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Lower Respiratory Infections Pneumonia
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- Inflammatory process in the lung tissue-places patient more at risk for microbial invasion
- - Most common death from infectious disease in the US for all ages and both genders (along with influenza)
- - Bacteria commonly enter lower airway but do not cause pneumonia in the presence of an intact host defense mechanism
- - Pneumonitis more general term describes an inflammatory process in lung tissue that my predispose or place the patient at risk for microbial invasion
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Causes of pneumonia:
- 1.Bacteria, viral or fungal pathogens, most common are S. pneumonia, Haemophilus, and staphylococcus
- 2.Foreign Substance in the lung (aspiration pneumonia). Impaired cough reflex
- 3.Immunocompromised individuals (elderly, young persons with chronic disease) at risk for developing pneumonia, also, smokers
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Pathophysiology
- May be classified according to: microorganism, site of involvement (lobes), or etiology (aspiration) Most common forms of pneumonia are viral
- Bacterial pneumonia-more severe, requires antibiotics, most common reason for hospitalization
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Pathophysiology
- Hospital acquired pneumonia – nosocomial pneumonia, onset of pneumonia symptoms more than 48 hours after admission
- Affects both ventilation and diffusion. Inflammatory reaction can occur in alveoli producing an exudate interfering with exchange of oxygen
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Bacterial Pneumonia
- Pneumococcal and streptococcal pneumonia – rust colored sputum
- Pseudomonas pneumonia – foul smelling green or yellow sputum
- Klebsella pneumonia – blood tinged sputum
- Mycoplasmal pneumonia – neither bacterial or viral. Tends to have milder symptoms – light colored sputum
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Assessment
- Productive cough
- Fever
- Chills, shaking
- Extreme fatigue
- Rales /crackles
- Change mental status (esp. with elderly)
- SOB
- Pleuritic chest pain
- WBC > 11,000
- CXR – consolidation
- History of URI, cold
- Anorexia
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Lung Sounds
- Rales/Crackles – discrete noncontinuous sounds that result from delayed reopening of deflated airways, may or may not clear with coughing-underlying inflammation or congestion – discontinuous popping, inspiration
- Wheezes – changes in airway diameter, continuous musical, high pitched, whistle like - insp. and exp.
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Diagnostic Tests
- CXR
- CBCD
- Blood Cultures – always collect any cultures before beginning antibiotics
- Sputum Cultures – also collect prior to antibiotics
- ABG’s with SOB
- Blood cultures because bloodstream invasion possible.
- Sputum obtained by having pt.
- 1. rinse mouth with water to minimize contamination with normal flora
- 2. breathe deeply several times,
- 3. cough deeply
- 4. expectorated the raised sputum into sterile container
- Gram stain determines type
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Nursing Diagnosis
- Ineffective Airway Clearance
- Impaired gas exchange
- Ineffective breathing pattern
- Altered nutrition < body requirements
- Hyperthermia
- Activity intolerance
- Knowledge deficit
- Risk for fluid volume deficit
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Interventions
- - Eliminate microorganisms thru admin of organism-specific antibiotics – may need IV then switch to PO upon discharge
- - Support oxygenation, monitor SaO2, ABG’s, O2 per Drs. Order
- - Limit activity – cluster activities to reduce fatigue, fatigue may continue for weeks after resolution of pneumonia
- - Pneumovax vaccine – primary prevention. One time vaccine for pneumococcal pneumonia. Recommended for those >65, chronic illness and immunocompromised
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Nursing Interventions
- - Semi Fowler’s, High Fowler’s
- - T,C,DB q 2 hours
- - Incentive spirometer q 1-2 hours
- - Deep secretions thin to aid in removal
- Humidify inspired air
- Fluid intake 2000 – 2500 ml/day unless contraindicated
- Discourage Smoking
- Chest Physiotherapy
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Pharmacology
- - Antibiotics as determined by culture
- - Bronchodilators
- - Expectorants (increase production resp. tract fluids to help liquefy and reduce viscosity of tenacious secretions
- - Antitussives (suppresses cough reflex)
- - Mucolytics (reduces viscosity pulmonary secretions)
- Bronchodilators – relax bronchial smooth muscle by stimulating beta-2 receptors (albuteral, Provental) – possible elevated heart rate (possible beta 1 stim), concurrent use with MAO inhibitors may cause hypertensive crises, may see urinary retention
- Expectorants- increase fluid flow in resp tract and reduce viscosity of secretions to aid in removal by cough, Robitussin- these not used as common because of question of effectiveness.
- Antitussives - Opioid and non opioid suppress cough reflex by directly affecting the cough center, non opioids do this without the CNS suppression, potential for addiction, contraindicated in clients with resp depression Dimetane(opioid), Benzonatate (non opioid)
- Mucolytics – admin by inhalation to liquefy mucus in resp tract Mucomyst – may cause bronchospasm, incompatible with some antibiotics
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Viral Pneumonia
- - Treatment primarily supportive
- - Antibiotics ineffective in viral upper respiratory infections
- - Antibiotics only when a secondary bacterial pneumonia, bronchitis or sinusitis is present
- - Hydration necessary
- - Antipyretics
- - Treatment other than antibiotics similar to bacterial pneumonia
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Aspiration Pneumonia
- - Aspiration of foreign material into the lungs
- - Causes serious pneumonia related to type of material ingested
- - Severe pneumonia can result from aspiration of stomach acid
- - Aspiration pneumonia can become infected secondarily with bacteria requiring treatment with an antibiotic
- - Due to respiratory anatomy, aspiration pneumonia most commonly affects right lung as the right mainstem bronchus extends more vertically into the lung
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Risk Factors for Aspiration Pneumonia
- - CVA – clients with strokes and impaired swallowing
- - Unconscious patients
- - Clients receiving tube feedings
- - Alcohol – intoxicated clients
- - Drowning
- - Petroleum distillate ingestions – kerosene, gas, furniture polish
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Assessment
- - Coughing, shortness of breath, wheezing
- - Fever is a late symptom
- - History to assess for risk
- - CXR – shows foreign object or changes in lung. May take up to 72 hours to be evident on CXR
- - ABG’s
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Prevention
- - Suction clients unable to cough effectively
- - Thickened liquid and small feedings
- - Check tube placement for NG or G-tube before feeding
- - Check residual – hold feeding if necessary
- - Elevate HOB when administering tube feedings
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Interventions
- - Bronchoscopy – to retrieve foreign object
- - Bronchodilators for wheezing
- - Antibiotics for bacterial contamination
- - Oxygen
- - Fever control
- - Aspiration precautions
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Pleural Conditions
- - Pleurisy: an inflammation of both layers of the pleurae
- - Inflamed surfaces rub together with respirations and cause sharp pain that is intensified with inspiration.
- - Pleural effusion: a collection of fluid in the pleural space, usually secondary to another disease process
- - Large effusions impair lung expansion and cause dyspnea.
- - Empyema: accumulation of thick, purulent fluid in the pleural space
- - Patient is usually acutely ill. Fluid, fibrin development, and loculation will impair lung expansion. Resolution is a prolonged process.
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