28/10/2009 1 pneumoniapneumonia dr ibrahim bashayreh, rn, phd

28/10/2009 1

PneumoniaPneumoniaPneumoniaPneumonia

Dr Ibrahim Bashayreh, RN, PhD.Dr Ibrahim Bashayreh, RN, PhD.Dr Ibrahim Bashayreh, RN, PhD.Dr Ibrahim Bashayreh, RN, PhD.

28/10/2009 2

PneumoniaPneumoniaPneumoniaPneumonia

Acute inflammation of lung (lower Acute inflammation of lung (lower respiratory tract) caused by respiratory tract) caused by microorganism, comes with fever, microorganism, comes with fever, focal chest symptoms, shadowing focal chest symptoms, shadowing on CXRon CXRLeading cause of death until 1936Leading cause of death until 1936Discovery of sulfa drugs and Discovery of sulfa drugs and

penicillinpenicillin

Acute inflammation of lung (lower Acute inflammation of lung (lower respiratory tract) caused by respiratory tract) caused by microorganism, comes with fever, microorganism, comes with fever, focal chest symptoms, shadowing focal chest symptoms, shadowing on CXRon CXRLeading cause of death until 1936Leading cause of death until 1936Discovery of sulfa drugs and Discovery of sulfa drugs and

penicillinpenicillin

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Classification Classification Classification Classification Community Acquired PneumoniaCommunity Acquired Pneumonia

Occur within 48 hrs of admission or in Occur within 48 hrs of admission or in patient’s who haven’t been hospitalized in the patient’s who haven’t been hospitalized in the last 2 wkslast 2 wks

Strep pneumonia, mycoplasma pneumonia, Strep pneumonia, mycoplasma pneumonia, influenza A, Haemophilus influenza, and influenza A, Haemophilus influenza, and Legionella are more common pathogensLegionella are more common pathogens

Patients with chronic diseases are more prone Patients with chronic diseases are more prone to Klebsiella and other gram negative to Klebsiella and other gram negative organismsorganisms

Highest incidence in winterHighest incidence in winterSmoking important risk factorSmoking important risk factor

Community Acquired PneumoniaCommunity Acquired PneumoniaOccur within 48 hrs of admission or in Occur within 48 hrs of admission or in

patient’s who haven’t been hospitalized in the patient’s who haven’t been hospitalized in the last 2 wkslast 2 wks

Strep pneumonia, mycoplasma pneumonia, Strep pneumonia, mycoplasma pneumonia, influenza A, Haemophilus influenza, and influenza A, Haemophilus influenza, and Legionella are more common pathogensLegionella are more common pathogens

Patients with chronic diseases are more prone Patients with chronic diseases are more prone to Klebsiella and other gram negative to Klebsiella and other gram negative organismsorganisms

Highest incidence in winterHighest incidence in winterSmoking important risk factorSmoking important risk factor

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Types of PneumoniaTypes of PneumoniaTypes of PneumoniaTypes of Pneumonia

Hospital-acquired pneumonia (HAP) (Nasocomial Infection)Hospital-acquired pneumonia (HAP) (Nasocomial Infection)

Develops 2 or more days after admissionDevelops 2 or more days after admission Gram negative bacilli (Klebsiella, Pseudomonas, E coli, Gram negative bacilli (Klebsiella, Pseudomonas, E coli,

Proteus) or Staphylococcus are more common pathogensProteus) or Staphylococcus are more common pathogens Aspiration around an ETT/reduced consciousness or Aspiration around an ETT/reduced consciousness or

difficulty swallowing allows pathogens in the oropharynx to difficulty swallowing allows pathogens in the oropharynx to colonize the lungscolonize the lungs

Ventilator-associated pneumonia (VAP): in patients on Ventilator-associated pneumonia (VAP): in patients on ventilatorsventilators

Aspiation: follows aspiration of gastric contentsAspiation: follows aspiration of gastric contents Immunosuppression: chemotherapy/bone marrow Immunosuppression: chemotherapy/bone marrow

transplant/HIV patients susceptible to fungi and viral transplant/HIV patients susceptible to fungi and viral infections as well as other pathogeninfections as well as other pathogen

Highest mortality rate of nosocomial infectionsHighest mortality rate of nosocomial infections

Hospital-acquired pneumonia (HAP) (Nasocomial Infection)Hospital-acquired pneumonia (HAP) (Nasocomial Infection)

Develops 2 or more days after admissionDevelops 2 or more days after admission Gram negative bacilli (Klebsiella, Pseudomonas, E coli, Gram negative bacilli (Klebsiella, Pseudomonas, E coli,

Proteus) or Staphylococcus are more common pathogensProteus) or Staphylococcus are more common pathogens Aspiration around an ETT/reduced consciousness or Aspiration around an ETT/reduced consciousness or

difficulty swallowing allows pathogens in the oropharynx to difficulty swallowing allows pathogens in the oropharynx to colonize the lungscolonize the lungs

Ventilator-associated pneumonia (VAP): in patients on Ventilator-associated pneumonia (VAP): in patients on ventilatorsventilators

