REPLY POSTS:Reply separately to two of your classmates posts (See attached classmates posts, post#1 and post#2). Instructions: - For post # 1 response, also consider commenting on the following: "Beca
POST # 2: Danika
Note: For this peer response also consider elaborating on ---"Flu vaccinations are recommended for all individuals each season" --- Why yearly? Explain.
Use at least two scholarly references per peer post. The expectation is not that you “agree” or “disagree” with your peers but that you develop a reply post with information that is validated via citations to encourage learning and to bring your own perspective to the conversation.
Danika post: Case study: Influenza and Pneumonia
The purpose of this initial post is to summarize and discuss a case study on influenza and pneumonia. Mrs. A. H. was diagnosed with an acute episode of influenza A with was complicated by pneumococcal pneumonia. Influenza A is an RNA othromyxovirus and is the most prevalent influenza pathogen. It is a viral infection that starts in the respiratory mucosa. The virus replicates and invades the tissue causing inflammation, necrosis, and swelling leading to congested, obstructed airways. The virus can spread along the mucosa to the ears, sinuses, bronchi, and lungs causing otitis media, sinusitis, and pneumonia (VanMeter & Hubert, 2018).
The respiratory system has normal mechanisms to defend against infection. When air is inhaled, foreign material is filtered out by the mucous secretions and hairs that line the upper respiratory tract. The mucous secretions are formed by pseudostratified ciliated columnar epithelium like goblet cells. The “ciliary elevator” refers to when the mucous blanket traps foreign material and the cilia sweep the debris up and out of the respiratory tract. This process may stimulate a cough or sneeze when there are excessive amounts of unwanted debris. Additionally, the lymphoid tissue in the pharyngeal and palatine tonsils serve as another defense mechanism. If foreign material gets past the first defensive mechanisms and enters the lungs, alveolar macrophages will remove the debris to keep the alveolar functioning optimally.
Mrs. A.H. lives in a seniors’ apartment building where many residents have had the flu in the past month. It can be expected that many of the residents would be affected by influenza because the virus is highly contagious and is present in the respiratory secretions of infected people. This makes it easy to spread through large droplet particles when coughing or sneezing. Contaminated surfaces can be another potential source of infection. The virus may begin shedding 24 to 48 hours before onset of disease manifestation (Moghadami, 2017). Elder individuals are predisposed to influenza (explained below) so the infection rate may be high in her facility.
Residents can take precautions to avoid influenza. Flu vaccinations are recommended for all individuals each season (VanMeter & Hubert, 2018). Care should be taken everyday to prevent the spread of the virus like washing hands, avoiding contact with sick people, and covering nose and mouth with a tissue when sneezing (CDC, 2019). Residents should isolate themselves if they are ill. Antiviral drugs, like Tamiflu, can reduce the risk of spreading to others and may be useful in hospitals and nursing homes (VanMeter & Hubert, 2018). To reduce the risk of respiratory infection for myself, colleagues, and patients, I will perform the same precautions. I receive a flu vaccine every year, practice vigilant hand hygiene, and wear a mask with suspected or flu positive patients. The CDC (2019) also recommends disinfecting surfaces frequently.
Antibiotics are not effective against the influenza virus because they target the bacterial cell wall or metabolism and viruses do not have these components. A provider may prescribe antibacterial drugs when a virus is present to reduce the risk of a secondary bacterial infection (VanMeter & Hubert, 2018).
Mrs. A.H.’s age and influenza episode predispose her to pneumonia. As people age, the skeletal muscle atrophies, elasticity in the lung tissue is reduced, and coastal cartilage between the ribs can be calcified reducing movement. These factors can impair inspirations and expirations leading to a reduction in deep breathing and coughing. The risk of lung infections increases in elderly due to weaker immune systems and an inability to remove secretions. Influenza increases the risk of pneumonia because the necrotic lung tissue is vulnerable and suspectable to a bacterial infection (VanMeter & Hubert, 2018). Streptococcus pneumoniae (pneumococcus) is normal resident flora of the nasopharynx (Donkor, 2013) so the disruption of the intact epithelial barrier from a virus can favor colonization (Alspaugh & Velkey, 2016). Additionally, Mrs. A.H. could have been more immobile during her flu episode. Immobility allows secretions to build up and predisposes her to respiratory complications (VanMeter & Hubert, 2018).
