PNEUMONIA
An inflammatory process in the lungs that produces excess fluid and exudate that fill the alveoli |
Classified as bacterial, viral, fungal, or chemical |
Pneumonia is triggered by infectious organisms or by the aspiration of an irritant, such as fluid or a foreign object |
Can be a primary disease of a complication of another disease or condition |
Young clients, older adult clients, and clients who are immunocompromised are more susceptible |
TYPES OF PNEUMONIA
Ventilator associated pneumonia (VAP): |
Occurs 48 to 72 hr after endotracheal intubation |
Community acquired pneumonia (CAP): |
The most common type and often occurs as a complication of influenza |
Health care acquired pneumonia (HAP): |
Has a higher mortality rate and is more likely to be resistant to antibiotics. It usually takes more than 48 hr from the time the client is exposed to acquire HAP. |
CONTRIBUTING FACTORS
Advanced age |
No pneumococcal vaccination within the last 5 years |
No influenza vaccine within the last year |
Chronic lung disease |
Immunocompromised |
Mechanical ventilation |
Postoperative |
Sedation |
Opioid use |
Prolonged immobility |
Tobacco use |
Enteral tube feeding |
EXPECTED FINDINGS
Anxiety |
Fatigue |
Weakness |
Chest discomfort due to coughing |
Confusion from hypoxia is a common manifestation of pneumonia in older adult clients
MANIFESTATIONS
Fever |
Chills |
Flushed face |
Diaphoresis |
Shortness of breath or difficulty breathing |
Tachypnea |
Pleuritic chest pain (sharp) |
Sputum production (yellow-tinged) |
Crackles |
Wheezes |
Dull chest percussion over areas of consolidation |
Coughing |
Decreased oxygen saturation levels |
Purulent, blood tinged or rust colored sputum |
LABORATORY TESTS
CBC: |
Elevated WBC |
| |
(Might not be present in older adult clients) |
ABGs: |
Hypoxemia |
| |
(PaO2 less than 80 mm Hg) |
Blood culture: |
To rule out organisms in the blood |
Serum electrolytes: |
To identify dehydration |
Sputum culture and sensitivity: |
Obtain specimens before starting antibiotic therapy |
| |
Obtain specimen by suctioning if the client is unable to cough |
DIAGNOSTIC PROCEDURES
Chest x-ray: |
Will show consolidation (solidification, density) of lung tissue |
| |
Might not indicate pneumonia for a few days after manifestations develop |
Pulse oximetry: |
Clients who have pneumonia usually have oximetry levels less than the expected reference range of 95-100% |
NURSING CARE
Position the client to maximize ventilation (high-Fowler's) unless contraindicated |
Encourage coughing or suction to remove secretions |
Administer breathing treatments & medications |
Adminiter oxygen therapy |
Monitor for skin breakdown around the ears, nose, and mouth from the oxygen device |
Encourage deep breathing with an incentive spirometer to prevent alveolar collapse |
Determine the client's physical limitations and structure activity to include periods of rest |
Encourage fluid intake of 2.5 to 3 L/day to promote hydration and thinning of secretions, unless contraindicated due to another condition |
Provide rest periods for clients who have dyspnea |
Reassure the client who is experiencing respiratory distress |
MEDICATIONS
Antibiotics |
Bronchodilators |
Anti-inflammatories |
ANTIBIOTICS
Antibiotics are given to destroy infectious pathogens. |
Commonly used antibiotics include fluoroquinolone, penicillins, and cephalosporins. |
Antibiotics are often initially given via IV and then switched to an oral form as the condition improves. |
Obtain any culture specimens prior to giving the first dose of an antibiotic. Once the specimen is obtained, the antibiotics can be given while waiting for the results of the culture. |
Nursing Actions: |
Observe clients taking cephalosporins for frequent stools |
| |
Monitor kidney function, especially older adults who are taking penicillins and cephalosporins |
Client Education: |
Encourage clients to take penicillins and cephalosporins with food |
| |
Some penicillins should be taken 1 hr before meals or 2 hr after |
|
|
BRONCHODILATORS
Bronchodilators are given to reduce bronchospasm and reduce irritation. |
Short-acting beta2 agonists, such as albuterol, provide rapid relief. |
