Pneumonia PDF

Pneumonia People can aspirate when they inhale something accidentally. Do you know what aspiration is? It’s like when someone says, “it went down the wrong pipe.” This can happen more often when someone is lying flat in bed, increasing their risk of aspiration. That’s why we encourage patients to si...

Pneumonia People can aspirate when they inhale something accidentally. Do you know what aspiration is? It’s like when someone says, “it went down the wrong pipe.” This can happen more often when someone is lying flat in bed, increasing their risk of aspiration. That’s why we encourage patients to sit up, especially when drinking. People generally breathe better when they’re upright, particularly if they’re in respiratory distress. In more advanced cases, pneumonia is a concern. Did you know that 1% of the population gets pneumonia, and it has a high mortality rate? Approximately 1.5 million people are hospitalized for pneumonia annually. Have you seen patients in the hospital with pneumonia? Especially during certain seasons, it becomes very common. Aspiration can lead to pneumonia, particularly if someone has difficulty swallowing. If precautions aren’t followed, such as ensuring patients are on proper diets (like pureed foods), they can aspirate, leading to lung infections. During the COVID-19 pandemic, many people developed pneumonia as a complication, which was one of the leading causes of death in the United States. In fact, pneumonia from influenza and other infections is the ninth overall cause of death. Pneumonia is classified by the microorganism that causes it or the setting in which it develops. For example: Community-acquired pneumonia occurs when someone develops pneumonia outside of a hospital setting or within the first 48 hours of admission. Hospital-acquired pneumonia occurs after 48 hours of hospital admission. Ventilator-associated pneumonia occurs in patients on mechanical ventilation. Specific protocols are in place to prevent this because anything foreign in the throat, like a tube, increases the risk of infection. Pneumonia in immunocompromised patients is another classification. Let’s look at the respiratory system. The respiratory tract is normally considered a sterile environment, with protective mechanisms like coughing, sneezing, and cilia in the bronchopulmonary tree that help prevent infections. However, when something enters the lungs that shouldn’t be there, the body’s defenses can be overwhelmed. This leads to infection as the organism colonizes and causes inflammation in the lung tissue. The bacteria, endotoxins, and exotoxins damage the bronchial and alveolar membranes, resulting in inflammation and fluid buildup (edema). What happens then? The inflammatory response causes vascular permeability, edema, and exudate, which obstructs the lungs and decreases gas exchange. This consolidation of lung tissue impairs the lungs’ ability to function. Clinically, patients with pneumonia often present with the following symptoms: Chills and fever (common signs of infection). Cough with rust-colored or purulent sputum. Abnormal breath sounds like crackles or rhonchi. Crackles can be coarse or fine, depending on the severity of the fluid in the lungs. Shortness of breath, especially with exertion. Decreased oxygen saturation and possibly cyanosis. Increased respiratory rate and use of accessory muscles for breathing. Patients might also experience anxiety, confusion (especially in older adults), and fatigue due to low oxygen levels. Pain often increases with coughing or deep breathing. For patients in the community, several risk factors can increase the likelihood of developing pneumonia: Smoking. Pre-existing pulmonary conditions. Mental status changes, as seen in epilepsy or dementia. Swallowing difficulties (dysphagia), which can lead to aspiration pneumonia. Chronic illnesses such as HIV, kidney disease, or liver disease. Malnutrition or poor hygiene, especially poor dental hygiene. Immunosuppressive therapies, such as long-term steroid use. Being over 65 years old. Exposure to children or crowded environments, which increases susceptibility to infection. In hospitals, certain conditions increase the risk of hospital-acquired pneumonia, such as immobility, prolonged hospital stays, and prior exposure to antibiotics. This contributes to the rise in antibiotic-resistant organisms. Why does antibiotic resistance occur? One reason is that people often stop taking their antibiotics once they feel better, allowing the infection to return stronger. Patients on mechanical ventilation or with feeding tubes are also at risk of aspiration, especially if the tube becomes dislodged. Surgical patients lying flat for extended periods are similarly vulnerable. Diagnosis involves: 1. Identifying clinical signs and symptoms. For example, tachycardia may occur due to fever or difficulty breathing. 