something that can develop even in just a short amount of time after they had aspirated maybe some food or let's say medications or maybe they aspirated on the water that they just drink after eating their meal okay and the person here will develop shortness of breath and this again can develop as early as which is just a few hours after the incident and so when this happened their patient will also feel like they just can't get enough air and this is because the lungs are inflamed and filled with fluid and it's going to make it hard to breathe normally now the patient will also can have some cuff and this is the body's attempt to clear out the aspirated substance uh or let's say the infection from the lungs there are also going to be some rapid breathing and this is another way that the body will try to increase the oxygen intake when the lungs are not fully effective now guys when you are checking your your patients Vital Signs especially with Odo saturation and uh taking note into their skin color there might be some bluish skin discoloration that's not a good sign that's really telling you that the body is not getting enough oxygen that is hypoxemia and so the patient here has lower than normal level of the oxygen in the blood and as a result to that the skin especially around their lips and also the fingertips can turn purplish it could be bluish and this can really indicate that the body isn't getting enough oxygen now when you are osculating the patient you will notice that there might be some reduction of the breath sounds or air flow and uh this is because of that certain areas of the lungs that are becoming quieter than usual so basically they can be diminished and uh this can happen because parts of the lungs are filled with the fluid or could be pus instead of the air all right so the diminished brat sounds can be assessed let's say in let's say a severe form of a lung disease or it could start as just maybe a mild symptom or mild for this patient with a long disease but again guys when you are trying to Prior prioritize the problems that you had identified into this patient make sure that you are prioritizing those assessment findings that can lead to compromise of the ABCs the Airways breathing and circulation all right some of these manifestations can only support the ABCs now let's talk about the crackle so what is this this is basically going indicate that there is fluid in the small Airways and this is a bit like a rubbing hair between the fingers near next to your ear so you try to do that kind of grab maybe a cluster of hair and try to rub it against each other near your ear so the crackles will kind of like be V uh varied it can be fine crackles or it could be coarse crackles so if there is more of like fluid collection in the alv Oli or could be in the terminal Bron broni or bronchial rather then when the air passes through this fluid filled areas then it can create those adventitious sound now we'll talk about the plof friction rub and this is what we call as a very rough it's grading sound that is going to be heard of course with the statoscope and this is going to happen when there is inflammation of the lungs especially in the plura and this is caused by that rubbing against each other and so because of the inflammation in the lungs the pl friction rub can also manifest in this patient now when you are uh percussing the patient's chest you could start it maybe on the posterior maybe in the anterior chest wall of the patient when you do that there are those certain areas that may sound dull instead of being hollow and when there is that change when previously it was kind of like Hollow sounding or resonant but if you are noticing that this is becoming dull then there is probably fluid or solid material in the lungs where there should be air now probably there is now um accumulation of the Plus or fluid in those areas then there is that consolidation of the fluid in those um Alvi or terminal bronchials now we're also going to talk about the thick POS filled mucus now the mucus that the patients cuff can be really thick and it might contain p and that's a significant infection in the lungs all right remember about the uh process the mechanism our protective mechanism inside the body especially in the lungs when there is now a uh invading uh substance let's say in the form of an aspirated food or fluid when it lodges into those Airways this can cause the migration of those nutrifil and also it can lead into attracting other the chemical mediators that will try to fight off the invading substance and the and this is really going to cause some problems here if we are not treating this patient um in a timely manner now guys we'll talk about the diagnostic test and of course you probably have already um identifi this chest x-ray which is basically the key diagnostic tool for the aspiration pneumonia and initially like let's say maybe within just a few hours maybe about two hours after the aspiration has occurred then the The View might or the chess x-ray might appear or may reveal normal um view of the lungs but over time maybe after several hours it can show signs of consolidation and also other abnormalities indicative of the pneumonia so you can probably see the changes within just 24hour period now for the treatment the treatment of the aspir pneumonia will include several critical steps and of course we are going to make sure that we are clearing the blocked Airway and this is our first step okay so if you probably are in the middle of let's say administering the medication of the patient orally and they're probably eating their meal and when they're trying to take one of the tablets let's say for example and one of those tablets are quite big horse spills let's say potassium chloride and all of a sudden out of nowhere your patient started choking right because of that large tablet and probably they have not really clear their mouth before taking that medication maybe there might be some residual food particles in their mouth and so at that time when they are choking you have to really suspect that there might be some food contents that WI went in together with that tablet and so if probably a partial portion of that tablet has gone into the airway yeah that can be a real problem so what we're going to do is really to inspect the mouth of the patient we're going to remove as much as we can uh in order to prevent the entry of these additional um food items into the airway all right and if there is a visible blockage into the air we really want to make sure that this is going to be removed all right or for example they might be coughing maybe they have a pre-existing issue uh maybe thick tenacious secretions right they probably have um a pre-existing lung condition but it's not like the aspiration pneumonia yet and maybe they accidentally swallowed into that fleem or this feudum which can also lead to some more problems and so we are going to really clear that Airway probably we are going to use the yanar suction tip and this is going to at least remove those superficial um debris in the mouth maybe secretions and um we are going to also manually remove those foreign objects again possibly maybe we can do some suctioning into the traia um and also if uh they have already the endot tral tube then we really need to clear out those particles as well now in order for us to really fight off the infection you are going to see here the antibiotic therapy that will be part of the treatment okay and this is the Cornerstone treatment in order to address the bacterial infections okay because it once the foreign body is going to be inhaled into the respiratory tract remember that the mouth is abundant with all those natural or innate microorganisms and it can migrate into the lower respiratory tract and this can lead into