Clinical Presentation on Pnemonia

CLINICAL PRESENTATION ON PNEUMONIA

SUBMITTED TO

SUBMITTED BY

MRS.RAJALEKSHMY.K

MS.SREEKALA.R

ASSO.PROFESSOR

2 ND YR MSc NURSING STUDENT

GOVT.COLLEGE OF NURSING

GOVT.COLLEGE OF NURSING

ALAPPUZHA

ALAPPUZHA

SUBMITTED ON 24/12/2015

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INTRODUCTION Pneumonia and other lower respiratory tract infections are the leading causes of death worldwide. Because pneumonia is common and is associated with significant morbidity and mortality, properly diagnosing pneumonia, correctly recognizing any complications or underlying conditions, and appropriately treating patients are important. Although in developed countries the diagnosis is usually made on the basis of radiographic findings, the World Health Organization (WHO) has defined pneumonia solely on the basis of clinical findings obtained by visual inspection and on timing of the respiratory rate. DEFINITION Pneumonia is an inflammatory condition of the lung affecting primarily the microscopic air sacs known as alveoli. It is usually caused by infection with viruses or bacteria and less commonly other microorganisms, certain drugs and other conditions such as autoimmune diseases EPIDEMIOLOGY International statistics Pneumonia and other lower respiratory tract infections are the leading cause of death worldwide. The WHO Child Health Epidemiology Reference Group estimated the median global incidence of clinical pneumonia to be 0.28 episodes per child-year. This equates to an annual incidence of 150.7 million new cases, of which 11-20 million (7-13%) are severe enough to require hospital admission. Ninety-five percent of all episodes of clinical pneumonia in young children worldwide occur in developing countries. Approximately 150 million new cases of pneumonia occur annually among children younger than 5 years worldwide, accounting for approximately 10-20 million hospitalizations.A WHO Child Health Epidemiology Reference Group publication cited the incidence of communityacquired pneumonia among children younger than 5 years in developed countries as approximately 0.026 episodes per child-year and a study conducted in the United Kingdom showed that 59% of deaths from pertussis are associated with pneumonia. 2

Prognosis Overall, the prognosis is good. Most cases of viral pneumonia resolve without treatment; common bacterial pathogens and atypical organisms respond to antimicrobial therapy (see Treatment and Management). Long-term alteration of pulmonary function is rare, even in children with pneumonia that has been complicated by empyema or lung abscess. According to the WHO’s Global Burden of Disease 2000 Project, lower respiratory infections were the second leading cause of death in children younger than 5 years (about 2.1 million [19.6%]).Most children are treated as outpatients and fully recover. However, in young infants and immunocompromised individuals, mortality is much higher. In studies of adults with pneumonia, a higher mortality rate is associated with abnormal vital signs, immunodeficiency, and certain pathogens.

Etiology Pneumonia can be caused by a myriad of microorganisms. Clinical suspicion of a particular offending agent is derived from clues obtained during the history and physical examination. While virtually any microorganism can lead to pneumonia, specific bacterial, viral, fungal, and mycobacterial infections are most common in previously healthy children. The age of infection, exposure history, risk factors for unusual pathogens, and immunization history all provide clues to the infecting agent. Specific etiologic agents vary based on age groups (ie, newborns, young infants, infants and toddlers, 5-year-olds, school-aged children and young adolescents, older adolescents).

RISK FACTORS 

Smoking 3



Air pollution



Upper Respiratory Tract Infection



Altered consciousness: alcoholism, head injury, seizure disorder, drug overdose, general anesthesia



Tracheal intubation



Prolonged immobility



Immunosuppressive therapy: corticosteroids, chemotherapy



Non-functional immune system: AIDS



Severe periodontal disorders



Prolonged exposure to virulent organisms



Malnutrition



Dehydration



Chronic disease: Diabetes Mellitus, Heart disease, chronic lung disease



Prolonged debilitating disorders



Inhalation of noxious substances



Aspiration of oral/gastric material



Aspiration of foreign material



Chronically ill, elderly people who generally have poor immune systems, often residing in group living situations where there is an increase in probability of disease transmission especially through the respiratory system

Classification 1.

Community Acquired – used to describe infections found in the community rather than

the hospital/nursing home. Defined as an infection that begins outside the hospital or is

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diagnosed 48 hours after admission to the hospital in a person who has not resided in a long term facility for 14 days or more before admission 2.

Hospital Acquired or Nosocomial – is defined as a lower respiratory tract infection that

was not present or incubating on admission to the hospital. Increase risk for those with mechanical ventilation, compromised immune function, chronic lung disease and airway instrumentation such as e-tube, tracheostomy, etc. Types According to Causative Agent

1. Gram Positive Bacteria •

Streptococcus pneumonia (pneumococcal pneumonia)

•

most common cause of community acquired pneumonia.