2. Conducting a thorough medical history and physical examination. 3. Performing diagnostic tests, including chest X-rays, which often show infiltrates or consolidation in the lungs. 4. Collecting a sputum sample. This is crucial before starting antibiotics to ensure the correct treatment is given. Now, they do have broad-spectrum antibiotics, which are used in emergency situations, but they still need to send that sputum sample because each type of antibiotic targets a different organism. It might not even be a bacterial infection. Remember, it could also be viral, which would require antiviral treatment, or parasitic, which would require different medications. Parasites, though, are less commonly documented. Have you ever seen those scary cases on TV? Sometimes, I’ve watched too many of those weird shows. So, you’ve learned how to collect a sputum sample, right? Maybe in class 100? Yes? No? I’m not answering anymore questions about that class! Anyway, you can collect a sample in a few ways. Often, patients who aren’t intubated or ventilated will need to actually cough up the sputum themselves. Here’s how: have them rinse their mouth with water, take deep breaths several times, cough deeply, and expectorate the raised sputum into a sterile container. If you’re using suction to collect the sample, it needs to be sterile. The best time to collect a sputum sample is early in the morning. For more invasive methods, they might use a bronchoscopy. This is typically done by a pulmonologist (I couldn’t think of the name for a second there, but now I remember). Sometimes in critical care, the ICU team might perform the procedure to collect a sample directly from the patient. Other diagnostic tools include: CBC (Complete Blood Count): This includes white blood cells, which help indicate infection. The differential breakdown of white blood cells can provide even more information. Blood cultures: Sometimes, they culture everything to ensure nothing is missed, especially if a systemic infection is suspected. ABGs (Arterial Blood Gases): These assess oxygen and CO2 levels but require an arterial puncture, which carries a risk of bleeding. Respiratory therapists usually perform this procedure. Electrolytes: These are checked because when patients have difficulty breathing, they often stop eating and drinking, leading to imbalances. Now, let’s talk about treatment. If the patient isn’t oxygenating properly (low blood oxygen levels), we’ll administer oxygen therapy. You’ve already learned about the different types of oxygen therapy, right? For mild cases, a nasal cannula delivering 2 liters of oxygen might bring their oxygen saturation above 90%. However, in more severe respiratory distress, the patient may need intubation or higher oxygen levels. Remember, every patient is different, and treatments must be tailored to the individual. When starting antibiotics, they might initially use a broad-spectrum type, but this is only until the sputum or blood cultures are complete. Once the organism is identified, they can switch to a more targeted antibiotics. That’s why it’s so important to collect the sample before starting antibiotics. If the infection is viral, like influenza, they might use antivirals. Remember, we talked earlier about how influenza is a leading cause of death. Anti-inflammatory medications, like steroids (e.g., Solu-Medrol), can also be used. These reduce inflammation, which helps alleviate pain and improve breathing. Steroids are usually tapered off to avoid long-term side effects like high blood sugar or weakened immune systems. If a patient’s blood sugar rises due to steroids, they might require insulin managed on a sliding scale. Other treatments include: Bronchodilators (e.g., albuterol): These open up the airways and are usually inhaled. Mucolytics (e.g., acetylcysteine): These break up mucus to make it easier to clear. Cough expectorants: These help patients cough up secretions. Vaccines also play a role in prevention: The pneumonia vaccine (pneumococcal) is recommended for individuals over 65 or those with chronic illnesses. For younger people (ages 19-64), smokers and those with asthma are advised to get it too. The flu vaccine is offered during certain times of the year, typically from October to March, especially in hospitals before discharge. Supportive therapy is equally important. Patients often aren’t eating well, so providing adequate Nutrition is vital. When a patient presents with symptoms, we take a detailed history and perform a physical assessment. Common complaints include difficulty breathing, chest pain, and fatigue. They might have a productive cough, fever, or chills. Physical signs often include: Increased respiratory rate and use of accessory muscles for breathing. Low oxygen saturation. Crackles or rhonchi heard during lung auscultation. Altered mental