Chapter 33
Care of Patients
with Infectious
Respiratory
Problems
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Chapter 33 Care of Patients with Infectious
Respiratory Problems Learning Outcomes
1. Explain the pathophysiology of communicable respiratory
diseases and the airborne and droplet modes of organism
transmission.
2. Apply principles of infection control (e.g., hand hygiene,
Isolation Precautions, Airborne Precautions) when providing care
to patients with respiratory infections.
3. Use the “ventilator bundle” interventions to prevent
ventilator-associated pneumonia.
4. Prepare to participate in disease-containment activities in the
event of an outbreak of pandemic influenza.
5. Provide information to everyone about immunization against
influenza and pneumonia.
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Chapter 33 Care of Patients with Infectious Respiratory
Problems Learning Outcomes (Continued)
6. Teach everyone the use of specific infection control
techniques, especially hand hygiene and Centers for Disease
Control and Prevention (CDC) cough/sneeze etiquette, to avoid
acquiring and spreading respiratory infections.
7. Recognize manifestations of infectious respiratory diseases.
8. Provide information to the patient and family about side
effects of anti-tuberculosis (TB) therapy and when to notify the
health care provider.
9. Assess the TB test results for a person with normal immune
function and a person with compromised immune function.
10. Describe patients with Infectious Respiratory Problems and
the related nursing interventions and rationales.
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Chapter 33 Care of Patients with Infectious
Respiratory Problems
Disorders of the nose and sinuses
Rhinitis
Sinusitis
Disorders of the oral pharynx and tonsils
Pharyngitis
Tonsillitis
Peritonsillar abscess
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Chapter 33 Care of Patients with Infectious
Respiratory Problems (Continued)
Disorders of the larynx and lungs
Laryngitis
Seasonal influenza
Pandemic influenza
*Pneumonia*
Severe Acute Respiratory Syndrome (SARS)
Pulmonary tuberculosis
Lung abscess
Inhalation anthrax
Pulmonary empyema
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Rhinitis
• Inflammation of nasal mucosa
• “Hay fever” or “allergies”
• Manifestations:
– Headache
– Nasal irritation
– Sneezing
– Nasal congestion
– Rhinorrhea
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Rhinitis (cont’d)
• Interventions:
– Drug therapy—antihistamines, leukotriene
inhibitors, mast cell stabilizers, decongestants,
antipyretics, antibiotics
– Complementary and alternative therapy—
vitamin C, zinc
– Supportive therapy
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Rhinitis (cont’d)
• Interventions (continued):
– Supportive therapy
»
»
»
»
»
»
»
Comfort
Prevent spread of infection
Adequate Sleep
Adequate Hydration
Humidify air
Hand washing
Avoid close contact with others
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Sinusitis
• Inflammation of sinus mucous membranes
• Usually caused by Streptococcus pneumoniae,
Haemophilus influenzae, Diplococcus, Bacteroides
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Sinusitis (cont’d)
• Nonsurgical management:
– Broad-spectrum antibiotics
– Analgesics (pain and fever)
– Decongestants
– Steam humidification
– Hot/wet packs over sinus area
– Nasal saline irrigations
– Increased fluids
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Surgical Management
• Functional endoscopic sinus surgery (FESS)
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Pharyngitis
• Sore throat is a common inflammation of
pharyngeal mucous membranes
• Odynophagia, dysphagia, fever
• Self-care
• Epiglottitis
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Tonsillitis
• Inflammation/infection of tonsils and
lymphatic tissues
• Contagious airborne infection, usually
bacterial
• Antibiotics for 7 to 10 days
• Self care same as for pharyngitis
• Surgical intervention
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Peritonsillar Abscess (PTA)
• Complication of acute tonsillitis
• Manifestations:
– Pus causing one-sided swelling with deviation
of the uvula
– Trismus and difficulty breathing
– Bad breath, swollen lymph nodes
• Treatment:
– Percutaneous needle aspiration of abscess
– Antibiotics
– Other
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Peritonsillar Abscess (cont’d)
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Laryngitis
• Inflammation of mucous membranes lining
the larynx; possible edema of vocal cords
• Acute hoarseness, dry cough, difficulty
swallowing, temporary voice loss (aphonia)
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Laryngitis (cont’d)
• Treatment focused on relief and
prevention—voice rest, steam inhalation,
increased fluid intake, throat lozenges
• Reduce exposure of tobacco and alcohol
and pollutants which can irritate the larynx.