bacterial infections now another treatment here would be uh the use of the laryngoscopy or the broncoscopy and they are going to be very important to assess and clear the Airways now part of the Care is the administration of the oxygen and also if the patient is not going to respond to the O2 therapy then they might need to be placed on the mechanical ventilator if they are not able to maintain enough oxygenation and so we want to make sure that we are monitoring our patient during this acute period because they can deteriorate really fast all right now part of the Care is to provide the patient with um fluid volume replacement as ordered uh once the patient probably will start manifesting some decrease in their blood pressure and this is not a good sign it simply means that the body is actually trying to respond with the release of those systemic inflammatory or chemical mediators inside the body and this can lead to widespread vasil dilation and the patient will end up with low blood pressure and shock all right now when this happens what we're going to do is to stabilize the patient with the use of the IV fluids uh possibly the administration of IV boluses with the normal saline or followed after by the lactated ringer solution in order to stabilize the blood pressure and to maintain blood supply to the other major organs in the body then definitely we're going to go ahead and do that as well all right now communication is key especially when you are in the team make sure that you are notifying your charge nurse also notifying the rapid response team or it could be um the medical provider make sure that you are giving them updates about this patient all right now part of the Care is the correction of acidosis if the patient will have significant hypoxemia maybe they're now retaining CO2 um with respiratory acidosis we definitely need to address that okay now for the nursing care this is very important guys I don't want you to just focus in a few but we'll have to really pay attention because this is going to involve a cluster of nursing assessments and interventions all right so with the aspiration pneumonia our main assessment or our first and foremost assessment action here is to really assess and maintain a patent Airway we are going to check for any blockage in the airway of course this will include the mouth all right and into the Fingal area to see if we can see some visible items or any food particles that may be adding to the problem and so this is going to be the first step in order to assess a patient suspected with aspiration pneumonia and of course this will ensure that their Airway is clear and they are getting enough oxygen um while you are doing this it would be nice it would be really important that you are monitoring the patient with the pulse oximetry I would put that as a continuous pulse oximetry monitoring especially during the acute phase all right because you can easily detect of any uh progression that can happen rapidly now you're also going to check for the oxygen saturation like I have said make it a continuous mon monitoring for the O2 saturation not just like within 5 second or 5 minutes or 10 minutes while you are delivering care to the patient so here while you are checking for any signs of obstruction inside uh maybe difficulty of breathing maybe they are still choking or could be much more of the coughing sometimes they might continually continuously cough because that's a normal protective uh mechanism by the body so they're going to probably have those coughing episodes more often because of that large uh foreign body and of course you are going to also uh monitor for their breath sounds because there may be some progression from normal breat sounds into the adventitious bread SS now guys you have to really monitor the patients for any signs and symptoms of infection this is a big deal right so one of those is to check for the elevation of the temperature could be foul smelling sputum or could be congestion of the lung Fields so your oscilation would really help out in detecting for any worsening all right of this patient's condition now the fever of course really is one of those um early signs that the patient is developing an aspiration pneumonia um and also the foul smelling sputum again again this is now going to signal that there is bacterial infection going on all right now the congestion or the abnormal lung sounds maybe the crackles or the decreased breath sounds because of the presence of the fluid in the Alvi this will lead into the diminished breat sounds and again this indicate that there is now fluid or infection inside the lung now definitely when you are osculating um or when you are moving ahead with the assessment make sure that you're also um looking into the patient's level of Consciousness you have to determine guys is the patient much more drowsy this time than an hour ago when the aspiration occurred yes this is very important the level of Consciousness is an indicator maybe the patient is now having some worsening of their condition maybe they are very difficult to arouse okay maybe they are now becoming lethargic at this point that's not a good sign and also their gager Flex need to be assessed their swallowing ability and any aspiration risks all right now here guys we really need to um also check for the gag reflex as I've mentioned because this is actually the normal mechanism in our body to to prevent a any aspiration and also the um the gag reflex is one of those uh protective mechanism that is not going to be there anymore especially when their level of mentation is decreased okay make sure you remember that when the level of Consciousness is affected then the gag reflect will also be diminished so guys at this point you really have to refrain from putting any anything inside the patient's mouth do not give any po medications or any kind of fluids um no not a good practice so always uh keep in mind about the gag reflex diminishing and this is to really prevent more entry of the foreign substances okay now there's also a need for us to elevate the head of the bed okay so what is the um rational for elevating the head of the bed well of course when the patient has diminished a um level of Consciousness and of course the airway especially the mouth will not stop uh producing those salivary secretions and they can dry up so fast as well when their mouth is opened this can make the secretion thicker and this can also lead to some more problems in this patient now especially if you're uh maybe uh um treating the patient with some tube feeds maybe they are a stroke patients that are receiving the tube feedings then definitely it would also require you to assess your patient thoroughly is the uh aspiration caused by the tube feeding itself maybe there is increasing residual volume in the stomach that was not checked frequently and so it's causing the uh the food to back up into the esophagus and finally it went in into the patient's Airway all right so make sure that you're going to report that as well it might uh call for a um stopping of the tube feeding at this point until this is cleared okay now we are also going to have to uh pay attention about the patients need to be screened for dysphasia okay so what is this well there are so many ways of actually doing this um part of my experience as a neuro stroke nurse I did so many bedside dysphasia screening which is basically one of our roles so this is just like a very simple kind of dagia screen that we have been trained to do and so we have to um instruct the patient a few things um let's say having to kind of try to swallow their M um their saliva and if they can safely manage that then that's a good indicator and also we're going to have to proceed in having them take a little sip of water and if they can do that