•

follows influenza I situations in which groups of people live in close contact

•

rust colored sputum, blood tinged, purulent

•

Staphylococcus aureus

•

acquired thru blood or by aspiration

•

creamy yellow sputum

2. Gram Negative Bacteria •

Haemophilus influenza

•

common cause of infection in children

•

high mortality rate

•

greenish colored sputum

•

Klebsiella pneumoniae (Friedlander’s bacillus)

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•

most common gram negative organism acquired outside hospitals

•

occurs in people with malignancies

•

necrosis, abscess foration, hemoptysis and fibrotic changes occur

•

high mortality rate

•

red gelatinous sputum

•

Pseudomonas aeroginosa

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most common gram negative organism acquired in the hospital

•

common in the respiratory tract of hospital employees and those with cystic fibrosis

•

greenish colored sputum

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Legionella pneumophilia (Legionnaires’ disease)

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most common cause of community acquired pneumonia

•

found in warm standing water

3. ANAEROIC BACTERIAL PNEUMONIAS •

Commonly caused by anaerobic streptococcus

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History of poor dental hygiene, periodontal disease, dysphagia and altered consciousness

4. OTHER INFECTIOUS AGENTS •

Mycoplasma pneumoniae

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an organism with the characteristics of both bacteria and viruses

•

it causes atypical/interstitial pneumonia

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•

Viral agents

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influenza virus, adenovirus and parainfluenza virus

•

self-limiting

•

may predispose to secondary bacterial infection

•

Fungi

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candidiasis, histoplasmosis, blastomycosis, cryptococcosis, aspergillosis, actinomycosis

and nocardiosis •

follows after extended antibiotic use, immunocompromised and seriously ill people

•

Non-infectious causes

•

inhalation of toxic gases, chemicals or smoke from fires and aspiration of water due to

near drowning, gastric contents, vegetable/mineral oils, liquid petroleum •

Pneumocystis carinii pneumonia

•

opportunistic, often fatal form of lung infection seen in debilitated, impaired immune

function SIGNS AND SYMPTOMS 

Fever



Chills



Sweats



Dullness on percussion on affected area



Sputum production



Hemoptysis

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Pleuritic chest pain

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Dyspnea 7

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Headache



Fatigue



Unequal chest expansion



Cough

Pathophysiology Inhalation of droplet nuclei ↓ Establishes in the alveolus (usually lower lobe) ↓ Bacterial infection develops ↓ Vascular engorgement, presence of large number of bacteria ↓ Serous exudate pours into alveoli from dilated leaking vessels (engorgement first 4-12 hours) ↓ Decrease in RBC and Increase in Neutrophils and precipitation of fibrin that fills the alveoli ↓ Continuing accumulation of fibrin ↓ Consolidation of leukocytes and fibrin ↓ Exudate is lyzed and reabsorbed by macrophage

Pathogenesis Pneumonia is characterized by inflammation of the alveoli and terminal airspaces in response to invasion by an infectious agent introduced into the lungs through hematogenous spread or 8

inhalation. The inflammatory cascade triggers the leakage of plasma and the loss of surfactant, resulting in air loss and consolidation.

The activated inflammatory response often results in targeted migration of phagocytes, with the release of toxic substances from granules and other microbicidal packages and the initiation of poorly regulated cascades (eg, complement, coagulation, cytokines). These cascades may directly injure host tissues and adversely alter endothelial and epithelial integrity, vasomotor tone, intravascular hemostasis, and the activation state of fixed and migratory phagocytes at the inflammatory focus. The role of apoptosis (noninflammatory programmed cell death) in pneumonia is poorly understood.

Pulmonary injuries are caused directly and/or indirectly by invading microorganisms or foreign material and by poorly targeted or inappropriate responses by the host defense system that may damage healthy host tissues as badly or worse than the invading agent. Direct injury by the invading agent usually results from synthesis and secretion of microbial enzymes, proteins, toxic lipids, and toxins that disrupt host cell membranes, metabolic machinery, and the extracellular matrix that usually inhibits microbial migration.

Indirect injury is mediated by structural or secreted molecules, such as endotoxin, leukocidin, and toxic shock syndrome toxin-1 (TSST-1), which may alter local vasomotor tone and integrity, change the characteristics of the tissue perfusate, and generally interfere with the delivery of oxygen and nutrients and removal of waste products from local tissues.[6, 7]

On a macroscopic level, the invading agents and the host defenses both tend to increase airway smooth muscle tone and resistance, mucus secretion, and the presence of inflammatory cells and debris in these secretions. These materials may further increase airway resistance and obstruct the airways, partially or totally, causing airtrapping, atelectasis, and ventilatory dead space. In 9

addition, disruption of endothelial and alveolar epithelial integrity may allow surfactant to be inactivated by proteinaceous exudate, a process that may be exacerbated further by the direct effects of meconium or pathogenic microorganisms.

