PNA SV

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 caused by microorganisms

  • Organisms: bacteria, viruses, fungi, protozoa, parasites

  • Infection methods: aspiration and inhalation

  • Affects approximately 1% of the population

  • Leads to 1.5 million hospitalizations annually

  • Associated with high mortality and morbidity

  • COVID-19 pneumonia is a leading cause of death due to infectious sources in the U.S.

  • Influenza and pneumonia rank as the ninth overall cause of death

Classification of Pneumonia

  • Based on microbiologic cause and host conditions/settings:

    • Community-acquired pneumonia (CAP)

    • Hospital-acquired pneumonia (HAP)

    • Ventilator-associated pneumonia (VAP)

    • Pneumonia in immunocompromised patients

Pathophysiology Overview

  • Pathogens enter the lungs

  • Host defenses may be overwhelmed by the number and virulence of organisms

  • Colonization of organisms in alveoli incites inflammatory and immune responses

Pathophysiology Details

  • Antigen-antibody reactions and endotoxins damage bronchial and alveolar mucous membranes

  • Results in inflammation, vascular congestion, and edema

  • Exudate and debris fill alveoli, reducing gas exchange leading to consolidation of lung tissue

Clinical Manifestations of Bacterial Pneumonia

  • Chills (rigors)

  • Fever

  • Rust-colored or purulent sputum

  • Pleuritic chest pain

  • Adventitious breath sounds (decreased, crackles, rhonchi)

  • Dyspnea

  • Cough

  • Decreased oxygen saturation

  • Cyanosis

  • Anxiety

  • Confusion

  • Abrupt onset

Community-Acquired Pneumonia (CAP) Risk Factors

  • Smoking

  • Alcohol use disorder

  • Pre-existing conditions: hypoxemia, acidosis, toxic inhalations

  • Diseases: COPD, asthma, cardiovascular diseases (HF), cerebrovascular disease

  • Neurological conditions: Parkinson's disease, epilepsy, dementia

  • Factors: dysphagia, HIV, chronic kidney/liver disease, malnutrition

  • Immunosuppressive therapies

  • Poor dental hygiene

  • Age > 65 years

  • Intravenous drug use

  • Close contact with children

  • Crowded living situations

  • Previous pneumonia episodes

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

  • Risk factors include:

    • Debilitation and malnutrition

    • Altered mental status

    • Previous antibiotic exposure

    • Hospital stays of 5 days or longer

    • High rates of antibiotic resistance

    • Immunosuppressive therapies or diseases

    • Prolonged intubation or tracheostomy

    • Male biological sex

    • Treatment-related factors

    • Supine position

Diagnostic Evaluation

  • Chest X-ray

  • Sputum gram stain

  • Laboratory studies:

    • Complete Blood Count (CBC)

    • Blood cultures

    • Arterial blood gases

    • HIV test

    • Electrolytes

    • Bronchoscopy

Interprofessional Care- Pharmacotherapy

  • Oxygen therapy

  • Antibiotics

  • Antipyretics

  • Anti-virals

  • Anti-inflammatory agents

  • Bronchodilators

  • Mucolytics

  • Cough expectorants

Interprofessional Care

  • Vaccination for Flu and Pneumococcal disease

  • Supportive therapy

Nursing Assessment

  • Subjective Data (Patient history)

  • Objective Data (Physical Assessment)

  • Review of diagnostic test results

Goals of Care

  • Patient will exhibit:

    • Clear breath sounds

    • Normal breathing patterns

    • No signs of hypoxia

    • No complications associated with pneumonia

Client Problems

  • Ineffective airway clearance

  • Activity intolerance

  • Risk for deficient fluid volume

  • Malnutrition risk

  • Knowledge deficiency

Nursing Process- Planning

  • Goals of Care reiteration:

    • Clear breath sounds

    • Normal breathing patterns

    • No hypoxia

    • No complications

Health Promotion for Hospitalized Patients

  • Identify patients at risk for pneumonia

  • Positioning considerations for altered consciousness/aspiration risk

  • Encourage mobility and deep breathing

  • Maintain strict medical asepsis

Nursing Interventions: Improving Airway Patency

  • Removing secretions

  • Hydration (2 to 3 L/day) as tolerated

  • Humidification

  • Lung expansion maneuvers including:

    • Deep breathing and coughing

    • Incentive spirometer

    • Positioning (Good Lung down)

    • Chest physiotherapy

    • Consult Respiratory Therapy

Nursing Actions

  • Monitor respiratory parameters regularly:

    • Rate, rhythm, breath sounds, pulse oximetry, ABGs if ordered

  • Monitor neurologic status

  • Temperature monitoring every 4 hours

Nursing Actions cont.

  • Maintain head of bed at Fowler’s position with arm support

  • Provide supplemental humidified oxygen as prescribed

  • Encourage deep breathing and assist with position changes

Nursing Actions cont.

  • Assist with chest physiotherapy as appropriate

  • Teach and encourage use of incentive spirometer

  • Instruct patients to splint chest during coughing

Nursing Actions cont.

  • Encourage fluid intake (2-3 liters/day unless contraindicated)

  • Setup suction equipment for use if necessary

  • Administer antibiotics, inhalers, antipyretics as prescribed

Nursing Actions cont.

  • Provide comfort measures:

    • Dry bedclothes, sheets, oral care

    • Provide foods that are easier to chew and digest

    • Space activities with rest periods

Nursing Actions cont.

  • Provide receptacle for secretions and teach its importance

  • Allow time to address questions and reduce anxiety

Health (Discharge) Teaching

  • Hand hygiene

  • Importance of rest, nutrition, and exercise

  • Avoid known exposure to upper respiratory infections

  • Seek care for symptoms persisting beyond 7 days

Nursing Actions - Health Promotion

  • Obtain flu and pneumonia vaccines

  • Smoking cessation education

  • Ensure completion of the full course of antibiotics

  • Gradually resume activities

Complications of Pneumonia

  • Shock

  • Respiratory failure

  • Atelectasis

  • Pleural effusions

  • Superinfection

  • Confusion

Nursing Process- Evaluation

  • Assess if goals and outcomes are met

  • Consider criteria for evaluating effectiveness of medications and treatments

  • Review criteria to determine effectiveness of care plan.