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.