In the end, conducting airways offer much more resistance and may become obstructed, alveoli may be atelectatic or hyperexpanded, alveolar perfusion may be markedly altered, and multiple tissues and cell populations in the lung and elsewhere sustain injury that increases the basal requirements for oxygen uptake and excretory gas removal at a time when the lungs are less able to accomplish these tasks.

Alveolar diffusion barriers may increase, intrapulmonary shunts may worsen, and ventilation/perfusion (V/Q) mismatch may further impair gas exchange despite endogenous homeostatic attempts to improve matching by regional airway and vascular constriction or dilatation. Because the myocardium has to work harder to overcome the alterations in pulmonary vascular resistance that accompany the above changes of pneumonia, the lungs may be less able to add oxygen and remove carbon dioxide from mixed venous blood for delivery to end organs. The spread of infection or inflammatory response, either systemically or to other focal sites, further exacerbates the situation.

Viral infections are characterized by the accumulation of mononuclear cells in the submucosa and perivascular space, resulting in partial obstruction of the airway. Patients with these infections present with wheezing and crackles (see Clinical Presentation). Disease progresses when the alveolar type II cells lose their structural integrity and surfactant production is diminished, a hyaline membrane forms, and pulmonary edema develops.

In bacterial infections, the alveoli fill with proteinaceous fluid, which triggers a brisk influx of red blood cells (RBCs) and polymorphonuclear (PMN) cells (red hepatization) followed by the 10

deposition of fibrin and the degradation of inflammatory cells (gray hepatization). During resolution, intra-alveolar debris is ingested and removed by the alveolar macrophages. This consolidation leads to decreased air entry and dullness to percussion; inflammation in the small airways leads to crackles (see Clinical Presentation).

Four stages of lobar pneumonia have been described. In the first stage, which occurs within 24 hours of infection, the lung is characterized microscopically by vascular congestion and alveolar edema. Many bacteria and few neutrophils are present. The stage of red hepatization (2-3 d), so called because of its similarity to the consistency of liver, is characterized by the presence of many erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the alveoli. In the stage of gray hepatization (2-3 d), the lung is gray-brown to yellow because of fibrinopurulent exudate, disintegration of RBCs, and hemosiderin. The final stage of resolution is characterized by resorption and restoration of the pulmonary architecture. Fibrinous inflammation may lead to resolution or to organization and pleural adhesions.

Bronchopneumonia, a patchy consolidation involving one or more lobes, usually involves the dependent lung zones, a pattern attributable to aspiration of oropharyngeal contents. The neutrophilic exudate is centered in bronchi and bronchioles, with centrifugal spread to the adjacent alveoli.

In interstitial pneumonia, patchy or diffuse inflammation involving the interstitium is characterized by infiltration of lymphocytes and macrophages. The alveoli do not contain a significant exudate, but protein-rich hyaline membranes similar to those found in adult respiratory distress syndrome (ARDS) may line the alveolar spaces. Bacterial superinfection of viral pneumonia can also produce a mixed pattern of interstitial and alveolar airspace inflammation.

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Miliary pneumonia is a term applied to multiple, discrete lesions resulting from the spread of the pathogen to the lungs via the bloodstream. The varying degrees of immunocompromise in miliary tuberculosis (TB), histoplasmosis, and coccidioidomycosis may manifest as granulomas with caseous necrosis to foci of necrosis. Miliary herpesvirus, cytomegalovirus (CMV), or varicella-zoster virus infection in severely immunocompromised patients results in numerous acute necrotizing hemorrhagic lesions. DIAGNOSTIC EVALUATION Physical Examination The signs and symptoms of pneumonia are often nonspecific and widely vary based on the patient’s age and the infectious organisms involved. Tachypnea is the most sensitive finding in patients with diagnosed pneumonia.

Initial evaluation Early in the physical examination, identifying and treating respiratory distress, hypoxemia, and hypercarbia is important. Visual inspection of the degree of respiratory effort and accessory muscle use should be performed to assess for the presence and severity of respiratory distress. The examiner should simply observe the patient's respiratory effort and count the respirations for a full minute. In infants, observation should include an attempt at feeding, unless the baby has extreme tachypnea. children with tachypnea as defined by WHO respiratory rate thresholds were more likely to have pneumonia than children without tachypnea. The WHO thresholds are as follows:

Children younger than 2 months - Greater than or equal to 60 breaths/min Children aged 2-11 months - Greater than or equal to 50 breaths/min Children aged 12-59 month - Greater than or equal to 40 breaths/min

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Pulse oximetry Complete blood cell (CBC) count Sputum and blood cultures Serology Chest radiography Ultrasonography New data show that point-of-care ultrasonography accurately diagnoses most cases of pneumonia in children and young adults. In a study of 200 babies, children, and young adults (≤21 years), ultrasonography had an overall sensitivity of 86% and a specificity of 89% for diagnosing pneumonia. Ultrasonography may eventually come to replace x-rays for diagnosis Complete Blood Cell Count Testing should include a CBC count with differential and evaluation of acute-phase reactants (ESR, CRP, or both) and sedimentation rate. The total white blood cell (WBC) count and differential may aid in determining if an infection is bacterial or viral, and, together with clinical symptoms, chest radiography, and ESR can be useful in monitoring the course of pneumonia. In cases of pneumococcal pneumonia, the WBC count is often elevated. Sputum Gram Stain and Culture Sputum is rarely produced in children younger than 10 years, and samples are always contaminated by oral flora. In the cooperative older child with a productive cough, a sputum Gram stain may be obtained (see the image below); however, very few children are able to cooperate with such a test. An adequate sputum culture should contain more than 25 PMN cells per field and fewer than 10 squamous cells per field.