Mrs. A.H. is then admitted to the hospital after she developed severe chest pain and confusion. Pneumococcal pneumonia was suspected. The diagnostic tests that are appropriate are: 1) a sputum culture to identify the organism in order to assist in selecting the proper therapy, 2) A chest XRAY to diagnosis pneumonia and differentiate the type. Consolidation formed by the alveolar exudate is common in pneumococcal, 3) O2 saturations to assess oxygenation levels, 4) Blood gases to determine severity of systemic effects like acidosis and 5) lung auscultation may find rales, rhonchi, or friction rub.
The chest pain Mrs. A.H. is describing is most likely caused from pleurisy. This is caused when the inflamed lobe effects the adjacent pleurae. The inflamed membrane is aggravated when it is stretched with coughing and inspiration. Mrs. A.H. also presented with confusion. In older adults, confusion and delirium may be the initial manifestation of infection (Marrie & Taomanen, 2018). Ineffective ventilation creates cell hypoxia which can affect the brain quickly as it has little capacity for oxygen storage and constant demand (VanMeter & Hubert, 2018).
As the pneumonia progresses, Mrs. A.H. may experience systemic signs like fever with chills, fatigue, and leukocytosis as the body responds to infection. She may have dyspnea and tachypnea because ventilation is impaired due to exudate in the alveoli. Hypoxia causes the heart rate to increase in order to compensate. She will most likely have a productive cough with rust colored sputum due to the presence of RBCs in the exudate. Respiratory congestion from pneumonia can cause respiratory acidosis so we would expect to see a pH < 7.35, PCO2 > 45, decreased pO2 (below 75), and bicarb may initially be normal or slightly elevated because the kidneys cannot compensate as quickly as the lungs. The patient may hyperventilate in an attempt to blow off the built-up CO2 but gas exchange is impaired, so this is ineffective. The kidneys eventually will excrete more hydrogen and reabsorb bicarb to compensate for the acidosis. A compensated respiratory acidosis will have a pH around 7.35-7.4, the bicarb will be elevated (above 28), and CO2 will be elevated (above 45) (VanMeter & Hubert, 2018).
Fever, increased metabolic rate, and decreased appetite and thirst may lead to dehydration in Mrs. A.H. Her body prioritizes maintaining adequate oxygen instead of fluid intake. It is important to anticipate dehydration in these patients because it can further complicate the illness by causing low blood pressure (which can lead to shock) and electrolyte imbalances. Urinary tract infections and constipation are associated with lack of fluid intake. Dehydration can also create thicker mucous making her recovery longer (VanMeter & Hubert, 2018).
Treatment of Mrs. A.H.’s pneumococcal pneumonia would include supplemental oxygen, IV hydration, antibacterial medications (narrow spectrum once the organism is identified), and antipyretics to reduce the fever. She should be encouraged to use an incentive spirometer to improve ventilation. Efforts should be made to increase her mobility as tolerated so she does not experience negative affects from immobility. Some negative outcomes of immobility are decreased venous blood return and cardiac output which may cause orthostatic hypotension and edema. The stasis of blood in the veins can put her at risk for developing DVTs. Dehydration and bedrest can cause constipation and decrease appetite. In the supine position, stasis of urine can lead to urinary tract infections or renal stones. Skin breakdown is also a huge risk for patients experiencing immobility (VanMeter & Hubert, 2018).
References
Alspaugh, A., & Velkey, J. (2016). Pneumonia: Pathophysiology and Clinical Manifestations [Video file]. Retrieved June 9, 2020, from https://www.youtube.com/watch?time_continue=7&v=dYFOHZchWNg&feature=emb_title
CDC. (2019). CDC Says "Take 3" Actions to Fight Flu. Retrieved June 09, 2020, from https://www.cdc.gov/flu/prevent/preventing.htm
Donkor, E. S. (2013). Understanding the pneumococcus: Transmission and evolution. Frontiers in Cellular and Infection Microbiology, 3, 1-5. doi:10.3389/fcimb.2013.00007
Marrie, T., & Taomanen, E. (2018). Pneumococcal pneumonia in adults. Retrieved June 09, 2020, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/pneumococcal-pneumonia-in-adults?search=pneumonia+confusion
Moghadami, M. (2017). A Narrative Review of Influenza: A Seasonal and Pandemic Disease. Iranian Journal of Medical Sciences, 42(1), 2-13.
VanMeter, K. C., & Hubert, R. J. (2018). Gould's pathophysiology for the health professions. St. Louis, MO: Elsevier Saunders.
