PNEUMONIA

Acute infection of the lungs. Alveoli become inflamed and fluid-filled.

The patient may have:
■ Cough, chest pain, fever, tachycardia.
■ Shortness of breath, cyanosis, tachypnea, hemoptysis.
■ Joint pain, muscle aches.
■ Loss of appetite, fatigue.
IMMEDIATE INTERVENTIONS
■ Assess VS, and determine if patient has SOB.
■ Apply O2 if already ordered.
■ Assess HR and RR; note if patient is short of breath or struggling
to breathe.
■ Listen to lung sounds, assess use of accessory muscles.
■ Notify physician or NP of assessment findings.
■ Document phone call and physician or NP response.
FOCUSED ASSESSMENT
■ Assess sputum quantity and character.
■ Assess oxygen saturation by pulse oximetry.
■ Assess LOC and orientation.
■ Assess for pleuritic chest pain, chills.
■ Assess for cyanosis.
■ Assess appetite.
■ Assess for patent IV line.
STABILIZING AND MONITORING
■ Administer antibiotics as soon as they are available.
■ Maintain O2, and check oxygen saturation frequently.
■ Keep patient well hydrated.
■ Provide diet high in protein.
■ Assess for complications such as empyema, respiratory distress, or
superinfection (worsening signs and symptoms despite treatment).
BE PREPARED TO
■ Obtain sputum culture and sensitivity, blood cultures, ABGs, or other
laboratory work.
■ Assist with thoracentesis, and monitor for complications (pneumothorax).
■ Obtain chest x-ray STAT.
■ Suction the patient; assist with bronchoscopy.

Pneumonia
Pneumonia is an acute infection of the lung parenchyma that commonly
impairs gas exchange. The prognosis is usually good for
people who have normal lungs and adequate host defenses before
the onset of pneumonia; however, bacterial pneumonia is the fifth
leading cause of death in debilitated patients. The disorder occurs
in primary and secondary forms.

What causes it
Pneumonia is caused by an infecting pathogen (bacterial or viral)
or by a chemical or other irritant (such as aspirated material).
Certain predisposing factors increase the risk of pneumonia. For
bacterial and viral pneumonia, these include:
• chronic illness and debilitation
• cancer (particularly lung cancer)
• abdominal and thoracic surgery
• atelectasis, aspiration
• colds or other viral respiratory infections
• chronic respiratory disease, such as COPD,
asthma, bronchiectasis, and cystic fibrosis
• smoking, alcoholism
• malnutrition
• sickle cell disease
• tracheostomy
• exposure to noxious gases
• immunosuppressive therapy
• immobility or decreased activity level.

Aspiration pneumonia is more likely to occur in elderly or

debilitated patients, those receiving NG tube feedings, and those
with an impaired gag reflex, poor oral hygiene, or a decreased
LOC.
Pathophysiology
In general, the lower respiratory tract can be exposed to patho gens
by inhalation, aspiration, vascular dissemination, or direct contact
with contaminated equipment such as suction catheters. After
pathogens are inside, they begin to colonize and infection develops.
Stasis report
In bacterial pneumonia, which can occur in any part of the lungs,
an infection initially triggers alveolar inflammation and edema.
This produces an area of low ventilation with normal perfusion.
Capillaries become engorged with blood, causing stasis. As the
alveolar capillary membrane breaks down, alveoli fill with blood
and exudate, resulting in atelectasis. In severe bacterial infections,
the lungs look heavy and liverlike — similar to ARDS.
Virus attack!
In viral pneumonia, the virus first attacks bronchiolar epithelial
cells. This causes interstitial inflammation and desquamation. The
virus also invades bronchial mucous glands and goblet cells. It
then spreads to the alveoli, which fill with blood and fluid.

Subtracting surfactant
In aspiration pneumonia, inhalation of gastric juices or hydrocarbons
triggers inflammatory changes and inactivates surfactant
over a large area. Decreased surfactant leads to alveolar collapse.
Acidic gastric juices may damage the airways and alveoli. Particles
containing aspirated gastric juices may obstruct the airways
and reduce airflow, leading to secondary bacterial pneumonia.

What to look for

The five cardinal signs and symptoms of early bacterial pneumonia
are:
coughing
sputum production
pleuritic chest pain
shaking chills
fever.

What tests tell you

• Chest X-rays showing infiltrates and a sputum smear demonstrating
acute inflammatory cells support the diagnosis.
• Positive blood cultures in patients with pulmonary infiltrates
strongly suggest pneumonia produced by the organisms isolated
from the blood cultures.
• Occasionally, a transtracheal aspirate of tracheobronchial secretions
or bronchoscopy with brushings may be done to obtain
material for smear and culture.
How it’s treated
Antimicrobial therapy varies with the infecting agent. Therapy
should be reevaluated early in the course of treatment. Supportive
measures include:
• humidified oxygen therapy for hypoxemia
• mechanical ventilation for respiratory failure
• a high-calorie diet and adequate fluid intake
• bed rest
• an analgesic to relieve pleuritic chest pain.
What to do
• Maintain a patent airway and adequate oxygenation. Measure
ABG levels, especially in hypoxic patients. Administer supplemental
oxygen as ordered. If the patient has underlying COPD, give
oxygen cautiously.
• Administer antibiotics as ordered and pain medication as needed.
Fever and dehydration may require I.V. fluids and electrolyte
replacement.
Mangi, mangi!
• Maintain adequate nutrition to offset extra calories burned during
infection. Ask the dietary department to provide a high-calorie,
high-protein diet consisting of soft, easy-to-eat foods. Encourage the
patient to eat and to drink fluids. Monitor fluid intake and output.
• To control the spread of infection, dispose of secretions properly.
Teach the patient respiratory hygiene/cough etiquette, and tell
him to sneeze and cough into a disposable tissue; tape a waxed
bag to the side of the bed for used tissues.
• To prevent aspiration during NG tube feedings, elevate the
patient’s head, check the position of the tube, and administer
feedings slowly. Don’t give large volumes at one time because this could cause vomiting. If the patient has a tracheostomy
or an ET
tube, inflate the tube cuff. Keep his head elevated for at least 30
minutes after feeding.
• Be aware that antimicrobial agents used to treat cytomegalovirus,
PCP, and respiratory syncytial virus pneumonia may be
hazardous to fetal development. Pregnant health care workers or
those attempting conception should minimize exposure to these
agents (such as acyclovir [Zovirax], ribavirin [Virazole], and pentamidine
[Pentam 300]).
• Evaluate the patient. His chest X-rays should be normal and his
ABG levels should show PaO2 of 50 to 60 mm Hg. (See Pneumonia
teaching tips.)

Pneumonia
teaching tips
• Teach the patient how
to cough and perform
deep-breathing exercises
to clear secretions.
• Urge all postoperative
and bedridden patients to
perform deep-breathing
exercises frequently.
Position patients properly
to promote full ventilation
and drainage of secretions.
• Encourage annual
influenza and pneumococcal
vaccination for
high-risk patients, such
as those with COPD,
chronic heart disease,
or sickle cell disease.
• To prevent pneumonia,
advise the patient to
avoid using antibiotics
indiscriminately during
minor viral infections because
this may result in
upper airway colonization
with antibioticresistant
bacteria. If the
patient then develops
pneumonia, the infecting
organisms may require
treatment with more
toxic antibiotics.