safely then we are going to give them that corresponding value that they are able to manage any kind of fluid and so forth there are so many other sections in the dysphasia screening however though if the patient's dysphasia is much more severe then definitely we need to get the attention of our medical provider make sure that we are making proper referrals for speech therapy evaluation and this is very important guys because they are specializing into dealing with the dysphasia status of the patient so they can do a whole lot of treatment and evaluation that we can't do all right now along with that once they are going to establish those uh or once they have evaluated thoroughly the patient uh maybe they have probably recommended the barium swallow to uh or maybe the video swallow study is recommended then we have to really wait uh and to hold any kind of um oral intake in the patient no oral medications no oral fluids to be taken in by the patient up until the patient is cleared um with a uh test okay now we're also going to have to keep in mind guys once the patient has that aspiration incident do not resume any kind of oral feeding including any oral fluid no this is a big no and also if your patient is not alert right they cannot follow instructions or maybe they are drowsy or lethargic it is advisable to not reive any oral intake of any sort of food or fluid that is the recommendation now for those patients um especially if the the speech therapist has established those recommendations maybe the patient is now going to be placed into a modified kind of diet let's say thickened liquids or honey thick liquids or nectar thick liquids or maybe the patient's uh food items will be converted into mechanical soft or maybe uh the consistency of the food items should be the same in order to prevent any aspiration occurrence then we definitely need to follow those recommendations as ordered by the medical provider all right and also make sure that you are observing the different precautions that will be ordered for all other oral intake okay and so guys the speech therapy evaluation doesn't just happen once when the patient is in the hospital maybe if there is deterioration of the patient's condition or let's say there is some kind of improvement or maybe if you really need to make sure that the patient's uh dysphasia need to be re evaluated and of course you have to really communicate this to the medical provider in order that we can retest do another evaluation by the speech therapist so guys make sure that you're going to collaborate with them now guys we are also have to identify um other tube feeding safe practices so what are these well maybe you probably have known this in the past but I just want to make sure that you we're going to go over into these again uh because um we just need to reinforce your learning as well and so one of those is to assess for the correct tube placement and this is basic nursing care all right and you might be asked simply about this kind of a scenario so when you're doing the tube feeding make sure that before you start giving that maybe intermittent tube feeding or maybe continuous tube feeding make sure that you are checking for the correct tube placement well how are you going to do that well you have to keep an eye into the placement of the tube because there will be some documentation about which Mark has been advanced in that nasogastric tube okay make sure that we are noticing into how much length has been Advanced or has dislodged um maybe from the last shift or the previous shift make sure that we are looking to their documentation also looking into the um the placement by doing the oscilation right when you are going to introduce some air via the syringe we're going to introduce that to the tip of the NASA gastric tube and of course you're going to listen to the epigastric area and listen for that uh air gurgling sound while you are introducing that's one okay now if you have to really want to make sure everything is well in place then you can also use that uh litmus paper to check for the acidity of the gastric content so you're going to aspirate a little bit portion of that gastric content and check it with the litmus paper to check if it's acidic well of course if it's acidic then there's a higher chance that the the tip of the uh nasogastric tube is well placed in the stomach now if it's aqualine then that's not going to be a safe sign right maybe it's already dislodged into the airway now if you are suspecting that maybe the patient had pulled the nasogastric Tobe all right maybe the patient has accidentally pulled it because they are doing something else and maybe with a tension that has been cost maybe there is slight uh pull of the tubing and that could really harm the patient if we are not going to evaluate the the placement so again if this is An Occurrence that would really compromise the patient then call the medical provider if there is no standing order or if there is no such protocol to do a um abdominal x-ray then make sure that you communicate with a physician or the medical provider hey doctor this is what happened to my patient he accidentally pulled the nasogastric tube we want to make sure that we are continuing the tube feeding safely would you be able to order a uh stat abdominal x-ray to check for the nasogastric tube placement yes we can do that as well so make sure that this is going to be obtained before you resume the Tobe feeding all right make sure you do that always keep your patient safe all right this is going to be one of those risk reduction uh protocols or nursing interventions now we're also going to have to administer the tube feeding slowly okay it is advisable that when you are administering the intermittent tube feeding that you're going to do it via gravity not doing the push using the plunger right so that way it will just allow the passage of that tube feeding the liquid um to go into the stomach of the patient without any uh external force all right and of course you really have to observe the response of the patient are they tolerating the food intake or are they retaining so much to the food that they're not really digesting the food and if that happens we are going to check for the residual volume making sure that we are aspirating the stomach contents and if it's probably over 150 or 200 that is very significant guys okay and if the patient feels like hey I feel like I'm not really digesting my food listen to your patient if they are feeling full they are not really emptying their stomach that is not a good sign and so make sure that you are checking the residual volume and also if the patient may have some sort of a tracheostomy or um IND trachel tube then make sure that you check the Seal of the tracheostomy tube and also make sure um that before you proceed with the feeding make sure that you have checked off all those possible loopholes okay now here guys we're going to talk about the need for us to prepare care our patient in order for them to go into a special procedure so for example maybe if they have an order to go into an endoscopic type of procedure maybe upper or lower endoscopic type procedure or let's say any other uh diagnostic testing that may require the use of an anesthetic agent a general anesthesia well of course that would require us to prepare our patient to be place on NPO for at least 6 to8 hours but it would be safer to do it for eight hours right right and um this is something that you definitely need to check especially if that diagnostic test would require with the use of the general anesthesia because of its effect in um diminishing the gag reflex okay that's the reason right there now here we have to also keep that safe practice make sure that we are um checking the patient for food pocketing and this is a very