RESPIRATORY INFECTIONS
This term describes inflammation of the lung tissue, often caused by bacteria, viruses, or fungi.
What is pneumonia?
A tracheostomy is a surgical opening into this structure, below the level of the vocal cords.
What is the trachea?
Albuterol (Proventil, Ventolin) is this class of medication, often called a “rescue inhaler” for acute bronchospasm.
What is a beta2-adrenergic agonist?
(or short-acting bronchodilator, or SABA—short-acting beta agonist)
Normal arterial blood pH is this range. Values below indicate acidosis; values above indicate alkalosis.
What is 7.35-7.45?
<7.35 = acidosis
>7.45 = alkalosis
The type of isolation required for patients with active tuberculosis, which requires a negative pressure room and this specific type of mask.
What is airborne precautions (or airborne isolation)?
Requires N95 respirator (or PAPR: powered air-purifying respirator).
The most common bacterial cause of community-acquired pneumonia is this organism, often seen in patients who have had influenza.
What is Streptococcus pneumoniae (or pneumococcus)?
The inner cannula of a tracheostomy tube should be cleaned at least this often to prevent mucus buildup and airway obstruction.
What is every 8 hours?
(or per facility protocol; accept: 2-3 times daily, or more frequently if needed)
This common side effect of albuterol causes patients to feel jittery or experience increased heart rate due to beta-receptor stimulation.
What is tremor (or tachycardia, nervousness, palpitations)?
This ABG component measures the partial pressure of carbon dioxide in arterial blood. Normal range is 35-45 mmHg. This represents the RESPIRATORY component of acid-base balance.
What is PaCO₂?
(partial pressure of carbon dioxide)
A patient with suspected or confirmed active TB should be placed in this type of room, which prevents contaminated air from escaping into the hallway.
What is a negative pressure room (or airborne infection isolation room)?
Characteristics: Air flows INTO room (not out). Minimum 6-12 air changes per hour. Air exhausted directly outside or through HEPA filters. Door must remain closed
Unlike typical pneumonia, tuberculosis is caused by this acid-fast bacillus and primarily affects this part of the respiratory system.
What is Mycobacterium tuberculosis?
It primarily affects the lungs (upper lobes specifically). (Accept: pulmonary system)
When suctioning a tracheostomy, suction should be applied for no longer than this many seconds.
What is "maximum 10-15 seconds per suction pass ?"
(to prevent hypoxia)
When a patient uses BOTH a bronchodilator inhaler (albuterol) and a corticosteroid inhaler (beclomethasone/QVAR), they should use this one FIRST and wait 5 minutes before using the other.
Explain why.
Bronchodilator (albuterol) first
RATIONALE: Bronchodilator opens airways → allows corticosteroid to penetrate deeper into lungs → maximizes anti-inflammatory effect
- More effective medication delivery. Standard teaching: “Open the door (bronchodilator) before delivering the package (steroid)”
ADDITIONAL TEACHING: Wait 1-5 minutes between inhalers. Rinse mouth after corticosteroid (prevents oral thrush/candidiasis)
ABG interpretation:
pH 7.30, PaCO₂ 50, HCO₃⁻ 24
What is Respiratory Acidosis (Uncompensated)?
Analysis: pH 7.30 = ACIDOSIS (low, <7.35); PaCO₂ 50 = HIGH (normal 35-45); HCO₃⁻ 24 = NORMAL (normal 22-26)
Why uncompensated? HCO₃⁻ is still normal (kidneys haven’t compensated yet). Takes 24-48 hours for metabolic compensation
Clinical correlation: Seen in hypoventilation, COPD exacerbation, respiratory depression
The acronym RIPE represents the first-line anti-TB medication regimen. Name what each letter stands for and the typical treatment duration for drug-susceptible TB.
