PNEUMONIA

INTRODUCTION
It is an inflammatory condition of the lung that is
caused by a microbial agent.
“Pneumonitis” is a general tern that describes an
inflammatory process in the lung tissue that may
predispose a patient to or place a patient at risk for
inici obial invasion.

It is the leading cause of death from the infectious

disease.
 DEFINITION
“An inflammation of the lung
pai'enchyiiia (the respii'atory broiichioles
and the alveoli) is known as Pneumonia”.

Pneumonia is mainly caused by

microorganisms which enter the lower
respiratory systcin and eausc infection.
The microorganism includes bacteria,
mycobiictei'ia, mycoplasira, fungi,
parasites, and vii uses.
 EPIDEMIOLOGY
Common illness affecting approximately 450 million
people a year occurring in all pan of the world, and 4
million death yearly

Rates are greater in children less than five years and

adtilt older than 75 years.

It occurs five times lnore in the developing world than

in the developed woi'ld.
 EPIDEMIOLOGY cont...
• It is the eighth leading cause of death in United States ,
rcsulting in almost 70,000 deaths per year. In persons
65 years of age and oldei, it is the fifth leading cause of
death.

In India it is thc single largest cause Of death in

children, resulting in nearly 120 million cases a year.
CLASSIFICATION
• 1. According to the causative organisms
(a) Bacterial :-
• Pneumococcal pneumonia caused by Streptococcus pneumonia**
• Staphylococcal pneumonia caused by Sfaphylococcus uureus
• Influenzal pneumonia caused by Haemaphilus influenza
• Gmm-negative bacterial pneumonia caused by Klebsiella
pneumonia
• Anaerobic bacterial pneumonia caused by normal oral flora.
CLASSIFICATION contd...
• Rhinovims, cotonaviruses, infiuen2a virus, respiratory sncytial vinis(RSV),
adenovirus and parainfluenza.
• Herpes simplex virus rarely causes pneumonia in newboms, persons with
cancer, transplant recipients, and people with significant bums.

• People following organ transplantation or immunocomproniised present

high rates of cytomegalovirus pneumonia.
(c) Fungal :-
• Fungal pneumonia caused by histoplasmosis , blastomycosis,
coccidioidomycosis, aspergillosis, candidiasis.
CLASSIFICATION cont...
(d) Parasitic :-
• Parasitic pneumonia (caused by protozoa, nematodes,
platyhelminthes); common organism is Pneumocysiis
(carinii) fimveci
CLASSIFICATION cont...
2. According to the environment

Community-acquii'ed pneumonia.

Hospital acquired pneumonia.

° Pneuilionia in thC immuiio-GOnipromised host.

Ventilator acquired Pneumonia.(VAP)

 CLASSIFICATION cont...
3. According to the areas of the lung involved/affected
• Lobar pneumonia
• Multilobar pneumonia
• Bronchial pneumonia
• Interstitial pneumonia
• Alveolar (acinar) pneumonia
• Necrotizing pneumonia

• Segmental pneumonia
-
" CLASSIFICATION cont...
4. According to the cause
• Bronehiolitis obliterans organizing pneumonia (BOOP)/
ciyptogenic organizing pneumonitis (COP).
• Eosinophilic pneumonia : occur in response to infection with
parasite.
• Chemical pneumonia
• Aspiration pneumonia
• Dust pneumonia
• Bilateral pneumonia.
 ETIOLOY
There are many causes of pneumonia including
bacteria, viruses, inycoplasinas, fungal agents and
pi'otozoa. It may alsO result front inhalation of toxic
or caustic chemicals, smoke, dusts or gases or
aspiration of food, fluids, or voinitiis. Pneumonia may
complicate to chronic illnesses.
_
RISK FACTORS
• Age 60 or older
• Smoking
• Air pollution
• Altered consciousness : Alcoholism, head injury, anaesthesia,
drug overdose
• Tracheal intubation
• Upper Respiratory Tract Infection
• Chronic Disease : Chronic lung disease, Diabetes mellitus,
heart disease, cancer
RISK FACTORS contd... '
• Immunosuppression.
• Malnutrition.
• Inhalation of noxious substances.
• Prolonged Bed resi and immobility
• Aspiration of fluid, liquid, foreign or gastric content.
• Prolonged hospital stay.
• Residence in institutional areas/seeing where transmission is
prone.

