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Pneumonia Pneumonia Acute inflammation of lung caused by microorganism Leading cause of death until 1936 Discovery penicillin of sulfa drugs and Pneumonia Still leading cause of death from infectious disease Predisposing Factors Defense mechanisms are incompetent or overwhelmed Decreased cough and epiglottal reflexes (may allow aspiration) Predisposing Factors Mucociliary mechanism impaired Pollution Cigarette smoking Upper respiratory infections Tracheal intubation Aging Predisposing Factors Alteration of leukocytes from malnutrition Increased frequency of gramnegative bacilli (leukemia, diabetes, alcoholism) Acquisition of Organisms Aspiration from nasopharynx, oropharynx Inhalation of microbes Hematogenous spread from primary infection elsewhere Types of Pneumonia Organisms implicated S. pneumoniae Legionella Mycoplasma Chlamydia S. aureus Respiratory viruses Types of Pneumonia Community-acquired pneumonia (CAP) Onset in community or during first 2 days of hospitalization Highest incidence in winter Smoking important risk factor Types of Pneumonia Hospital-acquired pneumonia (HAP) Occurs > 48 hours after admission; not incubating at time of hospitalization Highest mortality rate of nosocomial infections Types of Pneumonia Causes of HAP Pseudomonas Enterobacter S. aureus S. pneumoniae Immunosuppressive therapy General debility Endotracheal intubation Types of Pneumonia Classification of Patients with HAP Severity of illness Specific host or therapeutic factors predisposing to pathogens present 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 Usually history of loss of consciousness Gag and cough reflexes suppressed Tube feedings risk factor Types of Pneumonia Forms of aspiration pneumonia Mechanical obstruction Chemical injury Bacterial infection Types of Pneumonia Opportunistic pneumonia Pneumocytis carnii CMV Fungi Patients with severe protein-calorie malnutrition, immune deficiencies, chemotherapy/radiation recipients, and transplant recipients are at risk Types of Pneumonia Opportunistic pneumonia Clinical manifestations – Fever – Tachypnea – Tachycardia – Dyspnea – Nonproductive cough – Hypoxemia Pathophysiology: Pneumococcal Pneumonia Congestion from outpouring of fluid into alveoli Microorganisms multiply and spread infection, interfering with lung function Pathophysiology: Pneumococcal Pneumonia Red hepatization Massive dilation of capillaries Alveoli fill with organisms, neutrophils, RBCs, and fibrin Causes lungs to appear red and granular, similar to liver Pathophysiologic course of pneumococcal pneumonia Fig. 27-1 Pathophysiology: Pneumococcal Pneumonia Gray hepatization Blood flow decreases Leukocyte and fibrin consolidate in affected part of lung Pathophysiology: Pneumococcal Pneumonia Resolution Resolution and healing if no complications Exudate lysed and processed by macrophages Tissue restored Clinical Manifestations CAP symptoms Sudden onset of fever Chills Cough productive of purulent sputum Pleuritic chest pain Clinical Manifestations Confusion or stupor may manifest in older or debilitated patient Physical exam findings Dullness on percussion Increased fremitus Bronchial breath sounds Crackles Clinical Manifestations CAP (alternative manifestations) Gradual onset Dry cough Headache Myalgias Fatigue Sore throat N/V/D Clinical Manifestations Manifestations of viral pneumonia are variable Chills Fever Dry and non-productive cough Extrapulmonary symptoms Complications Pleurisy Pleural effusion Usually is sterile and reabsorbed in 1-2 weeks or requires thoracentesis Atelectasis Usually clears with cough and deep breathing Complications Delayed resolution Persistent infection seen on x-ray as residual consolidation Lung abscess (pus-containing lesions) Empyema (purulent exudate in pleural cavity) Requires exudate antibiotics and drainage of Complications Pericarditis From spread of microorganism Arthritis Systemic spread of organism Exudate can be aspirated Meningitis Patient who is disoriented, confused, or somnolent should have lumbar puncture to evaluate meningitis Complications Endocarditis Microorganisms attack endocardium and heart valves Manifestations similar to bacterial endocarditis Diagnostic Tests History Physical exam Chest x-ray Gram stain of sputum Sputum culture and sensitivity Pulse oximetry or ABGs CBC, differential, chems Blood cultures Collaborative Care Antibiotic therapy Oxygen for hypoxemia Analgesics for chest pain Antipyretics Influenza drugs 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 of Predisposing/Risk Factors Lung cancer COPD Diabetes mellitus Debilitating disease Malnutrition Nursing Assessment History of Predisposing/Risk Factors AIDS Use of antibiotics, corticosteroids, chemotherapy, immunosuppressants Recent abdominal or thoracic surgery Smoking, alcoholism, respiratory infections Prolonged bed rest Nursing Assessment Clinical Manifestations Dyspnea Nasal congestion Pain with breathing Sore throat Muscle aches Fever Nursing Assessment Clinical Manifestations Restlessness or lethargy Splinting affected area Tachypnea Asymmetric chest movements Use of accessory muscles Crackles Green or yellow sputum Nursing Assessment Clinical Manifestations Tachycardia Changes in mental status Leukocytosis Abnormal ABGs Pleural effusion Pneumothorax on CXR Nursing Diagnoses Ineffective breathing pattern Ineffective airway clearance Acute pain Imbalanced nutrition: less than body requirements Activity intolerance Planning Goals: Patient will have 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 Nursing Implementation Encourage those at risk to obtain influenza and pneumococcal vaccinations Reposition patient q2h Assist patients at risk for aspiration with eating, drinking, and taking meds Nursing Implementation Assist immobile patients with turning and deep breathing Strict asepsis 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 controlled Verbalizes causal factors Adequate fluid and caloric intake Performs ADLs
