clinical presentation on pnemonia

7/25/2019 Clinical Presentation on Pnemonia

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CLINICAL PRESENTATION

ON PNEUMONIA

SUBMITTED TO SUBMITTED BY

MRS.RAJALEKSHMY.K MS.SREEKALA.R

ASSO.PROFESSOR 2NDYR MSc NURSING STUDENT

GOVT.COLLEGE OF NURSING GOVT.COLLEGE OF NURSING

ALAPPUZHA ALAPPUZHA

SUBMITTED ON

24/12/201

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INTRODUCTION

Pneumonia and other lower respiratory tract infections are the leading causes of death

worldwide. Because pneumonia is common and is associated with significant moridity and

mortality! properly diagnosing pneumonia! correctly recogni"ing any complications or

underlying conditions! and appropriately treating patients are important. #lthough in de$eloped

countries the diagnosis is usually made on the asis of radiographic findings! the %orld &ealth

Organi"ation '%&O( has defined pneumonia solely on the asis of clinical findings otained y

$isual inspection and on timing of the respiratory rate.

D)*INITION

Pneumoniais aninflammatorycondition of the lungaffecting primarily the microscopic air sacs

+nown as al$eoli.It is usually caused y infection with $irusesoracteriaand less commonly

other microorganisms! certaindrugsand other conditions such as autoimmune diseases

)PID),IO-O/

International statistics

Pneumonia and other lower respiratory tract infections are the leading cause of death worldwide.

The %&O Child &ealth )pidemiology Reference roup estimated the median gloal incidence

of clinical pneumonia to e 0.12 episodes per child3year. This e4uates to an annual incidence of

560.7 million new cases! of which 55310 million '73589( are se$ere enough to re4uire hospital

admission. Ninety3fi$e percent of all episodes of clinical pneumonia in young children

worldwide occur in de$eloping countries.

#ppro:imately 560 million new cases of pneumonia occur annually among children younger

than 6 years worldwide! accounting for appro:imately 50310 million hospitali"ations.# %&O

Child &ealth )pidemiology Reference roup pulication cited the incidence of community3

ac4uired pneumonia among children younger than 6 years in de$eloped countries as

appro:imately 0.01; episodes per child3year and a study conducted in the United


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Prognosis

O$erall! the prognosis is good. ,ost cases of $iral pneumonia resol$e without treatment>

common acterial pathogens and atypical organisms respond to antimicroial therapy 'see

Treatment and ,anagement(. -ong3term alteration of pulmonary function is rare! e$en in

children with pneumonia that has een complicated y empyema or lung ascess.

#ccording to the %&O?s loal Burden of Disease 1000 Pro@ect! lower respiratory infections

were the second leading cause of death in children younger than 6 years 'aout 1.5 million

A5=.;9(.,ost children are treated as outpatients and fully reco$er. &owe$er! in young infants

and immunocompromised indi$iduals! mortality is much higher. In studies of adults with

pneumonia! a higher mortality rate is associated with anormal $ital signs! immunodeficiency!

and certain pathogens.

)tiology

Pneumonia can e caused y a myriad of microorganisms. Clinical suspicion of a particular

offending agent is deri$ed from clues otained during the history and physical e:amination.

%hile $irtually any microorganism can lead to pneumonia! specific acterial! $iral! fungal! and

mycoacterial infections are most common in pre$iously healthy children. The age of infection!

e:posure history! ris+ factors for unusual pathogens! and immuni"ation history all pro$ide clues

to the infecting agent.

pecific etiologic agents $ary ased on age groups 'ie! neworns! young infants! infants and

toddlers! 63year3olds! school3aged children and young adolescents! older adolescents(.

RISK FACTORS

mo+ing

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#ir pollution

Upper Respiratory Tract Infection

#ltered consciousness alcoholism! head in@ury! sei"ure disorder! drug o$erdose! general

anesthesia

Tracheal intuation

Prolonged immoility

Immunosuppressi$e therapy corticosteroids! chemotherapy

Non3functional immune system #ID

e$ere periodontal disorders

Prolonged e:posure to $irulent organisms

,alnutrition

Dehydration

Chronic disease Diaetes ,ellitus! &eart disease! chronic lung disease

Prolonged deilitating disorders

Inhalation of no:ious sustances

#spiration of oralEgastric material

#spiration of foreign material

Chronically ill! elderly people who generally ha$e poor immune systems! often residing

in group li$ing situations where there is an increase in proaility of disease transmission

especially through the respiratory system

Classification

5. Community #c4uired F used to descrie infections found in the community rather than

the hospitalEnursing home. Defined as an infection that egins outside the hospital or is

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diagnosed G2 hours after admission to the hospital in a person who has not resided in a long term

facility for 5G days or more efore admission

1. &ospital #c4uired or Nosocomial F is defined as a lower respiratory tract infection that

was not present or incuating on admission to the hospital. Increase ris+ for those with

mechanical $entilation! compromised immune function! chronic lung disease and airway

instrumentation such as e3tue! tracheostomy! etc.

Types #ccording to Causati$e #gent

5. ram Positi$e Bacteria

H treptococcus pneumonia 'pneumococcal pneumonia(

H most common cause of community ac4uired pneumonia.

