Pneumonia Nursing Care Management and Study Guide

Pneumonia inflames the lung parenchyma and floods the alveoli, so the patient cannot move oxygen across them. You will see it on every floor and at every age. Your priorities are clearing the airway, supporting oxygenation, driving hydration to thin secretions, getting the right antibiotic in early, and watching for the slide into shock and respiratory failure.

What Is Pneumonia?

Pneumonia is inflammation of the lung parenchyma caused by bacteria, mycobacteria, fungi, or viruses. Pneumonitis is the broader term for inflammation of lung tissue that can predispose the patient to microbial invasion.

Classification

Pneumonia falls into four groups: community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), pneumonia in the immunocompromised host, and aspiration pneumonia.

Community-acquired pneumonia occurs in the community or within the first 48 hours after hospitalization. Causative agents in CAP that needs hospitalization include Streptococcus pneumoniae, H. influenza, Legionella, and Pseudomonas aeruginosa. A specific etiologic agent is identified in only 50% of cases. Streptococcus pneumoniae is the most common cause of CAP in people younger than 60 years of age, and viruses are the most common cause in infants and children.

Hospital-acquired pneumonia, also called nosocomial pneumonia, is the onset of pneumonia symptoms more than 48 hours after admission in a patient with no evidence of infection on admission. It is the most lethal nosocomial infection and the leading cause of death among patients with such infections. Common organisms include Enterobacter species, Escherichia coli, influenza, Klebsiella species, Proteus, Serratia marcescens, S. aureus, and S. pneumonia. It usually presents as a new pulmonary infiltrate on chest x-ray combined with evidence of infection.

Pneumonia in the immunocompromised host includes Pneumocystis pneumonia, fungal pneumonias, and Mycobacterium tuberculosis. These patients commonly develop pneumonia from organisms of low virulence, and may also be infected by the organisms seen in HAP and CAP.

Aspiration pneumonia is the pulmonary consequence of endogenous or exogenous substances entering the lower airway. The most common form is a bacterial infection from aspiration of bacteria that normally reside in the upper airways. It occurs in the community or the hospital. Common pathogens are S. pneumonia, H. influenza, and S. aureus.

Pathophysiology

Pneumonia arises from normal flora in a patient whose resistance has been altered, or from aspiration of flora present in the oropharynx. An inflammatory reaction in the alveoli produces exudate that interferes with the diffusion of oxygen and carbon dioxide, and white blood cells migrate in and fill the normally air-filled spaces. Secretions and mucosal edema leave areas of lung underventilated through partial occlusion of alveoli or bronchi. Hypoventilation follows, creating a ventilation-perfusion mismatch. Venous blood passing through the underventilated areas reaches the left heart still deoxygenated, and the mixing of oxygenated and poorly oxygenated blood produces arterial hypoxemia.

Epidemiology

Pneumonia and influenza account for nearly 60,000 deaths annually, and pneumonia ranks as the eighth leading cause of death in the United States. More than 915,000 episodes of CAP occur each year in U.S. adults 65 years and older. HAP accounts for 15% of hospital-acquired infections and is the leading cause of death among patients with such infections, with an estimated incidence of 4 to 7 episodes per 1000 hospitalizations.

Causes

In community-acquired pneumonia, Streptococcus pneumoniae is the leading cause in people younger than 60 years without comorbidity and in those 60 years and older with comorbidity. Haemophilus influenzae causes a CAP that frequently affects elderly people and those with comorbid illness. Mycoplasma pneumoniae is another cause.

In hospital-acquired pneumonia, Staphylococcus aureus pneumonia occurs through inhalation of the organism. Impaired host defenses let pathogens invade, and comorbid conditions that lower immunity allow bacteria to pool in the lungs. Prolonged supine positioning lets fluid pool and stagnate, and prolonged hospitalization raises the risk of nosocomial infection the longer the patient stays.

Clinical Manifestations

Expect a rapidly rising fever from the parenchymal inflammation, and pleuritic chest pain that deep breathing and coughing aggravate. The pulse is rapid and bounding and the patient is tachypneic as the body compensates for low oxygen. Sputum turns purulent as infection produces pus-filled secretions.

Prevention

The pneumococcal vaccine can prevent pneumonia in healthy patients with an efficiency of 65% to 85%. To prevent HAP, the CDC (2004) encouraged staff education and involvement in infection prevention, careful infection and microbiologic surveillance to guide prevention techniques, and modifying host risk for infection before it can take hold.

Complications

Shock and respiratory failure are seen chiefly in patients who received no specific treatment or inadequate or delayed treatment. Pleural effusion can develop, with fluid sent for analysis; it has three stages: uncomplicated, complicated, and thoracic empyema.

