Chapter 19
Management of Patients
with Chest and Lower
Respiratory Tract Disorders
Pneumonia
Inflammation of the lung parenchyma caused by
various microorganisms, including bacteria,
mycobacteria, fungi, and viruses
Classification
o Community-acquired (CAP)
o Health care–associated (HCAP)
o Hospital-acquired (HAP)
o Ventilator-associated (VAP)
o Refer to Chart 19-4
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Types of Pneumonia #1
Community-acquired
o Community setting or within first 48 hours post
hospitalization
o Rate of infection increases with age
o S. Pneumoniae is the most common cause
among adults
o Viral origin in infants and children
Health care–associated
o Often caused by multidrug‐resistant organisms
o Early diagnosis and treatment are critical
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Types of Pneumonia #2
Hospital-acquired
o Develops 48 hours or more after hospitalization
o Subtype of health care–associated pneumonia
o Potential for infection from many sources
o High mortality rate
o Colonization by multiple organisms due to
overuse of antimicrobial agents
o Pleural effusion, high fever, and tachycardia
o Common with debilitated, dehydrated patients
with minimal sputum production
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Types of Pneumonia #3
 Ventilator-associated
o Received mechanical ventilation for at least 48 hours
o Prevention is key
o VAP bundles (Chart 19-6)
 Pneumonia in the immunocompromised host
o Common agents include pneumocystis, fungi, and
tuberculosis
o Receiving immunosuppressive agents, history of
immunosuppressive condition
o Subtle onset with progressive dyspnea, fever, and
nonproductive cough
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Pneumonia Risk Factors
Refer to Table 19-2
Occurs in patients with certain underlying disorders
and diseases
o Heart failure, diabetes, alcoholism, COPD, and
AIDS
o Influenza
Cystic fibrosis
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Clinical Manifestations of Pneumonia
Varies depending on type, causal organism, and
presence of underlying disease
Streptococcal: Sudden onset of chills, fever, pleuritic
chest pain, tachypnea, and respiratory distress
Viral, mycoplasma, or Legionella: relative
bradycardia
Other: Respiratory tract infection, headache, lowgrade fever, pleuritic pain, myalgia, rash, and
pharyngitis
Orthopnea, crackles, increased tactile fremitus,
purulent sputum
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Assessment and Diagnosis of Pneumonia
History
Physical exam
Chest x-ray
Blood culture
Sputum examination
Bronchoscopy may be used for acute severe
infection
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Pneumonia Prevention
Pneumococcal vaccination
o Reduces the incidence of pneumonia,
hospitalizations for cardiac conditions, and
deaths in the older adult population
o Two types of pneumococcal vaccine
o Recommended for all adults 65 years of age or
older and 19 years or older with conditions that
weaken the immune system
Other preventive measures, see Table 19-2
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Medical Management of Pneumonia
Administration of the appropriate antibiotic as
determined by the results of a culture and
sensitivity
Supportive treatment includes fluids, oxygen for
hypoxia, antipyretics, antitussives, decongestants,
and antihistamines
Antibiotics not indicated for viral infections but are
used for secondary bacterial infection
Refer to Table 19-3
Gerontologic considerations
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COVID-19 Considerations
SARS-CoV-2
Asymptomatic to severe viral pneumonia
Fatigue, myalgia, congestion, sore throat, diarrhea,
anosmia, and ageusia
Mostly conservative outpatient management (rest,
hydrate, antipyretic agents)
Hospitalization for severe illness with pneumonia,
increased risk of venous thromboembolism
Can lead to shock and respiratory failure
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Assessment of the Patient with Bacterial
Pneumonia
Vital signs
Secretions: amount, odor, color
Cough: frequency and severity
Tachypnea, shortness of breath
Inspect and auscultate chest
Changes in mental status, fatigue, edema,
dehydration, concomitant heart failure, especially in
older adult patients
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Problems/Complications of the Patient
with Bacterial Pneumonia
Continuing symptoms after initiation of therapy
Sepsis and septic shock
Respiratory failure
Atelectasis
Pleural effusion
Delirium
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Planning and Goals for the Patient with
Bacterial Pneumonia
Improved airway patency
Increased activity
Maintenance of proper fluid volume
Maintenance of adequate nutrition
Understanding of the treatment protocol and
preventive measures
Absence of complications
Based on patient outcomes plan for home,
community, and transitional care
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Nursing Interventions for the Patient with
Bacterial Pneumonia
Oxygen with
humidification to loosen
secretions
o Face mask or nasal
cannula
Incentive spirometry
Nutrition
Hydration
Rest
Coughing techniques
Activity as tolerated
Chest physiotherapy
Patient education
Position changes
Self-care
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Expected Outcomes for the Patient with
Bacterial Pneumonia
Demonstrates improved airway patency
Rests and conserves energy and then slowly
increasing activities
Maintains adequate hydration; adequate dietary
intake
Verbalizes increased knowledge about management
strategies
Complies with management strategies
Exhibits no complications
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Aspiration
Inhalation of foreign material into the lungs leads to
inflammatory reaction, hypoventilation, and
ventilation–perfusion mismatch
Serious complication is broncho or lobar pneumonia
Risk factor is LOC; refer to Chart 19-8
Key pathophysiology is the volume and character of
aspirated contents (most often GI contents)
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Aspiration Prevention
Swallowing screening
Nursing interventions
o Keep HOB elevated and endotracheal cuff
elevated (if intubated)
o Avoid stimulation of gag reflex with suctioning or
other procedures
o Check for placement before tube feedings
o Soft diet, small bites, no straws
Refer to Chart 19-9
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