H follows influen"a I situations in which groups of people li$e in close contact

H rust colored sputum! lood tinged! purulent

H taphylococcus aureus

H ac4uired thru lood or y aspiration

H creamy yellow sputum

1. ram Negati$e Bacteria

H &aemophilus influen"a

H common cause of infection in children

H high mortality rate

H greenish colored sputum

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H most common gram negati$e organism ac4uired outside hospitals

H occurs in people with malignancies

H necrosis! ascess foration! hemoptysis and firotic changes occur

H high mortality rate

H red gelatinous sputum

H Pseudomonas aeroginosa

H most common gram negati$e organism ac4uired in the hospital

H common in the respiratory tract of hospital employees and those with cystic firosis

H greenish colored sputum

H -egionella pneumophilia '-egionnaires? disease(

H most common cause of community ac4uired pneumonia

H found in warm standing water

8. #N#)ROIC B#CT)RI#- PN)U,ONI#

H Commonly caused y anaeroic streptococcus

H &istory of poor dental hygiene! periodontal disease! dysphagia and altered consciousness

G. OT&)R IN*)CTIOU #)NT

H ,ycoplasma pneumoniae

H an organism with the characteristics of oth acteria and $iruses

H it causes atypicalEinterstitial pneumonia

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H iral agents

H influen"a $irus! adeno$irus and parainfluen"a $irus

H self3limiting

H may predispose to secondary acterial infection

H *ungi

H candidiasis! histoplasmosis! lastomycosis! cryptococcosis! aspergillosis! actinomycosis

and nocardiosis

H follows after e:tended antiiotic use! immunocompromised and seriously ill people

H Non3infectious causes

H inhalation of to:ic gases! chemicals or smo+e from fires and aspiration of water due to

near drowning! gastric contents! $egetaleEmineral oils! li4uid petroleum

H Pneumocystis carinii pneumonia

H opportunistic! often fatal form of lung infection seen in deilitated! impaired immune

function

SIGNS AND SYMPTOMS

*e$er

Chills

weats

Dullness on percussion on affected area

putum production

&emoptysis

Pleuritic chest pain

Dyspnea

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&eadache

*atigue

Une4ual chest e:pansion

Cough

Pathophysioloy

Inhalation of droplet nuclei

J

)stalishes in the al$eolus 'usually lower loe(

J

Bacterial infection de$elops

J

ascular engorgement! presence of large numer of acteria

J

erous e:udate pours into al$eoli from dilated lea+ing $essels 'engorgement first G351 hours(

JDecrease in RBC and Increase in Neutrophils and precipitation of firin that fills the al$eoli

J

Continuing accumulation of firin

J

Consolidation of leu+ocytes and firin

J

):udate is ly"ed and reasored y macrophage

Pathogenesis

Pneumonia is characteri"ed y inflammation of the al$eoli and terminal airspaces in response to

in$asion y an infectious agent introduced into the lungs through hematogenous spread or

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inhalation. The inflammatory cascade triggers the lea+age of plasma and the loss of surfactant!

resulting in air loss and consolidation.

The acti$ated inflammatory response often results in targeted migration of phagocytes! with the

release of to:ic sustances from granules and other microicidal pac+ages and the initiation of

poorly regulated cascades 'eg! complement! coagulation! cyto+ines(. These cascades may

directly in@ure host tissues and ad$ersely alter endothelial and epithelial integrity! $asomotor

tone! intra$ascular hemostasis! and the acti$ation state of fi:ed and migratory phagocytes at the

inflammatory focus. The role of apoptosis 'noninflammatory programmed cell death( in

pneumonia is poorly understood.

Pulmonary in@uries are caused directly andEor indirectly y in$ading microorganisms or foreign

material and y poorly targeted or inappropriate responses y the host defense system that may

damage healthy host tissues as adly or worse than the in$ading agent. Direct in@ury y the

in$ading agent usually results from synthesis and secretion of microial en"ymes! proteins! to:ic

lipids! and to:ins that disrupt host cell memranes! metaolic machinery! and the e:tracellular

matri: that usually inhiits microial migration.

Indirect in@ury is mediated y structural or secreted molecules! such as endoto:in! leu+ocidin!

and to:ic shoc+ syndrome to:in35 'TT35(! which may alter local $asomotor tone and integrity!

change the characteristics of the tissue perfusate! and generally interfere with the deli$ery of

o:ygen and nutrients and remo$al of waste products from local tissues.A;! 7

On a macroscopic le$el! the in$ading agents and the host defenses oth tend to increase airway

smooth muscle tone and resistance! mucus secretion! and the presence of inflammatory cells and

deris in these secretions. These materials may further increase airway resistance and ostruct

the airways! partially or totally! causing airtrapping! atelectasis! and $entilatory dead space. In

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addition! disruption of endothelial and al$eolar epithelial integrity may allow surfactant to e

inacti$ated y proteinaceous e:udate! a process that may e e:acerated further y the direct

effects of meconium or pathogenic microorganisms.

In the end! conducting airways offer much more resistance and may ecome ostructed! al$eoli

may e atelectatic or hypere:panded! al$eolar perfusion may e mar+edly altered! and multiple

tissues and cell populations in the lung and elsewhere sustain in@ury that increases the asal

re4uirements for o:ygen upta+e and e:cretory gas remo$al at a time when the lungs are less ale

to accomplish these tas+s.

#l$eolar diffusion arriers may increase! intrapulmonary shunts may worsen! and

$entilationEperfusion 'EK( mismatch may further impair gas e:change despite endogenous

homeostatic attempts to impro$e matching y regional airway and $ascular constriction or

dilatation. Because the myocardium has to wor+ harder to o$ercome the alterations in pulmonary

$ascular resistance that accompany the ao$e changes of pneumonia! the lungs may e less ale

to add o:ygen and remo$e caron dio:ide from mi:ed $enous lood for deli$ery to end organs.

