PNEUMONIA

Pneumonia is an inflammation of the lung parenchyma, involving the terminal airways and alveoli, leading to pulmonary consolidation because alveoli is filled with exudates.

Pneumonia may be divided into three groups:

• Community acquired, due to a number of organisms, including Streptococcus pneumoniae
• Hospital acquired (nosocomial), due primarily to gram-negative bacilli and staphylococci
• Pneumonia in the immunocompromised person

ETIOLOGY

Etiologic Agents

• Streptococcus pneumoniae – (Streptococcal/Pneumococcal Pneumonia)
• Staphylococcus aureus - Staphylococcal pneumonia
• Hemophilus influenzae (Haemophilus Influenza Pneumonia)
• Legionella pneumophila - Legionnaires' disease
• Others -
  •  
  • Klebsiella Pneumoniae,
  • Diplococcus Pneumoniae,
  • Escherichia Coli,
  • Pseudomonas Aeruginosa
  • Mycoplasma Pneumoniae,
  • Chlamydia Trachomatis
  • L. Pneumophila,
  • Rhinoviruses,
  • Adenovirus,
  • Varicella,
  • Rubella,
  • Rubeola,
  • Herpes Simplex,
  • Cytomegalovirus,
  • Epstein-Barr Virus
  • Aspergillus Fumigatus

 

High Risk Groups

• Children less than 5 year
• Elderly

Predisposing Factors

• Smoking
• Air pollution
• Immunocompromised
  • (+) AIDS
  • Kaposi's Sarcoma
  • Pneumocystis Carinii Pneumonia
  • Bronchogenic Carcinoma
• Prolonged immobility (hypostatic pneumonia)
• Aspiration of food (aspiration pneumonia)
• Over fatigue

Pathophysiology

SIGNS AND SYMPTOMS

• Sudden onset; shaking chill; rapidly rising fever of 101° F to 105° F.
• Productive cough with purulent sputum, greenish to rusty.
• Dyspnea, tachypnea with prolong expiratory grunt
• Pleuritic chest pain aggravated by respiration/coughing
• Nasal flaring, use of accessory muscles of respiration, fatigue
• Rapid, bounding pulse
• General body malaise
• Cyanosis
• Pleuritic friction rub
• Rales/crackles on auscultation
• Abdominal distention => paralytic ileus

Diagnostic Evaluation

• Chest X-ray - (+) pulmonary consolidation
• CBC - Elevated WBC and ESR
• ABG – PaO2 decreased (hypoxemia)
• Gram stain, culture & sensitivity tests of sputum-(+) to cultured microorganism
• Blood culture detects bacteremia
• Immunologic test detects microbial antigens in serum, sputum, and urine.

Complications

• Pleural effusion.
• Sustained hypotension and shock,
• Superinfection: pericarditis, bacteraemia, and meningitis.
• Delirium-this is considered a medical emergency.
• Atelectasis-due to mucous plugs.

Management

• Treatment algorithm for patient with suspected pneumonia

Becterial pneumonia

1. Antimicrobial therapy-depends on laboratory identification of causative organism and sensitivity to specific antimicrobials, or presumptive therapy with broad spectrum agent in milder cases.

• Macrolide antibiotics such as azithromycin or clarithromycin; doxycycline;
• Oral beta lactams such as cefuroxime, amoxicillin, or amoxicillin clavulanate.
• Cephalosporins;
• penicillinase-resistant extended-spectrum penicillins;
• vancomycin (Vancocin) for methicillin-resistant S. aureus

Viral pneumonia

• Treat symptomatically
• Amantadine (Symmetrel) relieves symptoms
• Prophylactic vaccination recommended for high-risk persons (over age 65; chronic cardiac or pulmonary disease, diabetes, and other metabolic disorders).

Fungal pneumonia

• Amphotericin B
• Itraconazole.

1. Oxygen therapy, if required.

Nursing Management

Nursing Assessment

• Take a careful history to help establish etiologic diagnosis.
  • History of recent respiratory illness including mode of onset
  • Presence of purulent sputum, increased amount of sputum, fever, chills, chest pain, dyspnea, tachypnea
  • Any family illness
  • Medications, alcohol, tobacco, or I.V. drug use
• Observe for anxious, flushed appearance, shallow respirations, splinting of affected side, confusion, disorientation.
• Auscultate for crackles overlying affected region, and for bronchial breath sounds when consolidation (filling of airspaces with exudate) is present.