common occurrence especially in the older population when you're dealing with the dementia patients Alzheimer's patient if they if you are probably giving the medication Orly and they are still eating their food uh make sure that when you have given the oral medication you better check their mouth have them open their mouth and make sure sure you do a good thorough visual check into their cheeks the bual area to check if there's any residual amount of medication that could just be hidden in those sides make sure that they swallow that because this can really cost them to aspirate and those medication and this is very common again in the elderly population all right so that's another safety measure make sure you are checking the patient for pocket of medication or any food items all right now guys let us going to shift into another topic here and this is on pneumonia not the aspiration pneumonia this time so we are going to discuss about the pneumonia that is going to pertain about the community acquired and also the hospital acquired pneumonia and we are going to compare their different causes and mechanisms and and the diagnostic test so let's go and we will also uh make some uh definitions here or let's define each clearly here so pertaining to the community acquired pneumonia or the cap this is that um pneumonia wherein there is let's say an infection that will cause the inflammation of the air saxs may be in one lung or could be the both lungs all right and so here the cative agents are the following and these are the most common ones we have the strap tocus pneumonia we have that as the majority of the infections is caused by that one about 60% of the cap is caused by the streptococus pneumonia and we also have the hemophilus influenza which counts about 15% of the cap type of pneumonia especially for those people that may have long diseases or may have some weakened immune system or the aerobic gram negative bacteria which accounts 6 to 10% and these are your cbella or could be the enterobacteria and they're going to thrive into oxygen rich environments they are aerobic yeah so they can Thrive so much more when they are inside the long now we also have the staff cookus orius which is going to count to about 2 to 10% uh for all the cap cases and they are known to really cause some skin infections but they can also lead to severe pneumonia if they are going to migrate into the uh Airway okay now guys let us talk about the risk factors well one of those risk factors involved here is the altered mental status okay so this can also be caused by the medications that they are probably taking maybe some sedatives or some of those opiates or let's say um some anti-pr presentence that might lead into some form of sleepiness um anti-convulsants as well and this is definitely going to affect their level of Consciousness right and they're going to be at risk to developing the pneumonia now smoking is a major factor as we know I'm not going to expound that and also alcohol this is going to cause pneumonia the reason that it will also um weaken the immune system and increases the risk of the aspiration especially and um when they are going to be sedate after maybe several bottles of any booze and definitely they're going to be to develop that pneumonia um if the patient has hypoxemia of course any toxic type of inhalations uh pulmonary edema which is probably a complication of congestive heart failure well the buildup of the fluid inside the lungs especially in the capillaries or let's say the alveoli this is now going going to create an environment where the bacteria can Thrive again guys pulmonary edema can really cause the bacteria to thrive and create their own environment because of that um watery or fluid medium now urmia which is going to be the presence of the waste products in the blood this is going to be uh one of those factors that can also weaken the immune system uh also the Mal nutrition wherein if there is poor nutrition it can also weaken the immune system and making it harder to fight the infections now guys for those patients that are immunocompromised especially the HIV patients or could be the AIDS patient alcoholic uh for those patients that are receiving corticosteroid therapy maybe they have uh some uh Adison disease that they need to take the CTIC corticosteroids lifelong then they are going to be prone to um developing the pneumonia or let's say for those patients undergoing chemotherapy or radiation uh for those cancer patient they are going to be exposed or they're going to be predisposed to developing the pneumonia as well so this is your typical community acquired pneumonia and this is quite related to the infectious microorganisms that we had mentioned now here we're going to go back into the community acquired pneumonia which is basically going to happen when the patient is outside of a hospital or within 72 hours of admission so pay please pay attention guys that the community acquired pneumonia is going to develop outside of a hospital or let's say it can happen within 72 hours after the admission and again our first type here is the typical community acquired pneumonia and then we are going to talk now about the atypical pneumonia so what is this atypical community acquired pneumonia well the cative microorganisms that have been identified um mostly are the micoplasma pneumonia okay this is the most common for the atypical type okay this is we what we call as the walking pneumonia all right and this type of U microorganism can often cause milder symptoms however the patient may have contracted the cidial type of pneumonia microorganism which is another form of bacteria bacterium uh this can cause respiratory infections as well and this is very common in the younger population uh could be that the atypical pneumonia is caused by the influenza type A and B or let's say the uh respiratory sensial virus or the RSV or could be the legionary disease okay so this is a uh this kind of species right here the Legionella spe species they are a form of that bacteria that is found in water systems that can really cause some severe form of pneumonia which is what we call the Legionnaire disease right now as we are going to transition into the hospital acquired pneumonia okay so what is this well we're going to identify here first those cative microorganisms well of course they are going to be common in the healthcare settings and these are your Gram negative ruds such as the eoli or the pomonis and these bacteria are very common in the health care settings and that's why they are called as Hospital acquired pneumonia and most of these microorganisms are actually resistant to many antibiotics especially with the pseudomonas yes and they are very hard to treat if the patient has that resistant type now we are going to talk about the other microorganism which is the staus orus so this is going to include the uh methylin resistant stail uh methylin resistant staus orius or the Mera all right so this is also one of those difficult microorganisms okay and you definitely need to put your patient in an isolation contact isolation for this one if in case they have this kind of uh type of pneumonia so guys what are the risk factors for a patient that may have had the hospital acquired pneumonia well some of those is the admission or the hospitalization at least re recent hospitalization within the 90 days all right so the hospital stat especially if the patient might be uh admitted to the hospital for quite a long time maybe they've been just back and forth between the med surge unit and they probably are deteriorating and they will be sent to the ICU and probably they're going to go back to the med surge again or maybe they're going to be discharged to their acute rehab and maybe they are not doing well in the acute rehab they're