Blood Culture

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Although blood cultures are technically easy to obtain and relatively noninvasive and nontraumatic, the results are rarely positive in the presence of pneumonia and even less so in cases of pretreated pneumonia Serology Because of the relatively low yield of cultures, more efforts are under way to develop quick and accurate serologic tests for common lung pathogens, such as M pneumoniae, Chlamydophila species, and Legionella. Inflammatory Markers The use of markers of inflammation to support a diagnosis of suspected infection, including pneumonia, remains controversial because results are nonspecific. Various indices derived from differential leukocyte counts have been used most widely for this purpose, although noninfectious causes of such abnormal results are numerous. Many reports have been published regarding infants with proven infection who initially had neutrophil indices within reference ranges.

Quantitative measurements of CRP, procalcitonin, cytokines (eg, interleukin [IL]-6), inter-alpha inhibitor proteins (IaIp),[35] and batteries of acute-phase reactants have been touted to be more specific but are limited by suboptimal positive predictive value.

Polymerase Chain Reaction Relatively rapid testing (1-2 d) of viral infections through multiplex PCR is available in many hospitals. PCR is more sensitive than antigen assays, and for some viruses (eg, hMPV), this study may be the only test available. Skin Testing

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These tests are used in diagnosing TB. Mantoux skin test (intradermal [ID] inoculation of 5 tuberculin units [TU] of purified protein derivative [PPD]) results should be read 48-72 hours after placement.

Gastric Aspirates In a child with suspected pulmonary TB, the cough may be scarce or nonproductive. Therefore, the best test for diagnosis is an early-morning gastric aspirate sent for acid-fast bacilli (AFB) stain, culture, and, if available, PCR. Gastric aspirates should be obtained by first placing a nasogastric (NG) tube the night before sample collection; a sample is aspirated first thing the following morning, before ambulation and feeding. This should be repeated on 3 consecutive mornings.

Cold Agglutinin Testing In the young child or school-aged child with pneumonia, particularly the patient with a gradual onset of symptoms and a prodrome consisting of headache and abdominal symptoms, a bedside cold agglutinins test may help confirm the clinical suspicion of mycoplasmal infection.

This test is easily performed by placing a small amount of blood in a specimen tube containing anticoagulant and inserting this into a cup filled with ice water. After a few minutes in the cold water, the tube is held up to the light, tilted slightly, and slowly rotated. Small clumps of RBCs coating the tube are indicative of a positive test result. Unfortunately, this test is positive in only half the cases of mycoplasmal infection, and it is not very specific.

Direct Antigen Detection Although antiviral therapies are not often used, performing a nasal wash or nasopharyngeal swab for RSV and influenza enzyme-linked immunoassay (ELISA) and viral culture can help to 15

establish a rapid diagnosis, which may be helpful in excluding other causes. Viral cultures can be obtained in 1-2 days using newer cell culture techniques and may permit discontinuation of unnecessary antibiotics. In addition, correct diagnosis allows for appropriate placement of patients in the hospital. For example, if necessary, 2 infants with RSV infection may share a room, whereas such patients would normally need isolation and may unnecessarily tie up a bed.

Chest Radiography Chest radiography is indicated primarily in children with complications such as pleural effusions and in those in whom antibiotic treatment fails to elicit a response. Computed tomography (CT) scanning of the chest and ultrasonography are indicated in children with complications such as pleural effusions and in those in whom antibiotic treatment fails to elicit a response Bronchoscopy Flexible fiberoptic bronchoscopy is occasionally useful to obtain lower airway secretions for culture or cytology. This procedure is most useful in immunocompromised patients who are believed to be infected with unusual organisms (Pneumocystis, other fungi) or in patients who are severely ill.

TREATMENT After initiating therapy, the most important tasks are resolving the symptoms and clearing the infiltrate. With successful therapy, symptoms resolve much sooner that the infiltrate. In a study of adults with pneumococcal pneumonia, the infiltrate did not completely resolve in all patients until 8 weeks after therapy (although it was sooner in most patients). If therapy fails to elicit a response, the whole treatment approach must be reconsidered.

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Complications Severe respiratory compromise may require intubation and transfer to a suitable intensive care unit (ICU) for more intensive monitoring and therapy. Indications for transfer include refractory hypoxia, decompensated respiratory distress (eg, lessening tachypnea due to fatigue, hypercapnia), and systemic complications such as sepsis.

