Definition?
Acute infection of the lung parenchyma.
8th leading cause of death in the US.
How is a normal airway protected from pneumonia?
Mechanical defense mechanisms: air filtration, epiglottis closure over the trachea, cough reflex, mucociliary escalator mechanism, reflex bronchoconstriction.
Immune defense mechanisms: secretion of immunoglobulins A and G and alveolar macrophages.
What causes pneumonia? (Etiology)
Pneumonia is more likely to occur when defense mechanisms are incompetent or overwhelmed by virulence or quantity of infectious agents.
1. Decreased consciousness —> weak cough and epiglottal reflexes —> aspiration.
2. Tracheal intubation —> bypasses normal filtration processes, interferes with cough reflex and mucociliary escalator mechanism.
3. Air pollution/smoking/viral URIs/normal changes with aging: affect mucociliary escalator mechanism.
4. Chronic diseases —> suppress immune system’s ability to handle pneumonia.
In what three ways do organisms that cause pneumonia reach the lungs?
- Aspiration
- Inhalation of microbes present in air
- Hematogenous spread from primary infection elsewhere in body.
Community Acquired Pneumonia?
Acute infection of the lung occurring in patients who have not been hospitalized or resided in a long-term care facility within 14 days of onset.
Empiric antibiotic therapy should be started ASAP, before the causative agent is confirmed.
Hospital-Acquired Pneumonia?
- Also known as nosocomial pneumonia.
- Pneumonia in a non intubated patient that begins 48 hours or longer after admission and was not present at admission.
- Ventilator-associated pneumonia is a separate condition.
- Multi drug resistant organisms (MDR) make treating pneumonia difficult. Major culprits are MRSA and gram-negative bacilli.
Aspiration Pneumonia?
- Results from abnormal entry of material from the mouth or stomach into the trachea and lungs. Aspirated material triggers an inflammatory response
- For patients who aspirate in hospitals, appropriate antibiotics should include coverage for both gram-negative organisms and MRSA.
Necrotizing Pneumonia:
Definition?
Causative Agents?
Signs/Symptoms?
Treatment?
- Rare complication of bacterial lung infection characterized by liquefaction and sometimes cavitation of lung tissue.
OFTEN RESULTS FROM COMMUNITY ACQUIRED PNEUMONIA. - Causative organisms: staphylococcus, Klebsiella, Streptococcus.
- Signs/Symptoms: immediate respiratory insufficiency/failure, leukopenia, bleeding into airways. Lung abscesses commonly occur
- Treatment: long-term antibiotics, possibly surgery.
Opportunistic pneumonia?
inflammation and infection of the lower respiratory tract in immunocompromised patients.
May develop and infection from microorganisms that normally do not cause an infection.
Pneumocystic Jiroveci Pneumonia (PJP)? Most common population found in?
Definition?
Symptoms?
Diagnostics?
Treatment?
Definition: rarely occurs in healthy people, but it is the most common pneumonia in those with HIV. CAN BE LIFE-THREATENING
Infection can spread to other organs (liver, bone marrow, lymph nodes, spleen, thyroid)
Signs/Symptoms: Onset is slow and subtle with symptoms of fever, tachypnea, tachycardia, dyspnea, nonproductive cough, hypoxemia.
Diagnostics: Chest X-ray shows diffuse bilateral infiltrates. In widespread disease, lungs have massive consolidation.
Treatment: Fungal infection, bacterial and viral infections must be ruled out first.
Anti-fungals do not work with this. It’s treated by trimethoprim/sulfamethoxazole (Bactrim/Septra)
CMV (herpesvirus)?
Definition?
Common population found in?
Definition: can cause viral pneumonia. It’s mild or asymptomatic in most people, but in immunocompromised it can be severe.
Population: Most life-threatening complication in hematopoietic stem cell transplantation.
Pathophysiology
Organisms trigger an inflammatory response in the lungs. Process attracts more neutrophils to the area, edema of airways occurs, fluid leaks from capillaries and tissues into the alveoli. O2 transport in affected, leading to hypoxia. Consolidation, typical feature of bacterial pneumonia, occurs when alveoli become filled with fluid and debris. Mucus production increases and obstructs airflow.
With antibiotics, macrophages lyse and process the debris, and lung tissue recovers.
Common Clinical Manifestations
Common: cough, fever, chills, dyspnea, tachypnea, pleuritic chest pain. Cough may not be productive. Sputum is green, yellow, or rust-colored (bloody)
Nonspecific: diaphoresis, anorexia, fatigue, myalgias, headache.
Clinical Manifestations in Elderly patients?
Confusion, stupor, hypothermia.
May not present with classic symptoms.
Physical exam clinical manifestations?
If consolidation?
If pleural effusion?
Fine or coarse crackles over affected region.
Consolidation: bronchial breath sounds, egophony, increased fremitus.
Pleural effusion: dullness to percussion over affected area.
Complications?
Uncommon ones?