going to be readmitted to the acute care back to the med Surge and probably their entire hospitalization will probably last for months and months and this is not really uncommon okay so I've seen patients like this even in my previous practice all right now another is that the patient who might be living in a nursing home or it could be a longterm long-term care facility for those people that are living in closed quarters or let's say if they are requiring frequent medical interventions they are going to be at a higher risk to developing this kind of Hospital acquired pneumonia and for those patients that may be receiving intravenous antimicrobial therapy yes they can also be one of those patients that may have a resistant type of bacteria or for those getting chemotherapy it can weaken their immune system making the infections more likely to occur and for those patients that may have some kind of wound care within the last 30 days prior to the onset of the pneumonia or let's say they might have some kind of invasive procedures maybe some open wounds this will really increase their risk of the infection all right so guys I hope that you're able to understand the different mechanisms of how they're going to have the either the hospital acquired pneumonia or the community acquired pneumonia it is very important that for you to understand the different types and they're also they cative agents in order for us to really plan the care and also that we can prevent this from occurring to our next patient now as we wrap up here I just want to make sure that I'm emphasizing this that the community acquired pneumonia is going going to typically involve more common bacteria like the strap tocus pneumonia while the hospital acquired pneumonia often involves more of the resistant type and aggressive bacteria and uh recognizing these factors for each type really will help us in the preventive measures and also remember that with the early detection and we can do an appropriate medical or a Nursing treatment and this is really going to help the recovery of our patient now this time we're going to talk about the uh another sign that there is an infection going on there is inflammation of course and here we have fatigue the patient will get so tired easily they will not be able to tolerate a whole lot of physical activities like before because their body is really working hard to fight up the infection and they might also manifest some productive cough with and accompanying putic chest pain so they are going to Cuff up that very thick mucus and this is of course the body's way of trying to clear out the infection right and so it's very important for us to really U monitor for the color of their mucus secretions or the exactor rate and to check for any signs of the puic chest pain because this is going to be one of the uh complaints that they might have they will have this sharp pain in the chest that will get worse when they are taking deep breathing or let's say when they are coughing then they are going to kind of hold their breath remember about our discussion in the flacy or the uh puitis remember about the kind of pain that uh they're going to end up holding their breath they don't really want to do a whole lot of deep breathing and so this can lead to some more problems hypostatic pneumonia and so guys we are also going to uh possibly see them with some difficulty of breathing disia and of course the use of the accessory muscles you might see them straining with their neck muscles or maybe their shoulder muscles in order for them to breathe and of course this is a body's attempt to really help to get some more air right and the Tachi cardiac which is going to be uh one of those manifestations that will accompany the fee uh the the shortness of breath and also the fever because of the increasing metabolic demand well this can also lead to the tachicardia right because of that um increasing metabolic demand the body will try to compensate now we'll talk about the diagnostic test that will be ordered possibly by the medical provider and of course the topmost diagnostic test is the chest x-ray well this is going to show us the pneumonia the u local area or maybe if it's already spread or maybe it's affecting different areas so let's say for example if uh the chess x-ray is showing low bar consolidation when it says that low bar consolidation so this simply means that the pneumonia is probably affecting in one or more loes of the lung so I really want you to review that the right lung consists of about three loes and we have the left lung only composed of two loes now if you're going to see maybe in the chess x-ray stating that the patient may have some multi- lobar consolidation then it's suggesting that this is much more a severe illness and this is in involving multiple lows maybe involving both long Fields so the Five Loaves Al together now we also have the sputum analysis which is very important for us to uh collect if the medical provider has ordered for us to do so and this is going to be needed for us to probably um get that requisition to do or for the medical uh the the lab people to do the gram staining and culture and this is going to help with a specific type of bacteria causing the infection so the identification really is the key here now keep in mind guys that when you are collecting the sample the sputum sample make sure that you are obtaining a quality sample meaning you are obtaining that sample that has no saliva mixture in it it's not contaminated with other stuff and make sure that you have instructed the patient to rinse their mouth with water first before they're going to do their coughing and exporation that this will actually going to prevent the mixture of the expectorate the mucus and um with the surrounding bacteria in the mouth okay and as I have said in the previous lecture regarding the diagnostic tests make sure that this is something that you will be doing early in the morning or as soon as the patient gets up in the morning morning then make sure that this is collected okay again make sure that you instruct the patient to rinse their mouth first but if guys if this is not really effective let's say maybe the patient is not able to follow the instructions and of course probably they're not really able to collect the quality um sputum sample then we need to communicate with a medical provider maybe the the uh respiratory therapist will be able to collect the sputum sample through suctioning okay naso trale suctioning which would be a whole lot better um type of uh specimen now we're also going to talk about the blood cultures so what is the importance of the blood closures here well because when we are talking about pneumonia this is an infection okay so before we're going to treat the patient with the antibiotics we want to make sure that we have at least collected the blood specimen for culture before we are going to start any kind of antibiotic therapy and um we want to make sure that uh this is done before ICU admissions or any specific risk factors let's say cafeteria rels or LIC capena or alcohol abuse or chronic or liver um disease or asplenia so these are the things that you need to also consider now now there's probably some immunologic tests that will also help detect the microbial antigens and so make sure that this is going to be carried out as well and so this can be done in so many forms it could be uh done uh through the serum or sputum or urine in order to identify the cative organism now at this point we're going to talk about the treatment well yeah the treatment is very important here is of course with the administration of the antibiotic therapy and this is going to be done according to the empiric type of uh empirical type of um recommendations so the medical provider here will prescribe