NURS 640 EVALUATION TEST QUESTIONS AND
ANSWERS SURE A+
✔✔Acute Severe Asthma Management - ✔✔High concentration of oxygen by face mask
yo achieve O2sat >90%.
Mainstay of treatment are high doses of SABA given either by nebulizer or metered-
dose inhaler w/ a spacer.
In severely ill patients with impending respiratory failure, IV B2-agonists may be given.
A nebulized anticholinergic may be added if there is not a satisfactory response to B2-
agonists alone, as there are additive effects.
In patients who are refractory to inhaled therapies, a slow infusion of aminophylline may
be effective, but it is important to monitor to monitor blood levels, especially of patients
have already been treated w/ oral theophylline.
Magnesium sulfate given IV or by nebulizer is effective when added to inhaled B2-
agonists, and is relatively well-tolerated but is not routinely recommended.
Prophylactic intubation may be indicated for impending resp failure, when PCO2 is
normal or rises.
For pts w/ resp failure, it is necessary to intubate and institute ventilation.
✔✔CAP - ✔✔Essentials of diagnosis include:
-Fever, tachypnea, cough with or w/o sputum, dyspnea, chest discomfort, sweats or
rigors
-Bronchial breath sounds or inspiratory crackles
- Parenchymal opacity on CXR
-Occurs outside the hospital OR within 28 hours of hospital admission in a patient not
residing in long term care facility
- Remember: Patient outcomes improve when initial antibiotic choice is appropriate for
the infecting organism, and improves antibiotic coverage, reduces unnecessary
hospitalization, and improves 30 day survival.
Pathogenesis: Bacteria more common than viruses, with S pneumoniae accounting for
⅔ of bacterial isolates.
,✔✔CAP patho, S&S - ✔✔Pathogenesis: Bacteria more common than viruses, with S
pneumoniae accounting for ⅔ of bacterial isolates.
Clinical Findings: Most patients experience acute or subacute onset of fever, cough with
or w/o sputum production and dyspnea. Other symptoms include sweats, chills, rigors,
chest discomfort, pleurisy, hemoptysis, myalgias, headache, abdominal pain.
Physical Findings: Fever or hypothermia, tachypnea, tachycardia, arterial oxygen
desaturation. Patients appear acutely ill, inspiratory crackles and bronchial breath
sounds heard.
✔✔CAP diagnosis - ✔✔A chest radiograph is essential to eval of suspected CAP
Diagnostic testing: In addition to CXR, sputum gram stain, urine antigen test for s.
Pneumoniae and legionella, and rapid antigen detection test for influenza may be used.
Blood cultures should be obtained prior to administration of antibiotics, other labs to be
drawn include CBC, chem panel, and ABG samples
Pulmonary opacity on CXR required for diagnosis of CAP; Chest CT more sensitive.
Findings range from patchy airspace opacities to lobar consolidation with air
bronchograms to diffuse aleveolar or interstitial opacities. Other findings can include
pleural effusions and cavitation. Patients with cavitary opacities should have sputum
fungal and myobacterial cultures
✔✔CAP Treatment - ✔✔-Treatment: Initial antibiotic choices are typically empiric, based
on acuity, patient risk factors for specific pathogens, and local antibiotic resistance
patterns.
- For previously healthy patients with no recent (90 days) use of antibiotics,
recommended treatment is macrolide (clazithromycin or azithromycin)
- In patients at risk for drug resistance (antibiotic therapy within past 90 days, age
greater than 65, comorbid illness, immunosuppression, exposure to child daycare),
recommended treatment is respiratory fluroquinolone (moxifloxacin or levfloxacin), or a
macrolide plus a beta lactam (high dose amoxicillin and amoxicillin-clavulanate)
- In regions where there is high incidence of macrolide resistant S pneumoniae, initial
therapy in patients w/o comorbidities may include respiratory fluroquinolone or combo of
beta-lactam added to macrolide.
- First line therapy for hospitalized patients is respiratory fluroquinolone (moxifloxacin,
levofloxacin, or gemifloxacin) or the combo of macrolide (clazithromycin or
azithromycin) plus a beta lactam (ceftriaxone, cefotaxime, ampicillin)
-Choice to keep patient at home, admit to hospital or ICU based on two clinical
prediction rules: The Pneumonia Severity Index and CURB-65.
✔✔HAP - ✔✔Occurs more than 48 hours after admission to hospital or other health
care facility, and excludes any infection present at the time of admission.
Micro: Most common organisms responsible for HAP is S aureus, P aeruginosa, gram-
negative rods, including non-extended spectrum beta lactamase producing and ESBL-
producing (e coli, enterobacter)
✔✔VAP - ✔✔Develops in a mechanically ventilated patient more than 48 hours after
intubation.