Nursing Diagnoses

1. Impaired Gas Exchange related to decreased ventilation secondary to inflammation and infection involving distal airspaces
2. Ineffective Airway Clearance related to excessive tracheobronchial secretions
3. Acute Pain related to inflammatory process and dyspnea
4. Risk for Injury secondary to complications

Nursing Interventions

Improving Gas Exchange

• Observe for cyanosis, dyspnea, hypoxia, and confusion, indicating worsening condition.
• Follow ABG levels/Sao₂ to determine oxygen need and response to oxygen therapy.
• Administer oxygen at concentration to maintain Pao₂ at acceptable level.
• Avoid high concentrations of oxygen in patients with COPD, particularly with evidence of CO₂ retention. If high concentrations of oxygen are given, monitor alertness and PaO₂ and PaCO₂ levels for signs of CO₂ retention.
• Place patient in an upright position to obtain greater lung expansion and improve aeration. Frequent turning and increased activity (up in chair, ambulate as tolerated) should be employed.

Enhancing Airway Clearance

• Obtain freshly expectorated sputum for gram stain and culture, preferably early morning specimen as directed. Instruct the patient as follows:
  • Rinse mouth with water to minimize contamination by normal flora.
  • Breathe deeply several times.
  • Cough deeply and expectorate raised sputum into sterile container.
• Encourage patient to cough; retained secretions interfere with gas exchange.
• Encourage increased fluid intake, unless contraindicated, to thin mucus and promote expectoration and replace fluid losses caused by fever, diaphoresis, dehydration, and dyspnea.
• Humidify air or oxygen therapy to loosen secretions and improve ventilation.
• Employ chest wall percussion and postural drainage when appropriate to loosen and mobilize secretions.
• Auscultate the chest for crackles and rhonchi.
• Administer cough suppressants when coughing is non-productive only if there is no evidence of retained secretions.
• Mobilize patient to improve secretion clearance and reduce risk of atelectasis and worsening pneumonia.

Relieving Pleuritic Pain

• Place in a comfortable position (semi-Fowler's) for resting and breathing.
• Encourage frequent change of position to prevent pooling of secretions in lungs.
• Avoid suppressing a productive cough.
• Administer prescribed analgesic agent to relieve pain. Avoid opioids in patients with a history of COPD.
• Apply heat and/or cold to chest as prescribed.
• Encourage modified bed rest during febrile period.
• Watch for abdominal distention or ileus, which may be due to swallowing of air during intervals of severe dyspnea. Insert a nasogastric (NG) or rectal tube as directed.

Monitoring for Complications

• Remember that fatal complications may develop during the early period of antimicrobial treatment.
• Monitor temperature, pulse, respiration, blood pressure, and oximetry at regular intervals to assess the patient's response to therapy.
• Auscultate lungs and heart. Heart murmurs or friction rub may indicate acute bacterial endocarditis, pericarditis, or myocarditis.
• Employ special nursing surveillance for patients with:
  • Alcoholism, COPD, immunosuppression-these people as well as elderly patients, may have little or no fever.
  • Chronic bronchitis-it is difficult to detect subtle changes in condition, because the patient may have seriously compromised pulmonary function.
  • Epilepsy-pneumonia may result from aspiration after a seizure.
  • Delirium-may be caused by hypoxia, meningitis, delirium tremens of alcoholism.
• Assess these patients for unusual behaviour, alterations in mental status, stupor, and heart failure.
• Assess for resistant fever or return of fever, potentially indicating bacterial resistance to antibiotics.

Health Education

• Advise patient that fatigue, weakness, and depression may be prolonged after pneumonia.
• Encourage chair rest after fever subsides; gradually increase activities to bring energy level back to preillness stage.
• Encourage breathing exercises to clear lungs and promote full expansion and function after the fever subsides.
• Explain that a chest X-ray is taken 4 to 6 weeks after recovery to evaluate lungs for clearing and detect any tumour or underlying cause.
• Advise smoking cessation. Cigarette smoke destroys tracheobronchial cilial action, which is the first line of defense of lungs; also irritates mucosa of bronchi and inhibits function of alveolar scavenger cells (macrophages).
• Advise the patient to keep up natural resistance with good nutrition, adequate rest. One episode of pneumonia may make the patient susceptible to recurring respiratory infections.
• Instruct patient to avoid fatigue, sudden extremes in temperature, and excessive alcohol intake, which lower resistance to pneumonia.
• Encourage yearly immunization for influenza and S. pneumoniae, a major cause of bacterial pneumonia.
• Advise avoidance of contact with people who have upper respiratory infections for several months after pneumonia resolves.
• Practice frequent handwashing, especially after contact with others.