Infectious Disorders of Adults: Pneumonia

INFECTIOUS DISORDERS OF ADULTS PNEUMONIA GRACE P. EPRES-TRIUMFANTE, RN, MAN PAGE 01 OBJECTIVES AT THE END OF THE DISCUSSION, STUDENTS WILL BE ABLE TO: describe Pneumonia identify types of Pneumonia explain pathophysiology of Pneumonia state the signs/sympto...

INFECTIOUS DISORDERS OF ADULTS PNEUMONIA GRACE P. EPRES-TRIUMFANTE, RN, MAN PAGE 01 OBJECTIVES AT THE END OF THE DISCUSSION, STUDENTS WILL BE ABLE TO: describe Pneumonia identify types of Pneumonia explain pathophysiology of Pneumonia state the signs/symptoms of the disease Describe the typical exam findings in a patient with pneumonia. Outline considerations that influence the management of pneumonia. apply the knowledge gained in clinical setting PAGE 02  OVERVIEW ABOUT PATHOPHYSIOLOGY SIGNS AND PNEUMONIA SYMPTOMS DIAGNOSTIC MANAGEMENT PAGE 03 it is an infection that affects one or both lungs WHAT IS PNEUMONIA? It causes the air sacs, or alveoli, of the lungs to fill up with fluid or pus. categorized according to how it is acquired: 1. Community-Acquired Pneumonia (CAP) - pneumonia acquired outside of a healthcare facility 2. Hospital-acquired pneumonia (HAP). This type of bacterial pneumonia is acquired during a hospital stay. It can be more serious than other types, as the bacteria involved may be more resistant to antibiotics. 3. Ventilator Associated Pneumonia (VAP) - pneumonia acquired 48 hours after endotracheal intubation 4. Aspiration pneumonia - Inhaling bacteria into the lungs from food, drink, or saliva can cause aspiration pneumonia. 5. Walking pneumonia - milder case; affected people may not even know they have pneumonia. symptoms may feel more like a mild respiratory infection than pneumonia. However, walking pneumonia may require a longer recovery period. PAGE 04  1. Community-Acquired Pneumonia ETIOLOGY Bacterial causes - Streptococcus pneumoniae, Staphylococcus aureus, Mycoplasma pneumoniae, and gram-negative enteric bacilli. Viral causes - influenza virus followed by respiratory syncytial virus, parainfluenza virus, and adenoviruses Fungal causes - Histoplasma, Blastomyces, and Coccidioides. 2. Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia Gram-negative bacilli like Escherichia coli, Pseudomonas Aerugenosa, Acinetobacter, and Enterobacter among others Gram-positive cocci like Staphylococcus aureus; both Methicillin-sensitive and resistant, although the latter is more prevalent Other viruses and fungi that are more prevalent in immunocompromised and severely ill patients - candida species 3. Walking pneumonia bacteria Mycoplasma pneumoniae PAGE 05 Signs and coughing that may produce phlegm (mucus) Symptoms fever sweating or chills shortness of breath that happens while doing normal activities, or even while resting chest pain that’s worse when you breathe or cough feelings of tiredness or fatigue loss of appetite nausea or vomiting headaches PAGE 06 Risk Factors people with certain chronic medical conditions, such infants from birth to 2 years old as: people ages 65 and older *asthma people with weakened immune systems due to: *cystic fibrosis *pregnancy *diabetes *HIV *COPD *the use of certain medications, such as steroids or certain *heart failure cancer drugs *sickle cell disease people who’ve been regularly exposed to lung irritants, *liver disease such as air pollution and toxic fumes, especially on the *kidney disease job PAGE 07 Risk Factors people who’ve been recently or are currently people who live in a crowded living environment, such hospitalized, particularly if they were or are on a as a prison or nursing home ventilator people who smoke, which makes it more difficult for people who’ve had a brain disorder, which can affect the body to get rid of mucus in the airways the ability to swallow or cough, such as: people who use drugs or drink heavy amounts of *stroke alcohol, which weakens the immune system and *head injury increases the odds of inhaling saliva or vomit into the *dementia lungs