Aspiation: follows aspiration of gastric contentsAspiation: follows aspiration of gastric contents Immunosuppression: chemotherapy/bone marrow Immunosuppression: chemotherapy/bone marrow

transplant/HIV patients susceptible to fungi and viral transplant/HIV patients susceptible to fungi and viral infections as well as other pathogeninfections as well as other pathogen

Highest mortality rate of nosocomial infectionsHighest mortality rate of nosocomial infections

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Causes of HAPCauses of HAPCauses of HAPCauses of HAP

PseudomonasPseudomonasEnterobacterEnterobacterS. aureusS. aureusS. pneumoniaeS. pneumoniaeImmunosuppressive therapyImmunosuppressive therapyGeneral debilityGeneral debilityEndotracheal intubationEndotracheal intubation

PseudomonasPseudomonasEnterobacterEnterobacterS. aureusS. aureusS. pneumoniaeS. pneumoniaeImmunosuppressive therapyImmunosuppressive therapyGeneral debilityGeneral debilityEndotracheal intubationEndotracheal intubation

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Aging, 65 years or olderAging, 65 years or olderMale Male Children under 2Children under 2Having HIV or AIDSHaving HIV or AIDSIncreased frequency of gram- negative bacilli Increased frequency of gram- negative bacilli (leukemia, diabetes, alcoholism)(leukemia, diabetes, alcoholism)SmokingSmokingBeing around certain chemicalsBeing around certain chemicalsLiving in certain parts of the countryLiving in certain parts of the countryBeing hospitalized in ICU & having ETTBeing hospitalized in ICU & having ETTPollutionPollutionMalnutritionMalnutrition

Aging, 65 years or olderAging, 65 years or olderMale Male Children under 2Children under 2Having HIV or AIDSHaving HIV or AIDSIncreased frequency of gram- negative bacilli Increased frequency of gram- negative bacilli (leukemia, diabetes, alcoholism)(leukemia, diabetes, alcoholism)SmokingSmokingBeing around certain chemicalsBeing around certain chemicalsLiving in certain parts of the countryLiving in certain parts of the countryBeing hospitalized in ICU & having ETTBeing hospitalized in ICU & having ETTPollutionPollutionMalnutritionMalnutrition

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Acquisition of OrganismsAcquisition of OrganismsAcquisition of OrganismsAcquisition of Organisms

AspirationAspiration from nasopharynx, from nasopharynx, oropharynxoropharynx

InhalationInhalation of microbes of microbes

Hematogenous spreadHematogenous spread from from primary infection elsewhereprimary infection elsewhere

AspirationAspiration from nasopharynx, from nasopharynx, oropharynxoropharynx

InhalationInhalation of microbes of microbes

Hematogenous spreadHematogenous spread from from primary infection elsewhereprimary infection elsewhere

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Signs & Symptoms Signs & Symptoms Signs & Symptoms Signs & Symptoms SymptomsSymptomsDyspneaDyspnea PleurisyPleurisy CoughCough Discolored sputumDiscolored sputum

SignsSigns CyanosisCyanosis TachycardiaTachycardia TachypneaTachypnea Dull percussionDull percussion CrepitusCrepitus Bronchial breath soundsBronchial breath sounds Pleural rubPleural rub Sweating, cold clammy skinSweating, cold clammy skin

Non-respiratory featuresNon-respiratory features Confusion, fatigueConfusion, fatigue Diarrhea, N&V.Diarrhea, N&V.

SymptomsSymptomsDyspneaDyspnea PleurisyPleurisy CoughCough Discolored sputumDiscolored sputum

SignsSigns CyanosisCyanosis TachycardiaTachycardia TachypneaTachypnea Dull percussionDull percussion CrepitusCrepitus Bronchial breath soundsBronchial breath sounds Pleural rubPleural rub Sweating, cold clammy skinSweating, cold clammy skin

Non-respiratory featuresNon-respiratory features Confusion, fatigueConfusion, fatigue Diarrhea, N&V.Diarrhea, N&V.

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Clinical ManifestationsClinical Manifestations Clinical ManifestationsClinical Manifestations

CAP symptomsCAP symptomsSudden onset of feverSudden onset of feverChillsChillsCough productive of purulent Cough productive of purulent

sputumsputumPleuritic chest painPleuritic chest pain

CAP symptomsCAP symptomsSudden onset of feverSudden onset of feverChillsChillsCough productive of purulent Cough productive of purulent

sputumsputumPleuritic chest painPleuritic chest pain

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Pathophysiology: Pathophysiology: Pneumococcal PneumoniaPneumococcal Pneumonia

Pathophysiology: Pathophysiology: Pneumococcal PneumoniaPneumococcal Pneumonia

Congestion from outpouring of Congestion from outpouring of fluid into alveoli fluid into alveoli Microorganisms multiply and Microorganisms multiply and

spread infection, interfering with spread infection, interfering with lung functionlung function

Congestion from outpouring of Congestion from outpouring of fluid into alveoli fluid into alveoli Microorganisms multiply and Microorganisms multiply and

spread infection, interfering with spread infection, interfering with lung functionlung function