• Fatigue
 PATHOPHYSIOLOGY
Infectious agent, Foreign substance, blood borne organisms
that enter the blood circulation or Aspiration of gastric content

Cause inflammation of pulmonary tissue affecting both

ventilation aad diffusion

The alveoli fills with Mucosal edema of

exudates alveolar membrane occur
 PATHOPHYSIOLOGY

interferes with the causing occlution of

gygb alveoli resulting in
carbon dioxide decrease alveolar oxygen
tension

Hypoxiq occur with retention of

carbon dioxide, Shortness of
breath, Fatigue ,Crackles in
lungs Or decrease Breath
CLINICAL MANIFESTATION
Fever
Chills and sweating
Productive cough
Shouness of breath
Pleuritic chest pain
Hypoxeiiiia

Fatigue
P"“
Tachypnea
 CLINICAL MANIFESTATION
CONTD...
Hemopiysis
Dyspnea
Tachypnea

1-Icadachc
Crackling sounds over’ affected ai'ea
Dullness on percussion on affected ai'ea
Decrease i» breath sounds

Unequal chcst expansion

 CLINICAL MANIFESTATION CONT...

SYMPTOM FREQUENCY

Cough 7R-91%

Fatigue 90%

Fever 71-75%

Shortness of breath 67—75%

Sputum

Chest pain 3 9%
 DIAGNOSTIC EVALUATION
Physical examination.
Chcst X—ray.
- Gram stain and culture and sensitivity tests of sptiiuiii.
• Blood culture.
Immunologic test to detect mici'obial antigens.
- CT Scan thorax.
Transtraclical aspirate.
Fibcroptic bronchoseopy or iransetitancous nccdlc aspiration
/biopsy.
Transcutaneous oxygen levcl analysis or ABG.
 MANAGEMENT
• Antimicrobial therapy

Penicillin G or Penicillin Macrolide antibiotics such as

V, or amoxicillin azithroinycin (Zithromax) or
Streptococcus clavulanate (Augmentin),
clarithromycin (Biaxin);
Pneumonia Trimethoprim doxycyc!ine; oral beta \actans
su\famethoxazole (TMP- such as cefuroxime (Ceftin),
SMZ). Linozolid.
Staphylococcus Penicillin. Cephalosporins; vancomycin
Aureus (Vancocin) for meihicillin-
resistant S. au+en.i.
2 /3 generation
Haemophilus
cephalosporins, # lactam- Azithromycin, TMP-SMZ
I nfiuenze
g- lactamase inhibitor,
doxycycline.
 MANAGEMENT con8..

Mycoplasma Doxycycline, ztacrolides,

Pneumonia Fluoroquinolone

3r° generntion cephalosporin Aztreonani, § 1actain-§-

Klebsiella with pr without lactamasc inhibitor,
Pneumonia aininiglycosidc, carbapcnams fluoroquinolone

Legionella Macrolide + rifampiii, Doxycyc\ine + rifaniyin

fiuoroquinolone
Pneumonia
TMP-SMZ, penta‹nidine + Dapsone + tri vethopri v +
prcdnisone. Clindamycin + priniaquine +
Pneumocysti Trimetrexate
 MANAGEMENT cont
• Oxygen therapy
• Nutritional suppor
• Fluid and electrolyte management
• Bronchodilaton medications: albuterol sulphate, metaprotcrcnol
or meihylxanthines.

• Decp bmathing exercises and spirometry

Percussion and Vibration
• Chest physiotherapy
Percussion & Vibration
Postural drainage

• Nasoiracheal suctioning
FIے:- Patient pos ions for postural drainage.
 COMPLICATION
• Empyema.
• Hypotension and shock,
• Lung Abscess. especially in gram negative
• Bronchiolitis Obliterans. bacterial disease, particularly in
• Acute Respimtory Distr s elderly patients.

Syndrome (ARDS). • Aielectasis.

• Sepsis. • Pleural effusion.

• Bacterimia. • Pericarditis.
 PROGNOSIS
With treatment, lTlost types of bacterial pneumonia
will stabilize in 3-6 days. It often takes a few
weeks before most sylnptoiiis resolved. III perSOl4S
requiring hospitalization, morality hay be as high
as 10%, and in those requiring intensive care it may
reach 30—50%.
 NURSING MANAGEMENT
• Nursing Assessment

• Take a careful history to help establish etiologic diagnosis.

• Assess the elderly patient for unusual behavior, altered mental
status, dehydration, excessive fatigue, and concomitant heart
failure.