due to sedation *Parkinson’s disease PAGE 08  Pathophysiology INFLAMMATORY RESPONSE IS INVASION OF A PATHOGEN TRIGGERED HISTAMINE, BRADYKININ, AND PROSTAGLANDINS EDEMA AND EXUDATE CREATION CAPILLARY LEAK REDUCED GAS EXCHANGE SEPSIS PAGE 09 Diagnosis 1. Clinical Evaluation: Medical history History and Physical Examination 2. Imaging Studies Chest X-Ray - lung consolidation (where air spaces are filled with fluid or pus) CT Scan of the Chest - provide a more detailed view of the lungs 3. Laboratory Tests Sputum Culture and Sensitivity Blood Tests - CBC, blood culture Pulse Oximetry and Arterial Blood Gas (ABG) 4. Microbiological Testing PCR Testing - For viral causes of pneumonia, such as influenza or COVID-19 Urinary Antigen Tests - detect specific bacteria like Streptococcus pneumoniae and Legionella pneumophila from a urine sample. 5. Additional Diagnostic Procedures Bronchoscopy - use when diagnosis is unclear PAGE 10 MANAGEMENT AND TREATMENT 1. Antibiotic Therapy Bacterial Pneumonia: First-Line Antibiotics: Empiric antibiotic therapy is typically started based on the most likely causative organisms and the patient’s clinical condition. Commonly used antibiotics include: >Amoxicillin or Amoxicillin-Clavulanate: Often used for community-acquired pneumonia (CAP). >Macrolides (e.g., Azithromycin or Clarithromycin): Effective against atypical pathogens like Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella. >Doxycycline: Another option for treating CAP, especially when a macrolide or beta-lactam antibiotic is not suitable. >Fluoroquinolones (e.g., Levofloxacin, Moxifloxacin): Reserved for patients with comorbidities or in cases of suspected drug-resistant pathogens. Hospital-Acquired Pneumonia (HAP): Treatment may include broader-spectrum antibiotics like piperacillin-tazobactam, cephalosporins (e.g., cefepime), carbapenems, or vancomycin, depending on the suspected or confirmed pathogens. Aspiration Pneumonia: Often treated with antibiotics that cover anaerobic bacteria, such as clindamycin, ampicillin-sulbactam, or metronidazole combined with a broader-spectrum agent. PAGE 11 MANAGEMENT AND TREATMENT 2. Antiviral Therapy Viral Pneumonia: 1. If the pneumonia is caused by a virus, antiviral medications may be prescribed: Influenza Virus: Antiviral drugs like oseltamivir (Tamiflu) or zanamivir are used to treat influenza-related pneumonia, especially if started within 48 hours of symptom onset. COVID-19: Treatment may include antiviral medications like remdesivir, along with supportive care and other therapies depending on disease severity. 3. Antifungal Therapy Fungal Pneumonia: In cases where pneumonia is caused by a fungal infection (e.g., Pneumocystis jirovecii in immunocompromised patients or endemic fungi like Histoplasma), antifungal medications such as fluconazole, itraconazole, or amphotericin B are used. PAGE 11 MANAGEMENT AND TREATMENT 4. Supportive Care Oxygen Therapy: For patients with hypoxemia (low blood oxygen levels), supplemental oxygen may be provided via nasal cannula, face mask, or more advanced modalities like high- flow nasal cannula or mechanical ventilation in severe cases. Hydration: Intravenous fluids may be administered to maintain hydration, especially in patients who are unable to take in fluids orally due to severe illness. Fever and Pain Management: >Antipyretics (e.g., acetaminophen) are used to reduce fever, and analgesics (e.g., ibuprofen) can help relieve chest pain associated with pleuritic inflammation. 5. Hospitalization Criteria for Hospitalization: Patients with severe pneumonia, those who are elderly, have significant comorbidities, or have inadequate home care may require hospitalization for closer monitoring and intensive treatment. ICU Admission: Severe cases, especially those with respiratory failure, septic shock, or multi-organ dysfunction, may require intensive care unit (ICU) admission. PAGE 11  MANAGEMENT AND TREATMENT 6. Mechanical Ventilation For Respiratory Failure: In cases where pneumonia leads to acute respiratory failure, mechanical ventilation may be necessary to support breathing and ensure adequate oxygenation. 