Nurse Practitioner
CLINICAL PROTOCOL
Pneumonia
INTRODUCTION
• Compared with community dwelling older adults, RACF residents acquire pneumonia
at a rate of 10 times higher, and are admitted to hospital 30 times more often.
• Pneumonia is the leading cause of death among aged care home residents,
• Pneumonia can be hospital acquired or community acquired. Aged care home
acquired pneumonia is a recognised variant of community acquired pneumonia.
• Aspiration may lead to either pneumonia or non- infectious chemical pneumonitis
(which does not require antibiotics).
EPIDEMIOLOGY
• In RACF, Streptococcus pneumoniae remains the commonest cause, and there are
higher rates of gram negative bacilli, Staphylococcus aureus and respiratory viruses,
and lower rates of atypical pathogens (legionella, chlamydia and mycoplasma) when
compared to the general community.
• Aspiration pneumonia may be caused by a wider range of organisms than community
acquired pneumonia, including Staphylococcus aureus, Haemophilus influenzae,
Gram negative aerobes and anaerobes.
Classification
Non –infectious
chemical
pneumonitis
•
•
•
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Pneumonia
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Manifestation
Cough
Difficulty catching breath
Abnormal lung sounds (wet,
gurgling)
+/- chest pain, tightness or
burning
New cough
Increased sputum production
Fever
Rigors
SOB
Wheezing
Pleuritic pain
Sore throat.
DIFFERENTIAL DIAGNOSIS
•
Pulmonary embolism
•
Pulmonary oedema
•
Aspiration pneumonitis
•
Malignancy
Additional symptoms
•
Non-specific symptoms
such as; tachypnea,
lethargy, incontinence
(new), functional decline,
loss of appetite, increased
confusion, agitation.
Nurse Practitioner
CLINICAL PROTOCOL
Pneumonia
CLINICAL PRACTICE GUIDELINE
Scope
Symptoms suggestive of pneumonia
Nurse
•
Practitioner
Medical
• Previously treated pneumonia not
Practitioner
responsive to antibiotics
+/Nurse
Practitioner
Initial Assessment and Interventions
Presenting
• Fever, rigor, facial flushing, new onset
Symptoms
cough, dyspnoea, chest discomfort,
confusion, sore throat, head cold
symptoms, lethargy, tachycardia,
increased resp rate, reduced O2
saturation, dullness on percussion
9consolidation), decreased air entry,
inspiratory crackles, wheeze, pleural
rub (rare).
• Atypical symptoms: tachypnoea,
functional decline, incontinence,
alteration in sleep pattern, loss of
appetite, confusion and aggression
Known risk
factors for
presenting
symptoms
Patient history
Physical
examination
Outcomes
Identify patients suitable for NP
Clinical Protocol
Identify patients not suitable
for NP Clinical Protocol and
redirect to GP +/- NP in team
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Outcomes
Gaining comprehensive
and holistic data in
order to prescribe
appropriate diagnostic
tests and interventions.
Ruling out differential
diagnosis to specific
pathophysiology
identified.
If known allergy to
recommended
formulary; NP and GP
instigate alternative
treatment option to
ensure a safe and
optimal response to
treatment.
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Dysphagia decreased cognitive and
physical functions, delirium, and
immunosuppression.
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Relevant medical and surgical history
Onset and duration of symptoms
Presence of co-morbidities
Known allergies
Current medication
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Predisposing and
associated conditions
will be detected and
considered when
determining diagnosis
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Vital signs
Pulse oximetry
Respiratory and CVS assessment
Pain assessment
•
Correct diagnosis,
provision of effective
treatment to eradicate
disease and provide
relief of symptoms.
Severe pneumonia is
diagnosed in pts.
displaying 2 or more of
the following: RR >30, P
•
Nurse Practitioner
CLINICAL PROTOCOL
Pneumonia
> 125, acute altered
mental state, systolic BP
<90mmHg and /or
diastolic <60mmHg, Hx
of dementia, CVD, renal
failure or liver disease,
need for O2 > 3L/min.
(RACGP guidelines).
Outcomes
Identification of
causative pathogen and
its sensitivities.
• Identify complications
associated with disease
state.
Imaging
• CXR
• Identify consolidation in
lungs and assist in
diagnosis.
Patient Education / Follow-up
Outcomes
Follow up
Verbal instruction to patient:
Ensure patient understands
appointment
• Review appointment may be indicated problem, treatment and follow
by pathology results; NP to contact
up
patient to schedule follow-up
Referral to GP will be
appointment.
determined on result of
• Response to Rx should be reassessed
laboratory tests and CXR.
in 48 hours.
