Pneumonia

1. Pneumonia

2. Pneumonia • Acute inflammation of lung caused by microorganism • Leading cause of death until 1936 • Discovery of sulfa drugs and penicillin

3. Pneumonia • Still leading cause of death from infectious disease

4. Predisposing Factors • Defense mechanisms are incompetent or overwhelmed • Decreased cough and epiglottal reflexes (may allow aspiration)

5. Predisposing Factors • Mucociliary mechanism impaired • Pollution • Cigarette smoking • Upper respiratory infections • Tracheal intubation • Aging

6. Predisposing Factors • Alteration of leukocytes from malnutrition • Increased frequency of gram- negative bacilli (leukemia, diabetes, alcoholism)

7. Acquisition of Organisms • Aspiration from nasopharynx, oropharynx • Inhalation of microbes • Hematogenous spread from primary infection elsewhere

8. Types of Pneumonia • Organisms implicated • S. pneumoniae • Legionella • Mycoplasma • Chlamydia • S. aureus • Respiratory viruses

9. 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

10. Types of Pneumonia • Hospital-acquired pneumonia (HAP) • Occurs > 48 hours after admission; not incubating at time of hospitalization • Highest mortality rate of nosocomial infections

11. Types of Pneumonia • Causes of HAP • Pseudomonas • Enterobacter • S. aureus • S. pneumoniae • Immunosuppressive therapy • General debility • Endotracheal intubation

12. 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

13. 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

14. Types of Pneumonia • Forms of aspiration pneumonia • Mechanical obstruction • Chemical injury • Bacterial infection

15. 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

16. Types of Pneumonia • Opportunistic pneumonia • Clinical manifestations • Fever • Tachypnea • Tachycardia • Dyspnea • Nonproductive cough • Hypoxemia

17. Pathophysiology: Pneumococcal Pneumonia • Congestion from outpouring of fluid into alveoli • Microorganisms multiply and spread infection, interfering with lung function

18. 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

19. Pathophysiologic course of pneumococcal pneumonia Fig. 27-1

20. Pathophysiology: Pneumococcal Pneumonia • Gray hepatization • Blood flow decreases • Leukocyte and fibrin consolidate in affected part of lung

21. Pathophysiology: Pneumococcal Pneumonia • Resolution • Resolution and healing if no complications • Exudate lysed and processed by macrophages • Tissue restored

22. Clinical Manifestations • CAP symptoms • Sudden onset of fever • Chills • Cough productive of purulent sputum • Pleuritic chest pain

23. Clinical Manifestations • Confusion or stupor may manifest in older or debilitated patient • Physical exam findings • Dullness on percussion • Increased fremitus • Bronchial breath sounds • Crackles

24. Clinical Manifestations • CAP (alternative manifestations) • Gradual onset • Dry cough • Headache • Myalgias • Fatigue • Sore throat • N/V/D

25. Clinical Manifestations • Manifestations of viral pneumonia are variable • Chills • Fever • Dry and non-productive cough • Extrapulmonary symptoms

26. Complications • Pleurisy • Pleural effusion • Usually is sterile and reabsorbed in 1-2 weeks or requires thoracentesis • Atelectasis • Usually clears with cough and deep breathing

27. Complications • Delayed resolution • Persistent infection seen on x-ray as residual consolidation • Lung abscess (pus-containing lesions) • Empyema (purulent exudate in pleural cavity) • Requires antibiotics and drainage of exudate

28. 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

29. Complications • Endocarditis • Microorganisms attack endocardium and heart valves • Manifestations similar to bacterial endocarditis

30. 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

31. 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

32. 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

33. Nursing Assessment • History of Predisposing/Risk Factors • Lung cancer • COPD • Diabetes mellitus • Debilitating disease • Malnutrition

34. 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

35. Nursing Assessment • Clinical Manifestations • Dyspnea • Nasal congestion • Pain with breathing • Sore throat • Muscle aches • Fever

36. Nursing Assessment • Clinical Manifestations • Restlessness or lethargy • Splinting affected area • Tachypnea • Asymmetric chest movements • Use of accessory muscles • Crackles • Green or yellow sputum

37. Nursing Assessment • Clinical Manifestations • Tachycardia • Changes in mental status • Leukocytosis • Abnormal ABGs • Pleural effusion • Pneumothorax on CXR

38. Nursing Diagnoses • Ineffective breathing pattern • Ineffective airway clearance • Acute pain • Imbalanced nutrition: less than body requirements • Activity intolerance

39. Planning • Goals: Patient will have • Clear breath sounds • Normal breathing patterns • No signs of hypoxia • Normal chest x-ray • No complications related to pneumonia

40. Nursing Implementation • Teach nutrition, hygiene, rest, regular exercise to maintain natural resistance • Prompt treatment of URIs

41. 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

42. Nursing Implementation • Assist immobile patients with turning and deep breathing • Strict asepsis • Emphasize need to take course of medication(s) • Teach drug-drug interactions

43. Evaluation • Dyspnea not present • SpO2> 95 • Free of adventitious breath sounds • Clears sputum from airway

44. Evaluation • Reports pain controlled • Verbalizes causal factors • Adequate fluid and caloric intake • Performs ADLs