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Seasonal Influenza
• Highly contagious acute viral respiratory
infection
• Severe headache, muscle ache, fever, chills,
fatigue, weakness,
• Vaccination is advisable
• Contaminated surfaces
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Pandemic Influenza
• Mostly prevalent among animals and birds;
virus can mutate becoming infectious to
humans
• Example: H1N1 (swine flu)
• Strict isolation precautions
• Antiviral drugs
– oseltamivir (Tamiflu), zanamivir (Relenza)
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Pneumonia
• Excess fluid in lungs resulting from
inflammatory process
• Inflammation triggered by infectious
organisms, inhalation of irritants
• Community-acquired infectious pneumonia
• Nosocomial or hospital-acquired
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Pneumonia (cont’d)
• Pneumoccocal Polysaccharide Vaccine
(PPV23)
– Who should get it?
– How often?
• Preventing Pneumonia
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Pneumonia (cont’d)
• Clinical manifestations
• Psychosocial assessment
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Ventilator-Associated Pneumonia (VAP)
• Incidence increasing, especially with ET
tubes in place for mechanical ventilation
• “Ventilator bundles” reduce incidence
– Hand hygiene
– Oral care
– Head of bed elevation
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Laboratory Assessment
• Gram stain, culture and sensitivity of
sputum
• CBC
• ABGs
• Serum BUN
• Electrolytes
• Blood culture
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Imaging & Diagnostic Assessment
•
•
•
•
•
Chest x-ray
Pulse oximetry
Transtracheal aspiration
Bronchoscopy
Direct needle aspiration of the
lung
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Pneumonia: Community-Based Care
• Home care management
• Teaching for self-management
• Health care resources
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Severe Acute Respiratory Syndrome
(SARS)
• From “coronaviruses” family
• Virus infection of respiratory tract cells,
triggering inflammatory response
• No known effective treatment
• Strict airborne isolation and contact
isolation
• Handwashing
• Spread by airborne droplets
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Pulmonary Tuberculosis
• Highly communicable; caused by
Mycobacterium tuberculosis
• Transmitted via aerosolization
• Secondary TB –reactivation of the disease
in a previously infected person
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Clinical Manifestations
•
•
•
•
•
•
•
•
Progressive fatigue
Lethargy
Nausea
Anorexia
Weight loss
Irregular menses
Low-grade fever, night sweats
Cough, mucopurulent sputum, blood
streaks
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Diagnostic Assessment
• Manifestation of signs/symptoms
• NAAT (results in 2 hr) -Nucleic acid
amplification tests
• Sputum smear for acid-fast bacillus
• Sputum culture of M. tuberculosis
• Tuberculin (Mantoux) test—PPD
Induration of 10 mm or greater
diameter 48-72 hours after injection=
positive for exposure
• Quantiferon-TB Gold
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Diagnostic Assessment (cont’d)
• Induration with PPD - Positive reaction does
not mean that active disease is present, but
does indicate exposure to TB or dormant
disease.
• BCG vaccine – bacillus Calmette-Guerin
vaccine given in other countries can
produce a false positive result
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PPD Skin Test
Positive tuberculin skin test with
induration.
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Interventions
• Combination drug therapy with strict
adherence (usually 6 months):
– Isoniazid
– Rifampin
– Pyrazinamide
– Ethambutol
• Negative sputum culture = no longer
infectious
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TB: Community-Based Care
• Home care management
• Teaching for self-management
• Health care resources
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Lung Abscess
• Localized area of lung destruction
• Caused by liquefaction necrosis, usually
related to pyogenic bacteria
• Pleuritic chest pain
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Lung Abscess
• Interventions:
– Antibiotics
– Drainage of abscess
– Frequent mouth care for Candida albicans
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Inhalation Anthrax
• Bacterial infection caused by Bacillus
anthracis from contaminated soil
• Fatality rate 100% if untreated
• Destroys lung cells and WBCs
• Drug therapy: ciprofloxacin, doxycycline,
amoxicillin
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Pulmonary Empyema
• Collection of pus in pleural space
• Most common cause—pulmonary
infection, lung abscess, infected pleural
effusion
• S+S
• Interventions:
– Empty empyema cavity
– Re-expand lung
– Control infection
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Pulmonary Empyema (cont’d)
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An 83-year-old retired teacher was brought to the ED by her
daughter. She reports a productive cough with fever for the
last 48 hours. She appears flushed and very short of breath
when answering questions. She has a history of type 2
diabetes mellitus and hypertension, but no known allergies.
A chest x-ray, CBC, and basic metabolic panel (electrolytes,
BUN, creatinine) are drawn in the ED. A saline lock is inserted
into her right forearm. She is admitted to the med-surg unit
with a diagnosis of suspected pneumonia.
