Community- Acquired Pneumonia

1. Community- Acquired Pneumonia Caitlin Darby Florida Hospital Tampa November 14, 2012

2. Objectives • Discuss the pathophysiology of pneumonia • Describe signs and symptoms of pneumonia • Discuss risk factors for pneumonia • Discuss the prevalence of pneumonia in our society • Discuss medical and nursing interventions for pneumonia from current research • Describe a patient case scenario • Discuss medical and nursing interventions, treatments and outcomes for a hospitalized patient with pneumonia

3. Pathophysiology • Infection of the lower respiratory tract caused by bacteria, viruses, fungi, protozoa or parasites. • The alveoli and interstitium of the lung are filled with inflammatory cells and fibrin (Loebinger, 2012) and (Huether& McCance, 2012)

4. Pneumonia Pathophysiology Video

5. Most Common Bacterial Microbes Responsible for Pneumonia • Streptococcus pneumoniae (most common cause of CAP) • Chlamydia pneumoniae • Mycoplasma pneumoniae • Haemophilusinfluenzae • Legionella spp. • Chlamydia psittaci • Staphylococcus aureus • Moraxella catarrhalis • The causative microorganism influences how the individual presents clinically, how the pneumonia is treated and the prognosis (Loebinger & Wilson, 2008)

6. Routes of Entry • Inhalation of airborne pathogens • Microorganisms that have been released into the air when we cough, sneeze or talk • Aspiration of gastric and nasopharyngeal flora • Spread from other infected sites (Loebinger & Wilson, 2012)

7. Risk Factors for Pneumonia • Age • 65 and older • Very young children whose immune systems haven’t fully developed • Smoking • Compromised immunity • Underlying disease • Alcoholism • Altered consciousness • Impaired swallowing • Endotracheal intubation • Malnutrition • Immobilization • Underlying cardiac or liver disease • Residence in a nursing home • Poverty • Long term corticosteroid use • Exposure to certain chemicals or pollutants (Huether, McCance, 2012)

8. Symptoms of Pneumonia • Cough • Vomiting • Headache • Dyspnea • Thoracic/Pleuritic pain • Abdominal pain • Poor appetite • Diarrhea • Rhinorrhea • Malaise/Lethargy • Sputum production • Sweating (Juven, Ruuskanen& Mertsola, 2003) (Loebinger& Watson 2012) (Thiem, Heppner & Pientka, 2011)

9. Signs of Pneumonia • Fever > 37.5°C • Cough • Rhinorrhea • Vomiting • Malaise/Lethargy • Confusion • Dyspnea • Poor appetite • Diarrhea • Sputum production • Dehydration • Adventitious breath sounds (rhonchi, rales/crackles, wheezing or decreased sounds) • Respirations > 30/min • Consolidation on chest X-ray • Sweating • Low blood pressure (Juven, Ruuskanen & Mertsola, 2003) (Loebinger & Watson, 2012) (Thiem, Heppner & Pientka, 2011)

10. Prevalence of Pneumonia in the United States • Bacterial pneumonia remains one of the leading causes of morbidity and mortality • Estimated 450 million cases per year worldwide • Estimated 4 million deaths per year worldwide • 6th leading cause of death worldwide • CAP= 350,000-620,000 hospitalizations each year (Loebinger & Watson, 2012) & (Huether& McCance, 2012)

11. Medical Interventions • From current research • Antibiotic therapy • Chest x-ray and/or CT scan • Bronchoscopy • Thoracentesis • Daily blood tests/labs to monitor status of illness • Oxygen therapy • Breathing treatments • Prescribing medication based upon the patient’s signs/symptoms • Continuous IV fluids http://health.nytimes.com/health/guides/disease/pneumonia/overview.html

12. Nursing Interventions • From current research • Incentive spirometry (5-10 breaths) every 2 hours • Chest physiotherapy • Rhythmic breathing and coughing every 4 hours • Monitoring breathing pattern, rate, effort, use of accessory muscles • Monitor O2 saturation and arterial blood gases • Assessing for changes in mental status, skin color and cyanosis • Administer antitussives, mucolytics and antibiotics as prescribed • Provide oxygen therapy • Reposition patient q2h and position them in fowlers or semi-fowlers position • Provide oral care after expectoration and provide tissues/bag for disposal • Suction secretions if cough is ineffective • Increase fluid intake http://nanda-nursinginterventions.blogspot.com/2011/05/nursing-interventions-for-pneumonia.html

13. Diagnostic Tests/Labs • Non-laboratory tests • Chest x-ray • Bronchoscopy • Throracentesis • Computed tomography scan (CT Scan) • Laboratory tests • Complete Blood Count (CBC) • Arterial Blood Gas (ABG) • Basic Metabolic Panel (BMP) • Tests for suspected bacterial pneumonia • Sputum culture & gram stain • http://labtestsonline.org/understanding/conditions/pneumonia/start/3

14. Commonly Used Medications

15. Prevention of Pneumonia • Smoking cessation • Frequent hand-washing • Coughing/sneezing into a tissue, elbow or sleeve • Cleaning frequently touched surfaces • Vaccination against Streptococcus. Pneumoniae • Most common cause of community acquired pneumonia • The vaccine doesn’t completely prevent pneumonia but it reduces the severity • Recommended for: • Patients over 5 years with immunodeficiency and chronic diseases (Loebinger & Wilson, 2012) http://labtestsonline.org/understanding/conditions/pneumonia/start/4

16. Patient Scenario • The patient is a 74 year old female who complains of severe chest pain, difficulty breathing and difficulty clearing secretions. She complains of pain in her right lower chest. When asked to describe the pain on a scale from 0-10 she reported the intensity as a 6/10. She describes the pain as throbbing, sharp and constant. Her pain and trouble breathing is worse when she lays flat. Her symptoms decrease when sitting up in a chair. The patient was admitted to the hospital on October 30, 2012 where she is underwent treatment for community acquired pneumonia caused by Streptococcus pneumoniae.