Transfer may need to be initiated at a lower threshold for infants or young children, as decompensation may be rapid. Transfer of very sick infants or young children to a pediatric ICU is best done with a specialist pediatric transfer team, even if that entails a slightly longer wait, compared with conventional medical transport or even air transport.

Severe coughing, especially in the context of necrotizing pneumonias or bullae formation, may lead to spontaneous pneumothoraces. These may or may not require treatment depending on the size of the pneumothorax and whether it is under tension and compromising ventilation and cardiac output.

Other complications include the following:

Pleural effusion Empyema Pneumatocele Lung abscess Necrotizing pneumonia Systemic infection with metastatic foci 20

Persistent newborn pulmonary hypertension Air leak syndrome, including pneumothorax, pneumomediastinum, pneumopericardium, and pulmonary interstitial emphysema Airway injury Obstructive airway secretions Hypoperfusion Chronic lung disease Hypoxic-ischemic and cytokine-mediated end-organ injury Sepsis Nursing Priorities 1.

Maintain/improve respiratory function.

2.

Prevent complications.

3.

Support recuperative process.

4.

Provide information about disease process, prognosis and treatment.

Discharge Goals 1.

Ventilation and oxygenation adequate for individual needs.

2.

Complications prevented/minimized.

3.

Disease process/prognosis and therapeutic regimen understood.

4.

Lifestyle changes identified/initiated to prevent recurrence.

5.

Plan in place to meet needs after discharge.

Nursing Care plans Below are 8 Nursing Care Plans (NCP) for Pneumonia. Ineffective Airway Clearance Nursing Diagnosis: Airway Clearance, ineffective

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May be related to 

Tracheal bronchial inflammation, edema formation, increased sputum production



Pleuritic pain



Decreased energy, fatigue

Possibly evidenced by 

Changes in rate, depth of respirations



Abnormal breath sounds, use of accessory muscles



Dyspnea, cyanosis



Cough, effective or ineffective; with/without sputum production

Desired Outcomes 

Identify/demonstrate behaviors to achieve airway clearance.



Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis. Nursing Interventions

Rationale Tachypnea, shallow respirations, and

Assess rate/depth of respirations and chest

asymmetric chest movement are frequently

movement.

present because of discomfort of moving chest wall and/or fluid in lung. Decreased airflow occurs in areas consolidated with fluid. Bronchial breath

Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds, e.g., crackles, wheezes.

sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/obstruction.

Elevate head of bed, change position

Lowers diaphragm, promoting chest

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frequently.

expansion, aeration of lung segments, mobilization and expectoration of secretions.

Assist patient with frequent deep-breathing exercises. Demonstrate/help patient learn to perform activity, e.g., splinting chest and effective coughing while in upright position. Suction as indicated (e.g., frequent or sustained cough, adventitious breath sounds, desaturation related to airway secretions). Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer warm, rather than cold, fluids. Assist with/monitor effects of nebulizer treatments and other respiratory physiotherapy, e.g., incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate.

Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough or decreased level of consciousness. Fluids (especially warm liquids) aid in mobilization and expectoration of secretions. Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudate/destruction. Coordination of treatments/schedules and oral intake reduces likelihood of vomiting with coughing, expectorations. Aids in reduction of bronchospasm and

Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics.

mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort/depress respirations.

Provide supplemental fluids, e.g., IV,

Fluids are required to replace losses

humidified oxygen, and room humidification.

(including insensible) and aid in mobilization 23

of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection. Monitor serial chest x-rays, ABGs, pulse oximetry readings.

Assist with bronchoscopy/thoracentesis, if indicated.

Follows progress and effects of disease process/therapeutic regimen, and facilitates necessary alterations in therapy. Occasionally needed to remove mucous plugs, drain purulent secretions, and/or prevent atelectasis.

Impaired Gas Exchange Nursing Diagnosis: Gas Exchange, impaired May be related to 

Alveolar-capillary membrane changes (inflammatory effects)



Altered oxygen-carrying capacity of blood/release at cellular level (fever, shifting oxyhemoglobin curve)



Altered delivery of oxygen (hypoventilation)

Possibly evidenced by 

Dyspnea, cyanosis



Tachycardia



Restlessness/changes in mentation



Hypoxia

Desired Outcomes 

Demonstrate improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.



Participate in actions to maximize oxygenation. 24

Nursing Interventions Assess respiratory rate, depth, and ease.

Rationale Manifestations of respiratory distress are dependent on/and indicative of the degree of lung involvement and underlying general health status.