Refer to current GP if no
response to Rx within 48 hrs.
Patient
Verbal instruction and patient information
Patient understanding of the
Education
handout re
problem, treatment and
• Hygiene and prevention strategies
measures which may reduce
the risk of pneumonia
Medication
• Verbal/written instructions from NP/GP Ensure patient understands
problem, treatment and follow
instructions
up
Referrals
• Unresolved pneumonia
Patients with problems outside
• Other problems outside of NP scope of the NPs scope of practice are
practice
referred to appropriate health
care providers
Ensure appropriate
Certificates
• Absence from work certificates
• Certificate of attendance
documentation completed
Letter
• Copy of notes to GP / Specialist or
Ensure continuity of care and
acute care facility
referral to health care team
GP Æ hospital admission
Interpretation of results and management decisions
Outcome
Pathology
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Investigations
Sputum (MCS)
FBE, U&E, Glucose
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All medications will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation
Nurse Practitioner
CLINICAL PROTOCOL
Pneumonia
Pharmacotherap
eutics
(See formulary)
Non
pharmacological
- The use and appropriateness of antibiotic
therapy in the treatment of pneumonia depends
on the symptoms and likely microbial organisms
to be treated.
- Refer to the Antibiotic Therapeutic Guidelines for
appropriate antibiotic drug administration.
•
Antibiotic therapy is
determined by the causative
pathogen, the pathogen’s
sensitivities, resistance & the
severity of the individual’s
clinical presentation and/or
PSI. Note that the PSI is only
a guide & NPs should consider
clinical & social contexts.
•
Non-pharmacological,
supportive nursing and
monitoring interventions
include: regular observation of
vitals’ status (RR, HR, BP,
SpO2, and T), bed rest,
adequate hydration and
nutrition, continuous oxygen
therapy, improving airway (i.e.
posture, humidification,
suctioning, deep breathing &
coughing exercises) and
assistance with activities of
daily living.
Relief of symptoms
Eradication of infection
Prevention of recurrence
Prevention of complications
Nurse Practitioner
CLINICAL PROTOCOL
Pneumonia
Goals of Treatment
• Relief of symptoms
•
Eradication of infection
•
Prevention of recurrence
•
Prevention of complications
Drug Formulary
ANTIBIOTIC TREATMENT
Amoxycillin 1g PO 8 hourly
and
clarithromycin 250mg PO 12 hourly
or
doxycycline 200mg initial dose then 100mg PO daily
Hypersensitivity to penicillin: replace amoxycillin:
Clarithromycin 250-500mg 12 hourly or doxycycline
Non-tropical region
benzyl penicillin 1.2g IV 6 hourly
or
KUB ultrasound, refer amoxy/ampicillin
1g IV 6 hourly
to current GP and
roxithromycin 300mg PO daily
or
doxycycline 200mg/100mg PO daily
Refer to and
current GP gentamicin 4-6mg/kg IV daily if gramnegative bacilli isolated
Tropical region
gentamicin 4-6mg/kg IV daily
and Refer to current GP ceftriaxone
2g IV daily
for investigation of other causes for symptoms Hypersensitivity to penicillin:
replace penicillin: cefotaxime 1g IV 8 hourly (or ceftriaxone 1g IV daily) until significant
improvement then cefuroxime 500mg PO 12 hourly5
Immediate sensitivity to penicillin:
replace penicillin: gatifloxacin 400mg PO daily
or
moxifloxacin 400mg PO daily
Nurse Practitioner
CLINICAL PROTOCOL
Pneumonia
ANALGESIA & ANTIPYRETIC TREATMENT
paracetamol 500mg-1g 6 hourly (max. 4g/day)
PO/PR
OXYGEN THERAPY
oxygen 6-10 L/min via nasal prongs or
Venturi Mask
to maintain oxygen saturation > 97%
FORMULARY
AMOXYCILLIN TRIHYDRATE
CLARITHROMYCIN
Drug (generic name): amoxicillin trihydrate
Drug (generic name): roxithromycin
Poisons schedule: schedule 4
Poisons schedule: schedule 4
Therapeutic class: 8(a) penicillins
Therapeutic class: 8(d) macrolides
Dosage range: 250-800mg 8 hourly, or in severe infection
Dosage range: 250-500mg
(pneumonia) 1G 8 hourly
Route: oral
Route: oral
Frequency of administration: 12 hourly
Frequency of administration: 8 hourly
Duration of order: 7 days
Duration of order: 7 days
Actions: binds to 50S ribosomal sub-unit, inhibits bacterial
Actions: intervene in cell wall peptidoglycan synthesis, is
protein synthesis, is bacteriostatic
bactericidal
Indications for use: upper & lower respiratory tract infections,
Indications for use: chronic bronchitis, CAP, acute bacterial
Contraindications for use: serious allergy to macrolides
otitis media, sinusitis, epididymo-orchitis, acute prostatitis,
Adverse drug reactions: taste disturbance.
