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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

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.
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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 WHOs 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
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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

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 (Friedlanders bacillus)

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

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

Legionella pneumophilia (Legionnaires disease)

most common cause of community acquired pneumonia

found in warm standing water

3. ANAEROIC BACTERIAL PNEUMONIAS

Commonly caused by anaerobic streptococcus

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

4. OTHER INFECTIOUS AGENTS

Mycoplasma pneumoniae

an organism with the characteristics of both bacteria and viruses

it causes atypical/interstitial pneumonia

Viral agents

influenza virus, adenovirus and parainfluenza virus

self-limiting

may predispose to secondary bacterial infection

Fungi

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

Pleuritic chest pain

Dyspnea
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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
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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
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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
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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
patients 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
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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
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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


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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 patients


acceptable range and absence of symptoms of respiratory distress.

Participate in actions to maximize oxygenation.


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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 bodys 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 patients 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
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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


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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


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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 patients acceptable range.
Nursing Interventions

Rationale

Evaluate patients response to activity.


Note reports of dyspnea, increased

Establishes patients 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
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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, patients general health, and


development of complications, isolation
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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 2448 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 13

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
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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 68 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
bodys 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.
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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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