1. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Focus on Pneumonia (Relates to Chapter 28, “Nursing Management: Lower Respiratory Problems,” in the textbook)

2. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pneumonia Acute inflammation of lung caused by microbial organismAcute 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 ratesDiscovery of sulfa drugs and penicillin decreased morbidity and mortality rates Acute inflammation of lung caused by microbial organismAcute 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 ratesDiscovery of sulfa drugs and penicillin decreased morbidity and mortality rates

3. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.Etiology Likely to result when defense mechanisms become incompetent or overwhelmedLikely to result when defense mechanisms become incompetent or overwhelmed  Predisposing Factors Depression of cough and gag reflexesDepression of cough and gag reflexes Decreased LOCDecreased LOC Tracheal intubationTracheal intubation Impaired mucociliary mechanismImpaired mucociliary mechanism ImmunosuppressionImmunosuppression AgeAge BedrestBedrest Likely to result when defense mechanisms become incompetent or overwhelmedLikely to result when defense mechanisms become incompetent or overwhelmed  Predisposing Factors Depression of cough and gag reflexesDepression of cough and gag reflexes Decreased LOCDecreased LOC Tracheal intubationTracheal intubation Impaired mucociliary mechanismImpaired mucociliary mechanism ImmunosuppressionImmunosuppression AgeAge BedrestBedrest

4. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology Three ways organisms reach lungsThree ways organisms reach lungs  Aspiration from nasopharynx or oropharynx  Inhalation of microbes such as Mycoplasma pneumoniae  Hematogenous spread from primary infection elsewhere in body Three ways organisms reach lungsThree ways organisms reach lungs  Aspiration from nasopharynx or oropharynx  Inhalation of microbes such as Mycoplasma pneumoniae  Hematogenous spread from primary infection elsewhere in body

5. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pathophysiology of Pneumococcal Pneumonia

6. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

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

8. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia Community-acquired pneumoniaCommunity-acquired pneumonia  4 million U.S. adults diagnosed yearly  Highest incidence in midwinter  Smoking important risk factor Community-acquired pneumoniaCommunity-acquired pneumonia  4 million U.S. adults diagnosed yearly  Highest incidence in midwinter  Smoking important risk factor

9. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia Organisms implicatedOrganisms implicated  Streptococcus pneumoniae  Haemophilus influenzae  Legionella  Mycoplasma  Chlamydia Organisms implicatedOrganisms implicated  Streptococcus pneumoniae  Haemophilus influenzae  Legionella  Mycoplasma  Chlamydia

10. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia Three-step approach to treatmentThree-step approach to treatment  Assess ability to treat at home  Calculate PORT (Pneumonia Patient Outcomes Research Team) severity index (table 28-3)  Clinician decision for inpatient or outpatient Three-step approach to treatmentThree-step approach to treatment  Assess ability to treat at home  Calculate PORT (Pneumonia Patient Outcomes Research Team) severity index (table 28-3)  Clinician decision for inpatient or outpatient

11. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia Hospital-acquired pneumoniaHospital-acquired pneumonia  Occurring 48 hours or longer after admission and not incubating at time of hospitalization  Second most common nosocomial infection  Includes ventilator - associated PNA and healthcare-associated PNA Hospital-acquired pneumoniaHospital-acquired pneumonia  Occurring 48 hours or longer after admission and not incubating at time of hospitalization  Second most common nosocomial infection  Includes ventilator - associated PNA and healthcare-associated PNA

12. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia Risk factors for HAPRisk factors for HAP  Immunosuppressive therapy  General debility  Endotracheal intubation Higher risk of MDR organismHigher risk of MDR organism Risk factors for HAPRisk factors for HAP  Immunosuppressive therapy  General debility  Endotracheal intubation Higher risk of MDR organismHigher risk of MDR organism

13. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia Treatment is based onTreatment is based on  Known risk factors  Severity of illness  Early (5 days post admission) or late (more than 5 days post admission) onset Treatment is based onTreatment is based on  Known risk factors  Severity of illness  Early (5 days post admission) or late (more than 5 days post admission) onset

14. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia Aspiration pneumonia  Sequelae occurring from abnormal entry of secretions into lower airway  May have a history of loss of consciousness Gag and cough reflexes suppressedGag and cough reflexes suppressed  Other risk factors specific to aspiration PNA Tube feedingTube feeding Aspiration pneumonia  Sequelae occurring from abnormal entry of secretions into lower airway  May have a history of loss of consciousness Gag and cough reflexes suppressedGag and cough reflexes suppressed  Other risk factors specific to aspiration PNA Tube feedingTube feeding

15. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia Aspiration pneumoniaAspiration pneumonia  Forms of aspiration pneumonia Mechanical obstructionMechanical obstruction Chemical injuryChemical injury Bacterial infectionBacterial infection  Prevention! Aspiration pneumoniaAspiration pneumonia  Forms of aspiration pneumonia Mechanical obstructionMechanical obstruction Chemical injuryChemical injury Bacterial infectionBacterial infection  Prevention!

16. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia Opportunistic pneumoniaOpportunistic pneumonia  Bacterial and viral causative agents Pneumocystis jiroveci (PCP)Pneumocystis jiroveci (PCP) CytomegalovirusCytomegalovirus FungiFungi Opportunistic pneumoniaOpportunistic pneumonia  Bacterial and viral causative agents Pneumocystis jiroveci (PCP)Pneumocystis jiroveci (PCP) CytomegalovirusCytomegalovirus FungiFungi

17. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of Pneumonia Opportunistic pneumoniaOpportunistic pneumonia  Patients at risk Severe protein-calorie malnutritionSevere protein-calorie malnutrition Immune deficienciesImmune deficiencies Chemotherapy/radiation recipientsChemotherapy/radiation recipients Transplant recipientsTransplant recipients Opportunistic pneumoniaOpportunistic pneumonia  Patients at risk Severe protein-calorie malnutritionSevere protein-calorie malnutrition Immune deficienciesImmune deficiencies Chemotherapy/radiation recipientsChemotherapy/radiation recipients Transplant recipientsTransplant recipients

18. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pathophysiologic Course of Pneumococcal Pneumonia Fig. 28-1

19. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Typical manifestation of PNATypical manifestation of PNA  Sudden onset of fever  Chills  Cough productive of purulent sputum  Pleuritic chest pain  Malaise and fatigue Typical manifestation of PNATypical manifestation of PNA  Sudden onset of fever  Chills  Cough productive of purulent sputum  Pleuritic chest pain  Malaise and fatigue

20. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Physical examination findingsPhysical examination findings  Dullness to percussion  Bronchial breath sounds  Crackles or rhonchi Physical examination findingsPhysical examination findings  Dullness to percussion  Bronchial breath sounds  Crackles or rhonchi

21. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Atypical manifestations of PNAAtypical manifestations of PNA  Gradual onset  Dry cough  Extrapulmonary manifestations Fatigue, myalgias, sore throat, vomiting, diarrheaFatigue, myalgias, sore throat, vomiting, diarrhea  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 Atypical manifestations of PNAAtypical manifestations of PNA  Gradual onset  Dry cough  Extrapulmonary manifestations Fatigue, myalgias, sore throat, vomiting, diarrheaFatigue, myalgias, sore throat, vomiting, diarrhea  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

22. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications PleurisyPleurisy Pleural effusionPleural effusion  Usually is sterile and reabsorbed in 1 to 2 weeks or requires thoracentesis PleurisyPleurisy Pleural effusionPleural effusion  Usually is sterile and reabsorbed in 1 to 2 weeks or requires thoracentesis

23. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications AtelectasisAtelectasis  Collapses alveoli  Usually clears with cough and deep breathing BacteremiaBacteremia  Bacterial infection in the blood  High mortality rate AtelectasisAtelectasis  Collapses alveoli  Usually clears with cough and deep breathing BacteremiaBacteremia  Bacterial infection in the blood  High mortality rate

24. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications Lung abscessLung abscess  Seen when caused by S. aureus and gram-negative pneumonias Empyema Empyema  Requires antibiotics and surgical drainage of exudate Lung abscessLung abscess  Seen when caused by S. aureus and gram-negative pneumonias Empyema Empyema  Requires antibiotics and surgical drainage of exudate

25. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications PericarditisPericarditis  Spread of microorganism to heart MeningitisMeningitis  Patient who is disoriented, confused, or somnolent should have lumbar puncture PericarditisPericarditis  Spread of microorganism to heart MeningitisMeningitis  Patient who is disoriented, confused, or somnolent should have lumbar puncture

26. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications EndocarditisEndocarditis  Microorganisms attack endocardium and heart valves  Manifestations similar to bacterial endocarditis EndocarditisEndocarditis  Microorganisms attack endocardium and heart valves  Manifestations similar to bacterial endocarditis

27. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Tests HistoryHistory Physical examinationPhysical examination Chest x-rayChest x-ray Gram stain of sputumGram stain of sputum Sputum culture and sensitivitySputum culture and sensitivity Pulse oximetry or ABGsPulse oximetry or ABGs HistoryHistory Physical examinationPhysical examination Chest x-rayChest x-ray Gram stain of sputumGram stain of sputum Sputum culture and sensitivitySputum culture and sensitivity Pulse oximetry or ABGsPulse oximetry or ABGs

28. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Tests CBC, differential, chemistriesCBC, differential, chemistries Blood culturesBlood cultures CBC, differential, chemistriesCBC, differential, chemistries Blood culturesBlood cultures

29. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Antibiotic therapyAntibiotic therapy  CAP is usually treated empirically  First line is a macrolide or doxycyline  Other drugs for present comorbidities  HAP and aspiration PNA often require longer therapy and multiple drugs Oxygen for hypoxemiaOxygen for hypoxemia Analgesics for chest painAnalgesics for chest pain AntipyreticsAntipyretics Antibiotic therapyAntibiotic therapy  CAP is usually treated empirically  First line is a macrolide or doxycyline  Other drugs for present comorbidities  HAP and aspiration PNA often require longer therapy and multiple drugs Oxygen for hypoxemiaOxygen for hypoxemia Analgesics for chest painAnalgesics for chest pain AntipyreticsAntipyretics

30. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Fluid intake at least 3 L per day, as ableFluid intake at least 3 L per day, as able Caloric intake at least 1500 per dayCaloric intake at least 1500 per day  Small, frequent meals may be better tolerated due to dyspnea and fatigue Fluid intake at least 3 L per day, as ableFluid intake at least 3 L per day, as able Caloric intake at least 1500 per dayCaloric intake at least 1500 per day  Small, frequent meals may be better tolerated due to dyspnea and fatigue

31. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Pneumococcal vaccinePneumococcal vaccine  Indicated for those at risk Chronic illness such as heart and lung disease, diabetes mellitusChronic illness such as heart and lung disease, diabetes mellitus Recovering from severe illnessRecovering from severe illness 65 or older65 or older In long-term care facilityIn long-term care facility Influenza vaccineInfluenza vaccine Pneumococcal vaccinePneumococcal vaccine  Indicated for those at risk Chronic illness such as heart and lung disease, diabetes mellitusChronic illness such as heart and lung disease, diabetes mellitus Recovering from severe illnessRecovering from severe illness 65 or older65 or older In long-term care facilityIn long-term care facility Influenza vaccineInfluenza vaccine

32. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment HistoryHistory  Lung cancer  COPD  Diabetes mellitus  Debilitating disease  Malnutrition  AIDS HistoryHistory  Lung cancer  COPD  Diabetes mellitus  Debilitating disease  Malnutrition  AIDS

33. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment HistoryHistory  Use of antibiotics, corticosteroids, chemotherapy, or immunosuppressants  Recent abdominal or thoracic surgery  Smoking  Alcoholism  Respiratory infections  Prolonged bedrest HistoryHistory  Use of antibiotics, corticosteroids, chemotherapy, or immunosuppressants  Recent abdominal or thoracic surgery  Smoking  Alcoholism  Respiratory infections  Prolonged bedrest

34. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment SymptomsSymptoms  Cough, sputum, SOB, DOE, fever, chills, fatigue, malaise, anorexia, nasal congestion SymptomsSymptoms  Cough, sputum, SOB, DOE, fever, chills, fatigue, malaise, anorexia, nasal congestion

35. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment SignsSigns  Fever  Splinting affected area  Tachypnea, asymmetric chest movements, use of accessory muscles  Crackles, rhonchi, friction rub, dullness to percussion  Sputum color and amount  Tachycardia  Altered level of consciousness SignsSigns  Fever  Splinting affected area  Tachypnea, asymmetric chest movements, use of accessory muscles  Crackles, rhonchi, friction rub, dullness to percussion  Sputum color and amount  Tachycardia  Altered level of consciousness

36. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment LeukocytosisLeukocytosis Abnormal ABGsAbnormal ABGs  Pa02  PaC02  pH Xray findingsXray findings  Infiltrate(s)  Pleural effusion LeukocytosisLeukocytosis Abnormal ABGsAbnormal ABGs  Pa02  PaC02  pH Xray findingsXray findings  Infiltrate(s)  Pleural effusion

37. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Diagnoses Ineffective breathing patternIneffective breathing pattern Ineffective airway clearanceIneffective airway clearance Acute painAcute pain Imbalanced nutrition: Less than body requirementsImbalanced nutrition: Less than body requirements Activity intoleranceActivity intolerance Ineffective breathing patternIneffective breathing pattern Ineffective airway clearanceIneffective airway clearance Acute painAcute pain Imbalanced nutrition: Less than body requirementsImbalanced nutrition: Less than body requirements Activity intoleranceActivity intolerance

38. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Health PromotionHealth Promotion  Teach nutrition, hygiene, rest, regular exercise to maintain natural resistance  Prompt treatment of URIs  Identification of at risk individuals  Encourage those at risk to obtain influenza and pneumococcal vaccinations Health PromotionHealth Promotion  Teach nutrition, hygiene, rest, regular exercise to maintain natural resistance  Prompt treatment of URIs  Identification of at risk individuals  Encourage those at risk to obtain influenza and pneumococcal vaccinations

39. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Acute interventionsAcute interventions  Reposition patient at least q2h  ATS recommends intubated patients be placed in semi Fowler’s position - HOB should be >=30 degrees  Consider “good lung down”  Prompt collection of specimens and initiation of antibiotics (4 hrs of arrival) Acute interventionsAcute interventions  Reposition patient at least q2h  ATS recommends intubated patients be placed in semi Fowler’s position - HOB should be >=30 degrees  Consider “good lung down”  Prompt collection of specimens and initiation of antibiotics (4 hrs of arrival)

40. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Oxygen administration as neededOxygen administration as needed Monitor vitals signs, lung sounds, work of breathing, oxygen saturationMonitor vitals signs, lung sounds, work of breathing, oxygen saturation Assist patients at risk for aspiration with eating, drinking, and taking medicationsAssist patients at risk for aspiration with eating, drinking, and taking medications Assist immobile patients with turning and deep breathingAssist immobile patients with turning and deep breathing Oxygen administration as neededOxygen administration as needed Monitor vitals signs, lung sounds, work of breathing, oxygen saturationMonitor vitals signs, lung sounds, work of breathing, oxygen saturation Assist patients at risk for aspiration with eating, drinking, and taking medicationsAssist patients at risk for aspiration with eating, drinking, and taking medications Assist immobile patients with turning and deep breathingAssist immobile patients with turning and deep breathing

41. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Emphasize need to take course of medication(s)Emphasize need to take course of medication(s) Teach drug–drug interactionsTeach drug–drug interactions Monitor for adverse drug reactionsMonitor for adverse drug reactions Emphasize need to take course of medication(s)Emphasize need to take course of medication(s) Teach drug–drug interactionsTeach drug–drug interactions Monitor for adverse drug reactionsMonitor for adverse drug reactions

42. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Evaluation Dyspnea not presentDyspnea not present SpO 2 ≥ 95SpO 2 ≥ 95 Free of adventitious breath soundsFree of adventitious breath sounds Clears sputum from airwayClears sputum from airway Dyspnea not presentDyspnea not present SpO 2 ≥ 95SpO 2 ≥ 95 Free of adventitious breath soundsFree of adventitious breath sounds Clears sputum from airwayClears sputum from airway

43. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Evaluation Reports pain controlReports pain control Verbalizes causal factorsVerbalizes causal factors Adequate fluid and caloric intakeAdequate fluid and caloric intake Perform activities of daily livingPerform activities of daily living Reports pain controlReports pain control Verbalizes causal factorsVerbalizes causal factors Adequate fluid and caloric intakeAdequate fluid and caloric intake Perform activities of daily livingPerform activities of daily living