17. Patient Scenario (cont.) • Subjective Findings (Symptoms) • Difficulty breathing • Dry mucous membranes • Fatigue (trouble sleeping) • Difficulty clearing secretions • Objective Findings (Signs) • Tachypneic (RR: 28) • Adventitious breath sounds (crackles in lower lobes) • Dry mucous membranes • Dyspnea • Pallor • Trouble clearing secretions • Temperature 100.6°F

18. Adventitious Lung Sounds(Crackles)

19. Patient Medications • Acetaminophen • Mucinex • ALPRAZolam • HYDROcodone • Amoxicillin

20. Nursing Diagnosis • Ineffective airway clearance r/t retained secretions a.e.b adventitious breath sounds • Ineffective breathing pattern r/t body position a.e.b orthopnea • Chest pain secondary to pneumonia a.e.b patient stating pain as a 6/10

21. Medical Interventions • What was done while the patient was in the hospital • Physician ordered a sputum culture to determine the virus or bacteria causing the pneumonia (Streptococcus pneumoniae) • Physician ordered a chest x-ray to determine the area where the consolidation is located • Prescribed pain medication (HYDROcodone) • Prescribed antibiotics (amoxicillin) • Prescribed Mucinex & ALPRAZolam • Ordered breathing treatments from respiratory therapy

22. Nursing Interventions • What was done while the patient was in the hospital • Monitor respiratory rate, pattern, depth and ease of respiration • Supplemental Oxygen (O2 @ 2L) • Incentive spirometer use every hour • Turn, cough and deep breath exercises every hour • Pursed lip breathing exercises • Assisting the patient to the chair every 3 hours to sit up to loosen lung secretions • Elevating the HOB to 45 degrees to allow the patient to sit up to loosen lung secretions • Respiratory therapy to provide breathing treatments 2x a day • Administer medications as prescribed • Increase fluids to prevent dehydration

23. Outcomes • The patient was able to clear lung secretions 2x during my shift • The patient transferred herself with assistance to the chair 3x during my shift • She tolerated the breathing treatments from respiratory therapy well and was cooperative with all interventions • Her breathing pattern and respiratory rate did not change before my shift ended • The patient was not discharged during my shift

24. NCLEX Question #1 • A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests? • ABG analysis • Chest x-ray • Blood cultures • Sputum culture and sensitivity http://amy47.com/nclex-style-practice-questions/airway-pneumonia-and-tb/

25. NCLEX Question #2 • When auscultating the chest of a client with pneumonia, the nurse would expect to hear which of the following sounds over areas of consolidation? • Bronchial • Bronchovestibular • Tubular • Vesicular

26. NCLEX Question #3 • An elderly client with pneumonia may appear with which of the following symptoms first? • Altered mental status and dehydration • Fever and chills • Hemoptysis and dyspnea • Pleuritic chest pain and cough

27. NCLEX Question #4 • Which of the following organisms most commonly causes community-acquired pneumonia in adults? • Haemiphilusinfluenzae • Klebsiellapneumoniae • Streptococcus pneumoniae • Staphylococcus aureus

28. NCLEX Question #5 • Clients with chronic illnesses are more likely to get pneumonia when which of the following situations is present? • Dehydration • Group living • Malnutrition • Severe periodontal disease

29. References • Loebinger, M., & Wilson, R. (2008). Pneumonia. Medicine, Volume 40(6).329-334. Retrieved from http://www.sciencedirect.com.ezproxy.lib.usf.edu/science/article/pii/ S1357303912000576 • Loebinger, M. & Wilson, R. (2012). Bacterial Pneumonia. Medicine, Volume 36(6). 285-290. Retrieved from http://www.sciencedirect.com.ezproxy.lib.usf.edu/science/article/pii/ S1357303908001059 • Thiem, U., Heppner, H., & Pientka, L. (2011). Elderly patients with community acquired pneumonia. Drugs and Aging, Volume 28(7). 519-537. Retrieved from http://ehis.ebscohost.com.ezproxy.lib.usf.edu/eds/pdfviewer/pdfviewer? sid=26065f11-e162-4a8a-be31-de89dd979930%40sessionmgr4&vid=3&hid=1 • Juven, T., Ruuskanen, O., & Mertsola, J. (2003). Symptoms and signs of community acquired pneumonia in children. Scandinavian Journal of Primary Health Care, Volume 21. 51-56. Retrieved from http:// ehis.ebscohost.com.ezproxy.lib.usf.edu/eds/pdfviewer/pdfviewer? sid=5a884c7c-680a-450b-a81a-85b6d41b2d09%40sessionmgr12&vid=3&hid=1 • Student Nursing Study Blog. [Web post]. Retrieved from http://amy47.com/nclex-style-practice-questions/airway-pneumonia-and-tb/ • Nursing Interventions for Pneumonia. [Web Post}. Retrieved from http://nanda-nursinginterventions.blogspot.com/2011/05/nursing-interventions-for- pneumonia.html • Hadjiliadis, D. (2012, May 29). Pneumonia-adults community acquired. The New York Times. Retrieved from http://health.nytimes.com/health/guides/disease/ pneumonia/overview.html

30. Questions??