The spread of infection or inflammatory response! either systemically or to other focal sites!

further e:acerates the situation.

iral infections are characteri"ed y the accumulation of mononuclear cells in the sumucosa

and peri$ascular space! resulting in partial ostruction of the airway. Patients with these

infections present with whee"ing and crac+les 'see Clinical Presentation(. Disease progresses

when the al$eolar type II cells lose their structural integrity and surfactant production is

diminished! a hyaline memrane forms! and pulmonary edema de$elops.

In acterial infections! the al$eoli fill with proteinaceous fluid! which triggers a ris+ influ: of

red lood cells 'RBCs( and polymorphonuclear 'P,N( cells 'red hepati"ation( followed y the

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deposition of firin and the degradation of inflammatory cells 'gray hepati"ation(. During

resolution! intra3al$eolar deris is ingested and remo$ed y the al$eolar macrophages. This

consolidation leads to decreased air entry and dullness to percussion> inflammation in the small

airways leads to crac+les 'see Clinical Presentation(.

*our stages of loar pneumonia ha$e een descried. In the first stage! which occurs within 1G

hours of infection! the lung is characteri"ed microscopically y $ascular congestion and al$eolar

edema. ,any acteria and few neutrophils are present. The stage of red hepati"ation '138 d(! so

called ecause of its similarity to the consistency of li$er! is characteri"ed y the presence of

many erythrocytes! neutrophils! des4uamated epithelial cells! and firin within the al$eoli. In the

stage of gray hepati"ation '138 d(! the lung is gray3rown to yellow ecause of firinopurulent

e:udate! disintegration of RBCs! and hemosiderin. The final stage of resolution is characteri"ed

y resorption and restoration of the pulmonary architecture. *irinous inflammation may lead to

resolution or to organi"ation and pleural adhesions.

Bronchopneumonia! a patchy consolidation in$ol$ing one or more loes! usually in$ol$es the

dependent lung "ones! a pattern attriutale to aspiration of oropharyngeal contents. The

neutrophilic e:udate is centered in ronchi and ronchioles! with centrifugal spread to the

ad@acent al$eoli.

In interstitial pneumonia! patchy or diffuse inflammation in$ol$ing the interstitium is

characteri"ed y infiltration of lymphocytes and macrophages. The al$eoli do not contain a

significant e:udate! ut protein3rich hyaline memranes similar to those found in adult

respiratory distress syndrome '#RD( may line the al$eolar spaces. Bacterial superinfection of

$iral pneumonia can also produce a mi:ed pattern of interstitial and al$eolar airspace

inflammation.

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,iliary pneumonia is a term applied to multiple! discrete lesions resulting from the spread of the

pathogen to the lungs $ia the loodstream. The $arying degrees of immunocompromise in

miliary tuerculosis 'TB(! histoplasmosis! and coccidioidomycosis may manifest as granulomas

with caseous necrosis to foci of necrosis. ,iliary herpes$irus! cytomegalo$irus 'C,(! or

$aricella3"oster $irus infection in se$erely immunocompromised patients results in numerous

acute necroti"ing hemorrhagic lesions.

DI#NOTIC )#-U#TION

Physical ):amination

The signs and symptoms of pneumonia are often nonspecific and widely $ary ased on the

patient?s age and the infectious organisms in$ol$ed. Tachypnea is the most sensiti$e finding in

patients with diagnosed pneumonia.

Initial e$aluation

)arly in the physical e:amination! identifying and treating respiratory distress! hypo:emia! and

hypercaria is important. isual inspection of the degree of respiratory effort and accessory

muscle use should e performed to assess for the presence and se$erity of respiratory distress.

The e:aminer should simply oser$e the patientLs respiratory effort and count the respirations for

a full minute. In infants! oser$ation should include an attempt at feeding! unless the ay has

e:treme tachypnea.

children with tachypnea as defined y %&O respiratory rate thresholds were more li+ely to ha$e

pneumonia than children without tachypnea. The %&O thresholds are as follows

Children younger than 1 months 3 reater than or e4ual to ;0 reathsEmin

Children aged 1355 months 3 reater than or e4ual to 60 reathsEmin

Children aged 5136= month 3 reater than or e4ual to G0 reathsEmin

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Pulse o:imetry

Complete lood cell 'CBC( count

putum and lood cultures

erology

Chest radiography

Ultrasonography

New data show that point3of3care ultrasonography accurately diagnoses most cases of

pneumonia in children and young adults. In a study of 100 aies! children! and young adults

'M15 years(! ultrasonography had an o$erall sensiti$ity of 2;9 and a specificity of 2=9 for

diagnosing pneumonia. Ultrasonography may e$entually come to replace :3rays for diagnosis

Complete Blood Cell Count

Testing should include a CBC count with differential and e$aluation of acute3phase reactants

')R! CRP! or oth( and sedimentation rate. The total white lood cell '%BC( count and

differential may aid in determining if an infection is acterial or $iral! and! together with clinical

symptoms! chest radiography! and )R can e useful in monitoring the course of pneumonia. In

cases of pneumococcal pneumonia! the %BC count is often ele$ated.

putum ram tain and Culture

putum is rarely produced in children younger than 50 years! and samples are always

contaminated y oral flora. In the cooperati$e older child with a producti$e cough! a sputum

ram stain may e otained 'see the image elow(> howe$er! $ery few children are ale to

cooperate with such a test. #n ade4uate sputum culture should contain more than 16 P,N cells

per field and fewer than 50 s4uamous cells per field.