status (e.g., confusion), which could indicate hypoxia. Chest X-rays showing infiltrates or consolidation. Finally, remember that patients often feel weak, dehydrated, and malnourished due to their illness. Ensuring proper hydration, nutrition, and rest is key to recovery. If we have abnormal breath sounds or diminished breath sounds, we might hear crackles. The respiratory rate will be high, and the patient may be working hard to breathe, using their accessory muscles. Our goal is to achieve a normal breathing pattern, with no signs of hypoxia or complications. Complications, however, can occur. Someone with an infection could become septic, which might lead to organ failure. We know these patients have thick secretions, so their airway isn’t clear. They are short of breath, which causes activity intolerance. They may also be at risk for fluid deficit since fever can lead to fluid loss. Malnutrition is another concern. When admitted to the hospital, every patient requires teaching to ensure they understand their condition and care plan. Teaching is critical. So, what are our goals? We want to address the risks for pneumonia. For example: If someone is in the hospital for more than five days, they are at risk. Intubated patients are at risk, as well as those who need weaning from intubation. Patients who undergo tracheostomy are also at risk. Who else is at risk? The geriatric population, immunocompromised individuals, and children are particularly vulnerable. A lot of people are at risk. For instance, aspiration is a big concern. If someone aspirates while eating or drinking, they could develop pneumonia. Interventions to prevent complications: 1. Sit the patient up. This improves lung expansion and reduces the risk of aspiration. 2. Encourage mobility. Even if they can only sit at the edge of the bed, getting them up and moving helps prevent complications. 3. Promote deep breathing exercises. These exercises help clear secretions and expand the lungs. 4. Emphasize hand hygiene and cleaning equipment. This prevents the spread of germs. It’s easy to forget to clean your equipment or hands, especially if you’re rushing to another patient. Take the extra second to sanitize everything. How do we improve airway patency? Encourage fluid intake of 2-3 liters a day to help thin secretions. However, there are exceptions: patients with heart failure or kidney failure may have fluid restrictions. Use humidified oxygen to prevent dryness and help liquefy secretions in the tracheobronchial tree. Encourage coughing and deep breathing exercises. Patients lying in bed may not expand their lungs properly, and secretions can settle. You must ensure they know how to do these exercises correctly. Always demonstrate and have the patient perform a teach-back to confirm understanding. Reposition the patient regularly. For example, if a patient has left-sided pneumonia, position them with the healthy lung down (right side) to mobilize secretions from the infected lung. Rotate their position frequently to prevent complications and encourage lung expansion. Monitoring and Assessments: Assess respiratory status frequently. For patients with abnormal ABGs, repeat testing after interventions (e.g., oxygen therapy) to evaluate effectiveness. Monitor respiratory rate and oxygen saturation. Normal oxygen saturation is generally, above 90%, but it might be continuously monitored in critical care settings. Observe changes in neurological status. Trouble speaking could indicate respiratory distress. Monitor temperature and vital signs every four hours or more frequently if necessary. Preventing pneumonia in postoperative patients: Encourage the use of an incentive spirometer, coughing, and deep breathing.  Promote mobility as soon as possible. Maintain the head of the bed in Fowler’s position (elevated). Never leave elderly patients lying flat, as this increases the risk of complications. In summary, preventing complications requires a combination of respiratory therapy, mobility, and patient education. Teaching should begin as soon as the patient arrives at the hospital. Ensure they understand the importance of their care plan and demonstrate how to perform exercises correctly. This way, when they leave the hospital, they have the knowledge they need to continue improving at home. Patients could aspirate, especially if they have a weak cough. This can lead to complications such as pulmonary edema. So, we don’t want patients lying flat; instead, keep the head of the bed elevated at least 30 degrees. If they’re short of breath, you’ll need to raise the head of the bed even higher, into Fowler’s position, with arms supported. We talked about humidified oxygen. What does it do? It helps break down secretions. Patients should also be encouraged to change positions and practice deep breathing. Chest physiotherapy (chest PT) is another