acute pyelonephritis, UTI, gonococcol inf., prophylaxis:
endocarditis, acute cholecystitis, peritonitis, combination
therapy for eradication: H. pylori
Contraindications for use: allergy to penicillins,
cephalosporins, carbapenems
Adverse drug reactions: nausea, diarrhoea, rash, allergy.
Nurse Practitioner
CLINICAL PROTOCOL
Pneumonia
DOXYCYCLINE
GENTAMICIN (GP only)
Drug (generic name): doxycycline
Drug (generic name): gentamicin
Poisons schedule: schedule 4
Poisons schedule: schedule 4
Therapeutic class: 8(c) tetracyclines
Therapeutic class: 8(f) aminoglycosides
Dosage range: 100mg-200mg (200mg first dose, followed by
Dosage range: 4-6mg/kg
100mg daily)
Route: intravenous
Route: oral
Frequency of administration: daily or as single dose depends
Frequency of administration: daily
on severity.
Duration of order: 6 days
Duration of order: until significant improvement
Actions: reversibly binds to 50S ribosomal sub-unit, inhibits
Actions: irreversibly binds to 50S ribosomal sub-unit, inhibits
bacterial protein synthesis, is bacteriostatic
bacterial protein synthesis, causes cell membrane damage, is
Indications for use: acne, M. pneumonia, CAP, chronic
bactericidal with concentration dependence
bronchitis, sinusitis, non-gonococcol genital tract infections,
Indications for use: gram-negative infections (empirical Rx),
PID, rickettsial infections, prostatitis, prophylaxis and treatment
systemic enterococcal infections, surgical & non-surgical
of malaria
prophylaxis, cystic fibrosis, bronchiectasis
Contraindications for use: children < 8years, allergy to
Contraindications for use: serious allergy to aminoglycoside
tetracycline
Adverse drug reactions: renal impairment, ototoxicity
Adverse drug reactions: nausea, vomiting, heartburn, tooth
discolouration, enamel dysplasia, reduced bone growth
(children), photosensitivity
BENZYLPENICILLIN (GP only)
AMOXYCILLIN/AMPICILLIN (GP only)
Drug (generic name): benzyl penicillin
Drug (generic name): amoxy / ampicillin
Poisons schedule: schedule 4
Poisons schedule: schedule 4
Therapeutic class: 8(a) penicillins
Therapeutic class: 8(a) penicillins
Dosage range: 1.2g
Dosage range: 1g
Route: intravenous
Route: intravenous amoxicillin sodium for IV
Frequency of administration: 6 hourly
Frequency of administration: 6 hourly
Duration of order: until significant improvement
Duration of order: 5days
Actions: intervene in cell wall peptidoglycan synthesis, is
Actions: intervene in cell wall peptidoglycan synthesis, is
bactericidal
bactericidal
Indications for use: bacterial endocarditis, meningitis,
Indications for use: chronic bronchitis, CAP, acute bacterial
aspiration pneumonia, lung abscess, CAP, syphilis,
otitis media, sinusitis, epididymo-orchitis, acute prostatitis,
Nurse Practitioner
CLINICAL PROTOCOL
Pneumonia
septicaemia in children
acute pyelonephritis, UTI, gonococcol infection, prophylaxis of
Contraindications for use: allergy to penicillins,
endocarditis, acute cholecystitis, peritonitis, combination
cephalosporin’s, carbapenems
therapy for eradication H. pylori, shigellosis
Adverse drug reactions: irritation at injection/IV site, nausea,
Contraindications for use: allergy to penicillins, cephalosporins,
diarrhoea, urticaria, rash, super infection, allergy (fever, chills,
carbapenems
headache and exacerbation of lesions when used in
Adverse drug reactions: irritation at injection/IV site, nausea,
syphilis/spirochete infections Jarisch-Herxheimer reaction)
diarrhoea, urticaria, rash, super infection, allergy
CEFTRIAXONE (GP only)
PARACETAMOL
Drug (generic name): ceftriaxone
Drug (generic name): paracetamol
Poisons schedule: schedule 4
Poisons schedule: unscheduled
Therapeutic class: 8(b) cephalosporins
Therapeutic class: 4(b) simple analgesics and antipyretics,
Dosage range: 2g
non-opioid analgesic.