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Pathophysiology: Pathophysiology: Pneumococcal PneumoniaPneumococcal Pneumonia Pathophysiology: Pathophysiology: Pneumococcal PneumoniaPneumococcal Pneumonia

Red hepatizationRed hepatizationMassive dilation of capillariesMassive dilation of capillariesAlveoli fill with organisms, Alveoli fill with organisms,

neutrophils, RBCs, and fibrinneutrophils, RBCs, and fibrinCauses lungs to appear red and Causes lungs to appear red and

granular, similar to livergranular, similar to liver

Red hepatizationRed hepatizationMassive dilation of capillariesMassive dilation of capillariesAlveoli fill with organisms, Alveoli fill with organisms,

neutrophils, RBCs, and fibrinneutrophils, RBCs, and fibrinCauses lungs to appear red and Causes lungs to appear red and

granular, similar to livergranular, similar to liver

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ComplicationsComplicationsComplicationsComplications

Pleurisy (pain with breathing)Pleurisy (pain with breathing)

Pleural effusionPleural effusionUsually is sterile and reabsorbed in 1-2 Usually is sterile and reabsorbed in 1-2

weeks or requires thoracentesisweeks or requires thoracentesis

AtelectasisAtelectasisUsually clears with cough and deep Usually clears with cough and deep

breathingbreathing

Pleurisy (pain with breathing)Pleurisy (pain with breathing)

Pleural effusionPleural effusionUsually is sterile and reabsorbed in 1-2 Usually is sterile and reabsorbed in 1-2

weeks or requires thoracentesisweeks or requires thoracentesis

AtelectasisAtelectasisUsually clears with cough and deep Usually clears with cough and deep

breathingbreathing

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Delayed resolutionDelayed resolutionPersistent infection seen on x-ray as Persistent infection seen on x-ray as

residual consolidationresidual consolidation

Lung abscess (pus-containing lesions)Lung abscess (pus-containing lesions)Empyema (purulent exudate in pleural Empyema (purulent exudate in pleural cavity)cavity)Requires antibiotics and drainage of Requires antibiotics and drainage of

exudateexudate

Delayed resolutionDelayed resolutionPersistent infection seen on x-ray as Persistent infection seen on x-ray as

residual consolidationresidual consolidation

Lung abscess (pus-containing lesions)Lung abscess (pus-containing lesions)Empyema (purulent exudate in pleural Empyema (purulent exudate in pleural cavity)cavity)Requires antibiotics and drainage of Requires antibiotics and drainage of

exudateexudate

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PericarditisPericarditisFrom spread of microorganismFrom spread of microorganism

ArthritisArthritisSystemic spread of organismSystemic spread of organismExudate can be aspiratedExudate can be aspirated

MeningitisMeningitisPatient who is disoriented, confused, or Patient who is disoriented, confused, or

somnolent should have lumbar puncture somnolent should have lumbar puncture to evaluate meningitisto evaluate meningitis

PericarditisPericarditisFrom spread of microorganismFrom spread of microorganism

ArthritisArthritisSystemic spread of organismSystemic spread of organismExudate can be aspiratedExudate can be aspirated

MeningitisMeningitisPatient who is disoriented, confused, or Patient who is disoriented, confused, or

somnolent should have lumbar puncture somnolent should have lumbar puncture to evaluate meningitisto evaluate meningitis

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EndocarditisEndocarditisMicroorganisms attack endocardium and Microorganisms attack endocardium and

heart valvesheart valvesManifestations similar to bacterial Manifestations similar to bacterial

endocarditisendocarditis

EndocarditisEndocarditisMicroorganisms attack endocardium and Microorganisms attack endocardium and

heart valvesheart valvesManifestations similar to bacterial Manifestations similar to bacterial

endocarditisendocarditis

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Diagnostic TestsDiagnostic Tests Diagnostic TestsDiagnostic Tests

HistoryHistory

Physical examPhysical exam

Chest x-rayChest x-ray

Gram stain of sputumGram stain of sputum

Sputum culture and sensitivitySputum culture and sensitivity

Pulse oximetry or ABGsPulse oximetry or ABGs

CBC, differential, chemsCBC, differential, chems

Blood culturesBlood cultures

HistoryHistory

Physical examPhysical exam

Chest x-rayChest x-ray

Gram stain of sputumGram stain of sputum

Sputum culture and sensitivitySputum culture and sensitivity

Pulse oximetry or ABGsPulse oximetry or ABGs

CBC, differential, chemsCBC, differential, chems

Blood culturesBlood cultures

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Collaborative CareCollaborative CareCollaborative CareCollaborative Care

