Pleural Effusion - accumulation of pleural fluid in the pleural space (space between the parietal and

visceral pleurae of the lung).

 parapneumonic effusion - any pleural effusion associated with bacterial pneumonia, lung
abscess, or bronchiectasis.

 thoracentesis may be performed to remove the fluid

3 Stages of Parapneumonic Pleural

1. Complicated
2. Uncomplicated
3. Thoracic empyema.

 empyema occurs when thick, purulent fluid accumulates within the pleural space

NURSING MANAGEMENT
 The nurse assists in the procedure and explains it to the patient. (BEFORE THORACENTESIS)
 The nurse monitors the patient for pneumothorax or recurrence of pleural effusion. (AFTER)
 If chest tube needs to be inserted, the nurse monitors the patient’s respiratory status

Aspiration is inhalation of foreign material (e.g., oropharyngeal or stomach contents) into the lungs.
 If serious that can cause pneumonia : tachycardia, dyspnea, central cyanosis, hypertension,
hypotension, and potentially death.
 Aspiration pneumonia develops after inhalation of colonized oral or pharyngeal material.
 the causative organisms in community acquired aspiration pneumonia may include S. aureus, S.
pneumoniae, H. influenzae, and Enterobacter species

RISK FACTORS
 Seizure activity
 Brain injury
 Decreased level of consciousness from trauma, drug or alcohol
 intoxication,
 excessive sedation, or general anesthesia
 Flat body positioning
 Stroke Swallowing disorders
 Cardiac arrest

Esophageal COnditions that also cause : dysphagia, esophageal strictures, neoplasm or diverticula,
tracheoesophageal fistula, and gastroesophageal reflux disease.

For patients with known swallowing dysfunction or those recently extubated following prolonged ET
intubation, a swallowing screen is necessary.

 positioning the patient semirecumbent or upright prior to eating

 Soft diet and encourage small bites
 keep the chin tucked and the head turned with repeated swallowing
 Straws should not be used

Clinical Practices That Prevent Aspiration

 Maintain head-of-bed elevation at an angle of 30 to 45 degrees, unless contraindicated
 Use sedatives as sparingly as possible
 Before initiating enteral tube feeding, confirm the tip location
 For patients receiving tube feedings, assess placement of the feeding tube at 4-hour intervals,
assess for gastrointestinal residuals (<150 mL before next feeding) to the feedings at 4-hour
intervals
 For patients receiving tube feedings, avoid bolus feedings in those at risk for aspiration
 Consult with primary provider about obtaining a swallowing evaluation before oral feedings are
started for patients who were recently extubated but were previously intubated for >2 days
 Maintain endotracheal cuff pressures at an appropriate level, and ensure that secretions are
cleared from above the cuff before it is deflated.

Pulmonary Tuberculosis
 Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma
 it also may be transmitted to other parts of the body, including the meninges, kidneys, bones,
and lymph nodes.
 primary infectious agent, M. tuberculosis, is an acid-fast aerobic rod that grows slowly and is
sensitive to heat and ultraviolet light
 Mycobacterium bovis and Mycobacterium avium
 TB is a worldwide public health problem that is closely associated with poverty, malnutrition,
overcrowding, substandard housing, and inadequate health care
 TB spreads from person to person by airborne transmission - person releases droplet nuclei
(usually particles 1 to 5 mcm in diameter) through talking, coughing, sneezing, laughing, or
singing

RISK FACTORS
 Close contact with someone who has active TB. Inhalation of airborne nuclei from a person who
is infected is proportional to the amount of time spent in the same air space, the proximity of
the person, and the degree of ventilation
 Immunocompromised status
 Substance use disorder (individuals who use IV/injection drug or abuse alcohol
 Any person without adequate health care (those experiencing homelessness; those who are
impoverished; and racial–ethnic minorities, particularly children <15 years and young adults
between ages 15 and 44 yeaR
 Preexisting medical conditions or special treatment (e.g., diabetes, chronic kidney disease,
malnourishment, select malignancies,hemodialysis, transplanted organ, gastrectomy, and
jejunoileal bypass).
 Immigration from or recent travel to countries with a high prevalence of TB
 Living in overcrowded, substandard housing
 Being a health care worker performing high-risk activities: administration of aerosolized
pentamidine and other medications, sputum induction procedures, bronchoscopy, suctioning,
coughing procedures, caring for patients who are immune suppressed, home care with the high-
risk population, and administering anesthesia and related procedures (e.g., intubation,
suctioning)

 Some people develop reactivation TB (also called adult-type progressive TB). The reactivation of
a dormant focus occurring during the primary infection is the cause.

CLINICAL MANIFESTATION
 . Most patients have a low-grade fever, cough, night sweats, fatigue, and weight loss
 The cough may be nonproductive, or mucopurulent sputum may be expectorated.
 Hemoptysis (i.e., coughing up blood) also may occur.

