Pneumonia

10 Pneumonia




Overview/pathophysiology


Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). As a result of the inflammation involved, lung tissue becomes edematous and air spaces fill with exudate (consolidation), gas exchange cannot occur, and nonoxygenated blood is shunted into the vascular system, causing hypoxemia. Bacterial pneumonias involve all or part of a lobe, whereas viral pneumonias appear diffusely throughout the lungs.


Influenza, which can cause pneumonia, is the most serious viral airway infection for adults. Patients older than 50 yr, residents of extended care facilities, and individuals with chronic health conditions have the highest mortality rate from influenza.


Pneumonias generally are classified into two types: community acquired and hospital associated (nosocomial). A third type is pneumonia in the immunocompromised individual.




Community acquired:


The most common. Individuals with community-acquired pneumonia generally do not require hospitalization unless an underlying medical condition, such as chronic obstructive pulmonary disease (COPD), cardiac disease, or diabetes mellitus, or an immunocompromised state complicates the illness.



Hospital associated (nosocomial):


Nosocomial pneumonias usually occur following aspiration of oropharyngeal flora or stomach contents in an individual whose resistance is altered or whose coughing mechanisms are impaired (e.g., a patient who has decreased level of consciousness [LOC], dysphagia, diminished gag reflex, or a nasogastric tube or who has undergone thoracoabdominal surgery or is on mechanical ventilation). Bacteria invade the lower respiratory tract via three routes: (1) gastric acid aspiration (the most common route) causing toxic injury to the lung, (2) obstructions (foreign body or fluids), and (3) infections (rare). Gram-negative pneumonias are associated with a high mortality rate, even with appropriate antibiotic therapy. Aspiration pneumonia is a nonbacterial (anaerobic) cause of hospital-associated pneumonia that occurs when gastric contents are aspirated.



Pneumonia in the immunocompromised individual:


Immunosuppression and neutropenia are predisposing factors in the development of nosocomial pneumonias from both common and unusual pathogens. Severely immunocompromised patients are affected not only by bacteria but also by viruses (cytomegalovirus) and fungi (Candida, Aspergillus, Pneumocystis jirovecii). Most commonly, P. jirovecii is seen in persons with human immunodeficiency virus infection or in persons who are immunosuppressed therapeutically following organ transplantation.



Health care setting


Primary care, with acute or intensive care hospitalization resulting from complications



Assessment


Findings are influenced by patient’s age, extent of the disease process, underlying medical condition, and pathogen involved. Generally, any factor that alters integrity of the lower airways, thereby inhibiting ciliary activity, increases the likelihood of developing pneumonia.




General signs and symptoms:


Cough (productive and nonproductive), increased sputum (rust colored, discolored, purulent, bloody, or mucoid) production, fever, pleuritic chest pain (more common in community-acquired bacterial pneumonias), dyspnea, chills, headache, and myalgia. Older adults may be confused or disoriented and run low-grade fevers but may present with few other signs and symptoms.



General physical assessment findings:


Restlessness, anxiety, decreased skin turgor and dry mucous membranes secondary to dehydration, presence of nasal flaring and expiratory grunt, use of accessory muscles of respiration (scalene, sternocleidomastoid, external intercostals), decreased chest expansion caused by pleuritic pain, dullness on percussion over affected (consolidated) areas, tachypnea (respiratory rate [RR] more than 20 breaths/min), tachycardia (heart rate [HR] more than 90 bpm), increased vocal fremitus, egophony (“e” to “a” change) over area of consolidation, decreased breath sounds, high-pitched and inspiratory crackles (rales) increased by or heard only after coughing, low-pitched inspiratory crackles (rales) caused by airway secretions, and circumoral cyanosis (a late finding).



Diagnostic tests




Chest x-ray examination:


To confirm presence of pneumonia (i.e., infiltrate appearing on the film).



Sputum for gram stain and culture and sensitivity tests:


Sputum is obtained from the lower respiratory tract before initiation of antibiotic therapy to identify causative organism. It can be obtained via expectoration, suctioning, transtracheal aspiration, bronchoscopy, or open-lung biopsy.



White blood cell (WBC) count:


Will be increased (more than 12,000/mm3) in the presence of bacterial pneumonias. Normal or low WBC count (less than 4000/mm3) may be seen with viral or mycoplasma pneumonias.