Route: intravenous
Dosage range: 500mg-1g
Frequency of administration: daily
Route: oral/rectal
Duration of order: until significant improvement
Frequency of administration: 4- 6 hourly
Actions: intervenes in bacteria cell wall peptidoglycan
Duration of order: as required max 4g daily
synthesis
Actions: inhibition of prostaglandin synthesis
Indications for use: severe pneumonia, orbital cellulitis,
Indications for use: mild-moderate pain, migraine, headache,
bacterial meningitis, gonococcal infection, PID, epiglottitis,
fever, muscular pain
septicaemia, prophylaxis: meningococcal disease, H.
Contraindications for use: nil –caution for resident with liver
influenzae, cholecystitis, peritonitis, Salmonella, typhoid,
disease.
sexually transmitted epididymo-orchitis
Adverse drug reactions: (rare) rash, drug fever, mucosal
Contraindications for use: allergy to penicillins, cephalosporins,
lesions, neutro/pancyto/thrombocytopenia
carbapenems
Adverse drug reactions: nausea, diarrhoea, electrolyte
imbalance, rash, pancreatitis, cholecystitis, psuedolithiasis,
nephrolithiasis.
Nurse Practitioner
CLINICAL PROTOCOL
Pneumonia
Unexpected
representation
NP Clinical
Practice
Evaluative strategies
Review Patient Notes. Full audit of clinical
events.
NP Clinical Practice/Medical Report Audit
Key Terms
NP – Nurse Practitioner
CPG – Clinical Practice Guideline
GP – General Practitioner
S4 – Schedule of the drug administration
act
References
1. Clinical Practice Guidelines for Nurses in Primary Care [monograph online]. 2000 [cited 2006
Apr 12]. Available from: http://www.hc-sc.gc.ca/msb/fnihp.
2. The Royal Australian College of General Practitioners. Medical Care of Older Persons in
Residential Aged Care Facilities. 4th ed. South Melbourne: The Royal Australian College of
General Practitioners; 2005.
3. Dartnell JG, editor. Therapeutic guidelines: antibiotic. 12th ed. Victoria: Therapeutic
Guidelines Limited; 2003.
4. Rossi S, editor. Australian medicines handbook. Adelaide SA: Australian Medicines
Handbook Pty Ltd; 2006.
5. eMIMS MIMS. MIMS medicine information [standard online]. c2005 [cited 2006 Oct 20].
Available from: eMIMS MIMS Online.
6. Johnson PD, Irving LB, Turnidge JD. 3: Community-acquired pneumonia. Medical Journal of
Australia. 2002; 176: 341-347.
7. Maxwell DJ, McIntosh KA, Pulver LK, Easton KL. Emperic management of communityacquired pneumonia in Australian emergency departments. Medical Journal of Australia. 2005;
183(10): 520-524.
8. Kennedy M L, Fletcher KR, Plank LM. Management guidelines for nurse practitioners
working with older adults. 2nd ed. Philadelphia: F. A. Davis; 2004.
9. etg complete (internet). Melbourne: Therapeutic Guidelines Limited; 2011 Nov. Accessed
2001 Nov 25 at http://etg.tg.com.au/ref/ref
Nurse Practitioner
CLINICAL PROTOCOL
Pneumonia
Authorship, Endorsement and acknowledgement
This CP was originally written by:
Reviewed and authorised by:
Carol Jones
Nurse Practitioner
Dr. Frank Reedman Jones
Murray Medical Centre Mandurah
MBBCh, DCH, DRCOG, FRACGP, FACRRM
Murray Medical Centre: Primary Care
Physician
We acknowledge the authorship and
input of :
Hall and Prior Residential health and Aged
Care Organisation: CPG Pneumonia.
Dr. Eileen Bristol
MBChB,MRCGP,DRCOG,FRACGP
Murray Medical Centre: Primary Care
Physician
Carol Jones
RN, RM, PGradDipNursePractitioner, NP
Nurse Practitioner
Date Written: November 2011
Review Date: November 2013