Antibiotic therapyAntibiotic therapy

Oxygen for hypoxemiaOxygen for hypoxemia

Analgesics for chest painAnalgesics for chest pain

AntipyreticsAntipyretics

Influenza drugsInfluenza drugs

Influenza vaccineInfluenza vaccine

Fluid intake at least 3 L per dayFluid intake at least 3 L per day

Caloric intake at least 1500 per dayCaloric intake at least 1500 per day

Antibiotic therapyAntibiotic therapy

Oxygen for hypoxemiaOxygen for hypoxemia

Analgesics for chest painAnalgesics for chest pain

AntipyreticsAntipyretics

Influenza drugsInfluenza drugs

Influenza vaccineInfluenza vaccine

Fluid intake at least 3 L per dayFluid intake at least 3 L per day

Caloric intake at least 1500 per dayCaloric intake at least 1500 per day

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Collaborative CareCollaborative CareCollaborative CareCollaborative Care

Pneumococcal vaccinePneumococcal vaccineIndicated for those at riskIndicated for those at risk

Chronic illness such as heart and lung Chronic illness such as heart and lung disease, diabetes mellitusdisease, diabetes mellitus

Recovering from severe illnessRecovering from severe illness65 or older65 or olderIn long-term care facilityIn long-term care facility

Pneumococcal vaccinePneumococcal vaccineIndicated for those at riskIndicated for those at risk

Chronic illness such as heart and lung Chronic illness such as heart and lung disease, diabetes mellitusdisease, diabetes mellitus

Recovering from severe illnessRecovering from severe illness65 or older65 or olderIn long-term care facilityIn long-term care facility

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Nursing AssessmentNursing Assessment Nursing AssessmentNursing Assessment

History of Predisposing/Risk FactorsHistory of Predisposing/Risk Factors

Lung cancerLung cancerCOPDCOPDDiabetes mellitusDiabetes mellitusDebilitating diseaseDebilitating diseaseMalnutritionMalnutrition

History of Predisposing/Risk FactorsHistory of Predisposing/Risk Factors

Lung cancerLung cancerCOPDCOPDDiabetes mellitusDiabetes mellitusDebilitating diseaseDebilitating diseaseMalnutritionMalnutrition

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Nursing AssessmentNursing Assessment Nursing AssessmentNursing AssessmentHistory of Predisposing/Risk FactorsHistory of Predisposing/Risk Factors

AIDSAIDSUse of antibiotics, corticosteroids, Use of antibiotics, corticosteroids,

chemotherapy, immunosuppressantschemotherapy, immunosuppressantsRecent abdominal or thoracic Recent abdominal or thoracic

surgerysurgerySmoking, alcoholism, respiratory Smoking, alcoholism, respiratory

infections infections Prolonged bed restProlonged bed rest

History of Predisposing/Risk FactorsHistory of Predisposing/Risk FactorsAIDSAIDSUse of antibiotics, corticosteroids, Use of antibiotics, corticosteroids,

chemotherapy, immunosuppressantschemotherapy, immunosuppressantsRecent abdominal or thoracic Recent abdominal or thoracic

surgerysurgerySmoking, alcoholism, respiratory Smoking, alcoholism, respiratory

infections infections Prolonged bed restProlonged bed rest

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Clinical ManifestationsClinical ManifestationsDyspneaDyspneaNasal congestionNasal congestionPain with breathingPain with breathingSore throatSore throatMuscle achesMuscle achesFeverFever

Clinical ManifestationsClinical ManifestationsDyspneaDyspneaNasal congestionNasal congestionPain with breathingPain with breathingSore throatSore throatMuscle achesMuscle achesFeverFever

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Nursing AssessmentNursing AssessmentNursing AssessmentNursing Assessment

Clinical ManifestationsClinical ManifestationsRestlessness or lethargyRestlessness or lethargySplinting affected areaSplinting affected areaTachypneaTachypneaAsymmetric chest movementsAsymmetric chest movementsUse of accessory musclesUse of accessory musclesCracklesCracklesGreen or yellow sputumGreen or yellow sputum

Clinical ManifestationsClinical ManifestationsRestlessness or lethargyRestlessness or lethargySplinting affected areaSplinting affected areaTachypneaTachypneaAsymmetric chest movementsAsymmetric chest movementsUse of accessory musclesUse of accessory musclesCracklesCracklesGreen or yellow sputumGreen or yellow sputum

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Clinical ManifestationsClinical ManifestationsTachycardiaTachycardiaChanges in mental Changes in mental

statusstatusLeukocytosisLeukocytosisAbnormal ABGsAbnormal ABGsPleural effusionPleural effusionPneumothorax on CXRPneumothorax on CXR

Clinical ManifestationsClinical ManifestationsTachycardiaTachycardiaChanges in mental Changes in mental

statusstatusLeukocytosisLeukocytosisAbnormal ABGsAbnormal ABGsPleural effusionPleural effusionPneumothorax on CXRPneumothorax on CXR

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Nursing DiagnosesNursing Diagnoses Nursing DiagnosesNursing Diagnoses

Ineffective breathing patternIneffective breathing pattern

Ineffective airway clearanceIneffective airway clearance

Acute painAcute pain

Imbalanced nutrition: less than body Imbalanced nutrition: less than body requirementsrequirements

Activity intoleranceActivity intolerance

Ineffective breathing patternIneffective breathing pattern


Acute painAcute pain

Imbalanced nutrition: less than body Imbalanced nutrition: less than body requirementsrequirements

