1 Study Guide: Pneumonia

Pneumonia
Etiology = Infection of the lower respiratory tract caused by bacteria, fungi, protozoa, parasites or
viruses; usually occurs when immune systems cannot combat invader

Pathogenesis:
Infection = 3 pathways:
a. aspiration of microbes from oropharynx into lungs (may be d/t bronchitis, strep)
b. Inhalation of aerosolized microbes
a. Someone sneezes, cough, esp. strep pneumonia (pneumococcus), viral influenza or
mycoplasma pneumonia
c. Infection from existing bacteremia (via blood flow into lungs)
d. May be acquired in hospital (nosocomial) or Community (proof calls these forms, cbill calls these
vectors)
Inflammation response in lungs:
 Fights off organism but damages bronchial membranes and alveolocapillary membranes 
bronchioles fill with infectious debris & exudates  bacterial spread throughout lung
Consolidation = Bronchioles fill with pus and fluid  lack of airspace in lungs (this is different from
pleural effusion, which is fluid in the pleural space) aka lobar pneumonia = segment or lobe
Bronchopneumonia = diffused in patches around bronchi
Lungs stiffen  atalectasis = collapse of lung tissue = compression atalectasis

Risk factors:
Community:
 Extremes of age – v. old, v. young  Chronic health issues or coexists
 ETOH & smoking  Recent exposure to viral respiratory or
 No pneumonia vaccination (or 6+ yrs since) influenza infection
 No ‘flu vaccination

Hospital:
 Old adult  Immunocompromised state
 Gram-negative colonization: mouth, throat,  Altered LOC
stomach  Recent aspiration event
 Underlying lung disease  Use of drugs gastric pH (H2 Histamine
 Endotracheal intubation (also trach, NG) blockers, antacids, alkaline feedings)
 Poor nutrition  VAP = Ventilator acquired

Some facts:
 Community acquired > hospital acquired
 Often late fall & winter
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Health Promotion & maintenance
 Encourage vaccination  Avoid pollutants
 Wash hands  Don’t smoke
 Seek help if fever lasts 24h+, sx worsen or  If smoke, cut back or try to quit
lasts more than a week  Healthy balanced diet
 Ventilator bundle = hand hygiene + **oral  Enough rest and sleep
care** + head of bed elevation  Drink 3L fluid/day
 Mobility issues: cough, turn, move, and deep
breathing exercises

Manifestations (physical assessment):

 Flushed cheeks  Pleural friction rub
 Bright eyes  Coughing: assess productivity, appearance of
 Anxious expression, myalgia sputum [productive = P(bacterial)]
 HA  Lung sounds: crackles  fluid in interstitial and
 Chills alveolar areas
 Fever  Wheezes: inflammation and exudates in airways
 Tachycardia  Bronchial breath over areas of
 Tachypnea density/consolidation
 Sputum  Rapid weak pulse may be hypoxemia, dehydration,
 Muscle weakness impending shock
 Compression atalectasis (lung collapse)  Hypoxemia = low serum O2
 Dyspnea = SOB =>  lung expansions  Hypoxia: pt will be uncomfortable lying down
 Pain = with inspiration + d/t pleural friction rub and will sit upright, balancing with hands
+ paretic (d/t movement)  descriptors of pain
 important

Common SX Older Adults:

 Weakness  May not have fever or cough
 Fatigue  Hypoxemia present
 Lethargy  Most common sx = acute confusion from
 Confusion hypoxia
 Poor appetite
Assessment:
Labs:
 Sputum for gram stain, culture, sensitivity  Chest X-ray for consolidation/pleural
testing effusion, may not show until 2+ days after 1st
 CBC: look for  WBC (leukocytosis) manifestations – in older adult, e-ray =
o Na essential for early dx
o  BUN  Urine: check CHON, pus, blood, is pt septic?
o Electrolyte imbalances  ABG to determine baseline O2 & CO2 levels
 Pulse ox for hypoxemia
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 Bronchoscope to see what’s going on  Thorracentesis = remove fluid from pleural
 Needle aspiration to check fluids space – watch that lung doesn’t puncture!

