Pneumonia Notes

Pneumonia

Learning Outcomes

  • Describe the pathophysiology of pneumonia
  • Identify the types of pneumonia and risk factors
  • Recognize and analyze cues with diagnostic assessment findings
  • Formulate a plan of care for the patient with pneumonia
  • Discuss the medical management of pneumonia
  • Evaluate interventions

Pneumonia Overview

  • Infection of the lower respiratory tract
  • Causes: Aspiration, inhalation, bacteria, viruses, fungi, protozoa, and parasites
  • Prevalence: Affects 1% of the population
  • Hospitalization: 1.5 million hospitalizations annually
  • Significance: High mortality and morbidity
  • Mortality Ranking: Influenza and other pneumonias are the ninth overall cause of death
  • Global Impact: Responsible for over 2.5 million deaths annually, disproportionately affecting low- and middle-income countries.

Classification of Pneumonia

  • Based on: Microbiologic cause, host condition, host setting
  • Types:
    • Community-acquired pneumonia (CAP)
    • Hospital-acquired (nosocomial) pneumonia (HAP)
    • Ventilator-associated pneumonia (VAP)
    • Pneumonia in an immunocompromised patient

Pathophysiology of Pneumonia

  • Pathogen Entry: Pathogens enter the lung
  • Defense Overwhelmed: Host defenses are overwhelmed by the number of organisms or virulence in order for infection to develop
  • Colonization: Organisms colonize in alveoli, triggering an inflammatory and immune response

Pathophysiology Details

  • Antigen-Antibody Reactions: Antigen-antibody complexes and endotoxins damage bronchial and alveolar mucous membranes
  • Inflammation and Edema: Leads to inflammation, vascular congestion, and edema
  • Alveolar Impairment: Exudate and debris fill alveoli, decreasing gas exchange, which leads to consolidation of lung tissue

Clinical Manifestations of Bacterial Pneumonia

  • Chills (Rigors)
  • Fever
  • Sputum: Rust-colored or purulent
  • Pain: Pleuritic chest pain
  • Breath Sounds: Adventitious breath sounds (decreased, crackles, rhonchi)
  • Dyspnea
  • Cough
  • Decreased oxygen saturation
  • Cyanosis
  • Anxiety
  • Confusion

Risk Factors for Community-Acquired Pneumonia (CAP)

  • Age-Related Risks
    • Infants and young children: Immature immune systems
    • Elderly individuals (65+ years): Decreased immune function and underlying health conditions
  • Lifestyle & Behavioral Factors
    • Smoking: Damages lung defenses
    • Alcohol abuse: Weakens the immune system and may lead to aspiration pneumonia

Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP)

  • Debilitation
  • Malnutrition
  • Altered mental status
  • Previous exposure to antibiotics (within the last 90 days)
  • Hospital stays of 5 days or longer
  • High rates of antibiotic resistance (hospital or unit-specific)
  • Immunosuppressive therapies or diseases
  • Prolonged (greater than 48 hours) intubation or a tracheostomy
  • Treatment related, e.g., mechanical ventilation, unintentional extubation, upper abdominal surgery, thoracic surgery
  • Supine position

Diagnostic Evaluation

  • Chest X-ray
  • Sputum gram stain
  • Laboratory Studies
    • CBC
    • Blood cultures
    • Arterial blood gases
    • HIV test
    • Electrolytes
    • Bronchoscopy

Interprofessional Care

  • Respiratory: consult for inhalers, breathing treatments, and suctioning
  • Nutritional services: consult for weight loss or gain related to medications and diagnosis
  • Rehab: consult for prolonged weakness; PT and OT involvement

Interprofessional Care - Pharmacotherapy

  • Oxygen therapy
  • Antibiotics
  • Antipyretics
  • Anti-virals
  • Anti-inflammatory agents
  • Bronchodilators
  • Mucolytics
  • Cough Expectorants

Medications

  • Antibiotics:
    • Administration: IV initially, then switched to PO as patient improves.
    • Examples: Penicillin & cephalosporins (Take with Food)
    • Monitoring: Frequent stools and kidney function
  • Bronchodilators:
    • Function: Reduce bronchospasms and irritation
    • Short acting beta 2 agonists: Albuterol, provides rapid relief.
    • Cholinergic antagonists: Ipratropium, increase bronchodilation and decrease pulmonary secretions.
    • Methylxanthines: Theophylline, relaxes bronchial smooth muscles to increase or improve air flow.
    • Monitoring: Toxicity level with Theophylline, tachycardia for albuterol and dry mouth with ipratropium.

