Pneumocystis carinii pneumonia (PCP) is an acute or subacute pulmonary infection that can be fatal. It occurs in 5% to 10% of transplant paitents and is the most common infection in people with human immunodeficiency virus (HIV) infections and the leading cause of death in this population. With prophylactic medications, an estimated 1% to 20% of people with HIV infection develop PCP at some point in their lifetimes. PCP is viewed as an opportunistic infection because normal cell-mediated immunity protects most humans from infection. Epidemiological surveys have found that by age 3 to 4, most humans have been exposed to the pathogen.
Early in the infection, the organisms line up along the alveolar wall near the type I pneumocytes. The alveoli become infiltrated with a fluid that contains proteins, organisms in varying states of development, cellular debris, and surfactant. As the alveoli become clogged with fluid and wastes, gas exchange is impaired. As the disease progresses, alveoli hypertrophy, type I pneumocytes die, and the patient has markedly diminished gas exchange. PCP affects both lungs and can lead to complications such as pulmonary insufficiency, respiratory failure, and even death. People infected with HIV have a 10% to 20% mortality rate, whereas other immunocompromised individuals have a 40% mortality rate.
Although the causative agent, P. carinii, is often classified as a protozoa, its structure and function are closer to a fungus. Human transmission occurs by the airborne route, where it multiplies aggressively in the alveoli. Incubation is estimated to be between 4 and 8 weeks. Individuals at risk for PCP are immunocompromised and have conditions such as HIV infection or are premature infants. Other vulnerable populations include patients who receive corticosteroid therapy and organ transplantation.
Nursing care plan assessment and physical examination
Patients with PCP often appear acutely ill and weak. They often have pallor, weight loss, and fatigue on exertion and become short of breath even when speaking. Determine if the patient has a history of leukemia, lymphoma, organ transplantation, or HIV, all of which compromise the immune system and increase the risk of PCP. Because symptoms of PCP develop over a period of weeks (4 to 8 weeks, generally), initial symptoms may be vague. Determine if the patient has experienced nonproductive cough or increasing shortness of breath, which are frequent initial symptoms of PCP. Ask about a recent history of anorexia, nausea, vomiting, weight loss, or a low-grade intermittent fever. Note that before PCP prophylaxis in HIV-positive patients, this disease was the first indication of HIV infection in 60% of HIVpositive patients.
Assess for signs of respiratory difficulties, such as stridor, nasal flaring, and rapid breathing. If the patient has a cough, note the type. Examine the patient’s skin, noting its color, turgor, temperature, and whether or not it is dry and flaky. Check for pallor, flushing, and cyanosis. Note the type, amount, and color of sputum, which is commonly blood-tinged. Observe the patient’s level of consciousness and irritability. Note any muscle wasting or guarding of painful areas. Auscultate the lungs for abnormal breath sounds, crackles, or diminished or absent breath sounds, either unilaterally or bilaterally. Late in PCP, when you percuss the chest, you may hear dullness from lung consolidation.
PCP is a serious and life-threatening infection; in addition, it may be the defining condition for diagnosis of AIDS, according to the Centers for Disease Control and Prevention. The patient may experience anxiety, depression, or difficulty in coping with the change in heath status. Identify the patient’s support system, and evaluate its effectiveness. The diagnosis of AIDS presents many complex familial and societal issues.
Nursing care plan primary nursing diagnosis: Risk for infection related to immunosuppression.
Nursing care plan intervention and treatment plan
Patients require pharmacologic treatment to eradicate the organism. PCP infections may be treated with incentive spirometry, percussion and postural drainage, and humidified oxygen. Some patients may require intubation and mechanical ventilation to maintain gas exchange. If the patient is not intubated and is able to take oral nutrition, a high-calorie, protein-rich diet is recommended. If the patient cannot tolerate large amounts of food, smaller, more frequent meals can be offered. IV fluids and total parenteral nutrition may be needed to maintain fluid balance if the patient cannot tolerate oral enteral feedings.
Patients with PCP infection are often weak and debilitated. They may become short of breath even when speaking, and their dyspnea is severe. Discuss your concerns with the physician if the patient remains uncomfortable. Alterations in the medication regimen may be necessary. Position the patient so that he or she is comfortable and breathes with as little effort as possible. Usually, if you elevate the bed and support the patient’s arms on pillows, the respiration eases. A major nursing responsibility is to coordinate periods of activity and rest. Schedule diagnostic tests and patient care activities with ample rest periods between them. As the patient gains strength, encourage coughing and deep-breathing exercises, and teach him or her how to perform incentive spirometry. Evaluate the patient’s gait, and if it is steady, encourage periods of ambulation interspersed with periods of rest.
Reduce the patient’s anxiety by providing a restful environment, including diversional activities. Teach the patient guided imaging or relaxation techniques for nonpharmacologic relief of discomfort. Provide time each day to allow the patient to ask questions and explore fears. Include the family and significant others in all teaching activities as appropriate.
Nursing care plan discharge and home health care guidelines
Advise the patient to quit smoking, rest, avoid excess alcohol intake, maintain adequate nutrition, and avoid exposure to crowds and others with upper respiratory infections. Teach the
patient appropriate preventive measures, such as covering the mouth and nose while coughing when in contact with susceptible individuals. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Teach the patient to recognize symptoms, such as dyspnea, chest pain, fatigue, weight loss, fever and chills, and productive cough, that should be reported to healthcare personnel.