important intervention. Chest PT can include vibration and percussion to help loosen secretions. In some facilities, there are special beds or equipment for this, while in others, respiratory therapy or nurses may do it manually. For example, in some places, nurses are responsible for performing chest PT, while in others, it’s handled exclusively by respiratory therapists. Did you learn how to do chest PT? It often involves clapping on the back to help clear the lungs. Managing Pain During Interventions: Patients with chest pain from coughing or deep breathing may need to splint their chest to reduce discomfort. Remember, coughing can be painful, but it’s necessary for clearing secretions. Fluid Intake: We generally recommend 2-3 liters of fluid per day to thin secretions. However, not everyone can have that much fluid. For instance, patients with heart failure or kidney failure might be on fluid restrictions. If a patient is receiving intravenous fluids, you’ll need to calculate their total intake carefully to ensure they don’t exceed their allowance. Additionally, fluid is lost through evaporation and secretions, which further increases their hydration needs. Setting Up a Patient’s Room: When preparing a patient’s room, think about your priorities. Rooms don’t always come fully set up, so you’ll need to make sure everything is in place. For example, suction equipment should be properly set up with a canister attached. A horror story from the past: in the 1960s, a patient with tuberculosis had suction hooked up without a canister. Where were those secretions going? Nobody wanted to find out! Your room setup should include: Suction canisters and equipment. Gloves.  Ambu bag. Flow meters for oxygen. Any other necessary supplies. If something is missing, it’s your responsibility to get it. Nobody else will do it for you. Antibiotic Administration: Before administering antibiotics, always ensure a culture has been taken. I know you haven’t covered antibiotics in detail yet, but it’s important to note that you can’t administer medications unless they’re ordered by a provider. You also can’t give extra doses. Oxygen, though commonly used, is technically considered a medication. Years ago, oxygen was given to almost everyone, but we’ve since learned that too much oxygen can cause toxicity. If a patient is in respiratory distress, you can administer oxygen in an emergency, but you should notify the provider. Comfort Measures: When patients break a fever, they often sweat heavily and end up lying on wet sheets. Change the sheets promptly to prevent skin breakdown. Don’t forget about oral care—patients need to have their teeth brushed or their mouths cleaned, especially if they are NPO (nothing by mouth) or have an endotracheal (ET) tube. For those unable to perform oral care themselves, you’ll need to do it for them, often using solutions like chlorhexidine. Document oral care every 12 hours for intubated patients. Dietary Considerations: For patients who have difficulty swallowing, provide foods that are easier to chew and digest, such as soft or pureed meals. Space out activity with rest periods to avoid overexertion. Germs and Infection Control: Patients admitted to the hospital with pneumonia can spread germs, so ensure everything is disposed of properly. Set up a system to collect secretions safely and keep rooms clean. Teaching patients about infection prevention is crucial. They need to understand hand hygiene, including when to use soap and water versus hand sanitizer. Emotional Support: Patients are often anxious when they’re in the hospital. You might not see the “true” version of the person—they could be experiencing one of the worst times in their life. Answer their questions, provide emotional support, and be empathetic to their situation.. Handwashing: Does everyone here know how to wash their hands? You do, but what about your patients? Teach them the importance of proper hand hygiene. They can use hand sanitizer if their hands aren’t visibly dirty, but otherwise, they should use soap and water. Promoting Rest and Nutrition: Encourage rest, but not complete bedrest—patients should remain as active as possible. Ensure they receive adequate nutrition, and if they have difficulty swallowing, provide soft or pureed meals. Support their recovery with balanced activity and rest periods. We want patients engaging in progressive, high-energy exercises to build strength, but we must avoid exposing them to upper respiratory infections. If someone around them is sick, they need to stay away. I love children, but they do carry a lot of germs. Whenever I’m around my grandkids, I always catch a little cold. If a patient has symptoms lasting longer than seven days, they need to go back to the doctor. We talked about the flu vaccine and the pneumococcal (pneumonia) vaccine. Smokers who are admitted to the