Observe color of skin, mucous

Cyanosis of nailbeds may represent

membranes, and nailbeds, noting

vasoconstriction or the body’s response to

presence of peripheral cyanosis

fever/chills; however, cyanosis of earlobes, mucous

(nailbeds) or central cyanosis

membranes, and skin around the mouth (“warm

(circumoral).

membranes”) is indicative of systemic hypoxemia. Restlessness, irritation, confusion, and somnolence

Assess mental status.

may reflect hypoxemia/ decreased cerebral oxygenation. Tachycardia is usually present as a result of

Monitor heart rate/rhythm.

fever/dehydration but may represent a response to hypoxemia.

Monitor body temperature, as indicated. Assist with comfort measures

High fever (common in bacterial pneumonia and

to reduce fever and chills, e.g.,

influenza) greatly increases metabolic demands

addition/removal of bedcovers,

and oxygen consumption and alters cellular

comfortable room temperature, tepid or

oxygenation.

cool water sponge bath. Maintain bedrest. Encourage use of

Prevents overexhaustion and reduces oxygen

relaxation techniques and diversional

consumption/demands to facilitate resolution of

activities.

infection.

Elevate head and encourage frequent

These measures promote maximal inspiration,

position changes, deep breathing, and

enhance expectoration of secretions to improve

effective coughing.

ventilation.

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Assess level of anxiety. Encourage verbalization of concerns/feelings. Answer questions honestly. Visit frequently, arrange for SO/visitors to stay with patient as indicated.

Anxiety is a manifestation of psychological concerns and physiological responses to hypoxia. Providing reassurance and enhancing sense of security can reduce the psychological component, thereby decreasing oxygen demand and adverse physiological responses.

Observe for deterioration in condition, noting hypotension, copious amounts of

Shock and pulmonary edema are the most

pink/bloody sputum, pallor, cyanosis,

common causes of death in pneumonia and require

change in level of consciousness,

immediate medical intervention.

severe dyspnea, restlessness. Monitor ABGs, pulse oximetry.

Administer oxygen therapy by appropriate means, e.g., nasal prongs, mask, Venturi mask.

Follows progress of disease process and facilitates alterations in pulmonary therapy. The purpose of oxygen therapy is to maintain Pao2 above 60 mm Hg. Oxygen is administered by the method that provides appropriate delivery within the patient’s tolerance.

Risk for Deficient Fluid Volume Nursing Diagnosis: Risk for Deficient Fluid Volume Risk factors may include 

Excessive fluid loss (fever, profuse diaphoresis, mouth breathing/hyperventilation, vomiting)



Decreased oral intake

Desired Outcomes 

Demonstrate fluid balance evidenced by individually appropriate parameters, e.g., moist mucous membranes, good skin turgor, prompt capillary refill, stable vital signs. Nursing Interventions

Rationale 26

Elevated temperature/prolonged fever increases Assess vital sign changes, e.g., increased

metabolic rate and fluid loss through

temperature/prolonged fever, tachycardia,

evaporation. Orthostatic BP changes and

orthostatic hypotension.

increasing tachycardia may indicate systemic fluid deficit. Indirect indicators of adequacy of fluid volume,

Assess skin turgor, moisture of mucous

although oral mucous membranes may be dry

membranes (lips, tongue).

because of mouth breathing and supplemental oxygen.

Note reports of nausea/vomiting.

Presence of these symptoms reduces oral intake.

Monitor intake and output (I&O), noting color, character of urine. Calculate fluid

Provides information about adequacy of fluid

balance. Be aware of insensible losses.

volume and replacement needs.

Weigh as indicated. Force fluids to at least 3000 mL/day or as

Meets basic fluid needs, reducing risk of

individually appropriate.

dehydration

Administer medications as indicated, e.g., antipyretics, antiemetics. Provide supplemental IV fluids as necessary. Administer medications as indicated, e.g., antipyretics, antiemetics. Provide supplemental IV fluids as necessary.

Useful in reducing fluid losses. In presence of reduced intake/excessive loss, use of parenteral route may correct/prevent deficiency. Useful in reducing fluid losses. In presence of reduced intake/excessive loss, use of parenteral route may correct/prevent deficiency.

Imbalanced Nutrition

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Nursing Diagnosis: Risk for Imbalanced Nutrition Less Than Body Requirements Risk factors may include 

Increased metabolic needs secondary to fever and infectious process



Anorexia associated with bacterial toxins, the odor and taste of sputum, and certain aerosol treatments



Abdominal distension/gas associated with swallowing air during dyspneic episodes

Desired Outcomes 

Demonstrate increased appetite.



Maintain/regain desired body weight. Nursing Interventions Identify factors that are contributing to nausea/vomiting, e.g., copious sputum, aerosol treatments, severe dyspnea, pain.

Rationale Choice of interventions depends on the underlying cause of the problem.

Provide covered container for sputum and remove at frequent intervals. Assist with/encourage oral hygiene after emesis, after aerosol and postural drainage

Eliminates noxious sights, tastes, smells from the patient environment and can reduce nausea.

treatments, and before meals. Schedule respiratory treatments at least 1

Reduces effects of nausea associated with these

hr before meals.

treatments. Bowel sounds may be diminished/absent if the

Auscultate for bowel sounds. Observe/palpate for abdominal distension.

infectious process is severe/prolonged. Abdominal distension may occur as a result of air swallowing or reflect the influence of bacterial toxins on the gastrointestinal (GI) tract.