to start with a broadspectrum antibiotics and this is going to be based on the common cative organisms before the blood or sputum culture comes back with the results all right so again it can be to start the the antibiotic therapy it can be empiric and once the sputum specimen or the sputum culture is now showing the microorganism or let's say the blood culture has identified the infecting microorganism then there might be a need for the medical provider to switch into a different kind of antibiotic where the a microorganism is sensitive to okay now we'll also um tackle on the oxygen therapy so what we are doing here is that we are going to monitor the patient level of oxygenation to see how low they are or if they are improving or dis uh maybe they are deteriorating and so we're going to have to go through the protocol starting with the lowf flow oxygen first and then we'll have to notify for any changes if the patient would really require much higher level of oxygen concentration so that definitely would require notification in order for the physician to be aware that the patient's condition is worsening all right now if there is a need for um transitioning into the non-invasive ventilation let's say with the use of the BiPAP then this can possibly work for the patient especially if they are developing um hypoxemia and they are not really tolerating the regular delivery oxygen methods like the mask the non-rebreather or the highlow and so maybe this is something that they can benefit from and so if there is no need yet for an immediate intubation um then this probably would work for them as well now if in case the non-invasive ventilation therapy is ineffective then maybe the medical provider will suggest the mechanical ventilation into Trill to placement and so here we have our ventilation strategy most of the time we're going to going to have to set low tidal volume using about 6 ml per kilogram of the ideal body weight okay so this is the recommendation for those patients with diffuse bilateral pneumonia in also with an accompanying acute respiratory distress syndrome all right so this is our initial recommendation for the mechanical vent now guys was as you are going going to really participate in the care of the patient maybe you might be um taking care of this patient for the next two Three Chefs then or also with the care team make sure that you are advocating about the patients's early ambulations okay so this is really going to encourage the movement as soon as the patient is clinically stable and this will really shorten their Hospital stay and will improve better will lead to better outcomes as well now part of the Care here is to check the patients vaccination status ensuring that the patients are up to dat to their influenza and pneumococcal vaccines before their discharge and also with a smoking sensation this is very helpful we are going to advise the patient assess the patients who smoke in order for them to start quitting okay again it's just a matter of some preliminary teaching for this patient maybe they are very resistant about the smoking sensation because they don't like the effects of stopping smoking they are probably afraid that they might gain a whole lot of weight once they stop well there are different modalities on how to do that okay and so you initiate that conversation with them that they definitely need to stop smoking whenever they're going to encounter any of these um serious lung problems now respiratory hygiene this is very important guys um especially in uh the outpatient or let's say Emergency Settings we really need to encourage our patient to do hint hygiene and make sure that they're also using the mask if they have the pneumonia uh and also with the use of the tissues for cough for coughing uh in order to prevent them from spreading the infections now guys let's talk about the possible complications and there are so many complications that can arise from having the Infectious pneumonia so one of those is plural infusion well we know that this is the fluid buildup between the lungs and the chest wall which can really uh complicate the pneumonia so you have to keep an eye on this one plural effusion not a good thing to have oops let me erase that that now there's also the shock like I've said earlier the body will try to defend itself from the infecting microorganism of course with the uh Congregation of the nutrifil and also the chemical mediators going into the site of infection right this will trigger the systemic inflammatory response or known as the Sears okay this is our preliminary step or phase in the shock septic shock and so again our main concern concern here is the persistent low blood pressure because of the widespread Vaso dilation and again we definitely need to keep an eye out make sure that we are delivering those antibiotics that will be prescribed um stat in order to fight of the infection and also the boluses or maybe the vasopressors that will be ordered to prevent um the shock to occur or maybe to counter uh affect the shock now we're also going to talk about the impim as one of the complications here and this is the collection of the p in the plural cavity and this is going to require drenage and treatment and also the super infection which is going to um probably these are your pericarditis the bacteria or the menitis so these are the secondary infections uh once the patient has the pneumonia now delirium what is this this is the acute confusion that is considered a medical emergency guys if you are the nurse um taking care of this patient that has that pneumonia and out of nowhere the patient develops the delirium that is a bad sign that that's an omous sign that the patient is having a severe type of infection and there might be an underlying systemic infections that could have been masks or maybe some other complications hiding it okay now also there is also a problem this is a problem uh that is very common in the elderly population especially if they're going to develop the delirium this is a marker that they have developed much serious issue that would really require immediate attention okay now the delirium can also lead to some other problems maybe the patient could lead could actually harm themselves they can lead to false self injury they might start pulling IV uh could be nasogastric tube they probably would not really be able to cooperate they will be combative as well so again delirium is not a good sign at all now another complication is atelectasis or the lung collapse so this is caused by the mucus plugs blocking the Airways and also the alvioli or The Terminal bronchial now guys we'll talk about the nursing assessment and interventions this time so part of your care here is to really get a detailed medical history so as much as you can gather detailed past and present medical history because understanding the possible causes of pneumonia and also the patient's background can really help us tailor the management and to plan effectively now we also need to ask the patient about what possible causes of their infection have they been exposed to anyone um with a respiratory infection or maybe they have traveled recently or maybe uh traveled to areas known for specific outbreaks or have they uh had some local disease Trends so those are the things or maybe an outbreak uh simple outbreak or let's exposures have they been exposed to any kind of chemicals or animals or environments that may contribute to respiratory issues now we are also going to document for any recent type of respiratory infections um we're going to have to obtain their full medical and social history and their risk factors in order for us to identify those precursors or let's say contributory factors to the current conditions and make sure that we are updating the full medical history