Medications - Anti-inflammatories

  • Function: Help decrease airway inflammation.
  • Glucocorticosteroids: fluticasone and Prednisone, are prescribed to decrease inflammation. (Take with food)
  • Monitoring:
    • Hyperglycemia
    • Fluid retention and weight gain
    • Canker sores
    • Report black tarry stools

Prevention

  • Vaccines: Influenza & Pneumococcal Vaccines
  • Supportive therapy

Patient-Centered Care

  • Patient Assessment Includes:
    • Subjective Data (Patient history)
    • Objective Data (Physical Assessment)
    • Review diagnostic test results

Assessment Findings

  • Fever
  • Tachypnea/dyspnea
  • Tachycardia
  • Chills
  • Cough, productive or nonproductive
  • Pleuritic chest pain
  • Fatigue
  • Myalgia/arthralgia

Nursing Goals of Care

  • Patient will exhibit:
    • Clear breath sounds
    • Breathing pattern within normal limits
    • No signs of hypoxia
    • No complications associated with pneumonia

Client Problems

  • Ineffective airway clearance related to copious tracheobronchial secretions
  • Impaired gas exchange
  • Activity intolerance related to impaired respiratory function
  • Risk for deficient fluid volume related to fever, a rapid respiratory rate, and sepsis
  • Malnutrition risk for less than body requirements
  • Knowledge deficiency about the treatment regimen and preventive health measures

Nursing Process - Planning

  • Goals of Care: Patient will exhibit:
    • Clear breath sounds
    • Breathing pattern within normal limits
    • No signs of hypoxia
    • No complications associated with pneumonia

Nursing - Health Promotion (Hospitalized patient)

  • Identify patient at risk for pneumonia
  • Careful consideration of positioning of patient with altered level of consciousness or aspiration risk
  • Encourage patient to get out of bed
  • Encourage deep breathing
  • Maintain strict medical asepsis during patient care and in between patient contact

Nursing Interventions: Improving Airway Patency

  • Removing secretions
  • Hydration (2 to 3 L/day) as tolerated
  • Humidification
  • Lung expansion maneuvers such as:
    • Deep breathing and cough
    • Incentive spirometer
    • Good Lung down
    • Chest PT
  • Consult Respiratory

Nursing - Monitoring

  • Monitor respiratory parameters on ongoing basis (rate, rhythm, breath sounds, pulse oximetry, ABGs if ordered)
  • Monitor Neurologic status
  • Monitor Temperature every 4 hours

Nursing Process - Implementation

  • Maintain head of bed at High Fowler’s position with arms supported Unless Contraindicated
  • Provide supplemental humidified oxygen as prescribed
  • Encourage deep breathing with incentive spirometry.
  • Assist with position changes

Nursing Process - Implementation (cont.)

  • Assist with Chest Physiotherapy as appropriate
  • Teach & encourage incentive spirometer use
  • Teach pt to splint chest with coughing

Nursing Process - Implementation (cont.)

  • Encourage fluids (2-3 liters per day unless contraindicated)- may be PO & or IV
  • Encourage Coughing to help remove secretions
  • Set up suction equipment and suction if necessary
  • Administer antibiotics, inhalers, antipyretics as prescribed

Nursing Process - Implementation (cont.)

  • Provide comfort measures (dry bedclothes, sheets, oral care)
  • Provide foods that are easier to chew and digest
  • Space activity with rest periods.

Nursing Process - Implementation (cont.)

  • Provide receptacle to place secretions & teach pt. importance of placing items in receptacle
  • Provide time to answer questions & to allay anxiety and fears

Nursing Process - Implementation - Health Teaching (Discharge)

  • Hand hygiene
  • Obtain rest, nutrition, exercise
  • Avoid known exposure to URIs
  • Obtain care for symptoms > 7 days

Nursing Process - Implementation (cont.)

  • Obtain Flu and Pneumonia vaccines (Health Promotion)
  • Provide smoking cession education (Health Promotion)
  • Complete full course of antibiotics
  • Resume activities gradually

Complications

  • Atelectasis:
    • Airway inflammation and edema need to alveolar collapse and increases the risk of hypoxemia.
    • Client has diminished or absent breath sounds over affected area.
    • Chest X-ray shows an area of density (WHITE OUT)
  • Bacteremia:
    • Occurs if pathogens enter the bloodstream from the infection in the lungs.
  • Acute Respiratory Distress Syndrome (ARDS)
    • Hypoxemia persists despite oxygen therapy
    • Lung volume capacity and elasticity reduces
    • Dyspnea worsens as bilateral pulmonary edema develops
    • X-ray shows an area of density with ground-glass appearance
    • blood gas findings show high levels of carbon dioxide(hypercarbia) with decreased saturation

Nursing Process - Evaluation

  • Are Goals and Outcomes Met?
  • How would you evaluate if medications and treatment are effective?
  • What criteria would you use to determine if plan of care has been effective?

Patient Education

  • Continue medication for treatment of pneumonia.
  • DO NOT SAVE MEDS FOR ANOTHER TIME.
  • Rest as needed.
  • Maintain hand hygiene to prevent infection.
  • Avoid crowded areas to reduce risks of infection.
  • Treatment and recovery time may vary.
  • Obtain immunizations for influenza and pneumonia.
  • Stop smoking.