Concept - Infection

Exemplars: Influenza, pneumonia, tuberculosis

Directions: To complete this preparation guide use the provided websites and the
pages from your textbooks as directed.
1. Review the presentation “Concept: Infection” on Canvas
2. Read Pearson Concepts – Influenza: 606-612; read articles posted on Canvas
3. Read Pearson Concepts – Pneumonia: 622-636; read article posted on Canvas
4. Read Pearson Concepts –Tuberculosis: 643-655
5. Read Adams, Urban, & Sutter: pages as needed for specified medication
classifications
6. Answer the italicized questions.
Influenza p 606
1. Overview: Influenza (flu) is a contagious respiratory illness caused by influenza viruses.
It can cause mild to severe illness. Serious outcomes of flu infection can result in
hospitalization or death. What is the difference between an epidemic and a pandemic?
 Epidemic: widespread outbreak of an infectious disease
 Pandemic: global outbreak
The flu pandemic of 1918 infected 500 million people around the world and resulted in the
deaths of 50 to 100 million (three to five percent of the world's population), making it one of
the deadliest natural disasters in human history.
https://www.cdc.gov/features/1918-flu-pandemic/index.html
2. How is influenza usually spread?
Human to human via airborne droplets or direct contact

Droplet precautions

3. Which groups of people are at greatest risk of getting influenza?

 Infants, young children
 Age 50 or older
 Residents of nursing homes or other LTCF
 Patients w chronic disorders: diabetes; cardiac, renal, pulmonary diseases
 Pregnant women
 Patients w weakened or compromised immune systems: AIDS; receiving tx for
cancer; taking immunosuppressive meds
 Healthcare providers
 Child care providers

4. How is influenza prevented?

 Preventing community outbreaks
 Protecting vulnerable populations
 Hand washing
 Avoid touching eyes, mouth, nose
 Vaccination
1. What is one contraindication to vaccination with the flu vaccine?

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 Concept - Infection
Exemplars: Influenza, pneumonia, tuberculosis

 Severe allergy to eggs

 Severe hypersensitivity
2. What is a serious but extremely rare complication of influenza
vaccination
 Guillain-Barre syndrome – acute neurologic disorder characterized
by muscle weakness and distal sensory loss

5. What are the clinical manifestations of influenza?

 3 syndomes
o Uncomplicated nasopharyngeal inflammation
o Viral upper respiratory infection followed by bacterial infection
o Viral pneumonia
 Onset is rapid
 Abrupt onset of chills and fever
 Malaise
 Muscle aches
 HA
 Cough, sore throat, substernal burning, coryza (
o cough may be severe, dry and unproductive, or productive
 Fatigue, weakness

6. Pharmacological management:
 Identify the function of the over-the-counter medications taken for flu:
1. Antipyretics (p 725)
Lowers body temperature
Ibuprofen, acetampinophen
2. Antitussives (p 825)
Decrease/suppress cough, promoting rest
3. Expectorants (p 826)
Increase bronchial secretions
4. Decongestants (p 822)
Relieve nasal congestion
 Make drug cards for zanamivir (Relenza) and oseltamivir (Tamiflu). See Adams,
Urban, & Sutter: 982-986
 What are contraindications to receiving these two medications?
1. Zanamivir: pts w existing respiratory dz – may initiate
bronchospasm, children < 7 years
2. Oseltamivir: infants < 12 months

Drug Zanamivir Oseltamivir (Tamiflu)

Action/Use Neuraminidase inhibitor Neuraminidase inhibitor; tx for influenza A
or B; symptoms in pts infected resolve 1.3
days (30%) faster if adminstered
Common Side Effects Nausea, vomiting, diarrhea Nausea, vomiting, diarrhea

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 Concept - Infection
Exemplars: Influenza, pneumonia, tuberculosis