7. Adjunctive Therapies Corticosteroids: In certain cases, particularly with severe or refractory pneumonia, corticosteroids like prednisone or methylprednisolone may be used to reduce inflammation, though their use is controversial and should be carefully considered. Bronchodilators: >For patients with underlying COPD or asthma, bronchodilators like albuterol may Prevention be used to open up the airways and ease breathing. Vaccination: >Pneumococcal Vaccine: Recommended for older adults, young children, and individuals with chronic illnesses to prevent pneumococcal pneumonia. >Influenza Vaccine: Helps prevent viral pneumonia caused by the flu virus, which can lead to secondary bacterial pneumonia. Smoking Cessation: Quitting smoking is crucial as smoking damages the lungs and increases the risk of PAGE 11 pneumonia.  Complication of Pneumonia Respiratory failure, which requires a breathing machine or ventilator Empyema or lung abscesses. These are infrequent, but serious, complications of pneumonia. They occur when pockets of pus form inside or around the lung. These may sometimes need to be drained with surgery. Sepsis, a condition in which there is uncontrolled swelling (inflammation) in the body, which may lead to organ failure Acute respiratory distress syndrome (ARDS), a severe form of respiratory failure PAGE 12 Primary Nursing Diagnosis: Ineffective airway clearance related to increased production of secretions and increased viscosity as evidenced by productive cough Nursing Care Planning & Goals At the end of the 8 hours shift, the patient will be able to: Improve airway patency. Rest to conserve energy. Maintenance of proper fluid volume. Maintenance of adequate nutrition. Understanding of treatment protocol and preventive measures. Absence of complications. PAGE 13 Nursing Priorities: 1. Maintain/improve respiratory Nursing Interventions function. To improve airway patency: 2. Prevent complications. Removal of secretions. Secretions should be 3. Support recuperative process. removed because retained secretions interfere with 4. Provide information about disease gas exchange and may slow recovery. process, prognosis, and treatment. Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions. Humidification may loosen secretions and improve ventilation. Coughing exercises. An effective, directed cough can also improve airway patency. Chest physiotherapy. Chest physiotherapy is important because it loosens and mobilizes secretions. PAGE 14  Nursing Intervention: To promote rest and conserve energy: 1. Encourage avoidance of overexertion and possible exacerbation of symptoms. 2. Semi-Fowler’s position. The patient should assume a comfortable position to promote rest and breathing and should change positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion. Nursing Intervention: To promote fluid intake: 1. Fluid intake. Increase in fluid intake to at least 2L per day to replace insensible fluid losses. PAGE 14 Nursing Intervention: To maintain nutrition: 1. Fluids with electrolytes. This may help provide fluid, calories, and electrolytes. 2. Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also help restore proper nutrition. Nursing Intervention: To promote patient’s knowledge: 1. Instruct patient and family about the cause of pneumonia, management of symptoms, signs, and symptoms, and the need for follow-up. 2. Instruct patient about the factors that may have contributed to the development of the disease. PAGE 14  Evaluation Expected patient outcomes include the following: 1. Demonstrates improved airway patency. 2. Rests and conserves energy by limiting activities and remaining in bed while symptomatic and then slowly increasing activities. 3. Maintains adequate hydration. 4. Consumes adequate dietary intake. 5. States explanation for management strategies. 