Cholinergic antagonists (anticholinergic medications), such as ipratropium, block the parasympathetic nervous system, allowing for increased bronchodilator and decreased pulmonary secretions. |
Nursing Actions (Albuterol): |
Increase fluid intake if not contraindicated |
| |
Can cause hypokalemia, insomnia, headache, or nausea |
| |
Monitor for tremors, tachycardia, hypertension, nervousness, palpitations, and dry mouth |
Nursing Actions (Ipratropium): |
Observe for dry mouth and difficulty with urination |
| |
Monitor heart rate |
| |
Adverse effects can include headache, blurred vision, and palpitations, which can indicate toxicity |
Client Education: |
Reinforce teaching on how to use a metered-dose inhaler (MDI) |
| |
Encourage clients to suck on hard candies to moisten dry mouth while taking ipratropium |
| |
Encourage increased fluid intake unless contraindicated |
ANTI-INFLAMMATORIES
Anti-inflammatories decrease airway inflammation. |
Glucocorticosteroids, such as fluticasone (MDI) and prednisone (oral), are prescribed to reduce inflammation. |
Monitor for immunosuppression, fluid retention, hyperglycemia, hypertension, hypokalemia, and poor wound healing. |
Nursing Actions: |
Monitor for decreased immunity function and infection |
| |
Monitor for hyperglycemia |
| |
Monitor for hypertension |
| |
Advise the pt to report black, tarry stools |
| |
Observe for fluid retention and weight gain |
| |
Monitor for electrolyte imbalance |
| |
Monitor the client's throat and mouth for aphthous lesions (canker sores) |
Client Education: |
Drink plenty of fluids to promote hydration |
| |
Take glucocorticosteroids with food |
| |
Avoid discontinuing glucocorticosteroids without consulting provider |
| |
Use MDI |
| |
Rinse mouth and gargle after inhaled glucocorticoids to reduce the risk of dysohonia and candidiasis |
INTERPROFESSIONAL CARE
Consult with respiratory services for inhalers, breathing treatments, and suctioning for airway management. |
Consult with nutritional services for weight loss or gain related to medications or diagnosis. |
Consult with rehabilitation care if the client has prolonged weakness and needs assistance with increasing level of activity. |
CLIENT EDUCATION
Continue medications for treatment of pneumonia |
Rest as needed |
Maintain hand hygiene to prevent infection |
Avoid crowded areas to reduce the risk of infection |
Receive immunizations for influenza and pneumonia |
Stop smoking |
COMPLICATIONS OF PNEUMONIA
Atelectasis: |
Airway inflammation and edema lead to alveolar collapse and increase the risk of hypoxemia |
| |
The pt reports shortness of breath and exhibits findings of hypoxemia |
| |
The pt has diminished or absent breath sounds over the affected area |
| |
A chest x-ray shows an area of density |
Bacteremia (sepsis): |
This occurs if pathogens enter the bloodstream from the infection in the lungs |
Acute respiratory distress syndrome: |
Hypoxemia persists despite oxygen therapy |
| |
Dyspnea worsens as bilateral pulmonary edema develops that is non cardiac related |
| |
A chest x-ray shows an area of density with a ground-glass appearance |
| |
Blood gas findings demonstrate high arterial blood levels of carbon dioxide (hypercarbia) and pulse oximetry shows decreased saturation |
APPLICATION EXERCISES
1. A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (select all that apply) |
A. client who has dysphagia |
B. client who has AIDS |
C. client who received vaccines for pneumoccocus and influenza 6 months ago |
D. client who is ambulatory after receiving a local anesthesia |
E. client who has a closed head injury |
F. client who has myasthenia graves |
2. A nurse is caring for a client who has pneumonia. Data collection findings include temperature 37.8 C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Which of the following actions is the nurse's priority? |
A. administer antibiotics |
B. administer oxygen therapy |
C. perform a sputum culture |
D. administer antipyretic medication to promote client comfort |
|
Created By
Metadata
Favourited By
Comments
aaa
Add a Comment
Related Cheat Sheets
More Cheat Sheets by harpieee