Provide small, frequent meals, including

These measures may enhance intake even 28

dry foods (toast, crackers) and/or foods

though appetite may be slow to return.

that are appealing to patient.

Presence of chronic conditions (e.g., COPD or Evaluate general nutritional state, obtain

alcoholism) or financial limitations can

baseline weight.

contribute to malnutrition, lowered resistance to infection, and/or delayed response to therapy.

Acute Pain Nursing Diagnosis: Pain, acute May be related to 

Inflammation of lung parenchyma



Cellular reactions to circulating toxins



Persistent coughing

Possibly evidenced by 

Reports of pleuritic chest pain, headache, muscle/joint pain



Guarding of affected area



Distraction behaviors, restlessness

Desired Outcomes 

Verbalize relief/control of pain.



Demonstrate relaxed manner, resting/sleeping and engaging in activity appropriately. Nursing Interventions

Rationale

Determine pain characteristics, e.g.,

Chest pain, usually present to some degree with

sharp, constant, stabbing. Investigate

pneumonia, may also herald the onset of

changes in character/location/intensity

complications of pneumonia, such as pericarditis

of pain.

and endocarditis.

Monitor vital signs.

Changes in heart rate or BP may indicate that

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patient is experiencing pain, especially when other reasons for changes in vital signs have been ruled out. Provide comfort measures, e.g., back rubs, change of position, quiet music or conversation. Encourage use of relaxation/breathing exercises.

Nonanalgesic measures administered with a gentle touch can lessen discomfort and augment therapeutic effects of analgesics. Patient involvement in pain control measures promotes independence and enhances sense of well-being. Mouth breathing and oxygen therapy can irritate

Offer frequent oral hygiene.

and dry out mucous membranes, potentiating general discomfort.

Instruct and assist patient in chest splinting techniques during coughing episodes. Administer analgesics and antitussives as indicated.

Aids in control of chest discomfort while enhancing effectiveness of cough effort. These medications may be used to suppress nonproductive/paroxysmal cough or reduce excess mucus, thereby enhancing general comfort/rest.

Activity Intolerance Nursing Diagnosis: Activity intolerance May be related to 

Imbalance between oxygen supply and demand



General weakness



Exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing, and dyspnea

Possibly evidenced by 

Verbal reports of weakness, fatigue, exhaustion



Exertional dyspnea, tachypnea 30



Tachycardia in response to activity



Development/worsening of pallor/cyanosis

Desired Outcomes 

Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs within patient’s acceptable range. Nursing Interventions

Rationale

Evaluate patient’s response to activity. Note reports of dyspnea, increased

Establishes patient’s capabilities/needs and

weakness/fatigue, and changes in vital

facilitates choice of interventions.

signs during and after activities. Provide a quiet environment and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities

Reduces stress and excess stimulation, promoting rest

as appropriate. Bedrest is maintained during acute phase to Explain importance of rest in

decrease metabolic demands, thus conserving

treatment plan and necessity for

energy for healing. Activity restrictions thereafter

balancing activities with rest.

are determined by individual patient response to activity and resolution of respiratory insufficiency.

Assist patient to assume comfortable position for rest/sleep.

Patient may be comfortable with head of bed elevated, sleeping in a chair, or leaning forward on overbed table with pillow support.

Assist with self-care activities as necessary. Provide for progressive

Minimizes exhaustion and helps balance oxygen

increase in activities during recovery

supply and demand.

phase. and demand. Risk for Infection 31

Nursing Diagnosis: Risk for [Spread] of Infection Risk factors may include 

Inadequate primary defenses (decreased ciliary action, stasis of respiratory secretions)



Inadequate secondary defenses (presence of existing infection, immunosuppression), chronic disease, malnutrition

Desired Outcomes 

Achieve timely resolution of current infection without complications.



Identify interventions to prevent/reduce risk/spread of/secondary infection. Nursing Interventions

Rationale

Monitor vital signs closely, especially

During this period of time, potentially fatal

during initiation of therapy.

complications (hypotension/shock) may develop.

Instruct patient concerning the disposition of secretions (e.g., raising and expectorating versus swallowing) and reporting changes in color, amount, odor of secretions.

Although patient may find expectoration offensive and attempt to limit or avoid it, it is essential that sputum be disposed of in a safe manner. Changes in characteristics of sputum reflect resolution of pneumonia or development of secondary infection.

Demonstrate/encourage good

Effective means of reducing spread or acquisition

handwashing technique.

of infection.

Change position frequently and provide good pulmonary toilet. Limit visitors as indicated.

Promotes expectoration, clearing of infection. Reduces likelihood of exposure to other infectious pathogens.