Activity intoleranceActivity intolerance

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PlanningPlanning PlanningPlanning

Goals: Patient will haveGoals: Patient will haveClear breath soundsClear breath soundsNormal breathing patternsNormal breathing patternsNo signs of hypoxiaNo signs of hypoxiaNormal chest x-rayNormal chest x-rayNo complications related to pneumoniaNo complications related to pneumonia

Goals: Patient will haveGoals: Patient will haveClear breath soundsClear breath soundsNormal breathing patternsNormal breathing patternsNo signs of hypoxiaNo signs of hypoxiaNormal chest x-rayNormal chest x-rayNo complications related to pneumoniaNo complications related to pneumonia

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Nursing ImplementationNursing ImplementationNursing ImplementationNursing Implementation

Teach nutrition, hygiene, rest, regular Teach nutrition, hygiene, rest, regular exercise to maintain natural resistanceexercise to maintain natural resistance

Prompt treatment of URIsPrompt treatment of URIs

Teach nutrition, hygiene, rest, regular Teach nutrition, hygiene, rest, regular exercise to maintain natural resistanceexercise to maintain natural resistance

Prompt treatment of URIsPrompt treatment of URIs

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Encourage those at risk to obtain Encourage those at risk to obtain influenza and pneumococcal influenza and pneumococcal vaccinationsvaccinations

Reposition patient q2hReposition patient q2h

Assist patients at risk for aspiration Assist patients at risk for aspiration with eating, drinking, and taking medswith eating, drinking, and taking meds

Encourage those at risk to obtain Encourage those at risk to obtain influenza and pneumococcal influenza and pneumococcal vaccinationsvaccinations

Reposition patient q2hReposition patient q2h

Assist patients at risk for aspiration Assist patients at risk for aspiration with eating, drinking, and taking medswith eating, drinking, and taking meds

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Assist immobile patients with turning Assist immobile patients with turning and deep breathingand deep breathing

Strict asepsisStrict asepsis

Emphasize need to take course of Emphasize need to take course of medication(s)medication(s)

Teach drug-drug interactionsTeach drug-drug interactions

Assist immobile patients with turning Assist immobile patients with turning and deep breathingand deep breathing

Strict asepsisStrict asepsis

Emphasize need to take course of Emphasize need to take course of medication(s)medication(s)

Teach drug-drug interactionsTeach drug-drug interactions

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EvaluationEvaluationEvaluationEvaluation

Dyspnea not presentDyspnea not present

SpOSpO22 >> 95 95

Free of adventitious breath soundsFree of adventitious breath sounds

Clears sputum from airwayClears sputum from airway

Dyspnea not presentDyspnea not present

SpOSpO22 >> 95 95

Free of adventitious breath soundsFree of adventitious breath sounds

Clears sputum from airwayClears sputum from airway

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EvaluationEvaluationEvaluationEvaluation

Reports pain controlledReports pain controlled

Verbalizes causal factorsVerbalizes causal factors

Adequate fluid and caloric intakeAdequate fluid and caloric intake

Performs ADLsPerforms ADLs

Reports pain controlledReports pain controlled

Verbalizes causal factorsVerbalizes causal factors

Adequate fluid and caloric intakeAdequate fluid and caloric intake

Performs ADLsPerforms ADLs

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TuberculosisTuberculosisTuberculosisTuberculosisFamous people who have had TB

Fredric Chopin*Eleanor Roosevelt*Nelson MandelaRingo StarrTom JonesTina Turner

*Died of TB

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What is tuberculosis (TB)?What is tuberculosis (TB)?What is tuberculosis (TB)?What is tuberculosis (TB)?Disease caused by bacteria called Disease caused by bacteria called Mycobacterium tuberculosisMycobacterium tuberculosisChronic bacterial infectionChronic bacterial infectionWas once the leading cause of death in USWas once the leading cause of death in USThe number of cases declined in the 1940’s The number of cases declined in the 1940’s when drugs were developed to treat TBwhen drugs were developed to treat TBTB is still a problem worldwideTB is still a problem worldwide8 million people develop TB yearly8 million people develop TB yearly3 million die3 million die

Disease caused by bacteria called Disease caused by bacteria called Mycobacterium tuberculosisMycobacterium tuberculosisChronic bacterial infectionChronic bacterial infectionWas once the leading cause of death in USWas once the leading cause of death in USThe number of cases declined in the 1940’s The number of cases declined in the 1940’s when drugs were developed to treat TBwhen drugs were developed to treat TBTB is still a problem worldwideTB is still a problem worldwide8 million people develop TB yearly8 million people develop TB yearly3 million die3 million die

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TuberculosisTuberculosisTuberculosisTuberculosis

5-10%5-10% become become activeactiveOnly Only contagiouscontagious when activewhen activePrimarily affect Primarily affect lungslungs but… but…KidneysKidneysLiverLiverBrainBrainBoneBone

5-10%5-10% become become activeactiveOnly Only contagiouscontagious when activewhen activePrimarily affect Primarily affect lungslungs but… but…KidneysKidneysLiverLiverBrainBrainBoneBone

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How is TB spread?How is TB spread?How is TB spread?How is TB spread?

