Pneumonia, TB and chest tubes

Pneumonia

• An acute infection that fills the air sacs with fluid or pus, from bacteria, viruses or fungi.
• Types: community, hospital, ventilator, aspiration. Aspiration risks: trouble swallowing, an impaired gag reflex, oversedation, heavy alcohol or drug use.
• Cough, sometimes with purulent sputum; breathlessness; chest pain on breathing; fast breathing; fine crackles; falling saturation; fast pulse; fever with shaking chills; new confusion.
• Chest X-ray shows consolidation; white cells rise; a sputum culture names the organism.

Pneumonia care

• Treat the cause: antibiotics for bacteria, adjusted by the culture, or antivirals or antifungals.
• Oxygen to keep the saturation in range, usually above 92%; fever medicine as ordered.
• Coach coughing, deep breathing and the incentive spirometer; use infection control.
• Teach clients to finish the antibiotic course.
• Adult pneumococcal vaccine: routine from age 50, risk-based if younger, timed by prior vaccines.

TB: latent or active

Evaluate sooner: A cough of 3 weeks or more is a warning symptom, not a required duration: evaluate sooner when risk or symptoms warrant. Risks: close contact with TB, HIV or weak immunity, substance misuse, a high-TB region, homelessness, crowded settings like prisons.

Reading the TB skin test

Skin test: 0.1 mL of PPD given intradermally in the inner forearm. A trained reader reads it at 48 to 72 hours; a missed window means repeating it. Measure the induration in mm, not the redness.

After a positive test

• Positive means TB germs are present, not that the disease is active: a chest X-ray and sputum tests decide that.
• After the BCG vaccine, a blood test is preferred; the vaccine can make the skin test positive.
• A sputum smear is fast; a sputum culture confirms active TB, but takes weeks. TB is reported to public health.
• Close contacts are tested; teach cough etiquette and tissue disposal.

TB drugs

Influenza and other viruses

• Flu: fever, fatigue, body aches, cough, sore throat, headache. RSV: cough and wheezing, hardest on infants. Rhinovirus: the common cold.
• Influenza needs droplet precautions: a mask on entering the room, and a private room when available.
• Antivirals like oseltamivir work best started within 1 to 2 days of symptoms, and are recommended promptly for hospitalized and high-risk clients, even after 2 days (pregnancy, asthma, chronic lung disease, diabetes, heart disease). They're not antibiotics.

Pneumothorax

• Air around the lung is a pneumothorax; blood is a hemothorax. Part or all of the lung collapses.
• Spontaneous: no known cause, or lung disease like COPD. Traumatic: a chest wound, rib fracture or procedure.
• Sudden sharp chest or shoulder pain, worse with a breath or cough; short of breath; decreased or absent breath sounds on that side.
• Tension pneumothorax is an emergency: blood can't return to the heart, and the pressure drops. The trachea may shift only late: escalate at once so decompression isn't delayed.

Routine chest tube care

• Shift start: check the orders and suction level; baseline vital signs, saturation, lung sounds, breathing effort, trachea position.
• Dressing dry and intact. Crepitus, a crackling under the skin, means air has leaked into the tissue.
• Keep the tubing free of kinks and tape the connections; never strip it.
• Don't clamp routinely: it can cause a tension pneumothorax. For transport, don't clamp; disconnect the suction.

The drainage system

Keep it: Upright and below the chest, on a stable surface or hung on the bed. A trained operator chooses a safe insertion site, usually the triangle of safety.

Problems and emergencies

• Report drainage that is cloudy, stops in the first day, or passes the ordered limit (rule of thumb: over 200 mL an hour). In trauma, report an initial output over 1,500 mL.
• Emergency help for sudden worse breathlessness, a saturation under 90%, or a shifted trachea. A fast pulse with low pressure can mean a tension pneumothorax.
• Tube comes out: stay, send for help, assess. Cover the site at once with a sterile occlusive dressing, follow the local pleural-drain protocol, and never reinsert the old tube.
• Disconnected tubing or a cracked unit: follow the current local and device procedure. Unit tipped over: set it upright, check the water seal.
• Removal: prescribed pain medicine about 30 minutes before; no clamping first; breathe in deeply and hold as it comes out.