Blood Culture

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#lthough lood cultures are technically easy to otain and relati$ely nonin$asi$e and

nontraumatic! the results are rarely positi$e in the presence of pneumonia and e$en less so in

cases of pretreated pneumonia

erology

Because of the relati$ely low yield of cultures! more efforts are under way to de$elop 4uic+ and

accurate serologic tests for common lung pathogens! such as , pneumoniae! Chlamydophila

species! and -egionella.

Inflammatory ,ar+ers

The use of mar+ers of inflammation to support a diagnosis of suspected infection! including

pneumonia! remains contro$ersial ecause results are nonspecific. arious indices deri$ed from

differential leu+ocyte counts ha$e een used most widely for this purpose! although

noninfectious causes of such anormal results are numerous. ,any reports ha$e een pulished

regarding infants with pro$en infection who initially had neutrophil indices within reference

ranges.

Kuantitati$e measurements of CRP! procalcitonin! cyto+ines 'eg! interleu+in AI-3;(! inter3alpha

inhiitor proteins 'IaIp(!A86 and atteries of acute3phase reactants ha$e een touted to e more

specific ut are limited y suoptimal positi$e predicti$e $alue.

Polymerase Chain Reaction

Relati$ely rapid testing '531 d( of $iral infections through multiple: PCR is a$ailale in many

hospitals. PCR is more sensiti$e than antigen assays! and for some $iruses 'eg! h,P(! this

study may e the only test a$ailale.

+in Testing

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These tests are used in diagnosing TB. ,antou: s+in test 'intradermal AID inoculation of 6

tuerculin units ATU of purified protein deri$ati$e APPD( results should e read G2371 hours

after placement.

astric #spirates

In a child with suspected pulmonary TB! the cough may e scarce or nonproducti$e. Therefore!

the est test for diagnosis is an early3morning gastric aspirate sent for acid3fast acilli '#*B(

stain! culture! and! if a$ailale! PCR. astric aspirates should e otained y first placing a

nasogastric 'N( tue the night efore sample collection> a sample is aspirated first thing the

following morning! efore amulation and feeding. This should e repeated on 8 consecuti$e

mornings.

Cold #gglutinin Testing

In the young child or school3aged child with pneumonia! particularly the patient with a gradual

onset of symptoms and a prodrome consisting of headache and adominal symptoms! a edside

cold agglutinins test may help confirm the clinical suspicion of mycoplasmal infection.

This test is easily performed y placing a small amount of lood in a specimen tue containing

anticoagulant and inserting this into a cup filled with ice water. #fter a few minutes in the cold

water! the tue is held up to the light! tilted slightly! and slowly rotated. mall clumps of RBCs

coating the tue are indicati$e of a positi$e test result. Unfortunately! this test is positi$e in only

half the cases of mycoplasmal infection! and it is not $ery specific.

Direct #ntigen Detection

#lthough anti$iral therapies are not often used! performing a nasal wash or nasopharyngeal swa

for R and influen"a en"yme3lin+ed immunoassay ')-I#( and $iral culture can help to

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estalish a rapid diagnosis! which may e helpful in e:cluding other causes. iral cultures can e

otained in 531 days using newer cell culture techni4ues and may permit discontinuation of

unnecessary antiiotics. In addition! correct diagnosis allows for appropriate placement of

patients in the hospital. *or e:ample! if necessary! 1 infants with R infection may share a

room! whereas such patients would normally need isolation and may unnecessarily tie up a ed.

Chest Radiography

Chest radiography is indicated primarily in children with complications such as pleural effusions

and in those in whom antiiotic treatment fails to elicit a response. Computed tomography 'CT(

scanning of the chest and ultrasonography are indicated in children with complications such as

pleural effusions and in those in whom antiiotic treatment fails to elicit a response

Bronchoscopy

*le:ile fieroptic ronchoscopy is occasionally useful to otain lower airway secretions for

culture or cytology. This procedure is most useful in immunocompromised patients who are

elie$ed to e infected with unusual organisms 'Pneumocystis! other fungi( or in patients who

are se$erely ill.

TR)#T,)NT

#fter initiating therapy! the most important tas+s are resol$ing the symptoms and clearing the

infiltrate. %ith successful therapy! symptoms resol$e much sooner that the infiltrate. In a study

of adults with pneumococcal pneumonia! the infiltrate did not completely resol$e in all patients

until 2 wee+s after therapy 'although it was sooner in most patients(. If therapy fails to elicit a

response! the whole treatment approach must e reconsidered.

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Complications

e$ere respiratory compromise may re4uire intuation and transfer to a suitale intensi$e care

unit 'ICU( for more intensi$e monitoring and therapy. Indications for transfer include refractory

hypo:ia! decompensated respiratory distress 'eg! lessening tachypnea due to fatigue!

hypercapnia(! and systemic complications such as sepsis.

Transfer may need to e initiated at a lower threshold for infants or young children! as

decompensation may e rapid. Transfer of $ery sic+ infants or young children to a pediatric ICU

is est done with a specialist pediatric transfer team! e$en if that entails a slightly longer wait!

compared with con$entional medical transport or e$en air transport.

e$ere coughing! especially in the conte:t of necroti"ing pneumonias or ullae formation! may

lead to spontaneous pneumothoraces. These may or may not re4uire treatment depending on the

si"e of the pneumothora: and whether it is under tension and compromising $entilation and

cardiac output.

Other complications include the following

Pleural effusion

)mpyema

Pneumatocele

-ung ascess

Necroti"ing pneumonia

ystemic infection with metastatic foci

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Persistent neworn pulmonary hypertension

#ir lea+ syndrome! including pneumothora:! pneumomediastinum! pneumopericardium! and

pulmonary interstitial emphysema

#irway in@ury

Ostructi$e airway secretions

&ypoperfusion

Chronic lung disease

&ypo:ic3ischemic and cyto+ine3mediated end3organ in@ury

epsis

Nursing Priorities

5. ,aintainEimpro$e respiratory function.

