22 terms

Pneumocystis jiroveci (carinii) pneumonia

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Overview
Communicable, opportunistic lung infection commonly associated with human immunodeficiency virus (HIV)
Leading cause of opportunistic infection and death among patients with acquired immununodeficiency syndrome (AIDS) in industrialized countries
Also known as Pneumocystis, interstitial plasma cell pneumonia, or Pneumocystis carinii pneumonia (PCP)
Overview-Pathophysiology
With defective cellular and humoral immunity, the infecting organism invades the lungs bilaterally, multiplies extracellularly, and fills alveoli with organisms and exudate.
Alveolar capillary membrane permeability is altered.
As a result, gas exchange is impaired.
Alveoli hypertrophy and thicken, eventually leading to extensive consolidation.
Overview-Causes
P. jiroveci mainly spread through the air (Although part of the normal flora in most healthy people, this organism becomes an aggressive pathogen in immunocompromised patients.)
Possible role of B-cell function defects
Overview-Risk Factors
Immunocompromised state
Severe malnutrition
Hematologic and nonhematologic malignancies (solid tumors and lymphomas)
Overview-Incidence
P. jiroveci pneumonia is most common in patients receiving immunosuppressive therapy, and in those with HIV or AIDS.
It's a major cause of death in patients with AIDS.
Overview-Complications
Disseminated infection
Hypoxemia
Respiratory failure
Pneumothorax
Death
Assessment-History
Immunosuppression, as from HIV infection, leukemia, lymphoma, or organ transplantation
Dyspnea on exertion progressing to continuous dyspnea
Weakness
Fatigue
Malaise
Nonproductive cough, chest discomfort
Chills
Weight loss
Assessment-Physical Findings
Low-grade, intermittent fever
Tachypnea
Cough, nonproductive or productive, with scant amounts of white or clear sputum
Accessory muscle use for breathing
Cyanosis (with acute illness)
Dullness on percussion (with consolidation)
Crackles
Decreased breath sounds
Intercostal retractions (children)
Diagnostic Test Results-Laboratory
Histologic sputum specimen studies show P. jiroveci
Arterial blood gas (ABG) values indicate hypoxemia and an increased A-a gradient.
Serum lactate dehydrogenase levels are commonly increased.
CD4 cell count is usually less than 200/µL in HIV-positive individuals.
Diagnostic Test Results-Imaging
Chest X-rays may show slowly progressing, fluffy infiltrates; occasional nodular lesions; or spontaneous pneumothorax (may be normal in early disease).
High-resolution computed tomography reveals interlobular septal thickening and patchy areas resembling a ground-glass appearance.
Gallium scan may show increased uptake over the lungs.
Diagnostic Test Results-Diagnostic Procedures
Fiber-optic bronchoscopy is the most commonly used study to confirm PCP.
Transbronchial biopsy is an invasive procedure less commonly performed to confirm diagnosis.
Bronchoalveolar lavage identifies organism.
Sputum induction testing reveals organism
Open lung biopsy is an invasive procedure rarely performed to confirm diagnosis.
Pulmonary function test may show decreased diffusion capacity of carbon monoxide.
Treatment-General
Supportive care
Maintenance of optimal respiratory function
Mechanical ventilation
Treatment-Diet
High-calorie, high-protein
Nutritional supplements as needed
Small, frequent meals
Increased fluid intake
Treatment-Activity
Rest periods when fatigued
Treatment-Medications
I.V. trimethoprim and sulfamethoxazole (may be given prophylactically to patients with AIDS and other high-risk patients)
PredniSONE or methylPREDNISolone as adjunctive therapy
Pentamidine isethionate I.V., dapsone and trimethropim, clindamycin phosphate and primaquine, or atovaquone suspension as second-line agents
Oxygen
I.V. fluid therapy
Nursing Considerations-Nursing Diagnoses
Activity intolerance
Deficient fluid volume
Fear
Hyperthermia
Imbalanced nutrition: Less than body requirements
Impaired gas exchange
Impaired social interaction
Ineffective breathing pattern
Powerlessness
Nursing Considerations-Expected Outcomes
perform activities of daily living to the fullest extent possible
maintain adequate fluid volume
verbalize fears, feelings, and concerns
remain afebrile
experience no further weight loss
regain normal ABG values and maintain adequate ventilation and oxygenation
demonstrate effective social interaction skills
maintain an effective breathing pattern
participate in self-care and make decisions about care.
Nursing Considerations-Nursing Interventions
Implement standard precautions.
Give prescribed drugs such as I.V. trimethoprim and sulfamethoxazole over 60 to 90 minutes, initiate I.V. access if not already available, and maintain I.V. patency.
If pentamidine isethionate is ordered, obtain necessary laboratory tests, such as daily blood urea nitrogen (BUN) and creatinine, blood glucose levels, complete blood count, platelets, and liver function studies; maintain the patient in a supine position to prevent injury secondary to changes in blood pressure associated with pentamidine.
Administer I.V. fluids as ordered; provide small, frequent, well-balanced meals and snacks.
Auscultate lung sounds for changes; anticipate the need for endotracheal intubation and mechanical ventilation should patient's respiratory status deteriorate.
Administer oxygen as ordered based on oxygen saturation levels and ABG results.
Encourage ambulation if appropriate; urge the patient to perform deep-breathing exercises, and use incentive spirometry every 2 hours.
Provide adequate rest periods; cluster care activities to allow for rest periods and minimize oxygen demands.
Encourage the patient to express fears, feelings, and concerns; listen actively and nonjudgmentally; and provide emotional support, guidance, and encouragement.
Nursing Considerations-Monitoring
Vital signs
Respiratory status
ABG values
Fluid and electrolyte status
Activity tolerance
Coping strategies
Nursing Considerations-Associated Nursing Procedures
Arterial puncture for blood gas analysis
Chemotherapeutic drug administration
Chemotherapeutic drug preparation and handling
IV bag preparation
IV bolus injection
IV catheter insertion
IV pump use
Oral drug administration
Oxygen administration
Pulse assessment
Pulse oximetry
Respiration assessment
Sputum collection by tracheal suctioning
Temperature assessment
Venipuncture
Patient Teaching-General
disorder, diagnosis, and treatment, including the use of I.V. agents and oral corticosteroids
prescribed drug therapy regimen, including the drug name(s), dosage(s), route of administration, frequency, and duration of therapy
that I.V. trimethoprim and sulfamethoxazole therapy is administered for 21 days; that oral predniSONE therapy continues for 21 days
need to avoid exposure to direct sunlight if receiving trimethoprim and sulfamethoxazole
importance of receiving lifetime prophylaxis for P. jiroveci after initially treated unless CD4 count increases
possible adverse effects of drug therapy, such as photosensitivity, nausea, vomiting, and rash with trimethoprim and sulfamethoxazole; cushingoid effects with predniSONE
need for gradual dosage reduction when predniSONE is ordered
energy conservation techniques, coping strategies, and anxiety reduction techniques
standard precautions and infection control and prevention measures (for HIV-infected patients and other immunocompromised individuals)
home oxygen and I.V. drug therapy if indicated
importance of continued follow-up care with laboratory testing to evaluate infection and immune status.
Patient Teaching-Discharge Planning
Refer the patient to a pulmonologist or an infectious diseases specialist for follow-up care, as needed.
If the patient has AIDS or HIV, provide information about resources and support organizations.
Refer the patient for possible home health care services as appropriate.
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