• Observe for anxious, flushed appearance. shallow respirations,

splitting of affected side, confusion, disorientation.
• Auscultate for crackles overlying affected region, and for
bronchial breath sounds when consolidation (filling of airspaces
with exudate) is present.
 NURSIN NAGEMEN
NURSI NG DIAGNOSIS AND INTERVENTIONS

1. Impaired gas exchange refuted ta inflummatoi y pulinonai y

infection evidenced by presence oJ refereed seci'etions,
Change. in re.spiratory rnle dimini.shecl/ndventitiaii.i hrealh
sounds, dyspnea, cyanosis Ineffective cough
INTERVENTION
• Assess rate, depth of respirations and chest movement.
• Auscultate lung fields.
• Elevate head of bed.
• Assist and demonstrate client with frequent deep-breathing
exercises, splinting the chest and coughing.
• Suctioning is done as indicated.
• Force fluids to at least 2500 mL per day, unless
contraindicated, as in HF
 NURSING MANAGEMENT cont...
• Assist with and monitor effects of nebulizer treatments and
other respiratory physiotherapy, such as incentive spirometer,
percussion. and postural drainage.
• Administer medications, aS indicated, for example, mucolyliCS,
expectorants, bronchodilators, and analgesics.
• Provide supplemental fluids such as IV, humidified oxygen,
arid room humidification.
• Monitor serial chest x-rays, ABGs, and pulse oximetry
 '
! z. Impaired Gas Exchange related t oAfveolar-capillary
membrane changes Ventilation-perfusion imbalance, possibly
evidenced By dyspnea, abnormal skin color (e.g., pnfe,
dusky)tachycardia, restlessness, confusion ,Hypoxia
INTERVENTION
• Assess the respiratory staNs, skin colour, mental status, heart rhythm and
body temperature.
• Elevate head and encourage frequent position changes, deep breathing, and
effective coughing. And maintain bedrest
• Observe for deterioration in condition, noting hypotension, copious amounts
of pink or bloody sputum, pallor, cyanosis, change in level of
consciousness, severe dyspnea, and restlessness.
• Monitor ABGs and pulse oximetry.
• Administer oxygen therapy by appropriate .
 or a-inadequate
creased cilinry action, sfnsrs Of body fluid.s [respiratory
seci'eiions],’ Inadequate secondary defenses due to [presence of’
existing iiif'ection], iininimosupyression, c/ftHit/c di.scare,
mafiiu/rf/ioii, possibly evidenced By preseitce of signs and
.symptoms establishes not acfual diagnosis.
INTERVENTION
• Monitor vital signs closely, especially during initiation of
therapy.
• lnstruct client concerning the disposition of secretions
reporting changes in color, amount, and odor of secretions.
• Change position frequently and provide good pulmonary toilet,.
• perform proper suctioning technique for ventilated clients as
appropriate.
• Limit visitors, and institute isolation precautions as
individually appropriate.
 NURSING INTERVENTION cont...
Promote adequate nutritional intake.
Investigate sudden changes or deterioration in condition.
such as increasing chcst pain, cxtra heart sounds, altcrcd
sensoriuin, i’ecuri’iog t'ever, and changes iti sputum
characteristics

Adininistcr aniiinicrobials, as indicated, by rcsults of

sputum and blood cultures.
 .- !tivity I°ntoleran°ceergeol ba ance- oxygen
supply and demand, General wealmess, possibly evidenced by
report of weakness, fati e, exertional dyspnea , Tachypnea,
Abnormal heart rate response to activity.
INTERVENTION
• Evaluate client's response to activity. Note reports of dyspnea,
increased weakness and fatigue, and changes in vital signs
during and after activities
• Provide a quiet environment and limit visitors during acute
phase and encourage use of stress management and diversional
activities as appropriate.
• Explain importance of rest in treatment plan and necessity for
balancing activities with rest.
Assist with self-care activities as necessary.
 5. Acute Pain related NMnjurlag agents (e.g., b“
inflammation oflting parenchyma, cellular reactions to
circulating toxins, physical—persistent coughing possibly
evidenced by Verbal7coded report fpleuritic chest pain,
headache, muscle or joint para] aitd guarded behavior
expres.five behavior—restles.one.s.s.
INTERVENTION
• Determine pain characteristics, Investigate changes in
character, location, and intensity of pain.
• Monitor vital signs.
• Provide comfoo measures, such as back rubs, change of
position, and quiet music or conversation. Encourage use of
relaxation and breathing exercises.
• Instruct and assist client in chest-splinting techniques
during coughing episodes.
*. dminister analgesics and antitussives, as indicated.
 INTERVENTION
• Assess the level of understanding of the patient and knowledge.
• Explain cbout the disease condition, its signs and symptoms and treatment
modalities.
• Explain and demonstrate about the importance of ctTective coughing and deep
breathing exercises.
• Stress necessity of continuing antimicrobial therapy.
• Explain about balanced rest and activity, avoiding smoking, well-rounded diet,
program of aerobic exercise or strength training (particularly elderly
individuals), and avoidance of crowds during cold and fin season and of
persons wiiJ› uypcr rcspiretory infections.
• Stress importance of continuing medical follow-up and obtaining vaccinations
and immunizations as appropriate for both children and adults.
 EXPECTED OUTCOM E

