Pneumonia
What is Pneumonia?
It occurs when bacteria, viruses, or fungi carried in the nose, mouth, or sinuses spread to the lungs causing an infection that leads to inflammation of lung tissues and fluid accumulation in or around the alveoli
True or false
Treatment should be based on the presumed location pneumonia was acquired rather than the pathogens causing it
False
Evidence suggests that treatment should be based on which pathogens are causing the disease
True or false
A patient admitted to the hospital can be diagnosed with CAP.
True
A patient may have acquired pneumonia outside of the hospital and be diagnosed after admission. The most common cause of CAP among adults is pneumococcal pneumonia (caused by Streptococcus pneumoniae)
How many pt identifiers should be used to confirm identity prior to oral care procedure?
At least two pts identifier should be used according to Northwell Health policy
What are some conditions placing a pt at risk for dysphagia?
History of swallowing difficulty
Suspected stroke or stroke-like symptoms
Any neurological symptom or disease that impacts swallowing ability
ENT impairment
Intubation for more than 24 hours
Cardiothoracic surgery on current admission
Modifiable risk factors
Substance use(tobacco)
Vaccinations against organisms that cause pneumonia
Infection prevention practices such as hand washing, not sharing items when sick
Nutritional diet, adequate rest and exercise
Awareness of when to seek medical attention for respiratory symptoms
What is the most common type of nosocomial pneumonia?
Ventilator-associated pneumonia
It is a frequent fatal type seen in pts breathing with a ventilator, usually caused by the aspiration of contaminated secretions or stomach contents and may be bacterial, viral, or fungal
Risk factors
age 65 and older
previous CAP or influenza infection
IV drug use
Concurrent disorders such as asthma, COPD, chronic bronchitis
True or false
Prior to oral care for the intubated pt, the nurse should perform a focused assessment of oral cavity and the ET tube
True
The nurse should perform a focused assessment of oral cavity and ET tub to assess for condition of oral mucosa, condition of lips, tongue, and upper palate
Condition of oral mucosa (excessive dryness, encrustations & debris, excessive secretions, ulcerations, bleeding, dental plaque)
Condition of ET tube and securing device
Presence of pressure areas on tongue, lips, nares or corners of mouth and palate
True or false
If pt's dysphagia status is unclear, the pt should be kept NPO until status can be ascertained
True
According to Northwell Health policy, a patient with an unclear dysphagia status should be kept NPO, including PO meds, until status can be ascertained
Nursing Care
Use of standard precautions consistently
Hand hygiene
Provide adequate hydration to liquify secretions
Oral care (oral-tracheal suction according to NH policy)
Suction the pt if they're unable to clear airway
Assist the pt into positions that prevent aspiration and support airway clearance such as Semi or high Fowler
Teach pts how to use spirometer, especially postoperative pts at high risk for pneumonia
Request orders to remove invasive devices (endotracheal and enteral feeding tubes) as soon as clinically indicated
Administer antibiotics as ordered
What are some invasive devices that increase aspiration risks?
Endotracheal tube
Tracheostomy tube
Enteral tube (orogastric, nasogastric, orojejunal, nasojejunal)
Signs and symptoms
Dyspnea
Fever or hypothermia
Tachycardia
Tachypnea
Functional or cognitive decline
True or false
What are the procedures of oral care for pts with dentures?
Place dentures in in denture cup labeled with pt identification
Brush the patient palate, buccal surfaces, gums and tongue with soft toothbrush or swab at minimum twice daily
Brush dentures with a soft toothbrush and warm water
If needed, apply denture adhesive, and assist pt with putting dentures into the mouth
Apply moisturizer to the oral mucosa and lips every 2 to 4 hours
What are some unsafe conditions should water not be administered under?
Known current difficulty swallowing
Lethargy/unresponsiveness
Unable to position upright
Unable to maintain control of saliva
Unable to maintain adequate oxygen
Wet/gurgling voice and/or cough
Respiratory signs and symptoms of HAP
New cough or change in nature of chronic cough
New sputum or change in nature of chronic sputum
Dyspnea
Pleuritic pain
Tachypnea
Decreased breath sounds
Crackles
Rhonchi
Diagnostic tests
Chest xray
Ultrasound
What kind of toothbrush should be used for non-intubated pts?
A soft-bristled brush
A soft-bristled brush should be used to brush teeth, gums, and tongue to minimize trauma and discomfort for a minimum of 2 minutes
A suction toothbrush for pts with dysphagia, or excessive oral secretions
Moisten toothbrush and apply a small amount of toothpaste
What are some signs of dysphagia/aspiration?
Wet gurgling voice
Cough
Throat clearing
Spills water from mouth
Holds water in mouth (after each water administration. inspect pt's oropharynx to see if water is being held)
True or false
Pts with HAP may have a decline in mental or functional status
True
Pt may experience new onset of disorientation to time, place, or person
New onset of confusion
Incoherent or inappropriate verbal responses
Lack of verbal response
Functional decline
What are the 3 minor criteria that must be present to confirm severe CAP?
Tachypnea equal to or above 30 breaths per minute
Confusion/disorientation
Leukopenia greater than 4,000 cells per uL
What kind of toothbrush should be used for intubated pts?
Suction toothbrush
Teeth should be gently brushed using a suction toothbrush at least twice per day. An approved cleaning agent should be used to remove debris and plaque and after brushing, suction away accumulated oropharyngeal secretions
Name the three steps used for dysphagia screening
Step 1: Health history- review the pt's history to determine if the pt is at risk for dysphagia. If a pt is at risk for dysphagia proceed to step 2 and a pt without a risk for dysphagia requires no further screening
Step 2: Current clinical condition- determine the pt's current clinical condition and determine if it is safe to administer water. If the pt is safe to receive water, proceed to step 3, if unsafe, do not proceed
Step 3: Water swallow testing- perform water swallow test. If the pt does not exhibit signs of dysphagia/aspiration, continue screening, and if the pt exhibits signs of dysphagia/aspiration, do not proceed