Pneumonia is an inflammatory condition of the interstitial lung tissue in which fluid and blood cells escape into the alveoli. More than 3 million people in the United States are diagnosed each year with pneumonia. The disease process begins with an infection in the alveolar spaces. As the organism multiplies, the alveolar spaces fill with fluid, white blood cells, and cellular debris from phagocytosis of the infectious agent. The infection spreads from the alveolus and can involve the distal airways (bronchopneumonia), part of a lobe (lobular pneumonia), or an entire lung (lobar pneumonia).
The inflammatory process causes the lung tissue to stiffen, thus resulting in a decrease in lung compliance and an increase in the work of breathing. The fluid-filled alveoli cause a physiological shunt, and venous blood passes unventilated portions of lung tissue and returns to the left atrium unoxygenated. As the arterial oxygen tension falls, the patient begins to exhibit the signs and symptoms of hypoxemia. In addition to hypoxemia, pneumonia can lead to respiratory failure and septic shock. Infection may spread via the bloodstream and cause endocarditis, pericarditis, meningitis, or bacteremia.
Primary pneumonia is caused by the patient’s inhaling or aspirating a pathogen such as bacteria or a virus. Bacterial pneumonia, often caused by staphylococcus, streptococcus, or klebsiella, usually occurs when the lungs’ defense mechanisms are impaired by such factors as suppressed cough reflex, decreased cilia action, decreased activity of phagocytic cells, and the accumulation of secretions. Viral pneumonia occurs when a virus attacks bronchiolar epithelial cells and causes interstitial inflammation and desquamation, which eventually spread to the alveoli.
Secondary pneumonia ensues from lung damage that was caused by the spread of bacteria from an infection elsewhere in the body or by a noxious chemical. Aspiration pneumonia is caused by the patient’s inhaling foreign matter such as food or vomitus into the bronchi. Factors associated with aspiration pneumonia include old age, impaired gag reflex, surgical procedures, debilitating disease, and decreased level of consciousness.
Community-acquired pneumonia is caused by bacteria that are divided into two groups: typical and atypical. Organisms that cause typical pneumonia include Streptococcus pneumoniae (pneumococcus) and Haemophilus and Staphylococcus species. Organisms that cause atypical pneumonia include Legionella, Mycoplasma, and Chlamydia species.
Nursing care plan assessment and physical examination
The patient may have a history of a recent upper respiratory infection, influenza, or a viral syndrome. Elicit a history of a chronic pulmonary disease, such as asthma, bronchitis, or tuberculosis; prolonged immobility; sickle cell anemia; neurological disorders that cause paralysis of the diaphragm; surgery of the thorax or abdomen; smoking; alcoholism; IV drug therapy or abuse; and malnutrition. Establish any history of exposure to noxious gases, aspiration, or immunosuppressive therapy. Ask about the major symptoms of pneumonia: cough, fever, sputum production, chest pain, and shortness of breath. Ask the patient to describe the type of cough and the nature of the sputum production. Determine the location of any pain, especially chest pain. Ask about sore throat or chills, vomiting, diarrhea, or anorexia.
Observe the patient’s general appearance and respiratory pattern to determine level of fatigue, presence of cyanosis, and presence of dyspnea or tachypnea. Examine the patient’s extremities, torso, and face for rash. Assess vital signs for rapid, weak, thready pulse; fever; and blood pressure changes such as hypotension and orthostasis (postural hypotension). Palpate the chest to determine any areas of consolidation or tactile fremitus. Percuss the chest to detect dullness over the area of consolidation. When you auscultate the patient’s breathing, listen for rales, crackles, ronchi, and wheezes; “E” to “A” changes; and whispered pectoriloquy.
The patient with pneumonia may be anxious, fatigued, and in pain from the constant coughing. Assess the patient’s ability to cope with a sudden, debilitating illness. The patient may be anxious because of difficulty breathing and be distressed over purulent sputum.
Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to increased production of secretions and increased viscosity.
Nursing care plan intervention and treatment plan
Bacterial pneumonia is treated with medications. Physicians may request regular measurements of peak and trough levels, especially for patients who are receiving aminoglycosides, which can produce severe side effects such as renal failure and hearing loss. Many patients need oxygen therapy, even intubation and mechanical ventilation. High fever may be treated with antipyretics or IV hydration to replace fluid loss. Percussion and postural drainage may be prescribed to assist the patient in expectorating secretions.
Make sure the patient coughs and uses deep-breathing exercises at least every 2 hours. Encourage drinking 3 L of fluid daily, unless contraindicated, to help expectorate secretions. If the patient cannot cough up secretions, you may have to perform nasotracheal or orotracheal suction to maintain an open airway. Turn and position patients on bedrest to help keep the airway open and free of secretions. Elevate the head of the bed to at least 45 degrees to help the patient maintain an open airway, and find positions that ease breathing. Place the patient in an upright position with both arms well supported on pillows, or position the patient to lean forward and rest her or his arms on the overbed table.
Involve the patient in as much decision making as possible, and when possible, include the family in teaching situations. Explain all procedures, particularly intubation and suctioning. Teach the importance of adequate rest and the deep-breathing and coughing exercises that are designed to clear lung secretions.
Teach proper ways to dispose of secretions and proper hand-washing techniques to minimize the risk of spreading infection. Advise annual influenza vaccinations or avoidance of using antibiotics indiscriminately because such use creates a risk for upper airway colonization by antibiotic-resistant bacteria.
Nursing care plan discharge and home health care guidelines
Be sure the patient understands all medications, including dosage, route, action, and adverse effects. The patient and family or significant other need to understand the importance of avoiding fatigue by limiting activity and taking frequent rests. Advise small, frequent meals to maintain adequate nutrition. Fluid intake should be maintained at approximately 3000 mL/day so that the secretions remain thin. Teach the patient to maintain pulmonary hygiene measures of coughing, deep breathing, and incentive spirometry at home. Provide information about how to stop smoking.