Chemistry panel:


To detect presence of hypernatremia and/or hyperglycemia.



Blood culture and sensitivity:


To determine presence of bacteremia and aid in identification of causative organism. To attain the best yield, blood cultures should be drawn before administration of antibiotics.



Urinary antigen test:


To detect Legionella pneumophila and Streptococcus pneumoniae.



Oximetry:


May reveal decreased O2 saturation (92% or less).



Arterial blood gas (ABG) values:


May vary, depending on degree of lung involvement or other coexisting disease. Findings may demonstrate hypoxemia (PaO2 less than 80 mm Hg) and hypocarbia (PaCO2 less than 32-35 mm Hg), with a resultant respiratory alkalosis (pH more than 7.45) in the absence of an underlying pulmonary disease.



Serologic studies:


Acute and convalescent antibody titers drawn to diagnose viral pneumonia. A relative rise in antibody titers suggests viral infection.



Acid-fast stains and cultures:


To rule out tuberculosis.



Nursing diagnosis for patients at risk for developing pneumonia





Nursing diagnosis:



Risk for infection (nosocomial pneumonia)


related to inadequate primary defenses (e.g., decreased ciliary action), invasive procedures (e.g., intubation), and/or chronic disease


Desired Outcome: Patient is free of infection as evidenced by normothermia, WBC count 12,000/mm3 or less, and sputum clear to whitish in color.




































ASSESSMENT/INTERVENTIONS RATIONALES
Identify presurgical candidate who is at increased risk for nosocomial pneumonia. This assessment helps ensure that surgical patients remain free of infection because nosocomial pneumonia has a high morbidity and mortality rate. Factors that increase risk for nosocomial pneumonia in surgical patients include the following: older adult (older than 70 yr), obesity, COPD, other chronic pulmonary conditions (e.g., asthma), history of smoking, abnormal pulmonary function tests (especially decreased forced expiratory flow rate), intubation, and upper abdominal/thoracic surgery.
Perform thorough hand hygiene before and after contact with patient (even when gloves have been worn). This intervention helps prevent spread of infection by removing pathogens from hands. Hand hygiene involves using alcohol-based waterless antiseptic agent if hands are not visibly soiled or using soap and water if hands are dirty or contaminated with proteinaceous material.
Provide preoperative teaching, explaining and demonstrating pulmonary activities that will be used postoperatively to prevent respiratory infection. Pulmonary activities that help to prevent infection/pneumonia include deep breathing, coughing, turning in bed, splinting wounds before breathing exercises, ambulation, maintaining adequate oral fluid intake, and use of hyperinflation device.
Make sure patient verbalizes knowledge of these activities and their rationales and returns demonstrations appropriately. These actions help ensure patient is knowledgeable and capable of performing these activities. Learning how to apply information via a return demonstration is more helpful than receiving verbal instruction alone. A knowledgeable patient is more likely to adhere to therapy.
Advise individuals who smoke to discontinue smoking, especially during preoperative and postoperative periods. Refer to a community-based smoking cessation program as needed or provide nicotine replacement therapy. Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor that increases likelihood of developing pneumonia.
Administer analgesics ½ hr before deep breathing exercises. Support (splint) surgical wound with hands, pillows, or folded blanket placed firmly across site of incision. These interventions help control pain, which otherwise would interfere with lung expansion.
Identify patients who are at increased risk for aspiration. Individuals with depressed LOC, advanced age, dysphagia, or a nasogastric (NG) or enteral tube in place are at risk for aspiration, which predisposes them to pneumonia.
Maintain head of bed (HOB) at 30- to 45-degree elevation, and turn patient onto side rather than back. When patient receives enteral alimentation, recommend continuous rather than bolus feedings. Hold feedings when patient is lying flat. Aspiration is one of the two leading causes of nosocomial pneumonia. Aspiration precautions include maintaining HOB at 30-degree elevation, turning patient onto side rather than back, and using continuous rather than bolus feedings when patient receives enteral alimentation.
Recognize risk factors for infection in patients with tracheostomy and intervene as follows. Risk factors include presence of underlying lung disease or other serious illness, increased colonization of oropharynx or trachea by aerobic gram-negative bacteria, greater access of bacteria to lower respiratory tract, and cross-contamination caused by manipulation of tracheostomy tube.

– Wear gloves on both hands when handling tube or when handling mechanical ventilation tubing.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Pneumonia

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