Through the air from person to Through the air from person to person by coughingperson by coughingUsually attacks lungsUsually attacks lungsTwo stagesTwo stagesLatent TBLatent TB

asymptomatic and not contagiousasymptomatic and not contagious can take medication to prevent development of can take medication to prevent development of

diseasediseaseActive TB DiseaseActive TB Disease

May spread to othersMay spread to othersMay have abnormal chest x-rayMay have abnormal chest x-rayUsually have positive skin testUsually have positive skin test

Through the air from person to Through the air from person to person by coughingperson by coughingUsually attacks lungsUsually attacks lungsTwo stagesTwo stagesLatent TBLatent TB

asymptomatic and not contagiousasymptomatic and not contagious can take medication to prevent development of can take medication to prevent development of

diseasediseaseActive TB DiseaseActive TB Disease

May spread to othersMay spread to othersMay have abnormal chest x-rayMay have abnormal chest x-rayUsually have positive skin testUsually have positive skin test

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Symptoms of TBSymptoms of TBSymptoms of TBSymptoms of TB

ChillsChills

FeverFever

Weakness or fatigueWeakness or fatigue

Sweating while sleeping, Night sweatsSweating while sleeping, Night sweats

Cough that lasts longer than 2 weeksCough that lasts longer than 2 weeks

Pain in chestPain in chest

Coughing up blood or sputumCoughing up blood or sputum

ChillsChills

FeverFever

Weakness or fatigueWeakness or fatigue

Sweating while sleeping, Night sweatsSweating while sleeping, Night sweats

Cough that lasts longer than 2 weeksCough that lasts longer than 2 weeks

Pain in chestPain in chest

Coughing up blood or sputumCoughing up blood or sputum

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Risk FactorsRisk FactorsRisk FactorsRisk Factors

Close contact with someone who is infected Close contact with someone who is infected with TBwith TBTraveling to a country where TB is commonTraveling to a country where TB is commonForeign-born individuals and minorities Foreign-born individuals and minorities have a higher incidence of developing TBhave a higher incidence of developing TB2002: 50% of US cases were in foreign-2002: 50% of US cases were in foreign-

born individuals.born individuals.2002: 80% of all US TB cases were in 2002: 80% of all US TB cases were in

ethnic and racial minorities.ethnic and racial minorities.

Close contact with someone who is infected Close contact with someone who is infected with TBwith TBTraveling to a country where TB is commonTraveling to a country where TB is commonForeign-born individuals and minorities Foreign-born individuals and minorities have a higher incidence of developing TBhave a higher incidence of developing TB2002: 50% of US cases were in foreign-2002: 50% of US cases were in foreign-

born individuals.born individuals.2002: 80% of all US TB cases were in 2002: 80% of all US TB cases were in

ethnic and racial minorities.ethnic and racial minorities.

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Risk FactorsRisk FactorsRisk FactorsRisk Factors

ImmunocompromiseImmunocompromiseSubstance abuseSubstance abuseIndigent (POVERTY)Indigent (POVERTY)Living in overcrowded, substandard housingLiving in overcrowded, substandard housingHealth care workers performing high risk Health care workers performing high risk activitiesactivities

ImmunocompromiseImmunocompromiseSubstance abuseSubstance abuseIndigent (POVERTY)Indigent (POVERTY)Living in overcrowded, substandard housingLiving in overcrowded, substandard housingHealth care workers performing high risk Health care workers performing high risk activitiesactivities

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Multi-drug resistant TB (MDR TB)Multi-drug resistant TB (MDR TB)Multi-drug resistant TB (MDR TB)Multi-drug resistant TB (MDR TB)

Bacteria become resistant to antibioticsBacteria become resistant to antibioticsArose from improper use of antibiotics in the Arose from improper use of antibiotics in the treatment of TBtreatment of TBTreatment of one case can cost up to $1.3 millionTreatment of one case can cost up to $1.3 million45 states and Washington, DC have confirmed cases 45 states and Washington, DC have confirmed cases of MDR TB of MDR TB Treatment is difficult and costlyTreatment is difficult and costlyCan develop from not taking proper course of Can develop from not taking proper course of antibiotics for TBantibiotics for TBMDR TB can be spread by an infected personMDR TB can be spread by an infected person

Bacteria become resistant to antibioticsBacteria become resistant to antibioticsArose from improper use of antibiotics in the Arose from improper use of antibiotics in the treatment of TBtreatment of TBTreatment of one case can cost up to $1.3 millionTreatment of one case can cost up to $1.3 million45 states and Washington, DC have confirmed cases 45 states and Washington, DC have confirmed cases of MDR TB of MDR TB Treatment is difficult and costlyTreatment is difficult and costlyCan develop from not taking proper course of Can develop from not taking proper course of antibiotics for TBantibiotics for TBMDR TB can be spread by an infected personMDR TB can be spread by an infected person

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How to protect yourselfHow to protect yourselfHow to protect yourselfHow to protect yourself