1. Pre$ent complications.

8. upport recuperati$e process.

G. Pro$ide information aout disease process! prognosis and treatment.

Discharge oals

5. entilation and o:ygenation ade4uate for indi$idual needs.

1. Complications pre$entedEminimi"ed.

8. Disease processEprognosis and therapeutic regimen understood.

G. -ifestyle changes identifiedEinitiated to pre$ent recurrence.

6. Plan in place to meet needs after discharge.

Nursing Care plans

Below are 2 Nursing Care Plans 'NCP( for Pneumonia.

Ineffecti$e #irway Clearance

Nu!sin Dianosis #irway Clearance! ineffecti$e

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May "e !elate# to

Tracheal ronchial inflammation! edema formation! increased sputum production

Pleuritic pain

Decreased energy! fatigue

Possi"ly e$i#ence# "y

Changes in rate! depth of respirations

#normal reath sounds! use of accessory muscles

Dyspnea! cyanosis

Cough! effecti$e or ineffecti$e> withEwithout sputum production

Desi!e# Outcomes

IdentifyEdemonstrate eha$iors to achie$e airway clearance.

Display patent airway with reath sounds clearing> asence of dyspnea! cyanosis.

Nu!sin Inte!$entions Rationale

#ssess rateEdepth of respirations and chest

mo$ement.

Tachypnea! shallow respirations! and

asymmetric chest mo$ement are fre4uently

present ecause of discomfort of mo$ing

chest wall andEor fluid in lung.

#uscultate lung fields! noting areas of

decreasedEasent airflow and ad$entitious

reath sounds! e.g.! crac+les! whee"es.

Decreased airflow occurs in areas

consolidated with fluid. Bronchial reath

sounds 'normal o$er ronchus( can also

occur in consolidated areas. Crac+les!

rhonchi! and whee"es are heard on

inspiration andEor e:piration in response to

fluid accumulation! thic+ secretions! and

airway spasmEostruction.

)le$ate head of ed! change position -owers diaphragm! promoting chest

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fre4uently.e:pansion! aeration of lung segments!

moili"ation and e:pectoration of secretions.

#ssist patient with fre4uent deep3reathing

e:ercises. DemonstrateEhelp patient learn to

perform acti$ity! e.g.! splinting chest and

effecti$e coughing while in upright position.

uction as indicated 'e.g.! fre4uent or

sustained cough! ad$entitious reath sounds!

desaturation related to airway secretions(.

timulates cough or mechanically clears

airway in patient who is unale to do so

ecause of ineffecti$e cough or decreased

le$el of consciousness.

*orce fluids to at least 8000 m-Eday 'unless

contraindicated! as in heart failure(. Offer

warm! rather than cold! fluids.

*luids 'especially warm li4uids( aid in

moili"ation and e:pectoration of secretions.

#ssist withEmonitor effects of neuli"er

treatments and other respiratory

physiotherapy! e.g.! incenti$e spirometer!

IPPB! percussion! postural drainage. Perform

treatments etween meals and limit fluids

when appropriate.

*acilitates li4uefaction and remo$al of

secretions. Postural drainage may not e

effecti$e in interstitial pneumonias or those

causing al$eolar e:udateEdestruction.

Coordination of treatmentsEschedules and

oral inta+e reduces li+elihood of $omiting

with coughing! e:pectorations.

#dminister medications as indicated

mucolytics! e:pectorants! ronchodilators!

analgesics.

#ids in reduction of ronchospasm and

moili"ation of secretions. #nalgesics are

gi$en to impro$e cough effort y reducing

discomfort! ut should e used cautiouslyecause they can decrease cough

effortEdepress respirations.

Pro$ide supplemental fluids! e.g.! I!

humidified o:ygen! and room humidification.

*luids are re4uired to replace losses

'including insensile( and aid in moili"ation

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of secretions. Note ome studies indicate

that room humidification has een found to

pro$ide minimal enefit and is thought to

increase the ris+ of transmitting infection.

,onitor serial chest :3rays! #Bs! pulse

o:imetry readings.

*ollows progress and effects of disease

processEtherapeutic regimen! and facilitates

necessary alterations in therapy.

#ssist with ronchoscopyEthoracentesis! if

indicated.

Occasionally needed to remo$e mucous

plugs! drain purulent secretions! andEor

pre$ent atelectasis.

Impaired as ):change

Nu!sin Dianosis as ):change! impaired

May "e !elate# to

#l$eolar3capillary memrane changes 'inflammatory effects(

#ltered o:ygen3carrying capacity of loodErelease at cellular le$el 'fe$er! shifting

o:yhemogloin cur$e(

#ltered deli$ery of o:ygen 'hypo$entilation(


Dyspnea! cyanosis

Tachycardia

RestlessnessEchanges in mentation

&ypo:ia

Desi!e# Outcomes

Demonstrate impro$ed $entilation and o:ygenation of tissues y #Bs within patient?s

acceptale range and asence of symptoms of respiratory distress.

Participate in actions to ma:imi"e o:ygenation.

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#ssess respiratory rate! depth! and

ease.

,anifestations of respiratory distress are

dependent onEand indicati$e of the degree of lung

in$ol$ement and underlying general health status.

Oser$e color of s+in! mucous

memranes! and naileds! noting

presence of peripheral cyanosis

'naileds( or central cyanosis

'circumoral(.