, Micro: Acinetobacter and Stenotrophomonas maltrophilia
✔✔HCAP - ✔✔Pneumonia that occurs in a non-hospitalized patient with extensive
healthcare contact
Micro: HCAP patients may be infected with common organisms, such as S pneumonaie
and H influenza that are more likely to be drug-resistant
Pathogenesis (of nosocomial pneumonia): Microbiology of the nosocomial pneumonias
differs from CAP but is substantially the same among HAP, VAP, and HCAP. Anaerobic
organisms (anaerobic streptococci) may also cause pneumonia but are commonly part
of a polymicrobial flora.
✔✔Signs and symptoms of Nosocomial Pneumonia - ✔✔The signs and symptoms
associated with nosocomial pneumonia are nonspecific, however, two or more clinical
findings (fever, leukocytosis, purulent sputum) in the setting of new or progressive
pulmonary opacity on CXR were 75% specific for diagnosis of VAP.
Lab findings:
-Blood cultures can identify the pathogen in up to 20% of patients with nosocomial
pneumonia; Blood counts and chemistry tests do not establish a specific diagnosis of
HCAP but do help define severity of illness and identify complications.
-ABG assesses oxygenation and determines the need for assisted ventilation
Special considerations:
Endotracheal aspiration using sterile suction catheter can be used to obtain lower
respiratory tract secretions
Treatment
Is usually empiric, like with CAP, therapy should be started as soon as possible
because of the high mortality rate. After results of sputum, blood, and pleural fluid
cultures are available, it may be possible to de-escalate initially broad therapy. Duration
of antibiotic therapy should be individualized
✔✔o Obstruction grades by FEV1 severity - ✔✔§ I 80-100
§ II 50-80
§ III 30-50
§ IV 0-30
✔✔Tracheal stenosis - ✔✔s/t previous tracheotomy or endotracheal intubation.
Physical findings may absent until the tracheal diameter is reduced 50% or more →
wheezing, a palpable tracheal thrill and harsh breath sounds may be detected.
Dx test → plain films or CT of the trachea
Complications - recurrent pulmonary infection and life threatening respiratory failure.
Management - ensuring adequate ventilation and oxygenation, avoiding manipulative
procedures that may increase edema of the tracheal mucosa. Surgical reconstruction,
endotracheal stent placement, or laser photoresection may be required.
ANSWERS SURE A+
✔✔Acute Severe Asthma Management - ✔✔High concentration of oxygen by face mask
yo achieve O2sat >90%.
Mainstay of treatment are high doses of SABA given either by nebulizer or metered-
dose inhaler w/ a spacer.
In severely ill patients with impending respiratory failure, IV B2-agonists may be given.
A nebulized anticholinergic may be added if there is not a satisfactory response to B2-
agonists alone, as there are additive effects.
In patients who are refractory to inhaled therapies, a slow infusion of aminophylline may
be effective, but it is important to monitor to monitor blood levels, especially of patients
have already been treated w/ oral theophylline.
Magnesium sulfate given IV or by nebulizer is effective when added to inhaled B2-
agonists, and is relatively well-tolerated but is not routinely recommended.
Prophylactic intubation may be indicated for impending resp failure, when PCO2 is
normal or rises.
For pts w/ resp failure, it is necessary to intubate and institute ventilation.
✔✔CAP - ✔✔Essentials of diagnosis include:
-Fever, tachypnea, cough with or w/o sputum, dyspnea, chest discomfort, sweats or
rigors
-Bronchial breath sounds or inspiratory crackles
- Parenchymal opacity on CXR
-Occurs outside the hospital OR within 28 hours of hospital admission in a patient not
residing in long term care facility
- Remember: Patient outcomes improve when initial antibiotic choice is appropriate for
the infecting organism, and improves antibiotic coverage, reduces unnecessary
hospitalization, and improves 30 day survival.
Pathogenesis: Bacteria more common than viruses, with S pneumoniae accounting for
⅔ of bacterial isolates.
,✔✔CAP patho, S&S - ✔✔Pathogenesis: Bacteria more common than viruses, with S
pneumoniae accounting for ⅔ of bacterial isolates.
Clinical Findings: Most patients experience acute or subacute onset of fever, cough with
or w/o sputum production and dyspnea. Other symptoms include sweats, chills, rigors,
chest discomfort, pleurisy, hemoptysis, myalgias, headache, abdominal pain.
Physical Findings: Fever or hypothermia, tachypnea, tachycardia, arterial oxygen
desaturation. Patients appear acutely ill, inspiratory crackles and bronchial breath
sounds heard.