Serious Side Effects Bronochospasm …

Nursing Interventions Administer inhaled, powdered Administer PO suspension or capsule

formulation
…
…
Patient Teaching Must be started within 48 hrs of the Must be started within 48 hrs of the onset
onset of flu symptoms to be effective of flu symptoms to be effective

symptoms in pts infected resolve 1-2 symptoms in pts infected resolve 1.3 days
days faster if administered (30%) faster if administered

those w existing respiratory dz Should not be administered until 2 weeks

should use w caution – may initiate after administration of the live attenuated
bronchospasm influenza vaccine

Should not be administered until 2

weeks after administration of the live
attenuated influenza vaccine

7. What are the non-pharmacological interventions for the treatment of influenza?

 rest to alleviate fatigue and malaise, boost immune system, and prevent the spread
of infection
 Adequate fluid intake to prevent dehydration and reduce cough
o Water, juice, warm tea, soup
o IV fluids
 Hand hygiene
 Proper disposal of of infected waste materials
 Covering nose and mouth when coughing or sneezing
 Complementary health approaches that ease symptoms may be used as long as
they are not contraindicated against any OTC drugs or prescribed meds

8. What are important infection control measures when a patient is diagnosed with
influenza?
 Hand hygiene
 Proper disposal of of infected waste materials
 Covering nose and mouth when coughing or sneezing
 Use standard precautions, and droplet precautions for patients w suspected or
confirmed influenza, and encourage staff to cleanse hands frequently
 Instruct patients/visitors to control respiratory secretions by using tissues and to
maintain a distance of at least 3 ft from others when coughing/sneezing

9. Identify the nursing interventions for each of the nursing diagnoses listed.
 Ineffective airway clearance r/t increased secretion production aeb runny nose,
nonproductive cough, adventitious breath sounds, sputum production : goal –
maintain patent airway

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 Concept - Infection
Exemplars: Influenza, pneumonia, tuberculosis

1. Assist patient to maintain adequate hydration, assess mucous

membranes and skin turgor for evidence of dehydration
2. Increase the humidity of inspired air with a bedside humidifier – helps to
loosen thick secretions and soothe mucous membranes
3. Teach effective cough techniques – the Huff cough (small, low-pressure
coughs) is effective to maintain open airways, and it spares energy
4. Administer analgesics as ordered
5. Assess lung sounds
6. Elevate HOB
7. Assess mucous membranes

 Ineffective thermoregulation r/t viral infection and altered fluid balance aeb fever,
warm & dry skin, tachycardia, tachypnea, dry mucous membranes, changes in
mental status, electrolyte imbalances: goal – achieve and maintain normal body
temperature
1. Encourage adequate hydration
2. Administer analgesics/antipyretics as ordered
3. Encourage rest
4. Replace electrolytes
5. Assess orientation
6. Hygiene – hand, oral, body, preventing infection
7. OTC as recommended/ordered to relieve symptoms
8. Assess temperature
Pneumonia p 622
1. Overview: Pneumonia is a bacterial, viral, or fungal infection of one or both sides of the
lungs that causes the air sacs, or alveoli, of the lungs to fill up with fluid or pus.
(https://www.nhlbi.nih.gov/health/health-topics/topics/pnu)
 Pneumonia is more likely to occur if:
I. Immune system is weak
II. A pathogen is very strong
III. The body fails to filter germs out of the air that is breathed (e.g. d/t stroke,
sedation, narcotics)

2. What are the risk factors for pneumonia?

Modifiable Non-modifiable
*Alcohol intake *Age – infants, young children, older adults
over 65 less than 2
*Cigarette smoking
*Compromised immune system – HIV/AIDS,
*Drug abuse (injections in particular) on medication to prevent rejection of
transplanted organ, receiving tx for cancer
*Vaccination
*Debilitated or weakened condition – chronic
*Managing chronic dz cardiac or respiratory conditions

*Long-term steroid use

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*Exposure from farm animals – inhaling *Bed rest

particles from feces
*NG tube; tracheal intubation

*Altered LOC

3. How is pneumonia prevented? Vaccines include: p 623, 625

 Pneumococcal vaccine – made of antigens from 23 types of pneumococcus, imparts
lifetime immunity w single dose

4. How is pneumonia acquired?

Community-Acquired Pneumonia (CAP): An acute lung infection developing in people
who have not been in a health care setting within 14 days of developing symptoms.