BCG vaccine for TB is given in many countriesBCG vaccine for TB is given in many countries

Not recommended for healthcare workers Not recommended for healthcare workers unless a high percentage of patients are unless a high percentage of patients are infected with MDR TBinfected with MDR TB

PPD test if exposure is suspectedPPD test if exposure is suspected

USE proper PPE when in contact with patients USE proper PPE when in contact with patients who may have TBwho may have TB

BCG vaccine for TB is given in many countriesBCG vaccine for TB is given in many countries

Not recommended for healthcare workers Not recommended for healthcare workers unless a high percentage of patients are unless a high percentage of patients are infected with MDR TBinfected with MDR TB

PPD test if exposure is suspectedPPD test if exposure is suspected

USE proper PPE when in contact with patients USE proper PPE when in contact with patients who may have TBwho may have TB

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PPD Skin Test Procedure PPD Skin Test Procedure PPD Skin Test Procedure PPD Skin Test Procedure

Intradermal administration of PPD Intradermal administration of PPD L forearmL forearm

Must be “read” between 48 and 72 hoursMust be “read” between 48 and 72 hours

To accurately “read”To accurately “read”Visual inspection for erythemaVisual inspection for erythemaTactile inspection to monitor size of Tactile inspection to monitor size of

indurationinduration10 mm or > area of 10 mm or > area of indurationinduration

Consider positive and must be referred Consider positive and must be referred

Intradermal administration of PPD Intradermal administration of PPD L forearmL forearm

Must be “read” between 48 and 72 hoursMust be “read” between 48 and 72 hours

To accurately “read”To accurately “read”Visual inspection for erythemaVisual inspection for erythemaTactile inspection to monitor size of Tactile inspection to monitor size of

indurationinduration10 mm or > area of 10 mm or > area of indurationinduration

Consider positive and must be referred Consider positive and must be referred

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Diagnostic examsDiagnostic examsPPD PPD Mantoux skin testMantoux skin test > 10mm in diameter> 10mm in diameter indurationinduration Indicates: Indicates:

LatentLatent TB TB ReadRead

48-72 after 48-72 after Intradermal: 15-degreesIntradermal: 15-degrees Do not rubDo not rub

Diagnostic examsDiagnostic examsPPD PPD Mantoux skin testMantoux skin test > 10mm in diameter> 10mm in diameter indurationinduration Indicates: Indicates:

LatentLatent TB TB ReadRead

48-72 after 48-72 after Intradermal: 15-degreesIntradermal: 15-degrees Do not rubDo not rub

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Confirmation of DiseaseConfirmation of DiseaseConfirmation of DiseaseConfirmation of Disease

Positive reaction does not Positive reaction does not necessarily mean active disease.necessarily mean active disease.May indicate exposure to TBMay indicate exposure to TB

Diagnosis confirmed by: Diagnosis confirmed by: Positive smear for AFB andPositive smear for AFB andSputum culture of Sputum culture of

Mycobacterium tuberculosis Mycobacterium tuberculosis

Positive reaction does not Positive reaction does not necessarily mean active disease.necessarily mean active disease.May indicate exposure to TBMay indicate exposure to TB

Diagnosis confirmed by: Diagnosis confirmed by: Positive smear for AFB andPositive smear for AFB andSputum culture of Sputum culture of

Mycobacterium tuberculosis Mycobacterium tuberculosis

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InterventionsInterventions InterventionsInterventions

Combination drug Combination drug therapytherapyIsoniazidIsoniazidRifampicinRifampicinPyrazinamidePyrazinamideEthambutol or Ethambutol or

streptomycin streptomycin

Combination drug Combination drug therapytherapyIsoniazidIsoniazidRifampicinRifampicinPyrazinamidePyrazinamideEthambutol or Ethambutol or

streptomycin streptomycin

EducationEducationMust follow Must follow

exact drug exact drug regimenregimen

Proper Proper nutritionnutritionReverse weight Reverse weight

loss and lethargy loss and lethargy

About disease About disease

EducationEducationMust follow Must follow

exact drug exact drug regimenregimen

Proper Proper nutritionnutritionReverse weight Reverse weight

loss and lethargy loss and lethargy

About disease About disease

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Tuberculosis TreatmentTuberculosis TreatmentTuberculosis TreatmentTuberculosis Treatment

INHINH Isonicotinyl Hydrazine Isonicotinyl Hydrazine Isoniazid Isoniazid Toxic to the Toxic to the liverliver

RifampicinRifampicin Turns urine redTurns urine red

StreptomycinStreptomycin Causes 8th cranial nerve Causes 8th cranial nerve

damagedamage Acoustic nerveAcoustic nerve

INHINH Isonicotinyl Hydrazine Isonicotinyl Hydrazine Isoniazid Isoniazid Toxic to the Toxic to the liverliver

RifampicinRifampicin Turns urine redTurns urine red

StreptomycinStreptomycin Causes 8th cranial nerve Causes 8th cranial nerve

damagedamage Acoustic nerveAcoustic nerve

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CLASSIFICATIONCLASSIFICATIONCLASSIFICATIONCLASSIFICATION

Class 0—no exposureClass 0—no exposure

Class 1—exposure, no infectionClass 1—exposure, no infection

Class 2—latent infection; no disease (positive Class 2—latent infection; no disease (positive PPD but no evidence of active TBPPD but no evidence of active TB

