Pneumonia

Aaaa my lungs are filled with juice

Definition of pneumonia

• Infection of lungs that causes inflammation of the alveoli

• Caused by microbial organisms (bacterial, viral, fungal)

• Alveolar consolidation → Alveoli become filled with fluid, pus, etc

Most common cause of bacterial pneumonia

Streptococcus penumoniae

Viral pneumonia can be caused by

Often influenza and RSV

What often causes walking pneumonia?

Mycoplasma pneumonia

Types of pneumonia origins

• Community acquired pneumonia (CAP)

• Hospital acquired pneumonia (HAP)

• Ventilator associated pneumonia (VAP)

Community acquired pneumonia

• Infection is acquired outside of the hospital

• Can be bacterial, viral, fungal

Hospital acquired pneumonia

• Onset of symptoms 48 hours or more after admission

• Often caused by bacteria

Ventilator Associated Pneumonia

• Onset of symptoms 48 hours or more after intubation

• Often caused by bacteria

What are the various ways that the lungs can be infected by pneumonia-causing pathogens?

• Aspiration of normal flora from nasopharynx or oropharynx

  • Decreased cough/epiglottis reflexes

  • Decreased LOC

• Inhalation

• Increased secretions in the lungs + Impaired clearance

  • Smoking, post-viral, cystic fibrosis, COPD/asthma

• Hematogenous spread

  • Primary infection in another area of the body → Travels to lungs via the blood stream

What risk factors increase the chances of developing pneumonia>

• Abdominal or thoracic symptoms

• Elderly

• Altered LOC

• Bedrest and immobility

• Chronic conditions

• Immunosuppression

• Intestinal/gastric tubes

• Malnutrition

• Smoking

• Tracheal intubation

• Upper respiratory infection (cold, flu) and Altered oropharyngeal flora (mouth/throat infection)

Clinical manifestations of pneumonia

• Tachypnea and Dyspnea

• Adventitious lung sounds over affected area

  • Pleural rub, crackles, rhonchi

• Tachycardia

• Fever. Might have chills

• Cough (productive or dry)

  • Sputum → Green, yellow

    • Rust colored → might be bloody!

• General malaise

• Pleural chest pain

• Dull percussion (from fluid)

• Decreased SpO2

How might pneumonia present in geriatric populations?

• Altered mental status, confusion, stupor

• Hypothermia

• Diaphroetic

• Anorexia

• Fatigue

• Myalgia (muscle aches)

• Headaches

What imaging study is often used to diagnose pneumonia?

Chest X-ray

What diagnostic studies might be used to diagnose pneumonia?

• Chest x-ray

• Sputum

  • Gram stain and cultures

• CBC

  • Elevated WBCs

• CRP

  • Elevated → presence of inflammation (nonspecific)

• Procalcitonin

  • Elevated → Bacterial inflammatory stimulus

• SpO2 and ABGs

  • Hypoxemia

What diagnostic study indicates the presence of inflammation in response to bacterial infections?

• CRP

• Sputum culture

• Procalcitonin

Procalcitonin → Lab value, rises in response to inflammatory stimulus from bacteria (specific!)

Wrong answer:

• CRP → General inflammatory marker

• Sputum culture → Determines what specific bacteria is infecting the lungs. It’s close, but doesn’t detect the presence of inflammation

What possible nursing diagnoses might be used to describe a patient with pneumonia?

• Ineffective airway clearance

• Impaired gas exchange

• Risk for infection

• Activity intolerance

• Deficient knowledge

What goals are appropriate to have when caring for a patient with pneumonia?

• Maintain effective airway clearance

• Improve oxygenation and respiratory function

• Prevent complications such as sepsis and respiratory failure

• Educate on prevention strategies (especially for those with chronic/lifestyle risk factors)

What medication is used to prevent a patient at risk from getting pneumonia?

Pneumococcal vaccine

True or false:

For a patient with pneumonia, antibiotics aren’t given until the results of a sputum culture are obtained to determine the specific organism causing the illness.

FALSE.

• Empiric antibiotics (broad spectrum based on clinical presentation) are started immediately

• At least 2 medications

Take a culture before administering antibiotics, BUT start antibiotics before receiving results.

Empiric antibiotics

• Started immediately before specific pathogen causing the infection is known

• Based on the most likely cause and risk factors for multidrug resistant organisms

• At least 2 meds are given

  • Often levoquin, vancomycin, zosyn

Medications that are given to patients with pneumonia

• Preventative - pneumococcal vaccine

• Empiric antibiotics - broad spectrum, at least 2

• Bronchodilators - albuterol, anticholinergics

• Mucolytics

• Antipyretics

• Analgesics - morphine is preferred

True or false:

Dilaudid is the preferred analgesic for patients with pneumonia

FALSE

It’s not bad, but when given the choice, morphine is preferred

“Relaxes the muscles in the lungs”

Nursing interventions for patients with pneumonia

• Administer prescribed medications

• Supplemental oxygen

• Chest physiotherapy

• Fluids

• Rest, but ensure patient mobilizes themselves

• Position - High/semi-fowlers if BP tolerates

• Suction PRN

• Coughing, deep breathing, and incentive spirometer

• Assess vitals, breath sounds, skin color Q4 hours

What to assess/monitor in patients with pneumonia?

