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Nursing Care and Pathophysiology of Pneumonia

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Overview

  1. Inflammatory condition of the lungs
  2. Primarily affecting the alveoli
    1. May fill with fluid or pus
  3. Infectious vs Noninfectious
    1. Infectious
      1. Bacterial v. Viral
    2. Non-infectious
      1. Aspiration

Pathophysiology:

Pneumonia is an inflammatory response. This can be caused by an infection or things like aspiration where fluid gets into the lungs, which causes the alveoli to fill with fluid or pus. When the alveoli are filled with fluid or pus then proper gas exchange does not occur as well.

Nursing Points

General

  1. Diagnosis
    1. Chest X-ray
    2. Sputum culture to identify organism
  2. Causes
    1. Community Acquired
    2. Hospital Acquired
      1. Ventilator Associated
    3. Opportunistic

Assessment

  1. Viral
    1. Low grade fever
    2. Non productive cough
    3. WBCs normal to low elevation
    4. Chest X-ray shows minimal changes
    5. Less severe than bacterial
  2. Bacterial
    1. High fever
    2. Productive cough
    3. WBCs elevated
    4. Chest X-ray shows infiltrates
    5. More severe than viral
  3. Both
    1. Chills
    2. Rhonchi/Wheezes
    3. Sputum production

Therapeutic Management

  1. Medications
    1. Antibiotics
    2. Analgesics
    3. Antipyretics
  2. Supplemental O2
  3. Assess and maintain respiratory status
  4. Encourage activity as soon as possible
  5. Instruct on chest expansion exercises
    1. Incentive Spirometry
    2. Turn, cough, deep breathe
  6. Obtain vaccinations for influenza and pneumococcal pneumonia
  7. Proper hand hygiene
  8. Encourage 3 L/day of fluids unless contraindicated
    1. Thin secretions

Nursing Concepts

  1. Oxygenation
    1. Monitor SpO2
    2. Monitor airway and breathing
    3. Apply O2 as needed
  2. Gas Exchange
    1. Monitor RR
    2. Monitor LOC (↓ LOC may indicate gas exchange issues)
    3. Monitor ABG & P/F ratio
  3. Infection Control
    1. Hand Hygiene
    2. Prevent aspiration
    3. VAP bundle (to prevent Ventilator Associated Pneumonia)
    4. Administer Antibiotics

Patient Education

  1. Good hand hygiene
  2. Preventing community acquired pneumonia
  3. s/s to report to PCP
  4. Incentive spirometry and breathing exercises

Reference Links

Study Tools

Video Transcript

So we’re going to talk about pneumonia. I’m sure even before nursing school you had heard of pneumonia, but a lot of people have some misconceptions – so let’s review what it is and how we treat it.

Pneumonia is an inflammatory process within the lungs that causes the alveoli to fill with fluid or pus. So you can see here how the alveoli have this fluid accumulated in them. And if you remember from our gas exchange lecture, alveoli filled with fluid do not allow for efficient gas exchange, so this definitely causes problems. A common misconception is that pneumonia is a lung infection. Actually, it can be infectious or non infectious. If it is infectious, of course, it’s either a bacterial or viral source. Noninfectious pneumonia can come from things like aspiration where the patient breathes in food or fluid or even vomit – that fluid gets into the alveoli. Or we can see post-op pneumonia because patients are drowsy or in pain, they’re not taking deep breaths and they’re not moving around – so any mucus they have is going to settle in their lungs into the alveoli.

We can classify pneumonia by how the patient contracted it as well. There’s community acquired pneumonia – that’s when the patient contracts it from someone in the community – maybe someone came to work sick or sent their child sick to daycare. It’s acquired out in the community. There’s also hospital-acquired pneumonia. This means that the patient came in without pneumonia and developed it during their stay. The majority of the time, this is caused by poor hand hygiene and poor infection control on the part of the nurses. It could be ventilator-associated pneumonia – you can see sometimes we have to open the tube to suction, sometimes we don’t do good enough oral care, and that bacteria makes its way down the tube into the lungs. Again, if the patient aspirates they can get pneumonia and it’s our job to recognize the risk and prevent it. And again, we have a lot of interventions we can implement to prevent post-op pneumonia, so we need to make sure we’re implementing those. Then finally there’s something called opportunistic pneumonia. This occurs in immunocompromised patients. An organism makes its way into their system. Someone with a normal immune system would have been able to fight it off, but this patient can’t. It’s like a thief who sees a purse lying around so he just grabs it – it’s an easy target.

