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Chapter 24 Coordinating Care for Patients With Infectious Respiratory Disorders
infection resolves. Most antibiotics do not cross the blood– brain barrier, making the central nervous system a potential site of bacterial spread via the bloodstream. Acute meningitis can occur as a complication of a pneumococcal pneumonia. An empyema, a collection of purulent material in the pleural space, another possible complication, should be drained by the insertion of a chest tube. Pleurodesis, the injection of a sclerosing or scarring agent into the pleu- ral space, causing the visceral and parietal pleura to “stick together,” may be performed after the empyema has been resolved to prevent recurrence. Other significant complications that can develop as a result of pneumonia include bacteremia (bacteria in the bloodstream); atelectasis, a complete or partial collapse of the lung more typically seen in the postoperative or immobile patient; septic shock; and acute respiratory failure with multiple organ failure. Evidence of organ impairment/failure due to decreased tissue perfusion includes the following: l Agitation/confusion: It is important to stress that this may be the only presenting sign/symptom in patients over 65 years of age. l Peripheral cyanosis l Central cyanosis l Decreased urinary output/elevated creatinine level l Hypoactive bowel sounds l Increased liver function laboratory values (aspartate aminotransferase/alanine aminotransferase) Nursing Management Assessment and Analysis The clinical manifestations in the patient with pneumo- nia result from the initiation of the inflammatory response and the buildup of fluid and exudate in the alveoli. They include fever; the deterioration of oxygenation, resulting in tachypnea and tachycardia; and the resultant decreases in cardiac output. This decrease in oxygen delivery results in shunting blood away from the periphery, producing weak and thready pulses. Exudate and excess secretions in the lungs and alveoli result in adventitious breath sounds such as wheezing, rhonchi, and rales. Nursing Diagnoses/Problem List l Ineffective peripheral tissue perfusion related to decreased gas exchange l Ineffective breathing pattern
Decreased oxygen saturation: Impaired gas exchange at the alveolar level results in hypoxia. Tachypnea and tachycardia decrease cardiac output, reducing perfusion and peripheral oxygen saturation. Fever occurs as a part of the inflammatory response. l Neurological function Agitation, restlessness, anxiety, lethargy, and fatigue are the result of decreased tissue perfusion from altered alveolar gas exchange. Diminished cough, gag, and swallow reflexes resulting from altered levels of consciousness can contribute to aspiration risk. l Breath sounds Adventitious breath sounds such as wheezing, rhonchi, crackles, and rales may be audible on lung assessment as a result of bronchospasm and/or fluid and exudates filling the alveoli. l Peripheral pulses and skin temperature and color Diminished tissue perfusion causes blood to be shunted away from peripheral areas to the main core body organs. Peripheral pulses diminish, and skin becomes moist and pale. Peripheral cyanosis (bluish color to the nailbeds) is a late sign of tissue hypoxia. l Respiratory secretions Purulent and/or bloody secretions may result from a build-up of exudate in the alveoli. l Laboratory testing • Sputum microbiology Culture and sensitivity reports indicate the offending organism and list the antibiotics to which the organism is sensitive. • Arterial blood gases Bacterial respiratory infections may initially cause primary respiratory alkalosis (increased pH, decreased CO 2 ) due to increased respiratory rate. As the condition progresses, a primary respiratory acidosis will occur (decreased pH, increased CO 2 ). l Intake and Output Insensible losses from fever and tachypnea along with decreased intake from malaise and increased work of breath- ing can lead to more serious tachycardia and dehydration. ■ Actions l Administer humidified oxygen as ordered. Oxygen administration helps maintain adequate oxygen levels. Humidification of respiratory tract mucous mem- branes helps liquefy secretions to facilitate expectoration. Careful administration should be given to the patient with chronic lung pathology in whom the drive to breathe comes from decreased oxygen levels. l Administer antibiotics as ordered. Prompt administration of antibiotics to defeat the offending organism is the definitive treatment of choice. l Pulmonary hygiene: • Incentive spirometry • Coughing and deep breathing • Postural drainage
l Impaired gas exchange l Risk for acute confusion Nursing Interventions ■ Assessments l Vital signs
Tachypnea: The body’s first compensatory mechanism to a decreased oxygen delivery is increased respiratory rate and depth. Tachycardia: The body’s second compensatory mechanism for a continued impairment of oxygen delivery is to raise the heart rate.
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