 Atypical Pneumonia - Several types of bacteria - Legionella pneumophila,

mycoplasma pneumonia, and chlamydophila pneumoniae - cause atypical
pneumonia, a type of CAP. Atypical pneumonia is passed from person to person.
This form of pneumonia is ‘atypical’ because the presenation is not the normal
presentation. Pharyngitis or bronchitis occurs w/patchy inflammatory changes on
x-ray; usually seen in the young adult population; symptoms include fever, h/a,
myalgia, arthralgia, cough is dry/hacking/non-productive.

Different types of Healthcare Associated Pneumonia (HCAP)

 Hospital-Acquired Pneumonia/Hospital Associated Pneumonia (HAP):

Nosocomial pneumonia. An infection of the lungs that occurs during a hospital
stay in a non-intubated patient. Begins > 48 of admission.

 Ventilator Acquired Pneumonia/Ventilator Associated Pneumonia (VAP):

Ventilator-associated pneumonia (VAP) is pneumonia that develops > 48 hours
or longer after mechanical ventilation is given by means of an endotracheal tube
or tracheostomy. Ventilator-associated pneumonia (VAP) results from the
invasion of the lower respiratory tract and lung parenchyma by microorganisms.
Intubation compromises the integrity of the oropharynx and trachea and allows
oral and gastric secretions to enter the lower airways.

 Health Care-Associated Pneumonia (HCAP): Pneumonia in non-hospitalized

patients who had significant interaction with the healthcare system

 Aspiration Pneumonia: Aspiration is defined as the inhalation of either

oropharyngeal or gastric contents into the lower airways, that is, the act of taking
foreign material into the lungs. Aspiration pneumonia is caused by bacteria that
normally reside in the oral and nasal pharynx. Historically, aspiration pneumonia
referred to an infection caused by less virulent bacteria, primarily oral pharyngeal
anaerobes. It is now recognized that the many common community-acquired and
hospital-acquired pneumonias result from the aspiration of pathogens from the
oral cavity or nasopharynx. The micro-organisms that commonly cause these
pneumonias, such as Streptococcus pneumoniae, Haemophilus influenza,

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 Concept - Infection
Exemplars: Influenza, pneumonia, tuberculosis

Staphylococcus aureus, and gram-negative bacteria, are relatively virulent so

that only a small inoculum is required to result in a pneumonia.
i. Stroke
ii. NG/G tube
iii. Intoxicated
iv. Unconscious

 Opportunistic Pneumonia: Individuals at risk are “susceptible hosts”. Those

with immunodeficiency disorders, malnutrition, etc.

5. What are the clinical manifestations of pneumonia?

Local – cough, excess mucous production, SOB/dyspnea, hypoxia  apnea due to
respiratory collapse, hemoptysis (bloody sputum), chest pain

Systemic – fever, diminished appetite, malaise, cyanosis, other manifestations of impaired

gas exchange

6. For the following tests used to diagnose pneumonia, what results are indicative of
pneumonia?

Test Results
Chest X-ray fluid, infiltrates, consolidated lung tissue, and
atelectasis (areas of alveolar collapse) appear as
densities on the film
Sputum for culture and Infecting organism
sensitivity Appropriate antibiotic therapy
CBC Elevated WBC (> or = 10,000/mm3), increased
circulating immature leukocytes