ASSESSMENT AND DIAGNOSTIC FINDING

 positive skin test, blood test, or sputum culture for acid-fast bacilli
 These tests include a complete history, physical examination, tuberculin skin test, chest x-ray,
and drug susceptibility testing
 fever, anorexia, weight loss, night sweats, fatigue, cough, and sputum production prompt a more
thorough assessment o respiratory function
 diminished, bronchial sounds; crackles), fremitus, and egophony
 If the patient is infected with TB, the chest x-ray usually reveals lesions in the upper lobes.
TUBERCULIN SKIN TEST
 The Mantoux method is used to determine whether a person has been infected with the TB
bacillus and is used widely in screening for latent M. tuberculosis infection.
 is a standardized, intracutaneous injection procedure and should be performed only by those
trained in its administration and reading
 Tubercle bacillus extract (tuberculin), purified protein derivative (PPD), is injected into the
intradermal layer of the inner aspect of the forearm, approximately 4 inches below the elbow
 The needle, with the bevel facing up, is inserted beneath the skin. Then, 0.1 mL of PPD is injected
- a well-demarcated wheal 6 to 10 mm in diameter.
 site, antigen name, strength, lot number, date, and time of the test are recorded
 Tests read after 72 hours tend to underestimate the true size o induration (raised hard area or
swelling).
 delayed localized reaction indicates that the person is sensitive to tuberculin

SPUTUM CULTURE
 sputum specimen may be used to screen for TB. The presence of AFB on a sputum smear may
indicate disease but does not confirm the diagnosis of TB because some AFB are not M.
tuberculosis.
 Culture is done to confirm the diagnosis.

Gerontologic Considerations
 unusual behavior and altered mental status, fever, anorexia, and weight loss
 the tuberculin skin test produces no reaction (loss of immunologic memory) or delayed reactivity
for up to 1 week (recall phenomenon). A second skin test is performed in 1 to 2 weeks

MEDICAL MGT
 Pulmonary TB is treated primarily with anti-TB agents for 6 to 12 month
 RIFAMPIN,ISONIAZID,PYRAZINAMIDE,ETHAMBUTOL - Four first-line medications

TREATMENT GUIDELIINES FOR NEWLY DIAGNOSED CASES OF PULMONARY TB HAVE 2 PHASES

 an initial treatment phase and a continuation phase
 The initial phase consists of a multiple-medication regimen of isoniazid, rifampin, pyrazinamide,
and ethambutol plus vitamin B6 50 mg. All are taken once a day and are oral medications. This
initial intensive-treatment regimen is given daily for 8 weeks.
 continuation phase of treatment include isoniazid and rifampin or isoniazid and rifapentine. -
asts for an additional 4 or 7 months. The 4-month period is used for the large majority of
patients. The 7- month period is recommended for patients with cavitary pulmonary TB whose
sputum culture after the initial 2 months of treatment is positive

Isoniazid also may be used as a prophylactic (preventive) measure for people who are at risk for
significant disease:

1. Household family members of patients with active disease

2. Patients with HIV infection who have a PPD test reaction with 5 mm of induration or more
3. Patients with fibrotic lesions suggestive of old TB detected on a chest x-ray and a PPD reaction
with 5 mm of induration or more
4. Patients whose current PPD test results show a change from former test results, suggesting
recent exposure to TB and possible infection (skin test converters)
5. Patients who use IV/injection drugs who have PPD test results with 10 mm of induration or more
6. Patients with high-risk comorbid conditions and a PPD result with 10 mm of induration or more.
NURSING MGT
 promoting airway clearance, advocating adherence to the treatment regimen, promoting activity
and nutrition, and preventing transmission

Promoting Airway Clearance

 Increasing the fluid intake promotes systemic hydration and serves as an effective expectorant
 Postural drainage allows the force o gravity to assist in the removal of bronchial secretions.

Promoting Adherence to Treatment Regimen

 The nurse educates the patient to take the medication either on an empty stomach or at least 1
hour before meals, because food interferes with medication absorption (although taking
medications on an empty stomach frequently results in gastrointestinal upset
 patients taking isoniazid should avoid foods that contain tyramine and histamine (tuna, aged
cheese, red wine, soy sauce, yeast extracts)- may result in headache, flushing, hypotension,
lightheadedness, palpitations, and diaphrosis
 Avoid alcohol - hepatoxic effects
 Rifampin can alter the metabolism of certain other medications - These medications include
beta-blockers, oral anticoagulants such as warfarin, digoxin, quinidine, corticosteroids, oral
hypoglycemic agents, oral contraceptives, theophylline, and verapamil
 The nurse informs the patient that rifampin may discolor contact lenses and that the patient may
want to wear eyeglasses during treatment
 other side effects o anti-TB medications, including hepatitis, neurologic changes (hearing loss,
neuritis), and rash. Liver enzymes, BUN, and serum creatinine levels are monitored to detect
 to monitor the patient’s temperature and respiratory status. Changes in the patient’s respiratory
status are reported to the primary provider.