Physical assessment:
 Use of accessory muscles
 Nasal flaring
 Respirations
 Qualities of dyspnea
 SpO
 Check nail beds, cyanosis
 Coughing: production, color
and appearance of sputum
 May see dehydration
 Asucltation: wheezes,
crackles, location
 Fever
 Pain: paretic pain and nature
 Level of activity
 Lifestyle esp smoking
 Recent enviro exposure and
occupation
 Lethary?
 Meds, incl OTC
 Hx: CHF, COPD, HIV/AIDS
 Urine – UTI? Sepsis?
 Pulse – soft? Weak?

Nursing Considerations:
 Oxygen + perfusion  Dehydration  Hypoxia: color, dizziness,
 Pain  Malnutrition LOC, fever, VS:  HR to
 Edema & weight changes  Activity level compensate
 Safety – activity  How well sleep  Give oxygen if needed

Common nursing dx:

 Impaired gas exchange r/t effects of alveolar-capillary membrane changes
 Delivery of O2 therapy
o Nasal cannula or mask
o Incentive spirometer
 Prevent or reverse atelectasis
 Bronchial hygiene
 Ineffective Airway Clearance r/t effects of infection, excessive tracheobronchial secretions,
fatigue, decreased energy, chest discomfort, muscle weakness
 Maintain patent airway, indicators:
o Effective cough
o Absence of pallor/cyanosis
o Absence of crackles/wheezes
o SpO = 95+
 Help pt cough and deep breath q2h
 Incentive spirometer
 Avoid dehydration
 3L H2O daily
 Rx for Bronchodilators esp. β2 agonists if w/bronchospasms
 Bronchial asthma or swelling - steroids

 Acute pain r/t effects of inflammation of parietal pleura, coughing

 Deficient fluid volume r/t increased respiratory rate, fever, infection, increased metabolic rate
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 Sleep deprivation r/t pain, dyspnea, unfamiliar environment
 Potential for pleural effusion

Primary collaborative problem: Potential for sepsis

 Indicators, free of invader: absence of fever + absence of pathogens + WBC w/n normal
 Interventions:
o Eradication is key
o Anti-infectives (not for viral)
o IV may  to PO
 Drug resistent streptococcus pneumonia (DRSP)
o Most common: in 65 yo+ OR d/t exposure to young children in day care
 Aspiration
o Acidic substances  widespread inflammation  ARDS (acute respiratory distress syndrome)
 NSAIDs + ATB to reduce inflammatory response

Interventions:
 Incentive spirometer = sustained maximal inspiration = form of bronchial hygiene
 Finish ATB course
 Plenty of H2O
 Oxygen therapy
o Maintain patent airways o Monitor effectiveness of therapy (SpO, ABG)
o Clear oral, nasal, tracheal secretions as o Assure replacement of mask/cannula
appropriate o Monitor pt ability to tolerate removal when
o Restrict smoking eating
o Set up O2 equipment & adm thru heated, o Change delivery from mask to nasal prongs
humidified system during meals as tolerated
o Monitor O2 liter flow o Monitor for sx O2 toxicity & absorption
o Monitor position of delivery device atelectasis
o Instruct pt about importance of leaving O2 on o Monitor pt anxiety
o Check to ensure Rx concentration delivered o Monitor for skin breakdown d/t friction
o Provide for O when pt transported

TX:
 Cupping and clapping
 Incentive spirometer (bronchial hygiene)
o Can be delegated
o How often? About q2h
o Make sure follow up
o Document results
 Upright position
 Remember, some ATB affect efficiency of birth control pills
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Focused Assessment: pt recovering from pneumonia:
*Report:
 New onset confusion  Dyspnea  Increased sputum
 Chills  Wheezing production
 Fever  Hemoptysis (bloody  Increasing fatigue
 Persistent cough sputum)  Other unresolved sx
 Chest discomfort
*Assess:
 Fever  Cyanosis, esp. mouth or  Adventitious/abnormal
 Diaphoresis (excessive conjunctiva breath sounds
sweating usu assoc.  Dyspnea, Tachypnea,  Weakness
w/SHOCK) tachycardia

*Teachings: key = avoidance of upper respiratory tract infections/viri

 Avoid crowds  Vaccination – flu & pneumonia
 Avoid sick ppl – esp cold & flu  Balanced diet
 Avoid exposure to irritants incl smoke  Adequate fluid intake

*Evaluation: Outcome:
 Attains/maintains adequate gas exchange
 Maintain patent airway
 Free of invading organism
 Return to pre-pneumonia health status