Cyanosis of naileds may represent

$asoconstriction or the ody?s response to

fe$erEchills> howe$er! cyanosis of earloes! mucous

memranes! and s+in around the mouth 'warm

memranes( is indicati$e of systemic hypo:emia.

#ssess mental status.

Restlessness! irritation! confusion! and somnolence

may reflect hypo:emiaE decreased cereral

o:ygenation.

,onitor heart rateErhythm.

Tachycardia is usually present as a result of

fe$erEdehydration ut may represent a response to

hypo:emia.

,onitor ody temperature! as

indicated. #ssist with comfort measures

to reduce fe$er and chills! e.g.!

additionEremo$al of edco$ers!

comfortale room temperature! tepid or

cool water sponge ath.

&igh fe$er 'common in acterial pneumonia and

influen"a( greatly increases metaolic demands

and o:ygen consumption and alters cellular

o:ygenation.

,aintain edrest. )ncourage use of

rela:ation techni4ues and di$ersional

acti$ities.

Pre$ents o$ere:haustion and reduces o:ygen

consumptionEdemands to facilitate resolution of

infection.

)le$ate head and encourage fre4uent

position changes! deep reathing! and

effecti$e coughing.

These measures promote ma:imal inspiration!

enhance e:pectoration of secretions to impro$e

$entilation.

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#ssess le$el of an:iety. )ncourage

$erali"ation of concernsEfeelings.

#nswer 4uestions honestly. isit

fre4uently! arrange for OE$isitors to

stay with patient as indicated.

#n:iety is a manifestation of psychological

concerns and physiological responses to hypo:ia.

Pro$iding reassurance and enhancing sense of

security can reduce the psychological component!

therey decreasing o:ygen demand and ad$erse

physiological responses.

Oser$e for deterioration in condition!

noting hypotension! copious amounts of

pin+Eloody sputum! pallor! cyanosis!

change in le$el of consciousness!

se$ere dyspnea! restlessness.

hoc+ and pulmonary edema are the most

common causes of death in pneumonia and re4uire

immediate medical inter$ention.

,onitor #Bs! pulse o:imetry.*ollows progress of disease process and facilitates

alterations in pulmonary therapy.

#dminister o:ygen therapy y

appropriate means! e.g.! nasal prongs!

mas+! enturi mas+.

The purpose of o:ygen therapy is to maintain

Pao1 ao$e ;0 mm &g. O:ygen is administered y

the method that pro$ides appropriate deli$ery

within the patient?s tolerance.

Ris+ for Deficient *luid olume

Nu!sin Dianosis% Ris+ for Deficient *luid olume

Ris& facto!s may inclu#e

):cessi$e fluid loss 'fe$er! profuse diaphoresis! mouth reathingEhyper$entilation!

$omiting(

Decreased oral inta+e

Desi!e# Outcomes

Demonstrate fluid alance e$idenced y indi$idually appropriate parameters! e.g.! moist

mucous memranes! good s+in turgor! prompt capillary refill! stale $ital signs.


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#ssess $ital sign changes! e.g.! increased

temperatureEprolonged fe$er! tachycardia!

orthostatic hypotension.

)le$ated temperatureEprolonged fe$er increases

metaolic rate and fluid loss through

e$aporation. Orthostatic BP changes and

increasing tachycardia may indicate systemic

fluid deficit.

#ssess s+in turgor! moisture of mucous

memranes 'lips! tongue(.

Indirect indicators of ade4uacy of fluid $olume!

although oral mucous memranes may e dry

ecause of mouth reathing and supplemental

o:ygen.

Note reports of nauseaE$omiting. Presence of these symptoms reduces oral inta+e.

,onitor inta+e and output 'IO(! noting

color! character of urine. Calculate fluid

alance. Be aware of insensile losses.

%eigh as indicated.

Pro$ides information aout ade4uacy of fluid

$olume and replacement needs.

*orce fluids to at least 8000 m-Eday or as

indi$idually appropriate.

,eets asic fluid needs! reducing ris+ of

dehydration

#dminister medications as indicated!

e.g.! antipyretics! antiemetics.Useful in reducing fluid losses.

Pro$ide supplemental I fluids as

necessary.

In presence of reduced inta+eEe:cessi$e loss!

use of parenteral route may correctEpre$ent

deficiency.

#dminister medications as indicated!

e.g.! antipyretics! antiemetics.Useful in reducing fluid losses.

Pro$ide supplemental I fluids as

necessary.

In presence of reduced inta+eEe:cessi$e loss!

use of parenteral route may correctEpre$ent

deficiency.

Imalanced Nutrition

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Nu!sin Dianosis Ris+ for Imalanced Nutrition -ess Than Body Re4uirements


Increased metaolic needs secondary to fe$er and infectious process

#nore:ia associated with acterial to:ins! the odor and taste of sputum! and certain

aerosol treatments

#dominal distensionEgas associated with swallowing air during dyspneic episodes

Desi!e# Outcomes

Demonstrate increased appetite.

,aintainEregain desired ody weight.


Identify factors that are contriuting to

nauseaE$omiting! e.g.! copious sputum!

aerosol treatments! se$ere dyspnea! pain.

Choice of inter$entions depends on the

underlying cause of the prolem.

Pro$ide co$ered container for sputum and

remo$e at fre4uent inter$als. #ssist

withEencourage oral hygiene after emesis!

after aerosol and postural drainage

treatments! and efore meals.

)liminates no:ious sights! tastes! smells fromthe patient en$ironment and can reduce nausea.

chedule respiratory treatments at least 5

hr efore meals.