uh in order for us to identify those um conditions maybe a COPD um or it could be diabetes or heart disease or maybe they have some form of social history maybe smoking alcohol use or their living conditions are they living in a comp a very crowded living environment or are they any kind of Occupational exposures or hazards at work so make sure that you have this information as well or their other risk factors are they compromised are they getting any of the um immunosuppressant medications let's say maybe they're taking chemotherapeutic agents or maybe taking immunosuppressant medications because of a organ transplant maybe they have received an organ transplant about two months ago three months ago and so they're really prone to developing this or maybe if they have HIV or Aids this can really predispose them to getting the infection now guys we are going to note here about the purulent sputum or could be increase in the amount of the sputum that they're expector rating and also the fever the chills the fluidic chest pain and the disc tiia and teyia these are important manifestations that we need to pay close attention to um because the pneumonia can really present in so many ways in order for that for us to document and so if we are talking about the sputum we have to identify about that is there what color is it is it very thick and also observe the consistency now is this more of like an increasing amount have they had more of the speedum expectorated within the last 24 hours so make sure that you are assessing that as well also their elevation of the temperature maybe they're developing the chills overnight that really is going to signal that there is an infectious process going on now we're also going to observe the patient for any breathlessness um or also um illnesses patterns in the family so we have to investigate further if there is um some kind of like spread of infection among the family members right and we'll have to ask anyone if there is also somebody at home that is sick all right and we will be able to identify the Infectious nature of the pneumonia that they might be having now we're also going to have to um assess or obtain the um medic ation that the patient is currently taking and the allergies of those medications and so we are going to be able to identify and um to safeguard us from um giving medications that may contraindicate or may have some interactions with those medications right and also with the allergies we want to make sure that we have investigated this patient because we don't really want to cause any more serious occurrences in this patient with uh anaphylaxis no we don't want any more of that now part of the assessment here is for us to osculate the lung sounds of the patient make sure that we have that obtained as well to see if there is a rapid change in the lung sounds maybe they are now developing ronai or wheezes wheezing horse crackles no we don't want that we don't want that this is typically going to signal that there is no worsening patient condition now talking about the interventions here we are really going to have to monitor the patient's condition so we are going to monitor for the patients's breathlessness um their hypoxemia if there is uh appearance of cyanosis or if they are now getting confused so maybe before when you were the nurse working for this patient yesterday and then when you come back for the same patient then they are probably now is now confused that's a big big change all right so that definitely will call for the medical provider's attention hey our patient is really deteriorating she's now confused and able to really recall the events within the last four hours they cannot even recall what day it is today or the time and so this could really signal that there is now an underlying issue now we're also going to have to check the patients arterial blood gases their oxygen saturation we have to really determine their oxygen levels and also to see for those imbalances so we can address those real time and we have to administer the oxygen with humidification um make sure that we are also checking the patient's partial pressure of the oxygen also the saturation and uh we want to make sure that we are addressing the hypoxemia now part of the Care here is to humid y the oxygen if in case the administration of the oxygen exceeds 4 L per minute okay make sure it is humidified in order to prevent mucus membrane drin us okay now we are also going to be cautious in the delivery of the O um oxygen especially if the patient may have a history of CD remember about what I said about the COPD patients they're only going to require minimal amount of oxygen low oxygen concentration let's say 1 to two liters at most and we are going to maintain their oxygen level with this range from 88 maybe 90% or 90 or 92% this would be the safe range for them because if we are going to deliver them much higher concentration this will lose their drive to breathe and they're going to stop breathing and so make sure we're going on to administer them a low concentration okay and better yet with the use of the ventury Mask because there we can definitely use the safe amount of oxygen that they can get okay now we are going to also talk about the maximum position especially putting them in a sitting upright position especially when they are in distress to make sure that we are also allowing them to reposition themselves in bed um to allow um what do you call this movement of those what what you call this thick tenacious secretions in the alveoli all right now we'll talk about the collection of this sputum sample actually mentioned this earlier U make sure that this is collected correctly like I've said should be collected early in the morning have to make sure your patient does the oral care first have them rinse their mouth and make sure that they are not mixing the sample with the saliva okay and place in a correct sterile container now we're also going to encourage the patient to do the coughing and deep breathing exercises this is important guys and if in case they're not going to be able to Cuff out the fleem or the sputum thick tenacious sputum then they need to be assisted with the use of the suction okay it could be with the use of the naso trachel suction in order to get rid of the thick uh secretions we're also going to have to ENC encourage them to increase their oral fluid intake unless contraindicated because this will really help thin out their mucus secretions and we're also going to do that because of the fever that they're experiencing they might be losing a whole lot of the fluid through insensible water loss right because of the rapid respirations they're going to have that insensible increased insensible water loss so make sure that we are encouraging encouraging them to take a whole lot of water now we are also going to incorporate the use of Airway devices and this is something that is highly recommended by the respiratory therapist and I've mentioned this about the use of the positive expiratory pressure device uh one of those is the acapella I remember actually showing this to you way back this is that um device that has um that rubbery looking let me uh find that page for you um let me go back h let me just do this real quick hey here you go so this is that device here that I'm talking about that uh device we call acapella so this is going to require the patient to seal the mouth uh seal the mouthpiece with their mouth and they're going to have to inhale deeply and once they do that the device can deliver vibrations into the patient Airways and once it does that it will cause dislodgment of the mucose uh mucus inside the patients's airway and they're going to end up coughing that out all right now let's go back to that slide 276 I think we are here yes so that is the Acappella