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(cont’d)
You assess the patient’s blood glucose level and vital signs upon arrival
on the unit. Results are as follows:
BG – 239 mg/dL
BP – 138/88 mm Hg
HR – 128
RR – 36 breaths/min
O2 saturation – 88% (room air) Temp – 101.6° F
Which vital sign or test result takes priority when consulting the health
care provider?
A. Blood pressure
B. Respiratory rate
C. Temperature
D. Blood glucose
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• ANS: B
• All of the patient’s vital signs are abnormal.
However, the most important one to report
immediately is her increased respirations (and
decreased oxygen saturation). Even though a
diagnosis has not been confirmed, it is very
important to address these problems. The
patient is experiencing tachypnea.
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(cont’d)
After consulting with the provider, you receive the following orders:
– Full liquid diabetic diet
– IV fluids 1000 mL .9 NS at 60 mL/hr
– Oxygen at 2 L per nasal cannula
– Blood cultures x 3 and urinalysis
– Tylenol grain x every 4 hr for temp above 101° F
– Cefazolin (Ancef) 1 g IVP every 8 hr
Which of the provider’s orders should be implemented first?
A. IV fluids 1000 mL .9 NS at 60 mL/hr
B. Oxygen at 2 L per nasal cannula
C. Blood cultures and urinalysis
D. Cefazolin (Ancef) 1 g IVP every 8 hr
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• ANS: B
• All of the provider’s orders are very important.
However, the most important one is oxygen
therapy. Hypoxia is often seen with pneumonia,
so it is very important that supplemental oxygen
is started as soon as possible. IV fluids should be
started to enhance pulmonary toileting, and the
laboratory should be notified to draw the needed
blood cultures. UAP can obtain the specimen for
urinalysis. The blood cultures and the UA should
be obtained before the IVP Ancef is administered.
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(cont’d)
Two hours later, the patient has a weak
cough, crackles in both lower lobes, and an
SaO2 reading of 90% by pulse oximetry.
What interventions should be implemented
at this time?
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• The patient has developed problems with her
airway. Interventions should include helping
her to cough and deep breathe at least every
2 hours; teaching incentive spirometry every
hour while awake; encouraging the patient to
consume 3 L of fluid per day; monitoring
intake and output; and administering
bronchodilators if ordered.
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(cont’d)
The next morning, the patient’s daughter asks you if her
mother can take the antibiotics by mouth now that she is
beginning to feel better. What is your best response?
“Your mother will probably be switched to oral therapy
in 2 or 3 days.”
B. “The IV antibiotics are much stronger than pills.”
C. “We will be able to switch to pills as soon as your mother
is eating solid foods.”
D. “I will call your mother’s health care provider and ask
about the change.”
A.
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• ANS: A
• If IV drugs are used, the patient may be able
to be switched to oral therapy in 2 to 3 days
depending on the patient’s response to the
drug (e.g., the patient is stable and afebrile).
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Question 1
Which is the most common manifestation of
pneumonia in the older adult patient?
A. Fever
B. Cough
C. Weakness
D. Confusion
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• Answer: D
• Rationale: The older adult with pneumonia
often has weakness, fatigue, lethargy,
confusion, and poor appetite. Fever and cough
may be absent, but hypoxemia is usually
present. The most common manifestation of
pneumonia in the older adult patient is
confusion from hypoxia rather than fever or
cough.
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Question 2
A patient is admitted with cough, fever, sore
throat, progressive shortness of breath,
diarrhea, and vomiting. The patient states she
recently returned from a business trip overseas.
What does the nurse suspect the patient may
have?
A.
B.
C.
D.
Pneumonia
Avian influenza
Viral influenza
Tuberculosis exposure
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• Answer: B
• Rationale: The initial manifestations of avian
influenza are similar to other respiratory
infections but include cough, fever, sore throat,
shortness of breath, pneumonia, diarrhea,
vomiting, abdominal pain, and bleeding from the
nose and gums. Assess whether the patient has
recently (within the past 10 days) traveled to
areas of the world affected by H5N1. Pneumonia
and tuberculosis exposure will not present with
gastrointestinal symptoms.
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Question 3
A patient is experiencing fever, chills, night
sweats, and weight loss. In addition, the
patient’s point of maximal impulse (PMI) is
noted to be displaced when cardiac palpation is
performed, and the patient is hypotensive. What
are these symptoms indicative of?
A.
B.
C.
D.
Pneumonia
Tuberculosis
Influenza
Pulmonary empyema
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• Answer: D
• Rationale: Patients with pneumonia,
tuberculosis, and influenza may experience
some or all of the symptoms of fever, chills,
night sweats, and weight loss. However,
because pulmonary empyema is a collection
of pus in the pleural space that may cause
compromised cardiac function, displaced PMI
and hypotension may result.
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