The client will be able to :-

Airway with brCath SOHiids is clear and absence of
dyspnea and cyanOsis.

linproved ventilation and oxygenation of tissues by

ABGs within client's acceptable range.

• Pai4icipate in actions to maximize oxygenation

Achieve tiiiiely resolution of curient infection
complications.
 EXPECTED OUTCOME cont...
Identify interventions to prevent and i'educe risk and
spi'ead of a secondary infection.
- Report and demonstrate a measurable increase in
tolerance to activity.

Verbalize undei'standing of disease condition

pauicipate in treatment program.
 PATIENT EDUCATION AND HEALTH
MAINTENANCE
• Advise patient to complete entire course of antibiotics.
• Once clinically stable, encourage gradual increase in activities to
bring energy level back to pre-illness stage.
• Encourage breathing exercises.
• Explain that a chest X-ray is usually taken 4 to 6 weeks after
recovery .
• Advise smoking cessation .
• Advise patient to keep up natural resistance with good nutrition and
adequate resi.
• Instruct patient to avoid fatigue, sudden extremcs in temperature, and
excessive alcohol intake.
• Advice patient to practice frequent liandwashing, especially after
contact with others.
 RESEARCH INPUT
i. Oral health end ventilator-associated pneumonia omong
critically ill patients: a prospective study.
Saensoin D, Merchant AT, wara-Aswapati N, Ruaisungneon w, Pitiphat W

OBJECTIVfi - To evaluate the association between oral health and ventilator

associated pneumonia {VAP) among critically itt paiients.
METHODS:- A prospective cohort study was conducted among 162 critically
ill patients who are newly intiibaied and meeted with mechanical ventilator
in one tertiary hospital iii Thailand. Oral health status was assessed using
Oral Health Asscssnicnt Tool (OHAT), Plaque Index (PI), and number of
teeth. VA P, defined as Clinical Pulmonary Infection Score>6, was assessed
on Day 4 afler incubation. Hazard raiios and 95% confidence intervals {Cls1
were calculated using Cox proportional hazards regression adjusted for
confounders.
 RESEARCH INPUT contd..
• RESULTS:-
• Critically ill patients had deteriorating oral health status after
intubation.
• Early-onset VAP developed in 69 patients (42.6%), with VAP
incidence of 117 episodes per 1000 ventilator-days.
• Patients with moderate-to-very poor oral hygiene assessed by
PI had increased VAP risk of 1.66-folds .The number of teeth
was not associated with VAP development.
• CONCLUSION S :- There is a strong association between opro
oral health and increased risk for early-onset VAP. Routine oral
care possibly prevents VAP development among critic
patients treated with mechanical ventilator.
SUMMARY
REFERENCES
• Fischer Wnlker, C., Rudan, 1.,Liu, L. et at. Global burden uf childhood
pneumonia rind diarrhea, Lancet, 2D13.
• Lewis Mantik Sharpn, Hctkampcr Mclcan Margcrct, Dirkscn Ruff
Shannon. Medical Surgical Nursing : Assessment and Management of
Clinical Problems. 6' Edition. USA; PubJis! cd by Mosby. 2000.p. 595-
601.
• Lemone Priscil\a, Karen Burke. Medical Surgical Nursing: Critical
Thinking in Client Care. 4'" Edition. New Oelhi: Published by Dorling
Kindersley (India) Pvt, Ltd. 2003.p.1267-1276.
• Smeltzer C Suzanne, Bare G Brenda, Hinkle L Jainice, Cheever H Kerry.
Brunner arid Suddharih textbook of Medical-Surgical Nursing. 11'*
Edition. New Delhi: Published by Dorling Kindersley (India) Pvt, Ltd.
2DD8. P.636-G47.
• Ruuskancn, O;Lahti, fi; Jennings, LC; Murdoch, DR (201 I -04-09). “Viral
Pneumonia:. Lancet, 337 (9773): l2b4-75. doi:10.10 I b/S0l40-
6736( I0)fi1459-6. PMI D21435708.