RIPE: R = Rifampin (RIF); I = Isoniazid (INH); P = Pyrazinamide (PZA); E = Ethambutol (EMB)
Treatment Duration: Intensive Phase: ALL 4 drugs (RIPE) for 2 months; Continuation Phase: 2 drugs (Rifampin + Isoniazid) for 4 months; Total: 6 months minimum for drug-susceptible pulmonary TB
Critical Teaching: Must complete entire course (even when feeling better)!!! Stopping early → drug resistance → need for longer, more toxic drugs. Directly Observed Therapy (DOT) improves compliance
CLINICAL COMPARISON: Create a table comparing pneumonia and tuberculosis. Include: transmission method, onset of symptoms, primary symptoms (list 3 for each), and contagious period.
Pneumonia
Transmission: Droplet (bacterial/viral); aspiration
Onset: Acute (sudden, hours to days)
Symptoms: 1. Productive cough with colored sputum 2. Fever, chills 3. Pleuritic chest pain 4. Dyspnea 5. Crackles on auscultation
Contagious Period: 24-48 hours after antibiotics started
Tuberculosis
Transmission: Airborne (requires N95 mask)
Onset: Insidious (gradual, weeks to months)
Symptoms: 1. Persistent cough (>3 weeks)2. Night sweats3. Weight loss4. Hemoptysis5. Low-grade fever
Contagious Period: Until 2-3 weeks of anti-TB therapy AND negative sputum cultures
EMERGENCY SCENARIO: You enter your patient’s room and find the tracheostomy tube has been completely dislodged. The patient is in respiratory distress. Using clinical judgment, list your actions in PRIORITY ORDER (Name 3). Explain the rationale for your FIRST action.
Priority Actions in Order:
CALL FOR HELP immediately (pull code/emergency button, yell for assistance)
Hyperextend the patient’s neck (opens airway, straightens tracheal path)
Attempt to reinsert same size or one size smaller trach tube (if trained and tube available)
If UNABLE to reinsert OR not trained:
Cover stoma with gloved hand and attempt ventilation through mouth/nose (forces air through upper airway)
OR use occlusive dressing over stoma and bag-valve-mask over mouth/nose
Prepare for emergency intubation (have emergency equipment ready)
Administer oxygen (high-flow via face mask if upper airway route used)
Monitor oxygen saturation and vital signs continuously
Notify provider STAT/activate rapid response
RATIONALE for First Action (Call for Help): Trach dislodgement is a life-threatening emergency requiring multiple personnel. Need someone to call provider/RT while you manage airway. May need crash cart/emergency intubation equipment. Time is critical. Do not delay for help
MEDICATION MATCHING CHALLENGE: Review the following medications and identify which would be used for ACUTE asthma exacerbation vs. CHRONIC long-term control.
Medications:
1. Albuterol (Proventil)
2. Ipratropium (Atrovent)
3. Theophylline (Theo-24)
4. Beclomethasone (QVAR)
5. Cromolyn
6. Guaifenesin (Mucinex)
7. Acetylcysteine (Acetadote)
8. Codeine
ACUTE ASTHMA EXACERBATION (Rescue/Immediate Relief):
1. Albuterol: first-line rescue bronchodilator
2. Ipratropium: often combined with albuterol for severe exacerbations
LONG-TERM CONTROL (Preventive/Maintenance):
1. Beclomethasone: inhaled corticosteroid (controller)
2. Cromolyn: prevents mast cell degranulation (preventive)
3. Theophylline: sometimes used for maintenance (less common now)
ABG CASE ANALYSIS: Your patient with severe pneumonia has the following
ABG: pH: 7.48; PaCO₂: 32 mmHg; HCO₃⁻: 24 mEq/L; PaO₂: 76 mmHg; SaO₂: 92%
Interpret the acid-base status.
Explain the pathophysiology causing this ABG pattern.