hospital must be educated on quitting smoking. Can they resume smoking? No! If someone says yes, they’re mistaken. Patients need to quit smoking. Does anyone here smoke or know someone who does? You don’t have to tell me if you do—it’s your business. When discussing antibiotics, patients need to know that even if they feel better, they must finish the entire course. Stopping early can lead to complications. We also advise patients to gradually resume activities because they may still be short of breath. If they go too fast, they can tire themselves out. Complications to Watch For: Respiratory failure, which may require mechanical ventilation. Atelectasis, where fluid or mucus blocks the airways and collapses part of the lung. Fluid buildup in the lungs. Confusion, shock, or secondary infections caused by drug-resistant bacteria. How Do We Know Our Goals Are Met? To evaluate treatment effectiveness: Assess for clear breath sounds. Check if respiratory rates are within normal limits. Note if the patient is complaining less about shortness of breath. Look for a reduction in symptoms like fever or elevated white blood cell counts. When evaluating a medication, it’s important to understand why the patient is taking it. This helps you assess its effectiveness. For example, certain medications used for prostate disorders can also treat urinary symptoms in women, but it’s essential to be patient-specific when documenting. How do you know the medication is working? You assess for improvements in the patient’s condition and monitor for side effects. If a medication can affect the kidneys or liver, you should monitor labs such as LFTs (liver function tests), BUN, and creatinine. If it affects electrolytes, check baseline levels. For impaired gas exchange, improved gas exchange means we’ve successfully addressed the problem. Case Study Example: Let’s discuss a hypothetical case. A patient is admitted to the hospital with the following: Temperature: 102°F (38.9°C in some facilities). Pulse: 110. Respiratory rate: 28. Oxygen saturation: 95%. Blood pressure: 140/80. What would you do first? Exactly, address the patient’s respiratory needs. The patient presents with shortness of breath, rhonchi, and a nonproductive cough. What is the priority problem? Airway clearance. Always prioritize the airway! Remember, if we’re starting antibiotics, we still need to get cultures and sensitivities beforehand. Medication Teaching: When teaching patients about antibiotics, emphasize that they need to finish the full course. Gradually resume activity, as shortness of breath may limit their ability to do too much at once. Smoking will exacerbate their symptoms, so it must be avoided. What Indicates Improvement? Coughing and deep breathing at least 10 times an hour to clear airways. No smoking during recovery—quitting smoking is always advised. Let’s Review a Scenario: A patient comes to the ER or doctor’s office presenting with a cough, sputum production, and shortness of breath. They weigh 100 kilograms and occasionally smoke cigarettes. Their medical history includes COPD, and they are on medications like hydrochlorothiazide for blood pressure and inhalers for COPD. The assessment shows: Temperature: 102°F. Chest X-ray: Right lower lobe pneumonia. The patient is prescribed antibiotics and advised not to return to work until their symptoms improve. What is the priority problem? Airway clearance and managing COPD exacerbation. Teaching Points: Gradually resume activities. Cough and deep breathe at least 10 times an hour to assist airway clearance. Quit smoking to improve recovery and avoid exacerbations. Stay hydrated and maintain a healthy diet. Patients should avoid staying in bed all day. Activity and movement are essential, but they should balance activity with adequate rest. Oral and General Care: Remember to provide oral care, especially for patients who are NPO or intubated. Patients with an ET tube require suctioning and mouth care every 12 hours. Document this care to ensure it’s done properly. Room Setup and Equipment: When preparing a patient’s room, ensure all equipment is ready: Suction canisters and tubing. Flow meters. Ambu bags. Double-check everything because you never know when you’ll need it. If something is missing, it’s your responsibility to fix it. Don’t wait for someone else to do it. Infection Control and Emotional Support: Teach patients the importance of hand hygiene. They should use soap and water or hand sanitizer regularly. Also, provide emotional support. Patients in the hospital are often anxious and may not feel like themselves. Be compassionate and answer their questions. Summary: Encourage patients to rest, eat nutritious meals, and follow through with their prescribed treatment plans. For those with difficulty swallowing, offer soft or pureed foods. Balance activity and rest to ensure recovery