Promoting Activity and Adequate Nutrition

 A nutritional plan that allows for small, frequent meals may be required. Liquid nutritional
supplements may assist in meeting basic caloric requirements.

Preventing Transmission of Tuberculosis Infection

 important hygiene measures, including mouth care, covering the mouth and nose when
coughing and sneezing, proper disposal of tissues, and hand hygiene
 Spread or dissemination of TB infection to nonpulmonary sites of the body is known as miliary TB
 Miliary TB is seen in approximately 1.5% of all patients with TB (Lessnau, 2019). It is the result of
invasion of the bloodstream by the tubercle bacillus
 foci into the bloodstream, are carried throughout the body, and disseminate throughout all
tissues, with tiny miliary tubercles developing in the lungs, spleen, liver, kidneys, meninges, and
other organs.
 First symptoms - localizing signs except an enlarged spleen and a reduced number of leukocytes
 within a few weeks, the chest x-ray reveals small densities scattered diffusely throughout both
lung fields; these are the miliary tubercles, which gradually grow.
 The nurse monitors vital signs and observes for spikes in temperature as well as changes in renal
and cognitive function
Lung Abscess
 A lung abscess is a localized collection of pus caused by microbial infection
 caused by aspiration of anaerobic bacteria
 the chest x-ray demonstrates a cavity of at least 2 cm

Patients who are at risk for aspiration of foreign material and development of a lung abscess include
those with
 impaired cough reflexes who cannot close the glottis and those with swallowing difficulties
 risk include those with central nervous system disorders (seizure or stroke)
 substance use disorder
 esophageal disease
 compromised immune function
 patients without teeth
 those receiving nasogastric tube feedings
 patients with an altered state of consciousness due to anesthesia

PATHPHYSIOLOGY
 lung abscesses are a complication of bacterial pneumonia or are caused by aspiration of oral
anaerobes into the lung
 secondary to mechanical or functional obstruction of the bronchi by a tumor, foreign body, or
bronchial stenosis, or from necrotizing pneumonias, TB, pulmonary embolism (PE), or chest
trauma.
 found in areas of the lung that may be affected by aspiration
 For patients who are confined to bed, the posterior segment of an upper lobe and the superior
segment of the lower lobe are the most common areas.
 depending on the position o the patient when the aspiration occurred.
 If the bronchus is involved, the purulent contents are expectorated continuously in the form of
sputum. If the pleura is involved, the result is an empyema.

CLINICAL MANIFESTATION
 have a fever and a productive cough with moderate to copious amounts of foul-smelling,
sometimes bloody, sputum.
 fever and cough may develop insidiously and may have been present for several weeks before
diagnosis
 Leukocytosis may be present
 Pleurisy or dull chest pain, dyspnea, weakness, anorexia, and weight loss are common.

ASSESSMENT AND DX
 Physical examination of the chest may reveal dullness on percussion and decreased or absent
breath sounds with an intermittent pleural friction rub (grating or creaking sound) on
auscultation. Crackles may be present.
 Confirmation of the diagnosis is made by chest x-ray, sputum culture, and, in some cases,
fiberoptic bronchoscopY
 Chest x-ray reveals an infiltrate with an air–fluid level.
 CT-Scan

PREVENTION
1. Appropriate antibiotic therapy before any dental procedures
2. Adequate dental and oral hygiene
3. Appropriate antimicrobial therapy for patients with pneumonia

MEDICAL MGT
 Adequate drainage of the lung abscess may be achieved through postural drainage and chest
physiotherapy
 adequate cough
 insertion of a percutaneous chest catheter for long-term drainage of the abscess.
 Therapeutic use of bronchoscopy to drain an abscess is uncommon.
 A diet high in protein and calories is necessary
 Surgical intervention is rare - pulmonary resection (lobectomy) is performed if massive
hemoptysis occurs
 IV antimicrobial therapy depends on the results of the sputum culture and sensitivity
 Standard treatment of an anaerobic lung infection is clindamycin, ampicillin-sulbactam, or
carbapenem
 . Large IV doses are usually required -Treatment with IV antibiotics may continue for 3 weeks and
longer, depending upon the clinical severity and organism involved
 Treatment with IV antibiotics may continue for 3 weeks and longer, depending upon the clinical
severity and organism involved antibiotic therapy is continued for an additional 4 to 12 weeks
and sometimes longer. If treatment is stopped too soon, a relapse may occur.

NURSING MGT
 administers antibiotics and IV treatments as prescribed and monitors for adverse effects. CPT is
initiated as prescribed to facilitate drainage of the abscess
 how to perform deep-breathing and coughing exercises
 To ensure proper nutritional intake, the nurse encourages a diet that is high in protein and
calories
 nurse also offers emotional support