So there are two main things we use to diagnose pneumonia. The first is a chest x-ray. We’ll see infiltrates. These can be bilateral and diffuse (meaning all over) or they can be localized to one area of infection. You can see here how the patient has these infiltrates just in the right lower lobe. The second thing we use is a sputum culture. We have the patient cough up phlegm (not saliva) into a sterile cup. Or if the patient is intubated, we can suction directly in the tube to obtain sputum. This is so important because it’s how we identify the organism if it’s infectious. We have to do this to know if it’s bacterial or viral. Then if it is bacterial, we can identify what kind of bacteria so that we can treat it with the right antibiotics. The other diagnostic you will see in patients who have pneumonia is arterial blood gases. Remember from the ARDS lecture that pneumonia is one of the main causes. We know this patient is at risk, so we keep an eye on that P/F ratio to monitor for the development of ARDS.

When it comes to assessment, you will see some differences and similarities between viral and bacterial pneumonia. Viral is less severe, usually only has a low-grade fever and normal WBC’s, maybe slightly elevated. They have a non-productive cough and the x-ray may only show minimal changes. Bacterial is more severe, usually comes with a high fever over 101 and elevated white blood cell count. They will have a productive cough and definite infiltrates on their chest x-ray. Now, ALL pneumonias will have some symptoms in common – they will all get chills and you will hear rhonchi and wheezes. Remember rhonchi is that snoring-like sound caused by fluid in the airways and wheezing happens because the airways are narrowed by all the fluid. And of course because gas exchange is impaired, we’ll see evidence of decreased oxygenation.

So when it comes to therapeutic management there are some specific medical interventions and nursing interventions that we need to do. For meds, we’ll give antibiotics or antivirals, depending on the source, we’ll give antipyretics for the fever and analgesics to ease any pain so they can breathe deeper. We’ll give supplemental O2 as needed, and we’ll give them vaccines. All patients should get the flu vaccine and the pneumococcal pneumonia vaccine if indicated – these are so important, especially in the elderly population. Then we’ll give fluids and encourage PO intake – we want to try to get them 3L a day if it’s not contraindicated – this helps to thin out the secretions so they can get them out more easily.

For nursing care we want to monitor their respiratory status – sometimes these patients are really struggling and may need to be intubated, so we need to advocate for them. We need to encourage activity, especially after surgery. That will help mobilize the secretions and keep them from getting post-op pneumonia. We encourage chest expansion exercises like turn, cough, and deep breathing, incentive spirometry, and CPT or chest physiotherapy. Review the lesson on atelectasis to see more about these exercises. And then remember that the NUMBER ONE way to prevent the spread of infection is hand hygiene. It is SO important and remember it’s the main reason why people get hospital-acquired infections. Make sure you’re washing your hands into and out of the room. Every. Time.

The priority nursing concepts for pneumonia are pretty obvious. We’ve got to pay attention to oxygenation and gas exchange because their alveoli are filled with fluid – and we’re monitoring for ARDS. And infection control is a top priority to prevent pneumonia in the first place or to prevent it from spreading and treat the current infection. Make sure you check out the care plan attached to this lesson to see more specific nursing interventions.

So let’s recap quickly. Pneumonia is an inflammatory process in the lungs that involves fluid or pus filling the alveoli and preventing proper gas exchange. If it’s infectious it’s important that we identify the organism so we can treat it with the correct antimicrobials. Bacterial pneumonia is more severe than the others, but all pneumonias share some common symptoms like chills, rhonchi, wheezes, and a decreased SpO2. We treat them with antibiotics, antipyretics, and analgesics, plus we make sure they receive their vaccines and encourage fluids to thin out secretions. As nurses it’s imperative that we promote activity and deep breathing exercises and monitor their respiratory status. And above all, we have to remember good hand hygiene to prevent the spread!

So those are the basics of pneumonia, let us know if you have any questions. Go out and be your best self today. And, as always, happy nursing!

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