INTERPRETATION: Respiratory Alkalosis (Uncompensated) with Mild Hypoxemia
Cause: Hyperventilation (rapid, deep breathing)
Pneumonia → impaired gas exchange → hypoxemia (low PaO₂ 76) - Body compensates by increasing respiratory rate (blowing off more CO₂) - Tachypnea eliminates excess CO₂ → low PaCO₂ (32) - Low CO₂ → pH rises → alkalosis
MEDICATION MANAGEMENT: For each first-line TB drug, identify ONE major side effect the nurse must monitor for:
- Rifampin (RIF)
- Isoniazid (INH)
- Pyrazinamide (PZA)
- Ethambutol (EMB)
Rifampin (RIF): Hepatotoxicity, Orange discoloration of body fluids
Isoniazid (INH): Hepatotoxicity, Peripheral neuropathy
Pyrazinamide (PZA): Hepatotoxicity, Hyperuricemia (elevated uric acid)
Ethambutol (EMB): Optic neuritis (vision changes)
PATHOPHYSIOLOGY: Explain the difference between latent TB infection (LTBI) and active TB disease.
Include: infectiousness, chest X-ray findings, symptoms, treatment necessity, and why this distinction matters for public health.
LATENT TB INFECTION (LTBI): - Infectiousness: NOT contagious (cannot spread to others) - Chest X-ray: Normal (no visible disease) - Symptoms: None (asymptomatic) - TB skin test/IGRA: Positive (indicates exposure/infection) - Sputum test: Negative (no live bacteria in lungs) - Treatment: May be treated (shorter course, 3-4 months) to prevent progression to active disease - Status: Bacteria dormant, contained by immune system
ACTIVE TB DISEASE: - Infectiousness: YES—highly contagious via airborne transmission - Chest X-ray: Abnormal (infiltrates, cavitations, usually upper lobes) - Symptoms: Present (cough, hemoptysis, night sweats, weight loss, fever) - TB skin test/IGRA: Positive - Sputum test: Positive (live bacteria present) - Treatment: MUST be treated (6-9 months, multiple drugs) - Status: Bacteria actively multiplying and destroying lung tissue
PUBLIC HEALTH SIGNIFICANCE: - 5-10% of people with LTBI progress to active disease (higher if immunocompromised) - Treating LTBI prevents active disease and breaks transmission chain - Contact tracing focuses on active cases - Active TB is reportable disease; public health follows contacts - Directly Observed Therapy (DOT) ensures treatment completion for active TB
Your patient has a new tracheostomy (post-op day 3). Develop a comprehensive nursing care plan addressing:
1. THREE priority assessments (with frequency)
2. THREE interventions to prevent complications
3. TWO patient/family education priorities
4. ONE equipment must-have at bedside
PRIORITY ASSESSMENTS:
- Respiratory Status Assessment (Q 1-2 hours initially, then Q 4 hours)
- Trach Site Assessment (Q shift and PRN)
- Tube Security and Patency Assessment (Q 2-4 hours)
INTERVENTIONS TO PREVENT COMPLICATIONS:
- Maintain Humidification
- Provide Meticulous Trach Care
- Prevent Infection
PATIENT/FAMILY EDUCATION PRIORITIES:
- Communication Methods (Cannot speak with cuffed trach; Use communication board, writing, gestures; Call bell within reach at all times; Reassure that speech may return with speaking valve (when appropriate))
- What to Report Immediately (Difficulty breathing; Excessive bleeding; Tube feels loose or out of place; Fever, increased secretions, color change; Cannot cough up secretions)
EQUIPMENT AT BEDSIDE (Must-Haves): - Emergency equipment kit containing: - Spare trach tube (same size) - Spare trach tube (one size smaller) - Obturator (for reinsertion) - Suction equipment (connected and functional) - Manual resuscitation bag with trach adapter - Gloves, sterile water/saline
MEDICATION TEACHING: Your patient is newly diagnosed with asthma and prescribed: - Albuterol inhaler (2 puffs Q 4-6 hours PRN) - Beclomethasone inhaler (2 puffs BID) - Guaifenesin 400mg PO Q 4 hours PRN - Cetirizine 10mg PO daily
