Pneumonia

WHAT WENT WRONG?
Infectious pneumonia may be due to a variety of microorganisms and can be
community-acquired or hospital-acquired (nosocomial). Apatient can inhale bacteria,
viruses, parasites, or irritating agents, or a patient can aspirate liquids or foods. He
or she can also develop increased mucous production and thickening alveolar fluid
as a result of impaired gas exchange. All of these can lead to inflammation of the
lower airways.
Organisms commonly associated with infection include Staphylococcus
aureus, Streptococcus pneumoniae, Haemophilus influenza, Mycoplasma pneumo-
niae, Legionella pneumonia, Chlamydia pneumoniae (parasite), and Pseudomonas
aeruginosa.

PROGNOSIS
Prognosis will vary depending on patient’s age, preexisting lung disease, infect-
ing organism and response to antibiotics. Patients at risk for pneumonia are: older
patients; those with respiratory disease; patients with comorbid conditions such
as heart, liver, or kidney disease; and patients who develop complications (such as
atelectasis or pleural effusion). Patients at greater risk for complications from
pneumonia will be treated within the hospital, while those at lower risk may be
treated at home. Patients with respiratory rates over 30, tachycardia, altered men-
tal status, or hypotension also are considered higher-risk.
Patients without other coexisting conditions, who do not appear to have the
higher-risk symptoms listed above, can usually be safely treated as outpatients.
Patients with comorbidities (higher-risk coexisting symptoms) or who appear ill
are usually treated in the hospital. Some require critical care treatments and must
be closely monitored. There is still a significant mortality rate from pneumonia,
despite the recognition of pneumonia and use of antibiotics.


SIGNS AND SYMPTOMS

• Shortness of breath due to inflammation within the lungs, impairing gas
exchange
• Difficulty breathing (dyspnea) due to inflammation and mucus within the
lungs
• Fever due to infectious process
• Chills due to increased temperature
• Cough due to mucous production and irritation of the airways
• Crackles due to fluid within the alveolar space and smaller airways
• Rhonchi due to mucus in airways; wheezing due to inflammation within the
larger airways
• Discolored, possibly blood-tinged, sputum due to irritation in the airways or
microorganisms causing infection
• Tachycardia and tachypnea as the body attempts to meet the demand for
oxygen
• Pain on respiration due to pleuritic inflammation, pleural effusion, or atelec-
tasis development
• Headache, muscle aches (myalgia), joint pains, or nausea may be present
depending on the infecting organism

TEST RESULTS

• Shadows on chest x-ray, indicating infiltration, may be in a lobar or seg-
mental pattern or more scattered.
• Culture and sensitivity of the sputum to identify the infective agent and the
appropriate antibiotics.
• Elevated WBC (leukocytosis) showing sign of infection.
• Low oxygen saturation on pulse oximetry.
• Arterial blood gas may show low oxygen and elevated carbon dioxide levels.

TREATMENT

Supplemental oxygen is given to help meet the body’s needs. Antibiotics
are given for the most likely organism (empirically) until the sputum culture
results are returned. Patients may need bronchodilators to help open the
airways.
• Administer oxygen as needed.
• For bacterial infections, administer antibiotics such as macrolides (azithro-
mycin, clarithromycin), fluoroquinolones (levofloxacin, moxifloxacin),
beta-lactams (amoxicillin/clavulanate, cefotaxime, ceftriaxone, cefuroxime
axetil, cefpodoxime, ampicillin/sulbactam), or ketolide (telithromycin).
• Administer antipyretics when fever >101 for patient comfort:
• acetaminophen, ibuprofen
• Administer brochodilators to keep airways open, enhance airflow if needed:
• albuterol, metaproterenol, levalbuterol via nebulizer or metered dose
inhaler
• Increase fluid intake to help loosen secretions and prevent dehydration.
• Instruct the patient on how to use the incentive spirometer to encourage deep
breathing; monitor progress.

NURSING DIAGNOSES

• Risk for aspiration
• Impaired ventilation
• Ineffective airway clearance

NURSING INTERVENTION

• Monitor respiration for rate, effort, use of accessory muscles, skin color, and
breath sounds.
• Record fluid intake and output for differences, signs of dehydration.
• Record sputum characteristics for changes in color, amount, and consistency.
• Properly dispose of sputum.
• Explain to the patient:
• Take adequate fluids—3 liters per day—to prevent excess fluid loss through
the respiratory system with exhalation.
• Use of incentive spirometer.