Pneumonia
Pneumonia
Acute inflammation of lung caused
by microorganism
Leading cause of death until 1936
 Discovery
penicillin
of sulfa drugs and
Pneumonia
Still leading cause of death from
infectious disease
Predisposing Factors
Defense mechanisms are
incompetent or overwhelmed
Decreased cough and epiglottal
reflexes (may allow aspiration)
Predisposing Factors
Mucociliary mechanism impaired
 Pollution
 Cigarette
smoking
 Upper respiratory infections
 Tracheal intubation
 Aging
Predisposing Factors
Alteration of leukocytes from
malnutrition
Increased frequency of gramnegative bacilli (leukemia,
diabetes, alcoholism)
Acquisition of Organisms
Aspiration from nasopharynx,
oropharynx
Inhalation of microbes
Hematogenous spread from
primary infection elsewhere
Types of Pneumonia
 Organisms implicated
 S.
pneumoniae
 Legionella
 Mycoplasma
 Chlamydia
 S. aureus
 Respiratory viruses
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
Types of Pneumonia
Hospital-acquired pneumonia (HAP)
 Occurs
> 48 hours after admission; not
incubating at time of hospitalization
 Highest
mortality rate of nosocomial
infections
Types of Pneumonia
 Causes of HAP
 Pseudomonas
 Enterobacter
 S. aureus
 S. pneumoniae
 Immunosuppressive therapy
 General debility
 Endotracheal intubation
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
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
Types of Pneumonia
 Forms
of aspiration pneumonia
 Mechanical
obstruction
 Chemical injury
 Bacterial infection
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
Types of Pneumonia
Opportunistic pneumonia
 Clinical manifestations
– Fever
– Tachypnea
– Tachycardia
– Dyspnea
– Nonproductive cough
– Hypoxemia
Pathophysiology:
Pneumococcal Pneumonia
Congestion from outpouring of
fluid into alveoli
 Microorganisms multiply
and spread
infection, interfering with lung
function
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
Pathophysiologic course of
pneumococcal pneumonia
Fig. 27-1
Pathophysiology:
Pneumococcal Pneumonia
Gray hepatization
 Blood
flow decreases
 Leukocyte and fibrin consolidate in
affected part of lung
Pathophysiology:
Pneumococcal Pneumonia
Resolution
 Resolution and
healing if no
complications
 Exudate lysed and processed by
macrophages
 Tissue restored
Clinical Manifestations
CAP symptoms
 Sudden
onset of fever
 Chills
 Cough
productive of purulent
sputum
 Pleuritic chest pain
Clinical Manifestations
Confusion or stupor may manifest in
older or debilitated patient
Physical exam findings
 Dullness
on percussion
 Increased fremitus
 Bronchial breath sounds
 Crackles
Clinical Manifestations
CAP (alternative manifestations)
 Gradual
onset
 Dry cough
 Headache
 Myalgias
 Fatigue
 Sore throat
 N/V/D
Clinical Manifestations
Manifestations of viral pneumonia are
variable
 Chills
 Fever
 Dry
and non-productive cough
 Extrapulmonary symptoms
Complications
Pleurisy
Pleural effusion
 Usually
is sterile and reabsorbed in 1-2
weeks or requires thoracentesis
Atelectasis
 Usually
clears with cough and deep
breathing
Complications
Delayed resolution
 Persistent
infection seen on x-ray as
residual consolidation
Lung abscess (pus-containing lesions)
Empyema (purulent exudate in pleural
cavity)
 Requires
exudate
antibiotics and drainage of
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
Complications
Endocarditis
 Microorganisms
attack endocardium and
heart valves
 Manifestations similar to bacterial
endocarditis
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
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
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
Nursing Assessment
History of Predisposing/Risk Factors
 Lung
cancer
 COPD
 Diabetes mellitus
 Debilitating disease
 Malnutrition
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
Nursing Assessment
Clinical Manifestations
 Dyspnea
 Nasal congestion
 Pain with breathing
 Sore throat
 Muscle aches
 Fever
Nursing Assessment
Clinical Manifestations
 Restlessness or lethargy
 Splinting affected area
 Tachypnea
 Asymmetric chest movements
 Use of accessory muscles
 Crackles
 Green or yellow sputum
Nursing Assessment
Clinical Manifestations
 Tachycardia
 Changes in mental status
 Leukocytosis
 Abnormal ABGs
 Pleural effusion
 Pneumothorax on CXR
Nursing Diagnoses
Ineffective breathing pattern
Ineffective airway clearance
Acute pain
Imbalanced nutrition: less than body
requirements
Activity intolerance
Planning
Goals: Patient will have
 Clear breath
sounds
 Normal breathing patterns
 No signs of hypoxia
 Normal chest x-ray
 No complications related to pneumonia
Nursing Implementation
Teach nutrition, hygiene, rest, regular
exercise to maintain natural resistance
Prompt treatment of URIs
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
Nursing Implementation
Assist immobile patients with turning
and deep breathing
Strict asepsis
Emphasize need to take course of
medication(s)
Teach drug-drug interactions
Evaluation
Dyspnea not present
SpO2 > 95
Free of adventitious breath sounds
Clears sputum from airway
Evaluation
Reports pain controlled
Verbalizes causal factors
Adequate fluid and caloric intake
Performs ADLs