Atelectasis
Pleurisy (inflammation of pleura)
Pleural effusion (fluid in pleural space) (may need thoracentesis)
Bacteremia
Pneumothorax
Meningitis (may need lumbar puncture)
Acute respiratory failure
Sepsis/septic shock (can lead to mods)
Uncommon: lung abscess, empyema (accumulation of purulent exudate in pleural cavity)
Diagnostics?
What’s enough for early treatment?
What’s used to obtain fluid samples for patients not responding to initial therapy?
What is needed for antibiotics?
What’s needed for seriously ill patients?
History, physical exam, chest x-ray are often enough to make decisions for early treatment. X-ray may show pleural effusions.
Thoracentesis and bronchoscopy washings may be used to obtain fluid samples from patients not responding to initial therapy.
Sputum specimens ideally obtains prior to antibiotic administration, but should not be delayed.
Blood cultures on seriously ill patients.
ABGs to assess hypoxemia, hypercapnia, and acidosis.
CBC, WBC differential: leukocytosis occurs in majority of bacterial pneumonia patients with presence of bands (immature neutrophils).
Interprofessional Care:
What vaccine is used to prevent pneumonia in high risk patients?
Difference between treatment of bacterial and viral pneumonia?
General care? Drug therapy? Nutritional therapy?
- Pneumococcal vaccine is used to prevent Streptococcus pneumoniae.
- Bacterial pneumonia: antibiotics. Usually responds in 48-72 hours. Decreased temperature, improved breathing, reduced chest discomfort are signs of improvement. Repeat chest x-ray done in 6-8 weeks.
Viral pneumonia: usually resolves in 3-4 days, therapy is supportive. Antivirals exist for pneumonia secondary to influenza.
General Care:
Mobility improves diaphragm movement and chest expansion, mobilization of secretions, and prevention of venous stasis.
Drug therapy:
Empirical antibiotic therapy is based on presence of risk factors for patient to have MDR organism caused pneumonia.
Clinical improvement is usually seen in 3-5 days.
IV therapy should be switched to orals when patient is hemodynamically stable, improving clinically, and has functioning GI tract to handle oral.
Nutritional:
hydration is important to prevent dehydration and loosen secretions
Small, frequent meals are easier for dyspneic patients to tolerate.
Nursing Management
Subjective Assessment findings: in history? Medications? Any surgeries? Other risk factors? Symptoms patient may report (subjective)?
History: lung cancer, COPD, diabetes, immunosuppression
Medications: corticosteroids, chemo, immunosuppressants.
Surgeries: abdominal or thoracic surgery, splenectomy, endotracheal intubation, any surgery with general anesthesia, tube feedings.
Other: cigarette smoking, alcoholism, recent upper respiratory tract infection, prolonged bed rest or immobility,
Symptoms: malaise, fatigue, dyspnea, cough, nasal congestion, anorexia, nausea, vomiting, pain with breathing, chest pain, sore throat, headache, abdominal pain, aches.
Assessment findings (objective):
General?
Respiratory?
Cardiovascular?
Neurological?
General: fever, restlessness, lethargy, splinting of affected area.
Respiratory: TACHYPNEA, asymmetric chest movements or retraction, nasal flaring, use of accessory muscles, crackles, friction rubs, dullness on percussion over consolidated areas, increased tactile fremitus on palpation. Pink, rusty, green, yellow, or white sputum.
Cardiovascular: tachycardia
Neurological: changes in mental status, confusion to delirium
Assessment findings:
Diagnostics!
On a CBC?
Initial ABGS?
Later ABGs?
On chest x-ray?
CBC: leukocytosis
Initial ABGs: low or normal PaO2, low or normal PaCO2, high or normal pH.
Later ABGs: low PaO2, high PaCO2, low pH
X-ray: patchy or diffuse infiltrates, abscesses, pleural effusions, pneumothorax.
Nursing diagnoses
Impaired gas exchange related to fluid and exudate accumulation within the alveoli and surrounding lung tissue.
Ineffective breathing pattern related to inflammation and chest discomfort.
Acute pain related to inflammation and ineffective pain management and/or comfort measures.
Activity intolerance related to chest discomfort, inflammation, SOB, generalized weakness.
Planning
(Goals)
Clear breath sounds
normal breathing patterns
no signs of hypoxia
normal chest x-ray
normal WBC count
absence of complications
Implementation
Prevention:
What’re we teaching the patient is important in preventing pneumonia, especially in high risk patients? What’s important in preventing pneumonia in a post-op patient?
Teach good hand washing, proper nutrition, regular exercise, adequate rest, cough/sneeze into elbow. Avoidance of smoking.
Teach Avoid people with URIs. If you get a URI and it does not resolve in 7 days, seek medical attention.
Pneumococcal vaccine for at risk patients.
In post-op:
Position at least 30 degrees. Turn and reposition patients every 2 hours. Sit upright in chair.
*ICU: ventilator bundle (table 67-8) to reduce VAP
Early mobilization, incentive spirometer, and twice daily oral hygiene with chlorhexidine swabs have been shown to reduce incidence of pneumonia in post-operative patients.