7. Nursing Process
 What should the nurse ask the client during the health history?
i. Describe the current symptoms, their duration, and assess for chest pain
ii. Recent upper respiratory or other acute illnesses, and chronic diseases
such as diabetes, chronic lung dz, heart dz
iii. Current list of all meds and med allergies
iv. Immunization status
v. Smoking hx

 What should be included in the focused assessment?

i. Presence of SOB
ii. presence and nature of cough
iii. color and consistency of sputum
iv. observe skin color and use of accessory muscles while breathing
v. assess for presence of chest pain
vi. examine pt’s current presentation and any apparent distress
vii. LOC, vital signs, temp
viii. Lung sounds, ox sat

 Identify 3 priority nursing interventions for each of the following nursing

diagnoses:

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 Concept - Infection
Exemplars: Influenza, pneumonia, tuberculosis

i. Impaired gas exchange r/t increased mucous and poor ventilatory effort
1. High fowler position
2. Assist pt to cough, deep-breathe, and use assistive devices
3. Encourage fluid intake

ii. Risk for fluid volume deficit r/t increased work of breathing
1. Teach slow abdominal breathing
2. Administer oxygen as orders
3. Provide for rest periods to be able to encourage fluid intake
4. IV fluids as ordered

iii. Activity intolerance r/t hypoxemia

1. Administer oxygen as ordered, teach breathing techniques
2. Schedule activities, planning for rest periods
3. Assist w self-care activities
8. What should be included in discharge teaching?
a. Adequate sleep and rest – take meds as ordered/recommendes to relieve
symptoms during sleep for a better rest pd
b. Maintain adequate fluid and caloric intake
c. Demonstate strong cough sufficient to clear airway
d. Limit activities, schedule activities and rest pds
e. Importance of avoiding smoking or exposure to smoke
f. Manifestations to report to HCP – increasing SOB, dyspnea, increased fever,
fatigue, HA, sleepiness, or confusion
g. Importance of keeping all follow-up appointments
h. High fowler position
i. Cough and breathing techniques – slow abdominal breathing
j. Hygiene
k. Teach pt how to splint chest – hugging small pillow or teddy bear to make
coughing less painful
l. Relaxation techniques – visualization and meditation
m. Use assistive devices
n. How to minimize stress and anxiety

Tuberculosis
1. What is tuberculosis?
A chronic, recurrent, infectious dz caused by Mycobacterium tuberculosis,
Differences between latent TB infection and active TB disease

Latent TB infection (LTB) Active TB Disease

No symptoms Has symptoms
Does not feel sick Usually feels sick
Cannot spread TB to others Can spread TB to others
Usually diagnosed w/ skin or blood test Skin or blood test indicate infection
Chest x-ray normal or may show Positive CXR (TB bacilli no longer
tubercules (encased TB bacilli); negative encased in tubercules) &/or sputum
sputum smear smear

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 Concept - Infection
Exemplars: Influenza, pneumonia, tuberculosis

Treatment recommended to prevent Need treatment to treat disease

disease

2. How is tuberculosis transmitted?

Airbone; coughing, sneezing, talking
3. What are the risk factors for tuberculosis?
 Immigrants
 HIV/AIDS
 Disadvantaged populations
 Racial and ethinic minorities
 Foreign-born individuals
 Altered immune system
 Poor urban areas
o Injection drug use
o Homelessness
o Malnutrition
o Poor living conditions
 Overcrowded institutions

4. How is tuberculosis diagnosed? Describe the PPD test.

a. Intradermal purified protein derivative test (PPD-Mantoux test)
How is this test measured? What teaching does the nurse provide to the patient
when placing the PPD?