Reduces effects of nausea associated with these

treatments.

#uscultate for owel sounds.

Oser$eEpalpate for adominal distension.

Bowel sounds may e diminishedEasent if the

infectious process is se$ereEprolonged.#dominal distension may occur as a result of

air swallowing or reflect the influence of

acterial to:ins on the gastrointestinal 'I( tract.

Pro$ide small! fre4uent meals! including These measures may enhance inta+e e$en

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dry foods 'toast! crac+ers( andEor foods

that are appealing to patient.though appetite may e slow to return.

)$aluate general nutritional state! otain

aseline weight.

Presence of chronic conditions 'e.g.! COPD or

alcoholism( or financial limitations can

contriute to malnutrition! lowered resistance to

infection! andEor delayed response to therapy.

#cute Pain

Nu!sin Dianosis% Pain! acute

May "e !elate# to

Inflammation of lung parenchyma

Cellular reactions to circulating to:ins

Persistent coughing


Reports of pleuritic chest pain! headache! muscleE@oint pain

uarding of affected area

Distraction eha$iors! restlessness

Desi!e# Outcomes

erali"e reliefEcontrol of pain.

Demonstrate rela:ed manner! restingEsleeping and engaging in acti$ity appropriately.


Determine pain characteristics! e.g.!

sharp! constant! staing. In$estigate

changes in characterElocationEintensity

of pain.

Chest pain! usually present to some degree with

pneumonia! may also herald the onset of

complications of pneumonia! such as pericarditis

and endocarditis.

,onitor $ital signs. Changes in heart rate or BP may indicate that

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patient is e:periencing pain! especially when other

reasons for changes in $ital signs ha$e een ruled

out.

Pro$ide comfort measures! e.g.! ac+

rus! change of position! 4uiet music or

con$ersation. )ncourage use of

rela:ationEreathing e:ercises.

Nonanalgesic measures administered with a

gentle touch can lessen discomfort and augment

therapeutic effects of analgesics. Patient

in$ol$ement in pain control measures promotes

independence and enhances sense of well3eing.

Offer fre4uent oral hygiene.

,outh reathing and o:ygen therapy can irritate

and dry out mucous memranes! potentiating

general discomfort.

Instruct and assist patient in chest

splinting techni4ues during coughing

episodes.

#ids in control of chest discomfort while

enhancing effecti$eness of cough effort.

#dminister analgesics and antitussi$es

as indicated.

These medications may e used to suppress

nonproducti$eEparo:ysmal cough or reduce e:cess

mucus! therey enhancing general comfortErest.

#cti$ity Intolerance

Nu!sin Dianosis #cti$ity intolerance

May "e !elate# to

Imalance etween o:ygen supply and demand

eneral wea+ness

):haustion associated with interruption in usual sleep pattern ecause of discomfort!

e:cessi$e coughing! and dyspnea


eral reports of wea+ness! fatigue! e:haustion

):ertional dyspnea! tachypnea

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Tachycardia in response to acti$ity

De$elopmentEworsening of pallorEcyanosis

Desi!e# Outcomes

ReportEdemonstrate a measurale increase in tolerance to acti$ity with asence of

dyspnea and e:cessi$e fatigue! and $ital signs within patient?s acceptale range.


)$aluate patient?s response to acti$ity.

Note reports of dyspnea! increased

wea+nessEfatigue! and changes in $ital

signs during and after acti$ities.

)stalishes patient?s capailitiesEneeds and

facilitates choice of inter$entions.

Pro$ide a 4uiet en$ironment and limit

$isitors during acute phase as

indicated. )ncourage use of stress

management and di$ersional acti$ities

as appropriate.

Reduces stress and e:cess stimulation! promoting

rest

):plain importance of rest in

treatment plan and necessity for

alancing acti$ities with rest.

Bedrest is maintained during acute phase to

decrease metaolic demands! thus conser$ing

energy for healing. #cti$ity restrictions thereafter

are determined y indi$idual patient response to

acti$ity and resolution of respiratory insufficiency.

#ssist patient to assume comfortale

position for restEsleep.

Patient may e comfortale with head of ed

ele$ated! sleeping in a chair! or leaning forward on

o$ered tale with pillow support.

#ssist with self3care acti$ities as

necessary. Pro$ide for progressi$e

increase in acti$ities during reco$ery

phase. and demand.

,inimi"es e:haustion and helps alance o:ygen

supply and demand.

Ris+ for Infection

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Nu!sin Dianosis%Ris+ for Apread of Infection


Inade4uate primary defenses 'decreased ciliary action! stasis of respiratory secretions(

Inade4uate secondary defenses 'presence of e:isting infection! immunosuppression(!

chronic disease! malnutrition

Desi!e# Outcomes

#chie$e timely resolution of current infection without complications.

Identify inter$entions to pre$entEreduce ris+Espread ofEsecondary infection.


,onitor $ital signs closely! especially

during initiation of therapy.

During this period of time! potentially fatal

complications 'hypotensionEshoc+( may de$elop.

Instruct patient concerning the

disposition of secretions 'e.g.! raising

and e:pectorating $ersus swallowing(

and reporting changes in color! amount!

odor of secretions.

#lthough patient may find e:pectoration

offensi$e and attempt to limit or a$oid it! it is

essential that sputum e disposed of in a safe

manner. Changes in characteristics of sputum

reflect resolution of pneumonia or de$elopment of

secondary infection.

DemonstrateEencourage good

handwashing techni4ue.

)ffecti$e means of reducing spread or ac4uisition

of infection.