• Q4 hours - Respiratory status, vital signs, breath sounds, skin color

• Cough and sputum (consistency, color)

• ABGs, report abnormal values

• Pain, administer analgesia if needed

Complications of pneumonia

• Pleura

  • Pleurisy (inflammation of pleura)

  • Pneumothorax

  • Pleural effusion

• Systemic / Organs other than Lungs

  • Bacteremia (can lead to sepsis)

  • Sepsis, septic shock

  • Pericarditis, endocarditis

  • Meningitis

    • Strep. pneumoniae, haemophilus influenzae

• Atelectasis

• Lung abscess (not common)

  • Empyema

• Respiratory failure → DEATH!

What is the leading cause of death in patients with pneumonia?

Respiratory failure

What pathogens increase the risk of developing meningitis secondary to pneumonia infection?

• Streptococcus pneumoniae

• Haemophilus influenzae

Types of pleural effusion

• Transudative — watery

• Exudative — high amount of WBCs and proteins → Purulent

What is a pleural effusion?

Buildup of fluid in the pleural space

Clinical manifestations of pleural effusion?

Possible complication of pneumonia

• Dyspnea

• Pleuritic pain

• Decreased breath sounds

• Chest x-ray!!!!

True or false:

A chest tube might be required for a pleural effusion

True

What are signs that a patient with pneumonia is improving?

• Decreased work of breathing

• Normalized vital signs

• Clearer lung sounds

Wha

What are signs that a patient with pneumonia is experiencing complications?

• Worsening respiratory distress

• Signs of sepsis

• Worsening ABGs and pulse oximetry

• Worsening dyspnea

• Reduced lung capacity and elasticity

Methods of preventing ventilator-associated pneumonia

• Hand washing

• Check tubing, drain away from the patient

• Don’t instill normal saline through the endotrach tube

  • Suction every 2 hours instead to loosen mucus!

• For patients with altered LOC

  • Position to prevent aspiration

  • Turn every 2 hours

• VAP bundle

Methods to prevent VAP specific to patients with altered level of consciousness

• Positioning to prevent aspiration (elevated HOB)

• Turn and reposition → Every 2 hours

VAP Bundle

• Elevated HOB - 30-45 degrees

• Daily Sedation Vacations

  • Trying to see if patient can tolerate being off of sedation

• Prophylaxis for

  • Peptic ulcer disease (PPIs) → reduce GI stress

  • Venous thromboembolism (DVT) → prevent pulmonary embolism

• Q2 hours CARE

  • Suction (+ PRN)

  • Oral care Chlorohexidine (2-4 hours)

  • Oral moisturizer (2-4 hours)

• Brushing teeth Q12 hours

How often should patients on a ventilator and altered LOC be repositioned?

Q 2 hoursH

What do patients on a ventilator receive as prophylaxis in order to prevent VAP?

Prophylaxis for Peptic ulcer disease and DVT/VTE (thromboembolism)

How often should these actions be performed as indicated by the VAP bundle?

• Suctioning

• Oral care with chlorohexidine

• Oral moisturizer

• Teeth brushing

• Sedation vacation

• Suctioning — Q2 hours and PRN

• Oral care with chlorohexidine — Q2-4 hours

• Oral moisturizer Q2-4 hours

• Teeth brushing — Q12 hours

• Sedation vacation — Daily

Severe covid-19 infection is characterized by

• SpO2 < 94% on room air

• Respiratory rate > 30 BPM

• Lung infiltrates >50% of lung tissue

• Ratio oxygen pressure to fraction of inspired oxygen: PaO2/FiO2 < 300 mmHg

  • Overall — Gas exchange is BAD

When covid-19 progresses to critical illness in individuals, this can cause…

• Respiratory failure

• Septic shock

• Multiple organ dysfunction

Severe Covid-19 is higher in people who…

• Aged >65 years

• Living in nursing homes, long-term care facilities

• Chronic medical conditions

Lab values and what they indicate in patients with severe covid-19

** Lymphocytes may be increased in infections, but decreased in severe infections

Treatment for severe Covid-19 infections

• Corticosteroids

  • Reduces inflammatory response, lowers temperature

• Baricitinib

  • Inhibits virus infxn and cytokine signalling (inhibits excessive inflammation)

• Albumin

• Oxygen and ventilation

• Guidelines for Acute Hypoxemic Respiratory Failure (ARDS)

• VTE prevention - Heparin

• Antibiotics for other respiratory infxns