 Patient must return within 48-72 hrs after intradermal injection

 Read and recorded as the diameter of induration – raised area, not
erythema – in millimeters

b. Sputum for acid fast bacilli and M. tuberculosis culture – The presence of
acid-fast-bacilli (AFB) on a sputum smear or other specimen often indicates TB
disease. Acid-fast microscopy is easy and quick, but it does not confirm a
diagnosis of TB because some acid-fast-bacilli are not M. tuberculosis.
Therefore, a culture is done on all initial samples to confirm the diagnosis.
(However, a positive culture is not always necessary to begin or continue

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 Concept - Infection
Exemplars: Influenza, pneumonia, tuberculosis

treatment for TB.) A positive culture for M. tuberculosis confirms the diagnosis of
TB disease. Culture examinations should be completed on all specimens,
regardless of AFB smear results. M. tuberculosis culture takes 2-8 weeks.

c. How do you obtain a sputum culture?

 Collect in morning
 Pt rinses mouth
 Encourage deep breaths
 Produce productive cough and sputum goes into specimen cup
 Send to lab
*sputum needs to come from the lung – purpose of deep breaths

5. Who should be screened for TB?

 People w or at high risk for HIV infection
 Close contacts of ppl who have or are suspected of having infectious TB
 Ppl w medical risk factors – silicosis, chronic malabsorption, end-stage renal
failure, DM, immunosuppression, and hematologic and other malignancies
 Ppl born in countries w a high prevalence of TB
 Medically underserved, low-income populations, including racial and ethnic
minorities and the homeless
 Individuals w alcoholism and injection drug users
 Residents and staff of long term residential facilities – LTCF, correctional
institutions, and mental health facilities

6. Interpreting the PPD. If the client works with refugees from a severely economically
deprived country and their PPD is 7 mm, is that considered a positive PPD? No

7. What are the clinical manifestations of tuberculosis?

 Fatigue
 Weight loss
 Diminished appetite
 Low-grade afternoon fever

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 Concept - Infection
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 Night sweats
 Dry cough  productive, purulent and/or blood tinged (hemoptysis)
 SOB, chest pain
 Hypoxia
 Cyanosis
 Subq emphysema

*Elderly individuals with TB may not display typical signs and symptoms. Systemic infection
may have additional clinical manifestations.

8. Prophylaxis
a. Who should receive prophylaxis?
 Pts w a recent skin test conversion from negative to positive
 Ppl in close household contact w an individual whose sputum is positive
for bacilli
 HIV pts

b. What medication will they receive and how long will they take it?
Isoniazid, 300 mg/day for 6-12 months

9. What precautions are needed when a client is hospitalized and has tuberculosis, and
what personal protective equipment is necessary?
Airborne precautions; gown, N95 mask, goggles, gloves
10. Make a medication card for each of the first line medications used to treat
tuberculosis:
 Isoniazid (INH)
 Rifampin (RIF)
 Ethambutol (EMB)
 Pyrazinamide (PZA)

Drug/Class Mechanisms of Side Effects Nursing Considerations

Action
Rifampin Stimulates *red-orange body *administer on empty stomach
(RIF) microsomal enzymes fluids
of liver, increasing *monitor CBC, liver function, and renal function for
rate of metabolism of *fever, flulike evidence of toxicity
drugs and decreasing symptoms,
their effectiveness excessive fatigue, *reduces the effect of birth control, quinidine,
sore throat, corticosteroids, warfarin, methadone, digoxin, and
unusual bleeding hypoglycemics

*can cause Pt. Education:

hepatitis, drug *causes body fluids (sweat, urine, saliva, and tears) to turn
ineractions red-orange – not harmful. Avoid wearing soft contact
lenses, may be permanently stained.