Institute isolation precautions as

Dependent on type of infection, response to

individually appropriate.

antibiotics, patient’s general health, and development of complications, isolation 32

techniques may be desired to prevent spread/protect patient from other infectious processes. Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake.

Facilitates healing process and enhances natural resistance.

Monitor effectiveness of antimicrobial

Signs of improvement in condition should occur

therapy.

within 24–48 hr. Delayed recovery or increase in severity of

Investigate sudden

symptoms suggests resistance to antibiotics or

changes/deterioration in condition, such

secondary infection. Complications affecting

as increasing chest pain, extra heart

any/all organ systems include lung

sounds, altered sensorium, recurring

abscess/empyema, bacteremia,

fever, changes in sputum characteristics.

pericarditis/endocarditis, meningitis/encephalitis, and superinfections. Fiberoptic bronchoscopy (FOB) may be done in

Prepare for/assist with diagnostic

patients who do not respond rapidly (within 1–3

studies as indicated.

days) to antimicrobial therapy to clarify diagnosis and therapy needs.

Deficient Knowledge Nursing Diagnosis: Deficient Knowledge regarding condition, treatment, self-care, and discharge needs May be related to 

Lack of exposure



Misinterpretation of information



Altered recall

Possibly evidenced by 33



Requests for information; statement of misconception



Failure to improve/recurrence

Desired Outcomes 

Verbalize understanding of condition, disease process, and prognosis.



Verbalize understanding of therapeutic regimen.



Initiate necessary lifestyle changes.



Participate in treatment program. Nursing Interventions Review normal lung function, pathology of condition.

Rationale Promotes understanding of current situation and importance of cooperating with treatment regimen. Information can enhance coping and help

Discuss debilitating aspects of disease, length of convalescence, and recovery expectations. Identify self-care and homemaker needs/resources.

reduce anxiety and excessive concern. Respiratory symptoms may be slow to resolve, and fatigue and weakness can persist for an extended period. These factors may be associated with depression and the need for various forms of support and assistance.

Provide information in written and verbal form.

Stress importance of continuing effective coughing/deep-breathing exercises.

Fatigue and depression can affect ability to assimilate information/follow medical regimen. During initial 6–8 wk after discharge, patient is at greatest risk for recurrence of pneumonia.

Emphasize necessity for continuing

Early discontinuation of antibiotics may

antibiotic therapy for prescribed period.

result in failure to completely resolve

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infectious process Smoking destroys tracheobronchial ciliary Review importance of cessation of smoking.

action, irritates bronchial mucosa, and inhibits alveolar macrophages, compromising body’s natural defense against infection.

Outline steps to enhance general health and well-being, e.g., balanced rest and activity, well-rounded diet, avoidance of crowds during cold/flu season and persons with

Increases natural defenses/immunity, limits exposure to pathogens.

URIs. Stress importance of continuing medical follow-up and obtaining vaccinations/immunizations as appropriate.

May prevent recurrence of pneumonia and/or related complications.

Identify signs/symptoms requiring notification of healthcare provider, e.g., increasing dyspnea, chest pain, prolonged fatigue, weight loss, fever/chills, persistence

Prompt evaluation and timely intervention may prevent/minimize complications.

of productive cough, changes in mentation.

Prevention Preventing pneumonia in children is an essential component of a strategy to reduce child mortality. Immunization against Hib, pneumococcus, measles and whooping cough (pertussis) is the most effective way to prevent pneumonia.

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Adequate nutrition is key to improving children's natural defences, starting with exclusive breastfeeding for the first 6 months of life. In addition to being effective in preventing pneumonia, it also helps to reduce the length of the illness if a child does become ill.

Addressing environmental factors such as indoor air pollution (by providing affordable clean indoor stoves, for example) and encouraging good hygiene in crowded homes also reduces the number of children who fall ill with pneumonia.

In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the risk of contracting pneumonia. WHO response

The WHO and UNICEF integrated Global action plan for pneumonia and diarrhoea (GAPPD) aims to accelerate pneumonia control with a combination of interventions to protect, prevent, and treat pneumonia in children with actions to:

protect children from pneumonia including promoting exclusive breastfeeding and adequate complementary feeding; prevent pneumonia with vaccinations, hand washing with soap, reducing household air pollution, HIV prevention and cotrimoxazole prophylaxis for HIV-infected and exposed children; treat pneumonia focusing on making sure that every sick child has access to the right kind of care -- either from a community-based health worker, or in a health facility if the disease is severe -and can get the antibiotics and oxygen they need to get well; A number of countries including Bangladesh, India, Kenya, Uganda and Zambia have developed district, state and national plans to intensify actions for the control of pneumonia and diarrhoea. 36

Many more have integrated diarrhoea and pneumonia specific action into their national child health and child survival strategies. For many countries the post Millenium Development Goal agenda has explicitly included ending preventable diarrhoea and pneumonia deaths as a priority action.

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