Download Pneumonia

Focus on
Pneumonia
(Relates to Chapter 28,
“Nursing Management:
Lower Respiratory Problems,”
in the textbook)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
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
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Etiology
• Likely to result when defense
mechanisms become incompetent or
overwhelmed
 Predisposing Factors
• Depression of cough and gag reflexes
• Decreased LOC
• Tracheal intubation
• Impaired mucociliary mechanism
• Immunosuppression
• Age
• Bedrest
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
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
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Pathophysiology of Pneumococcal
Pneumonia
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Types of Pneumonia
• Community-acquired pneumonia
 Lower respiratory infection of lung
 Onset in community or during first 2 days
of hospitalization
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Types of Pneumonia
• Community-acquired pneumonia
 4 million U.S. adults diagnosed yearly
 Highest incidence in midwinter
 Smoking important risk factor
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Types of Pneumonia
• Organisms implicated
 Streptococcus pneumoniae
 Haemophilus influenzae
 Legionella
 Mycoplasma
 Chlamydia
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Types of Pneumonia
• Three-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
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
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
 Includes ventilator - associated PNA and
healthcare-associated PNA
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Types of Pneumonia
• Risk factors for HAP
 Immunosuppressive therapy
 General debility
 Endotracheal intubation
• Higher risk of MDR organism
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
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
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 suppressed
 Other risk factors specific to aspiration
PNA
• Tube feeding
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Types of Pneumonia
• Aspiration pneumonia
 Forms of aspiration pneumonia
• Mechanical obstruction
• Chemical injury
• Bacterial infection
 Prevention!
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Types of Pneumonia
• Opportunistic pneumonia
 Bacterial and viral causative agents
• Pneumocystis jiroveci (PCP)
• Cytomegalovirus
• Fungi
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Types of Pneumonia
• Opportunistic pneumonia
 Patients at risk
• Severe protein-calorie malnutrition
• Immune deficiencies
• Chemotherapy/radiation recipients
• Transplant recipients
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Pathophysiologic Course of
Pneumococcal Pneumonia
Fig. 28-1
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations
• Typical manifestation of PNA
 Sudden onset of fever
 Chills
 Cough productive of purulent sputum
 Pleuritic chest pain
 Malaise and fatigue
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations
• Physical examination findings
 Dullness to percussion
 Bronchial breath sounds
 Crackles or rhonchi
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations
• Atypical manifestations of PNA
 Gradual onset
 Dry cough
 Extrapulmonary manifestations
• Fatigue, 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
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Complications
• Pleurisy
• Pleural effusion
 Usually is sterile and reabsorbed in 1 to 2
weeks or requires thoracentesis
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Complications
• Atelectasis
 Collapses alveoli
 Usually clears with cough and deep
breathing
• Bacteremia
 Bacterial infection in the blood
 High mortality rate
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Complications
• Lung abscess
 Seen when caused by S. aureus and
gram-negative pneumonias
• Empyema
 Requires antibiotics and surgical
drainage of exudate
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Complications
• Pericarditis
 Spread of microorganism to heart
• Meningitis
 Patient who is disoriented, confused, or
somnolent should have lumbar puncture
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Complications
• Endocarditis
 Microorganisms attack endocardium and
heart valves
 Manifestations similar to bacterial
endocarditis
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Diagnostic Tests
•
•
•
•
•
•
History
Physical examination
Chest x-ray
Gram stain of sputum
Sputum culture and sensitivity
Pulse oximetry or ABGs
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Diagnostic Tests
• CBC, differential, chemistries
• Blood cultures
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Collaborative Care
• Antibiotic 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 hypoxemia
• Analgesics for chest pain
• Antipyretics
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
able
• Caloric intake at least 1500 per day
 Small, frequent meals may be better
tolerated due to dyspnea and fatigue
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
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
• Influenza vaccine
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Assessment
• History
 Lung cancer
 COPD
 Diabetes mellitus
 Debilitating disease
 Malnutrition
 AIDS
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Assessment
• History
 Use of antibiotics, corticosteroids,
chemotherapy, or immunosuppressants
 Recent abdominal or thoracic surgery
 Smoking
 Alcoholism
 Respiratory infections
 Prolonged bedrest
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Assessment
• Symptoms
 Cough, sputum, SOB, DOE, fever, chills,
fatigue, malaise, anorexia, nasal
congestion
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Assessment
• Signs
 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
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Assessment
• Leukocytosis
• Abnormal ABGs
 Pa02
 PaC02
 pH
• Xray findings
 Infiltrate(s)
 Pleural effusion
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Diagnoses
•
•
•
•
Ineffective breathing pattern
Ineffective airway clearance
Acute pain
Imbalanced nutrition: Less than body
requirements
• Activity intolerance
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Health 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
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Acute 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)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Oxygen administration as needed
• Monitor vitals signs, lung sounds, work
of breathing , oxygen saturation
• Assist patients at risk for aspiration with
eating, drinking, and taking medications
• Assist immobile patients with turning
and deep breathing
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Implementation
• Emphasize need to take course of
medication(s)
• Teach drug–drug interactions
• Monitor for adverse drug reactions
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Evaluation
•
•
•
•
Dyspnea not present
SpO2 ≥ 95
Free of adventitious breath sounds
Clears sputum from airway
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Evaluation
•
•
•
•
Reports pain control
Verbalizes causal factors
Adequate fluid and caloric intake
Perform activities of daily living
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.