Change position fre4uently and pro$ide

good pulmonary toilet.Promotes e:pectoration! clearing of infection.

-imit $isitors as indicated. Reduces li+elihood of e:posure to other infectiouspathogens.

Institute isolation precautions as

indi$idually appropriate.

Dependent on type of infection! response to

antiiotics! patient?s general health! and

de$elopment of complications! isolation

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techni4ues may e desired to pre$ent

spreadEprotect patient from other infectious

processes.

)ncourage ade4uate rest alanced with

moderate acti$ity. Promote ade4uate

nutritional inta+e.

*acilitates healing process and enhances natural

resistance.

,onitor effecti$eness of antimicroial

therapy.

igns of impro$ement in condition should occur

within 1GFG2 hr.

In$estigate sudden

changesEdeterioration in condition! such

as increasing chest pain! e:tra heart

sounds! altered sensorium! recurring

fe$er! changes in sputum characteristics.

Delayed reco$ery or increase in se$erity of

symptoms suggests resistance to antiiotics or

secondary infection. Complications affecting

anyEall organ systems include lung

ascessEempyema! acteremia!

pericarditisEendocarditis! meningitisEencephalitis!

and superinfections.

Prepare forEassist with diagnostic

studies as indicated.

*ieroptic ronchoscopy '*OB( may e done in

patients who do not respond rapidly 'within 5F8

days( to antimicroial therapy to clarify diagnosis

and therapy needs.

Deficient


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Re4uests for information> statement of misconception

*ailure to impro$eErecurrence

Desi!e# Outcomes

erali"e understanding of condition! disease process! and prognosis.

erali"e understanding of therapeutic regimen.

Initiate necessary lifestyle changes.

Participate in treatment program.


Re$iew normal lung function! pathology of

condition.

Promotes understanding of current situationand importance of cooperating with treatment

regimen.

Discuss deilitating aspects of disease!

length of con$alescence! and reco$ery

e:pectations. Identify self3care and

homema+er needsEresources.

Information can enhance coping and help

reduce an:iety and e:cessi$e concern.

Respiratory symptoms may e slow to

resol$e! and fatigue and wea+ness can persist

for an e:tended period. These factors may eassociated with depression and the need for

$arious forms of support and assistance.

Pro$ide information in written and $eral

form.

*atigue and depression can affect aility to

assimilate informationEfollow medical

regimen.

tress importance of continuing effecti$ecoughingEdeep3reathing e:ercises.

During initial ;F2 w+ after discharge! patient

is at greatest ris+ for recurrence of

pneumonia.

)mphasi"e necessity for continuing

antiiotic therapy for prescried period.

)arly discontinuation of antiiotics may

result in failure to completely resol$e

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infectious process

Re$iew importance of cessation of smo+ing.

mo+ing destroys tracheoronchial ciliary

action! irritates ronchial mucosa! and

inhiits al$eolar macrophages! compromising

ody?s natural defense against infection.

Outline steps to enhance general health and

well3eing! e.g.! alanced rest and acti$ity!

well3rounded diet! a$oidance of crowds

during coldEflu season and persons with

URIs.

Increases natural defensesEimmunity! limits

e:posure to pathogens.

tress importance of continuing medical

follow3up and otaining

$accinationsEimmuni"ations as appropriate.

,ay pre$ent recurrence of pneumonia andEor

related complications.

Identify signsEsymptoms re4uiring

notification of healthcare pro$ider! e.g.!

increasing dyspnea! chest pain! prolonged

fatigue! weight loss! fe$erEchills! persistence

of producti$e cough! changes in mentation.

Prompt e$aluation and timely inter$ention

may pre$entEminimi"e complications.

Pre$ention

Pre$enting pneumonia in children is an essential component of a strategy to reduce childmortality. Immuni"ation against &i! pneumococcus! measles and whooping cough 'pertussis( is

the most effecti$e way to pre$ent pneumonia.

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#de4uate nutrition is +ey to impro$ing childrenLs natural defences! starting with e:clusi$e

reastfeeding for the first ; months of life. In addition to eing effecti$e in pre$enting

pneumonia! it also helps to reduce the length of the illness if a child does ecome ill.

#ddressing en$ironmental factors such as indoor air pollution 'y pro$iding affordale clean

indoor sto$es! for e:ample( and encouraging good hygiene in crowded homes also reduces the

numer of children who fall ill with pneumonia.

In children infected with &I! the antiiotic cotrimo:a"ole is gi$en daily to decrease the ris+ of

contracting pneumonia.

%&O response

The %&O and UNIC)* integrated loal action plan for pneumonia and diarrhoea '#PPD(

aims to accelerate pneumonia control with a comination of inter$entions to protect! pre$ent! and

treat pneumonia in children with actions to

protect children from pneumonia including promoting e:clusi$e reastfeeding and ade4uate

complementary feeding>

pre$ent pneumonia with $accinations! hand washing with soap! reducing household air pollution!

&I pre$ention and cotrimo:a"ole prophyla:is for &I3infected and e:posed children>

treat pneumonia focusing on ma+ing sure that e$ery sic+ child has access to the right +ind of care

33 either from a community3ased health wor+er! or in a health facility if the disease is se$ere 33

and can get the antiiotics and o:ygen they need to get well>

# numer of countries including Bangladesh! India!


37/37

,any more ha$e integrated diarrhoea and pneumonia specific action into their national child

health and child sur$i$al strategies. *or many countries the post ,illenium De$elopment oal

agenda has e:plicitly included ending pre$entale diarrhoea and pneumonia deaths as a priority

action.

clinical presentation on pnemonia

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