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Pneumonia

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Description

  1. Pneumonia is an infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles.
  2. The edema associated with inflammation stiffens the lung, decreases lung compliance and vital capacity, and causes hypoxemia.
  3. Pneumonia can be community acquired or hospital acquired.
  4. The chest x-ray film shows diffuse patches throughout the lungs or consolidation in a lobe.
  5. A sputum culture identifies the organism.
  6. The white blood cells and the erythrocyte sedimentation rate are elevated.

Causes

  • Primary pneumonia is caused by the patient’s inhaling or aspirating a pathogen such as bacteria or a virus. Bacterial pneumonia, often caused by staphylococcus, streptococcus, or klebsiella, usually occurs when the lungs’ defense mechanisms are impaired by such factors as suppressed cough reflex, decreased cilia action, decreased activity of phagocytic cells, and the accumulation of secretions. Viral pneumonia occurs when a virus attacks bronchiolar epithelial cells and causes interstitial inflammation and desquamation, which eventually spread to the alveoli.
  • Secondary pneumonia ensues from lung damage that was caused by the spread of bacteria from an infection elsewhere in the body or by a noxious chemical. Aspiration pneumonia is caused by the patient’s inhaling foreign matter such as food or vomitus into the bronchi. Factors associated with aspiration pneumonia include old age, impaired gag reflex, surgical procedures, debilitating disease, and decreased level of consciousness.
  • Community-acquired pneumonia is caused by bacteria that are divided into two groups: typical and atypical. Organisms that cause typical pneumonia include Streptococcus pneumonia (pneumococcus) and Haemophilus and Staphylococcus species. Organisms that cause atypical pneumonia include Legionella, Mycoplasma, and Chlamydia species.

Pathophysiology 



Risk factors

  • Cigarette smoking
  • Recent viral respiratory infection (common cold, laryngitis, influenza)
  • Difficulty swallowing (due to stroke, dementia, Parkinson's disease, or other neurological conditions)
  • Chronic lung disease (COPD, bronchiectasis, cystic fibrosis)
  • Cerebral palsy
  • Other serious illnesses, such as heart disease, liver cirrhosis, or diabetes mellitus
  • Living in a nursing facility
  • Impaired consciousness (loss of brain function due to dementia, stroke, or other neurologic conditions)
  • Recent surgery or trauma
  • Immune system problem

Assessment

  1. Chills
  2. Elevated temperature
  3. Pleuritic pain
  4. Rhonchi and wheezes
  5. Use of accessory muscles for breathing
  6. Cyanosis
  7. Mental status changes
  8. Sputum production

Complications

  • Respiratory failure, which requires a breathing machine or ventilator
  • Empyema or lung abscesses. These are infrequent, but serious, complications of pneumonia. They occur when pockets of pus form inside or around the lung. These may sometimes need to be drained with surgery.
  • Sepsis, a condition in which there is uncontrolled swelling (inflammation) in the body, which may lead to organ failure
  • Acute respiratory distress syndrome (ARDS), a severe form of respiratory failure

Primary Nursing Diagnosis

  • Ineffective airway clearance related to increased production of secretions and increased viscosity

Diagnostic Evaluation

  • Sputum cultures and sensitivities reveals presence of infecting organisms. Cultures identify organism; sensitivity testing identifies how resistant or sensitive the bacteria are to antibiotics.
  • Chest x-ray reveals areas of increased density, (can be a lung segment, lobe, one lung, or both lungs). Findings reflect areas of infection and consolidation.

Medical Management

  1. Antibiotics are prescribed based on Gram stain results and antibiotic guidelines (resistance patterns, risk factors, etiology must be considered). Combination therapy may be used.
  2. Supportive treatment includes hydration, antipyretics, antihistamines, or nasal decongestants.
  3. Best rest is recommended until infection shows signs of clearing.
  4. Oxygen therapy is given for hypoxemia.
  5. Respiratory support includes endotracheal intubation, high inspiratory oxygen concentrations, and mechanical ventilation.
  6. Treatment of atelectasis, pleural effusion, shock, respiratory failure, superinfection is instituted, if needed.
  7. For groups of high risk for community-acquired pneumonia, pneumococcal vaccination is advised.

Pharmacologic Intervention


Antibiotics

  • Initial antibiotic: macrolides including erythromycin, azithromycin, roxithromycin and clarithyromycin. Macrolides provide coverage for likely organisms in community-acquired bacterial pneumonia.
  • Other antibiotics: Penicillin G for streptococcal pneumonia; nafcillin or oxacillin for staphylococcal pneumonia; aminoglycoside or a cephalosporin for klebsiella pneumonia; penicillin G or clindamycin for aspiration pneumonia .Alternatives: amoxicillin and clavulanate (Augmentin); doxycycline; trimethoprim and sulfamethoxazole (Bactrim DS, Septra); levofloxacin (Levaquin)

Nursing Interventions

  1. Administer oxygen as prescribed.
  2. Monitor respiratory status.
  3. Monitor for labored respirations, cyanosis, and cold and clammy skin.
  4. Encourage coughing and deep breathing and use of incentive spirometer.
  5. Position client in semi-Fowler position to facilitate breathing and lung expansion.
  6. Change client’s position frequently and ambulate as tolerated to mobilize secretions
  7. Provide CPT
  8. Perform nasotracheal suctioning if the client is unable to clear secreations.
  9. Monitor pulse oximetry.
  10. Monitor and record color, consistency, and amount of sputum.
  11. Provide a high-calorie, high protein diet with small frequent meals.
  12. Encourage fluids up to 3 L a day to thin secretions unless contraindicated.
  13. Provide a balance of rest and activity, increasing activity gradually.
  14. Administer antibiotics as prescribed.
  15. Administer antipyretics, bronchodilators, cough suppressants, mucolytic agents, and expectorants as prescribed.
  16. Prevent the spread of infection by hand washing and the proper disposal of secretions.

Documentation Guidelines

  • Physical findings of chest assessment: Respiratory rate and depth, auscultation findings, chest tightness or pain, vital signs
  • Assessment of degree of hypoxemia: Lips and mucous membrane color, oxygen saturation by pulse oximetry
  • Response to deep-breathing and coughing exercises, color and amount of sputum
  • Response to medications: Body temperature, clearing of secretions

Discharge and Home Healthcare Guidelines

  • Be sure the patient understands all medications, including dosage, route, action, and adverse effects.
  • The patient and family or significant other need to understand the importance of avoiding fatigue by limiting activity and taking frequent rests.
  • Advise small, frequent meals to maintain adequate nutrition.
  • Fluid intake should be maintained at approximately 3000 mL/day so that the secretions remain thin.
  • Teach the patient to maintain pulmonary hygiene measures of coughing, deep breathing, and incentive spirometry at home.
  • Provide information about how to stop smoking.


Sources:
http://www.nlm.nih.gov/medlineplus
Brunner
Saunders
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