Medical Surgical Nursing Bridging Program Academic Year 1434-1435 / 2013-2014

2014

College of Nursing

Definition
Is an inflammatory process of the lung parenchyma that is commonly caused by infectious agents.

Classification of pneumonia
Bacterial (the most common cause of pneumonia) Viral pneumonia Fungal pneumonia Chemical pneumonia (ingestion of kerosene or inhalation of irritating substance) Inhalation pneumonia (aspiration pneumonia)

According to causes

According to areas involved

Lobar pneumonia; if one or more lobe is involved Broncho-pneumonia; the pneumonic process has originated in one or more bronchi and extends to the surrounding lung tissue.

The more widely used classification scheme categorizes the major pneumonias as

I : Community-acquired Pneumonia II : Hospital-acquired Pneumonia III : Pneumonia in immunocompromised host IV : Aspiration Pneumonia V : Pneumonia due to emerging pathogens (new pathogens)

Mode of transmission
Bacteria and viruses living in the nose, sinuses, or mouth may spread to the lungs. breathe some of these germs directly into the lungs (droplets infection).
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 breathe in (inhale) food, liquids, vomit, or fluids from the mouth into the lungs (aspiration pneumonia).

Pathophysiology
The streptococci reach the alveoli and lead to inflammation and pouring of an exudates into the air spaces. WBCs migrates to alveoli, the alveoli become more thick due to its filling consolidation, involved areas by inflammation are not adequately ventilated, due to secretion and edema. This will lead to partial occlusion of alveoli and bronchi causing a decrease in alveolar oxygen content. Venous blood that goes to affected areas without being oxygenated and returns to the heart. This will lead to arterial hypoxemia and even death due to interference with ventilation.

Predisposing factors
Immuno-suppresed patients Cigarette smoking Difficult swallowing (due to stroke, dementia, Parkinson's disease, or other neurological conditions) Impaired consciousness ( loss of brain function due to dementia, stroke, or other neurological conditions) Chronic lung disease (COPD, bronchostasis) Frequent suction Other serious illness such as heart disease, liver cirrhosis, and DM Recent cold, laryngitis or flu Nothing-by-mouth status (NPO). Prolonged immobility and shallow breathing pattern. Advanced age.

Clinical manifestations
Sudden onset of Shaking chills Rapidly rising fever ( 39.5 to 40.5 degree), but in older adults and
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immunocomprimized patients may have low grade fever or normal temperature. Stabbing chest pain aggravated by respiration and coughing Tachypnea, nasal flaring Patient is very ill and lies on the affected side to decrease pain Use of accessory muscles of respiration e.g. abdomen and intercostals muscles Cough with purulent, blood tinged, rusty sputum Shortness of breath Flushed cheeks Loss of appetite, low energy, and fatigue Cyanosed lips and nail beds Focal chest signs on examination: decreased expansion, dullness on percussion, decreased air entry and crepetations.

Diagnostic tests
History taking Physical examination Chest x-ray Blood test Sputum culture

The British Thoracic Society recommends the CURB-65 scoring system This is a 6 points score (range 0-5) that gives one point for each of the following: Confusion (New disorientation in person, place and person.) Serum Urea > 7 mmol/l Respiratory rate 30 / m Low systolic Blood pressure <90 mmHg or diastolic pressure 60 mmHg Age 65 years or more. The score related to mortality, and severe pneumonia is defined as a CURB-65 score of 3 or more.