um another modality here is to have the chest percussion and also the postural drainage or or the use of the uh vibration kind of like vest and this is going to be done by the respiratory therapist to dislodge those thick um secretions in the lung fields and definitely we have to encourage the patient to mobilize as early as they can as they can tolerate as well in order to proove uh improve rather their ventilation and to clear their secretions and also to reduce their risk of the lung collapse okay now part of the Care here is to teach them about the chest splending especially when they are coughing in order to lessen the painful um sensation and another is to avoid suppressing the cough okay so what is this maybe they probably would be taking some of those cough suppressant or anti-us no we don't want that okay this will allow trapping of their those mucous secretions in the alveoli and this can prevent or it can further cause multiplication of the Infectious process in the lung Fields now we're also going to have to encourage bed rest into our patient um especially when they are having the fever in order for us to decrease the patients metabolic demands when they have that fever remember that they're going to end up with rapid breathing rapid heart rate yes they are going to be exhausted for that and so bed rest is very important around this time now we're also going to talk about the administration of the antimicrobial agents which is really one of the highlights because of the Infectious process we really need to eradicate that infe infectious microorganism all right now moving into the patient education and this is something that you can start even when the patient is still in the the acute care setting okay please take note of this the patient education is not limited during the discharge process okay this is very important for you to make sure that you imparting the knowledge and also um making sure that they understand what you have been teaching them so for example if this might in involve with the use of the incentives barometer make sure that they're able to use the device effectively and properly or correctly now guys we're going to talk about the patient education let's say the proper um or the compliance regarding the antibiotic therapy this is very important okay make sure that you recommend this to your patient in order to prevent antimicrobial resistance or back uh resistance through the antibiotic now we're also going to talk about informing the patient patient that fatigue can occur even after they had the pneumonia okay so this is something that the body will undergo this is just a normal physiological response the patient will have that because it's still in the process of repairing those um tissues that need healing now also we're going to have to gradually increase their physical activity after they are much more stable Okay so so make sure that they are um doing that to enhance their breathing and also minimize the risk of immobility yeah immobility means more complications we don't want that especially the patient is in the hospital immobility equates DVT deep vein thrombosis which is a very common complications uh complication to patients that are in the hospital all right we don't want that either now we're going to have to talk about performing lung clearing exercises and this is very important in order for them to clear their lungs and also enhance the full expansion and also the functionality of their lungs um we're also going to have to talk to them that there is going to be a need for them to have a follow-up chest x-ray after 4 to six weeks okay so this simple means that this is going to be done as an outpatient in order to reassess the lung clearance and also to detect any potential underlying causes maybe tumors so make sure that they're going to comply with this follow-up appointment now quitting smoking is big deal okay we are really going to highlight here the detrimental effects of the cigarette smoke on the lung defenses and also the lung function okay now we're going to have to talk about the maintenance or we're going to have to recommend maintaining natural resistance through their balance nutrition at home um adequate rest periods and also suitable physical activity and also making sure that they have um taken their recommended medications upon discharge in order for them to prevent the recurrence of the respiratory infection all right now part of the Care here is to really avoid fatigue and extreme temperatures and also exess alcohol because these factors can increase their susceptibility to the pneumonia um make sure that they have adequate rest periods and no rapid changes in their environmental temperature as well and alcohol definitely need to be stopped or lessen around that time now we're also going to talk about uh uh the need for them to get the pneumococcal vaccine or the flu vaccine especially if they are at a higher risk um we want to make sure that um they are screened if in case they have not received it yet make sure that we are evaluating their eligibility and we are going to have to support for the vaccination with the pumco and the influence of vaccines uh which is really U associated with the decrease hospitalizations and also decrease in the mortality from the pneumonia and influenza now guys we're also going to talk about uh the we're going to have to advise the patient from refraining uh from close contact with the individuals with um people experiencing oper respiratory infections for several months okay so we don't want them to get exposed by those people and another thing is we're going to have to prioritize the teaching on hand hygiene respiratory hygiene especially after contact UM careful handwashing is very important here guys now as we are going to recap regarding the discussion on pneumonia again in the pneumonia Care Nursing will have to prioritize on the regular assessment of the vital science the respiratory status the delivery of oxygen and also checking the patient saturation levels in order that we can monitor for any progression or deterioration and the nursing interventions that we're going to have to provide will will be geared into the administration of the antibiotics um could be the Bronco dilators as well if they have some COPD along with the pneumonia and we're also going to have to provide respiratory support like oxy therapy or let's say nebulization and it is very crucial for us nurses to Monitor and also address some complications maybe atelectasis or let's say sepsis these are something that can happen readily into our patient so we want to make sure that we are proactive in delivering those interventions uh make sure that we are adequately hydrating our patient mobilizing our patient and make sure that they have um they're doing the respiratory exercises now before we end we definitely make sure that they are receiving the correct information the patient education and also include the caregiver their family members to be educated um especially with a treatment that they are going to be receiving at home um the exercises that they should be doing like coughing deep breathing exercise and make sure that the patient will adhere to the medication therapy make sure that they complete whatever has been ordered and also make sure that they recognize those symptoms of worsening or let's say yeah worsening of their manifestations uh which is very important in order that they can get the necessary help as early as possible and so that is the end of our discussion today um we will be talking a different topic tomorrow but we will be posting the the name of the topic um through our thumbnail so please keep an eye out on that one so I really appreciate your time attending this short class and I will see you again tomorrow you take care bye-bye