Class 3—disease; clinically activeClass 3—disease; clinically active

Class 4—disease; not clinically activeClass 4—disease; not clinically active

Class 5—suspected disease; diagnosis Class 5—suspected disease; diagnosis pendingpending

Class 0—no exposureClass 0—no exposure

Class 1—exposure, no infectionClass 1—exposure, no infection

Class 2—latent infection; no disease (positive Class 2—latent infection; no disease (positive PPD but no evidence of active TBPPD but no evidence of active TB

Class 3—disease; clinically activeClass 3—disease; clinically active

Class 4—disease; not clinically activeClass 4—disease; not clinically active

Class 5—suspected disease; diagnosis Class 5—suspected disease; diagnosis pendingpending

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MEDICAL MANAGEMENTMEDICAL MANAGEMENTMEDICAL MANAGEMENTMEDICAL MANAGEMENT

Treated with chemotherapeutic agents for 6-12 Treated with chemotherapeutic agents for 6-12 monthsmonths

Resistance increasing. May be Resistance increasing. May be primary, primary, secondary, secondary, oror multidrug resistant. multidrug resistant.

Primary—Primary—resistance to one of first line drugs in resistance to one of first line drugs in those who have not had prior treatmentthose who have not had prior treatment

Secondary—Secondary—resistance to one or more anti-TB resistance to one or more anti-TB

drugs in patientsdrugs in patients undergoing txundergoing tx

Multidrug resistance—Multidrug resistance—resistance to two agents, resistance to two agents, INH and Rifampicin.INH and Rifampicin.

Treated with chemotherapeutic agents for 6-12 Treated with chemotherapeutic agents for 6-12 monthsmonths

Resistance increasing. May be Resistance increasing. May be primary, primary, secondary, secondary, oror multidrug resistant. multidrug resistant.

Primary—Primary—resistance to one of first line drugs in resistance to one of first line drugs in those who have not had prior treatmentthose who have not had prior treatment

Secondary—Secondary—resistance to one or more anti-TB resistance to one or more anti-TB

drugs in patientsdrugs in patients undergoing txundergoing tx

Multidrug resistance—Multidrug resistance—resistance to two agents, resistance to two agents, INH and Rifampicin.INH and Rifampicin.

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ComplicationsComplications

PleurisyPleurisy

PericarditisPericarditis

MeningitisMeningitis

Bone infectionsBone infections

MalnutritionMalnutrition

Drug-toxicityDrug-toxicity

ComplicationsComplications

PleurisyPleurisy

PericarditisPericarditis

MeningitisMeningitis

Bone infectionsBone infections

MalnutritionMalnutrition

Drug-toxicityDrug-toxicity

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Nursing DxNursing Dx

Impaired gas exchangeImpaired gas exchange


AnxietyAnxiety

Knowledge deficitKnowledge deficit

Alt. nutritionAlt. nutrition

Nursing DxNursing Dx

Impaired gas exchangeImpaired gas exchange


AnxietyAnxiety

Knowledge deficitKnowledge deficit

Alt. nutritionAlt. nutrition

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TuberculosisTuberculosisTuberculosisTuberculosisPreventative measuresPreventative measures

CleanClean well well ventilatedventilated living areas living areas

Resp. isolation Resp. isolation

Vaccine?Vaccine?BCGBCGDoes not prevent TBDoes not prevent TBCauses a + PPDCauses a + PPD

If exposed takeIf exposed takeINHINH

Preventative measuresPreventative measures

CleanClean well well ventilatedventilated living areas living areas

Resp. isolation Resp. isolation

Vaccine?Vaccine?BCGBCGDoes not prevent TBDoes not prevent TBCauses a + PPDCauses a + PPD

If exposed takeIf exposed takeINHINH

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Tuberculosis SummaryTuberculosis SummaryTuberculosis SummaryTuberculosis Summary

Chronic bacterial infection Chronic bacterial infection spread through the airspread through the air

Fever, chills, sweating while sleeping, Fever, chills, sweating while sleeping, persistent cough, coughing up blood persistent cough, coughing up blood or sputumor sputumMulti-drug-resistant tuberculosis Multi-drug-resistant tuberculosis MDR TBMDR TBUse proper PPE and get PPD test if Use proper PPE and get PPD test if exposedexposed

Chronic bacterial infection Chronic bacterial infection spread through the airspread through the air

Fever, chills, sweating while sleeping, Fever, chills, sweating while sleeping, persistent cough, coughing up blood persistent cough, coughing up blood or sputumor sputumMulti-drug-resistant tuberculosis Multi-drug-resistant tuberculosis MDR TBMDR TBUse proper PPE and get PPD test if Use proper PPE and get PPD test if exposedexposed

28/10/2009 1 pneumoniapneumonia dr ibrahim bashayreh, rn, phd

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