Focus on Pneumonia

Pneumonia Acute inflammation of lung caused by microbial organism Leading cause of death in the United States from infectious disease Discovery of sulfa drugs and penicillin decreased morbidity and mortality rates

Etiology Likely to result when defense mechanisms become incompetent or overwhelmed ↓ Cough and epiglottal reflexes may allow aspiration

Etiology Mucociliary mechanism impaired Pollution Cigarette smoking Upper respiratory infections Tracheal intubation Aging

Etiology Alteration of leukocytes from malnutrition Increased frequency of gram-negative bacilli from leukemia, alcoholism, and diabetes mellitus

Etiology Three ways organisms reach lungs Aspiration from nasopharynx or oropharynx Inhalation of microbes such as Mycoplasma pneumoniae Hematogenous spread from primary infection elsewhere in body

Pathophysiology of Pneumococcal Pneumonia

Types of Pneumonia Community-acquired pneumonia Lower respiratory infection of lung Onset in community or during first 2 days of hospitalization

Types of Pneumonia Community-acquired pneumonia 4 million U.S. adults diagnosed yearly Highest incidence in midwinter Smoking important risk factor

Types of Pneumonia Organisms implicated Streptococcus pneumoniae Haemophilus influenzae Legionella Mycoplasma Chlamydia

Types of Pneumonia Three-step approach to treatment Assess ability to treat at home Calculate PORT (Pneumonia Patient Outcomes Research Team) Clinician decision for inpatient or outpatient

Types of Pneumonia Hospital-acquired pneumonia Occurring 48 hours or longer after admission and not incubating at time of hospitalization Second most common nosocomial infection

Types of Pneumonia Risk factors for HAP Immunosuppressive therapy General debility Endotracheal intubation

Types of Pneumonia Treatment is based on Known risk factors Severity of illness Early (5 days post admission) or late (more than 5 days post admission) onset

Types of Pneumonia Fungal pneumonia Aspiration pneumonia Sequelae occurring from abnormal entry of secretions into lower airway

Types of Pneumonia Aspiration pneumonia Usually with history of loss of consciousness Gag and cough reflexes suppressed Tube feeding risk factor

Types of Pneumonia Aspiration pneumonia Forms of aspiration pneumonia Mechanical obstruction Chemical injury Bacterial infection

Types of Pneumonia Causes of opportunistic pneumonia Bacterial and viral causative agents Pneumocystis jiroveci (PCP) Cytomegalovirus Fungi

Types of Pneumonia Opportunistic pneumonia Patients at risk Severe protein-calorie malnutrition Immune deficiencies Chemotherapy/radiation recipients Transplant recipients

Types of Pneumonia Clinical manifestations of PCP Fever Tachypnea Tachycardia Dyspnea Nonproductive cough Hypoxemia

Pathophysiology Stage 1: Congestion from outpouring of fluid to alveoli Organisms multiply Infection spreads Interferes with lung function

Pathophysiology Stage 2: Red hepatization Massive dilation of capillaries Alveoli fill with organisms, neutrophils, RBCs, and fibrin Causes lungs to appear red and granular similar to liver

Pathophysiology Gray hepatization ↓ Blood flow Leukocyte and fibrin consolidate in affected part of lung

Pathophysiology Resolution Resolution and healing if no complications Exudate lysed and processed by macrophages Tissue restored

Pathophysiologic Course of Pneumococcal Pneumonia

Clinical Manifestations CAP symptoms Sudden onset of fever Chills Cough productive of purulent sputum Pleuritic chest pain

Clinical Manifestations Physical examination findings Dullness to percussion ↑ Fremitus Bronchial breath sounds Crackles

Clinical Manifestations CAP atypical manifestations Gradual onset Dry cough Extrapulmonary manifestations

Clinical Manifestations Confusion or stupor may manifest in older or debilitated patient Patients with infection from Staphylococcus aureus may present only with dyspnea and fever while lung tissue is necrotized

Complications Pleurisy Pleural effusion Usually is sterile and reabsorbed in 1 to 2 weeks or requires thoracentesis

Complications Atelectasis Bacteremia Usually clears with cough and deep breathing Bacteremia Bacterial infection in the blood

Complications Lung abscess Empyema Seen when caused by S. aureus and gram-negative pneumonias Empyema Requires antibiotics and drainage of exudate

Complications Pericarditis Meningitis Spread of microorganism to heart Patient who is disoriented, confused, or somnolent should have lumbar puncture

Complications Endocarditis Microorganisms attack endocardium and heart valves Manifestations similar to bacterial endocarditis

Diagnostic Tests History Physical examination Chest x-ray Gram stain of sputum Sputum culture and sensitivity Pulse oximetry or ABGs

Diagnostic Tests CBC, differential, chemistries Blood cultures

Collaborative Care Antibiotic therapy Oxygen for hypoxemia Analgesics for chest pain Antipyretics

Collaborative Care Influenza drugs and influenza vaccine Fluid intake at least 3 L per day Caloric intake at least 1500 per day

Collaborative Care Pneumococcal vaccine Indicated for those at risk Chronic illness such as heart and lung disease, diabetes mellitus Recovering from severe illness 65 or older In long-term care facility

Nursing Assessment History Lung cancer COPD Diabetes mellitus Debilitating disease Malnutrition AIDS

Nursing Assessment History Use of antibiotics, corticosteroids, chemotherapy, or immunosuppressants Recent abdominal or thoracic surgery Smoking Alcoholism Respiratory infections

Nursing Assessment Prolonged bed rest Dyspnea Nasal congestion Pain with breathing

Nursing Assessment Sore throat Muscle ache Fever Restlessness

Nursing Assessment Splinting affected area Tachypnea Asymmetric chest movements Use of accessory muscles

Nursing Assessment Crackles Green or yellow sputum Tachycardia Changes in mental status

Nursing Assessment Leukocytosis Abnormal ABGs Pleural effusion Pneumothorax on x-ray

Nursing Diagnoses Ineffective breathing pattern Ineffective airway clearance Acute pain

Nursing Diagnoses Imbalanced nutrition: Less than body requirements Activity intolerance

Planning Clear breath sounds Normal breathing patterns No signs of hypoxia Normal chest x-ray No complications related to pneumonia

Nursing Implementation Teach nutrition, hygiene, rest, regular exercise to maintain natural resistance Prompt treatment of URIs Strict asepsis

Nursing Implementation Encourage those at risk to obtain influenza and pneumococcal vaccinations Reposition patient q2h

Nursing Implementation Assist patients at risk for aspiration with eating, drinking, and taking medications Assist immobile patients with turning and deep breathing

Nursing Implementation Emphasize need to take course of medication(s) Teach drug–drug interactions

Evaluation Dyspnea not present SpO2 ≥ 95 Free of adventitious breath sounds Clears sputum from airway

Evaluation Reports pain control Verbalizes causal factors Adequate fluid and caloric intake Perform activities of daily living