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*do not miss or skip doses; flulike symptoms and fever

occur when drug is resumed

*aspirin may interfere w rifampin absorption and should

not be taken concurrently
Isoniazid TB prophylaxis Peripheral *Administer on empty stomach 1 hr before or 2 hrs after
(INH) neuropathy, meals for maximal effect if tolerated; may be given w
Tx of active dz hypersensitivity meals to reduce GI effects
rxns, anemia,
Effective against bruising, bleeding, *administer pyridoxine (Vitamin B6) concurrently
intracellular and infection r/t
extracellular agranulocytosis *isoniazid interferes w metabolism of diazepam,
organisms phenytoin, and carbamazepine. Doses of these drugs may
Diminished need to be reduced to prevent toxicity
appetite, nausea,
jaundice, allergic Pt. Education
rxn) *take med as prescribed for entire tx pd to prevent
incomplete eradication of the bacteria and development of
resistant strains

*take pyridoxine as prescribed to prevent peripheral

neuropathy

*avoid alcohol and other agents that may be harmful to the

liver

*use measures to prevent pregnancy while taking; drug

may be harmful to developing fetus
Pyrazinamide Typically given w Hyperuricemia, *administer w meals to reduce GI effects
(PZA) isoniazid and gout (painful, hot,
rifampin for first 2 red, swollen joint – *monitor liver fxn studies and serum uric acid levels, notify
months of TB tx rare), loss of HCP of any changes
appetite, nausea,
Concurrent use w vomiting, jaundice Pt. Education
pyrazinamide allows *Avoid using alcohol or other substances that may be
a shorter course of harmful to the liver
therapy

Toxic to liver
Ethambutol Bacteriostatic drug Optic neuritis *record baseline visual examination before therapy.
(EMB) that reduces the (decreased visual Schedule periodic eye exams during course of tx
development of acuity, loss of red-
resistance to the green *administer w meals to reduce GI effects
bactericidal first-line discrimination)
agents *monitor liver and renal fxn studies and neurologic status
Safe for use in while taking. Notify HCP of abnormal findings or significant
Added to intial tx pregnancy changes
regimen or
substituted for Pt. Education

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 Concept - Infection
Exemplars: Influenza, pneumonia, tuberculosis

isoniazid when *monitor vision daily by reading newspapers and looking

isoniazid-resistant at the same blue object (using corrective lenses if
strain of TB is appropriate). Notify HCP of changes in vision or color
suspected perception

11. How are these medications used in the management of tuberculosis?

 Isoniazid – prophylaxis
 These primary anti-TB drugs prevent development of resistance
 Newly dx TB typically treated w intial regimen of all 4 for the first 2 months

12. What is directly observed therapy? DOT

Healthcare provider is making sure the pt is taking their meds
Yields higher cure rate if pt is taking consistently
Less likely to develop resistant organism

Compliance
 3 days/week instead of everyday
 Encourage constantly to take meds – emphasize importance
 Availability
 Providing incentives/rewards
 Combination meds in certain countries

13. Identify three (3) nursing interventions for the following nursing diagnoses:

 Risk for ineffective management of therapeutic regimen

o Assess pt’s self-care abilities and support system – evaluate ability to follow
the prescribed regimen
o Assess pt’s knowledge and understanding of the dz, its complications, tx, and
risks to others
o Work collaboratively to identify barriers or obstacles to managing the
prescribed tx
o Assist pt to develop a plan for managing the prescribed regimen
o Provide verbal and written instructions that are cleR ns ppropriate for the pt’s
level of literacy, knowledge, and understanding
o Provide active intervention for homeless ppl, including shelter placement or
other housing and ongoing follow-up by easily accessed healthcare providers
and public health workers that do not present transportation or access
problems
o Refer pts who are unlikely to comply w tx to the public health department for
management and follow-up
 Knowledge deficit re: strategies to prevent transmission of infection
o Assess pt’s knowledge about dz process, and identify misperceptions and
emotional rxns
o Assess pt’s ability and interest in learning, developmental level, and
obstacles to learning – allows tailoring of the presentation of info to the
learning needs and style of the pt
o Identify pt’s support systems, include significant others
o Establish a relationship of mutual trust w pt and significant others
o Develop mutually acceptable learning goals w the pt and significant other

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 Concept - Infection
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o Select appropriate teaching strategies, using learning aids

o Document your teaching and level of pt’s understanding

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