Assessment and Diagnostic Findings

History taking, particularly a recent respiratory tract infection, anchors the diagnosis, and physical examination focuses on the number of breaths per minute and breath sounds. Chest x-ray identifies structural distribution (lobar, bronchial) and may reveal multiple abscesses or infiltrates and empyema (staphylococcus), scattered or localized infiltration (bacterial), or diffuse, extensive nodular infiltrates (more often viral); in mycoplasmal pneumonia the chest x-ray may be clear. Fiberoptic bronchoscopy may be diagnostic (qualitative cultures) and therapeutic (re-expansion of a lung segment). ABGs and pulse oximetry may be abnormal depending on the extent of lung involvement and underlying lung disease.

Gram stain and cultures use sputum collection, needle aspiration of empyema, pleural, transtracheal, or transthoracic fluids, lung biopsies, and blood cultures to recover the causative organism; more than one organism may be present, with common bacteria including Diplococcus pneumoniae, Staphylococcus aureus, a-hemolytic streptococcus, Haemophilus influenzae, and cytomegalovirus (CMV). Sputum cultures may not identify all offending organisms, and blood cultures may show transient bacteremia. CBC usually shows leukocytosis, although a low WBC count may appear in viral infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia; the erythrocyte sedimentation rate (ESR) is elevated. Serologic studies (viral or Legionella titers, cold agglutinins) help identify the specific organism. Pulmonary function studies may show decreased volumes (congestion and alveolar collapse), increased airway pressure, decreased compliance, and shunting with hypoxemia. Sodium and chloride levels may be low, and bilirubin may be increased. Percutaneous aspiration or open biopsy of lung tissue may reveal typical intranuclear and cytoplasmic inclusions (CMV) or characteristic giant cells (rubeola).

Medical Management

Management identifies the causative agent and treats the infection. Draw blood cultures to identify the pathogen and start antibiotics promptly when CAP is strongly suspected. Macrolides are recommended for drug-resistant S. pneumoniae. Hydration matters because fever and tachypnea cause insensible fluid losses. Antipyretics treat fever and headache, and antitussives treat the associated cough. Complete bed rest is prescribed until signs of infection diminish. Oxygen is given if hypoxemia develops, and pulse oximetry guides the need for oxygen and the effectiveness of therapy. Severe cases need aggressive respiratory measures: high concentrations of oxygen, endotracheal intubation, and mechanical ventilation.

Nursing Management

Nursing Assessment

Report fever, chills, or night sweats immediately, since these can signal bacterial pneumonia. Identify clinical manifestations such as pleuritic pain, bradycardia, tachypnea, fatigue, use of accessory muscles, cough, and purulent sputum. Assess changes in temperature and pulse; the amount, odor, and color of secretions; the frequency and severity of cough; the degree of tachypnea or shortness of breath; and changes on chest x-ray. In elderly patients, watch for altered mental status, dehydration, unusual behavior, excessive fatigue, and concomitant heart failure.

Diagnosis

Ineffective airway clearance related to copious tracheobronchial secretions. Activity intolerance related to impaired respiratory function. Risk for deficient fluid volume related to fever and a rapid respiratory rate.

Nursing Care Planning and Goals

Improve airway patency, conserve energy with rest, maintain proper fluid volume and adequate nutrition, ensure understanding of the treatment protocol and preventive measures, and prevent complications.

Nursing Priorities

Maintain or improve respiratory function, prevent complications, support the recuperative process, and provide information about the disease process, prognosis, and treatment.

Nursing Interventions

To improve airway patency, remove secretions, since retained secretions interfere with gas exchange and slow recovery. Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions, humidification loosens secretions and improves ventilation, an effective directed cough improves airway patency, and chest physiotherapy loosens and mobilizes secretions.

To promote rest and conserve energy, have the patient avoid overexertion and assume a comfortable Semi-Fowler's position, changing positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion.

To promote fluid intake, increase intake to at least 2L per day to replace insensible losses. To maintain nutrition, use fluids with electrolytes for fluid, calories, and electrolytes, and offer nutrition-enriched beverages and shakes.

To build the patient's knowledge, teach the patient and family the cause of pneumonia, symptom management, signs and symptoms, and the need for followup, and review the factors that may have contributed to the disease.

Evaluation

The patient demonstrates improved airway patency, rests and conserves energy while symptomatic and then slowly increases activity, maintains adequate hydration and dietary intake, explains and complies with management strategies, exhibits no complications, and complies with the treatment protocol and prevention strategies.

Discharge and Home Care Guidelines

Teach proper administration, potential side effects, and symptoms to report for oral antibiotics. Teach breathing exercises to promote secretion clearance and volume expansion. Stress strict compliance with followup checkups to review the latest chest x-ray or physical examination findings. Stop smoking, which inhibits tracheobronchial ciliary action and irritates the mucous cells of the bronchi.

Documentation Guidelines

Document breath sounds, the presence and character of secretions, and use of accessory muscles; the character of cough and sputum; respiratory rate, pulse oximetry and O2 saturation, and vital signs; the plan of care and who is involved; the client's response to interventions, teaching, and actions performed; use of respiratory devices or airway adjuncts; response to medications; and modifications to the plan of care.