The British Thoracic Society advocates management strategies based on this score:
0-1 2: Home treatment Non severe, hospital treatment

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3 or more: Severe, Hospital treatment

Medical management
Antibiotic, depending on sputum and blood culture Oxygen therapy Chest physiotherapy pneumonia Home treatment (Score 0-1) Treatment Oral Amoxicillin 500-1000mg, 3times daily :OR Oral Erythromycin 500mg, 4times daily :OR Oral Clarithromycin 500mg, twice daily Oral Amoxicillin 500-1000mg, 3times daily + Erythromycin 500mg, 4times daily :OR Oral Levofloxacin 400mg once daily :OR IV Ampicillin 500mg, 4 times daily IV Amoxicillin + Clavulonic Acid (Augmentin) 1-2gm, 3 times / daily or Cefotaxime 1gm 3 .times / daily Erythromycin 500mg, 4times daily or clarithromycin 500mg, twice daily :OR IV levofloxacin 500mg twice daily Benzyl penicillin 1200mg 4 times daily +

Hospital Treatment A: Non Severe )Score 2(

Hospital Treatment B: Severe Score 3 or ( )more

Treatment of viral pneumonia is supportive:

Antipyretic Bed rest Hydration Antitussive Warm-moist inhalation Antihistamines

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 Antibiotics are indicated only when a secondary bacterial pneumonia, bronchitis or sinusitis is present. Oxygen is administered Pulse oximetry or ABG is preferred to determine need for O2 & evaluate the effectiveness of therapy.

Treatment of Mycoplasma pneumonia:

Supportive Antibiotics: Erythromycin 500mg, 4times /day or Clarithromycin 500mg twice daily

Treatment of Fungal pneumonia:

Supportive Antifungal medications.

Nursing management : 1. ASSESSMENT

The nurse should monitor the following: Changes in temperature and pulse Amount, odor and color of secretions Frequency and severity of cough Degree of tachypnea and shortness of breath Changes in physical assessment findings

2. NURSING DIAGNOSIS :
Based on assessment, the major nursing diagnosis include: Ineffective airway clearance related to copious tracheobronchial secretion. Activity intolerance related to altered respiratory function. Risk for fluid volume deficit related to fever and tachypnea. Knowledge deficit about treatment regimen and preventive health measures.

3. PLANNING & GOALS:

The major goals:
Improve airway clearance
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Enough rest to conserve energy Maintain proper fluid volume Maintain adequate nutrition Compliant to the treatment protocol Absent complications Follow preventive measures

4. Nursing intervention
Maintain a patent airway and adequate oxygenation. Obtain sputum specimens as needed. Use suction if the patient cant produce a specimen. perform chest physiotherapy. Provide a high calorie, high protein diet of soft foods.

To prevent aspiration during nasogastric tube feedings, check the position of tube, and administer feedings slowly.
To control the spread of infection, dispose secretions properly. Provide a quiet, calm environment, with frequent rest periods. Monitor the patients ABG levels, especially if hypoxic. Assess the patients respiratory status. Auscultate breath sounds at least every 4 hours.

Monitor fluid intake and output. Encourage hydration (at least 2L/day)
Evaluate the effectiveness of administered medications. Explain all procedures to the patient and family.

Preventive measures
Frequent turning of bed ridden patients and early ambulation as much as possible. Coughing and breathing techniques. Sterilization of respiratory therapy equipment
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Suctioning of secretion in the unconscious who have poor cough and swallowing reflexes, to prevent aspiration of secretions and its accumulation. Encourage smoking cessation. Promote frequent oral hygiene to prevent colonization of bacteria and check placement of tube to prevent aspiration for NOP patient. Observe respiration after anesthesia and before administering sedation. Encourage ambulation, effective coughing and breathing exercise and promote nutritious diet for elderly. Vaccination with influenza vaccine yearly. Vaccination with pneumococcal vaccine to those with DM, chronic heart and lung diseases, immunocomprimized patients and sickle cell disease.

Prognosis
With treatment, most patients will improve within 2 weeks. Elderly or very sick patients may need longer treatment.

Complications
Acute respiratory distress syndrome (ARDS) Pleural effusion Lung abscesses Respiratory failure (which requires mechanical ventilator) Sepsis, which may lead to organ failure

REFERANCES:
Smeltzer, S.C. & Bare, B.G. Brunner and Suddarths Textbook of Medical Surgical Nursing. 12th Ed. Philadelphia: Lippincott Company, 2010. http://www.tabletsmanual.com/wiki/read/pneumonia

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