6. Complies with management strategies. 7. Exhibits no complications. 8. Complies with treatment protocol and prevention strategies. PAGE 15  Documentation Guidelines Documentation of data must be accurate and up-to-date to avoid unnecessary legal situations that might occur. Document breath sounds, presence and character of secretions, use of accessory muscles for breathing. Document character of cough and sputum. Document respiratory rate, pulse oximetry/O2 saturation, and vital signs. Document plan of care and who is involved in planning. Document client’s response to interventions, teaching, and actions performed. Document if there is use of respiratory devices or airway adjuncts. Document response to medications administered. Document modifications to plan of care. 1.. PAGE 15 A nurse is caring for an 89-year-old client admitted with pneumonia. He has an IV of normal saline running at 100 mL/hr and antibiotics that were initiated in the emergency department 3 hours ago. He has oxygen at 2 liters/nasal cannula. What assessment finding by the nurse indicates that goals for a priority diagnosis have been met for this client? A) The client is alert and oriented to person, place, and time. B) Blood pressure is within normal limits and client's baseline. C) Skin behind the ears demonstrates no redness or irritation. D) Urine output has been >30 mL/hr per Foley catheter An older adult resident in a long-term-care facility becomes confused and agitated, telling the nurse, "Get out of here! You're going to kill me!" Which action will the nurse take first? A) Check the resident's oxygen saturation. B) Do a complete neurologic assessment. C) Give the prescribed PRN lorazepam (Ativan). D) Notify the resident's primary care provider. Which pt is at higher risk for developing pneumonia? A. any hospitalized pt between 19 - 64 y.o. B. 36 y.o. trauma pt on mechanical ventilator C. disabled 51 y.o. with abdominal pain, d/c home D. Any pt who has not received the pneumonia vaccine Which conditions does the nurse recognize as a risk for developing aspiration pneumonia? Select All That Apply A. continuous tube feed B. bronchoscopy procedure C. MRI D. decreased LOC E. stroke F. chest tube The nurse is caring for a client with pneumonia who is having difficulty clearing the airway because of​ viscous, copious lung secretions. Which interventions should the nurse use to aid in airway​ clearance? ​( Select all that​ apply.) a Monitor arterial blood gas​ (ABG) results b Assess sputum for color and consistency c Provide a dehumidifier d Encourage fluids e Place in high Fowler position The nurse caring for a client with pneumonia administers a variety of classifications of pharmacologic therapies in collaboration with the healthcare team. Which medications may be appropriate for a client with​ pneumonia? ​( Select all that​ apply.)Select All That Apply a Broad spectrum antibiotics b Oxygen therapies c Liquefying agents d Laxatives e Bronchodilators The nurse understands that there are several ways that pneumonia is classified. Which type of pneumonia does the nurse suspect in a client who is not a resident of a​ long-term care facility and is diagnosed within 48 hours of admission to the​ hospital? a Hospital-acquired pneumonia ​b Healthcare-associated pneumonia c Community-acquired pneumonia d Ventilator-associated pneumonia REFERENCES Professional, Cleveland Clinic Medical. “Pneumonia.” Cleveland Clinic, my.clevelandclinic.org/health/diseases/4471- pneumonia. “What Is Pneumonia? | NHLBI, NIH.” NHLBI, NIH, 24 Mar. 2022, www.nhlbi.nih.gov/health/pneumonia. Jain, Vardhmaan. “Pneumonia Pathology.” StatPearls - NCBI Bookshelf, 31 July 2023, www.ncbi.nlm.nih.gov/books/NBK526116. Christina. “Pneumonia Pathophysiology (2018) - Nursing School of Success.” NursingSOS, 22 Jan. 2019, nursingschoolofsuccess.com/episode35. Rnpedia. “Pneumonia Nursing Care Plan & Management.” RNpedia, July 2017, www.rnpedia.com/nursing-notes/medical-surgical- nursing-notes/pneumonia. PAGE 11