Role-play a patient teaching moment and include:
1. Proper inhaler technique (step-by-step)
2. THREE critical side effects to report
PROPER INHALER TECHNIQUE MDI (Metered Dose Inhaler):
1. Remove cap and shake inhaler (5-10 times)
2. Prime if new (spray into air 4 times if first use or not used >2 weeks)
3. Breathe out completely (exhale fully, away from inhaler)
4. Position inhaler: - Option A: Hold inhaler 1-2 inches from open mouth (preferred) - Option B: Place mouthpiece between lips (seal tightly) - Option C: Use spacer device (recommended for better delivery)
5. Press canister down ONCE while simultaneously beginning slow, deep breath in
6. Continue breathing in slowly and deeply (over 3-5 seconds)
7. Hold breath for 10 seconds (allows medication to deposit in airways)
8. Breathe out slowly through nose
9. Wait 1 minute before second puff (if prescribed)
10. Rinse mouth after corticosteroid (prevents thrush)
Common Errors to Avoid: - Don’t breathe in through nose - Don’t breathe in too quickly (medication hits back of throat) - Don’t press canister multiple times during one breath - Don’t forget to shake before each puff
THREE CRITICAL SIDE EFFECTS TO REPORT:
Albuterol (Beta2-agonist): Chest pain or severe palpitations (cardiac effects); Paradoxical bronchospasm (worsening wheezing after use. Rare but serious); Need to use rescue inhaler more frequently (indicates worsening asthma)
Beclomethasone (Inhaled Corticosteroid): White patches in mouth (oral candidiasis/thrush); Hoarseness persisting (vocal cord inflammation); Signs of systemic absorption (with high doses): bruising, vision changes
MASTERING ABG INTERPRETATION: You receive FOUR ABG results. For EACH ABG, provide complete interpretation (including compensation status)
ABG #1: pH 7.32, PaCO₂ 48, HCO₃⁻ 25, PaO₂ 65
ABG #2: pH 7.29, PaCO₂ 38, HCO₃⁻ 18, PaO₂ 94
ABG #3: pH 7.50, PaCO₂ 30, HCO₃⁻ 23, PaO₂ 88
ABG #4: pH 7.38, PaCO₂ 60, HCO₃⁻ 34, PaO₂ 72
ABG #1: Respiratory Acidosis, UNCOMPENSATED - PLUS: Moderate Hypoxemia
ABG #2: Metabolic Acidosis, UNCOMPENSATED
ABG #3: Respiratory Alkalosis, UNCOMPENSATED
ABG #4: Chronic Respiratory Acidosis, FULLY COMPENSATED
DISCHARGE PLANNING: Your patient is newly diagnosed with active pulmonary TB and will be discharged home on RIPE therapy.
Develop a comprehensive discharge plan addressing infection control at home (4 key points)
For credit, name at least one item from each category.
Point #1: Respiratory Hygiene. Cover mouth/nose when coughing or sneezing (tissue or elbow, not hands). Dispose of tissues in plastic bag immediately. Perform hand hygiene after coughing. Wear surgical mask when around others (especially first 2 weeks of treatment). Patient wears mask (NOT N95—N95 is for healthcare workers)
Point #2: Ventilation. Open windows for fresh air circulation (dilutes airborne bacteria). Use fans to direct air OUTSIDE (away from others). Avoid closed, crowded spaces. Sleep in separate room if possible (especially first 2-3 weeks)
Point #3: Limiting Exposure. Avoid close contact with high-risk individuals:. Young children (<5 years). Pregnant women. Immunocompromised (HIV, cancer, transplant patients). Avoid crowded public places initially. Do NOT go to work/school until cleared by provider (usually after 2-3 weeks of treatment + clinical improvement)
Point #4: Household Precautions. No need for special dishes or utensils (TB not transmitted by shared items). Regular household cleaning sufficient. Launder patient’s linens/clothes separately with hot water (optional but recommended). All household contacts must be screened for TB (skin test or IGRA)