✔✔CAP diagnosis - ✔✔A chest radiograph is essential to eval of suspected CAP
Diagnostic testing: In addition to CXR, sputum gram stain, urine antigen test for s.
Pneumoniae and legionella, and rapid antigen detection test for influenza may be used.
Blood cultures should be obtained prior to administration of antibiotics, other labs to be
drawn include CBC, chem panel, and ABG samples
Pulmonary opacity on CXR required for diagnosis of CAP; Chest CT more sensitive.
Findings range from patchy airspace opacities to lobar consolidation with air
bronchograms to diffuse aleveolar or interstitial opacities. Other findings can include
pleural effusions and cavitation. Patients with cavitary opacities should have sputum
fungal and myobacterial cultures
✔✔CAP Treatment - ✔✔-Treatment: Initial antibiotic choices are typically empiric, based
on acuity, patient risk factors for specific pathogens, and local antibiotic resistance
patterns.
- For previously healthy patients with no recent (90 days) use of antibiotics,
recommended treatment is macrolide (clazithromycin or azithromycin)
- In patients at risk for drug resistance (antibiotic therapy within past 90 days, age
greater than 65, comorbid illness, immunosuppression, exposure to child daycare),
recommended treatment is respiratory fluroquinolone (moxifloxacin or levfloxacin), or a
macrolide plus a beta lactam (high dose amoxicillin and amoxicillin-clavulanate)
- In regions where there is high incidence of macrolide resistant S pneumoniae, initial
therapy in patients w/o comorbidities may include respiratory fluroquinolone or combo of
beta-lactam added to macrolide.
- First line therapy for hospitalized patients is respiratory fluroquinolone (moxifloxacin,
levofloxacin, or gemifloxacin) or the combo of macrolide (clazithromycin or
azithromycin) plus a beta lactam (ceftriaxone, cefotaxime, ampicillin)
-Choice to keep patient at home, admit to hospital or ICU based on two clinical
prediction rules: The Pneumonia Severity Index and CURB-65.
✔✔HAP - ✔✔Occurs more than 48 hours after admission to hospital or other health
care facility, and excludes any infection present at the time of admission.
Micro: Most common organisms responsible for HAP is S aureus, P aeruginosa, gram-
negative rods, including non-extended spectrum beta lactamase producing and ESBL-
producing (e coli, enterobacter)
✔✔VAP - ✔✔Develops in a mechanically ventilated patient more than 48 hours after
intubation.
, Micro: Acinetobacter and Stenotrophomonas maltrophilia
✔✔HCAP - ✔✔Pneumonia that occurs in a non-hospitalized patient with extensive
healthcare contact
Micro: HCAP patients may be infected with common organisms, such as S pneumonaie
and H influenza that are more likely to be drug-resistant
Pathogenesis (of nosocomial pneumonia): Microbiology of the nosocomial pneumonias
differs from CAP but is substantially the same among HAP, VAP, and HCAP. Anaerobic
organisms (anaerobic streptococci) may also cause pneumonia but are commonly part
of a polymicrobial flora.
✔✔Signs and symptoms of Nosocomial Pneumonia - ✔✔The signs and symptoms
associated with nosocomial pneumonia are nonspecific, however, two or more clinical
findings (fever, leukocytosis, purulent sputum) in the setting of new or progressive
pulmonary opacity on CXR were 75% specific for diagnosis of VAP.
Lab findings:
-Blood cultures can identify the pathogen in up to 20% of patients with nosocomial
pneumonia; Blood counts and chemistry tests do not establish a specific diagnosis of
HCAP but do help define severity of illness and identify complications.
-ABG assesses oxygenation and determines the need for assisted ventilation
Special considerations:
Endotracheal aspiration using sterile suction catheter can be used to obtain lower
respiratory tract secretions
Treatment
Is usually empiric, like with CAP, therapy should be started as soon as possible
because of the high mortality rate. After results of sputum, blood, and pleural fluid
cultures are available, it may be possible to de-escalate initially broad therapy. Duration
of antibiotic therapy should be individualized
✔✔o Obstruction grades by FEV1 severity - ✔✔§ I 80-100
§ II 50-80
§ III 30-50
§ IV 0-30
✔✔Tracheal stenosis - ✔✔s/t previous tracheotomy or endotracheal intubation.
Physical findings may absent until the tracheal diameter is reduced 50% or more →
wheezing, a palpable tracheal thrill and harsh breath sounds may be detected.
Dx test → plain films or CT of the trachea
Complications - recurrent pulmonary infection and life threatening respiratory failure.
Management - ensuring adequate ventilation and oxygenation, avoiding manipulative
procedures that may increase edema of the tracheal mucosa. Surgical reconstruction,
endotracheal stent placement, or laser photoresection may be required.
