1. Focus on Pneumonia

2. 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

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

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

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

6. 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

7. Pathophysiology of Pneumococcal Pneumonia

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

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

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

11. 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

12. 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

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

14. 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

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

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

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

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

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

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

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

22. 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

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

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

25. Pathophysiologic Course of Pneumococcal Pneumonia

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

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

28. Clinical Manifestations
CAP atypical manifestations
Gradual onset
Dry cough
Extrapulmonary manifestations

29. 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

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

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

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

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

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

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

37. Diagnostic Tests
CBC, differential, chemistries
Blood cultures

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

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

40. 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

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

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

43. Nursing Assessment Prolonged bed rest Dyspnea Nasal congestion
Pain with breathing

44. Nursing Assessment
Sore throat
Muscle ache
Fever
Restlessness

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

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

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

48. Nursing Diagnoses Ineffective breathing pattern
Ineffective airway clearance
Acute pain

49. Nursing Diagnoses Imbalanced nutrition: Less than body requirements
Activity intolerance

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

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

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

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

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

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

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