Pneumonia

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Pneumonia inflammatory parenchyma.

is an condition of

abnormal the lung

Pneumonitis is more general term that describe inflammatory process in the lung tissue that may predispose Click to edit Master subtitle style patient risk to microbial invasion.

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Pneumonia is a common illness in all parts of the world. It is a major cause of death among all age groups. In children, many of these deaths occur in the newborn period. The World Health Organization estimates that one in three newborn infant deaths are due to pneumonia. Over two million children under five die each year worldwide. WHO also estimates that up to 1 million of these (vaccine preventable) deaths are caused by the bacteria Streptococcus pneumoniae, and over 90% of these deaths take place in developing countries. Mortality from pneumonia generally decreases with age until late adulthood. Elderly 2/11/13 individuals, however, are at particular risk for

Combined clinical classification

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Community-acquired pneumonia (CAP) is infectious pneumonia in a person who has not recently been hospitalized or within the first 48 hours of hospitalization. CAP is the most common type of pneumonia. Haemophilus influenzae Streptococcus pneumoniae is the most common cause of community-acquired Click to edit Master subtitle style pneumonia worldwide. Mycoplasma pneumoniae -The term "walking pneumonia" has been used to describe a type of community-acquired pneumonia of less severity (because the sufferer can continue to "walk" rather than require hospitalization). Inluenza virus type A, B, adenovirus, cytomegaloviru,corona virus 2/11/13

Hospital-acquired Hospital-acquired pneumonia, also called nosocomial pneumonia, is pneumonia acquired during 48 hours after admission or after hospitalization for another illness or procedure with onset at least 72 hrs after admission. Hospitalized patients may have many risk factors for pneumonia, including mechanical ventilation, prolonged malnutrition, underlying heart and lung diseases, decreased amounts of stomach acid, and immune disturbances. Click to edit Master subtitle aureus vMRSA Methycillin resistant S. style vEnterobacter vPseudomonas auruginosa vKlebsiela Pneumonia - Incidence greater in elderly, alcoholics, with chronic disease like diabetes, heart failure, COPD. Patient in chronic care facilities and nursing homes.

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Staphylococcal Pneumonia - Staphylococcus aureus, greatest in immunocompromised, and as complication of epidemic influenza. Commonly nosocomial in origin and accounts 10-30% of HAC. Mortality rate is 25%-60%. Click to edit Master subtitle style
v

Example: Ventilator-associated pneumonia(VAP) is a subset of hospital-acquired pneumonia. VAP is pneumonia which occurs after at least 48 hours of intubation and mechanical ventilation.

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Pneumonia in Immunocompromised Host Pneumonitis Carinii/PCP Greatest in AIDS as

initial defining complication, cancer patients, organ transplant. Frequently seen in Cytomegalovirus. Mortality rate is 15%-20% in hospitalized and fatal if not treated. Greatest in immunocompromised and neutropenic patients.

Fungal Pneumonia/ Aspergillus Fumigatus

Tuberculosis Incidence greater in

immigrants, prison population, AIDS and homeless. Mortality <1% depending on 2/11/13

Other types of pneumonia

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Severe acute respiratory syndrome (SARS) SARS is a highly contagious and deadly type of pneumonia which first occurred in 2002 after initial outbreaks in China. SARS is caused by the SARS coronavirus , a previously unknown pathogen. Click to edit Master subtitle style Bronchiolitis obliterans organizing pneumonia (BOOP) BOOP is caused by inflammation of the small airways of the lungs. It is also known as cryptogenic organizing pneumonitis (COP).

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Eosinophilic pneumonia Eosinophilic pneumonia is invasion of

Chemical pneumonia Chemical pneumonia (usually called chemical pneumonitis) is caused by chemical toxicants such as pesticides, which may enter the body by inhalation or by skin contact. When the toxic substance is an oil, the pneumonia may be called lipoid pneumonia. Aspiration pneumonia Aspiration pneumonia (or aspiration pneumonitis) is caused by aspirating foreign objects which are usually oral or gastric contents, either while eating, or after reflux or vomiting which results edit Master subtitle style bronchopneumonia. The resulting Click to ininfection but can contribute to one, lung inflammation is not an since the material aspirated may contain anaerobic bacteria or other unusual causes of pneumonia. Aspiration is a leading cause of death among hospital and nursing home patients, since they often cannot adequately protect their airways and may have otherwise impaired defenses. Dust pneumonia Dust pneumonia describes disorders caused by excessive exposure to dust storms, particularly during the Dust Bowl in the United States. With dust pneumonia, dust settles all the way into the alveoli of the lungs, stopping the cilia from moving 2/11/13 and preventing the lungs from ever clearing themselves.

Necrotizing pneumonia, although overlapping with many other classifications, includes pneumonias that cause substantial necrosis of lung cells, and sometimes even lung abscess. Implicated bacteria are extremely commonly anaerobic bacteria, with or without additional facultatively anaerobic ones like Staphylococcus aureus, Klebsiella pneumoniae and Streptococcus pyogenes. Type 3 pneumococcus is uncommonly implicated.

Opportunistic pneumonia includes those that frequently strike to edit Master subtitle style immunocompromised like cytomegalovirus, Click Pneumocystis jiroveci, Mycobacterium avium-intracellulare, invasive candidiasis, as well as the "usual bacteria" that strike immunocompetent people as well

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Double pneumonia is a historical term for acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), the term was, and is used still, especially by lay people, to denote pneumonia affecting both lungs. Accordingly, the term 'double pneumonia' is more likely to be used to describe bilateral pneumonia than it is ALI or ARDS.

Risk Factors
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Conditions that produce mucus or bronchial

obstruction and interfere lung drainage e.g smoking, cancer,COPD

Immunosuppressed and neutropenic Prolonged immobility Depressed cough reflex or abnormal

swallowing
NPO-placement of NGT/ET Antibiotic therapy-in very ill people,

oropharynx is likely to be colonized by gram negative bacteria with aspiration, decrease white

Alcohol intoxication-suppress body reflex,may

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General

Anesthetic, sedative or opioid preparations that promote respiratory depression, causing shallow breathing pattern and predisposes pooling of bronchial secretions and potential to pneumonia reflex and nutritional depletion equipment.

Advance age- depressed cough and glottic Respiratory therapy with improperly cleaned

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PNEUMONIA

Bacterial Viral Fungal Aspiration Chemical Irritants

HYPERTROPHY OF MUCUS MEMBRANE Inflammation of the lung tissue - Increase sputum production -Wheezing -Dyspnea -Cough rales -Rhonchi
q

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CAPILLARY PERMEABILITY - Fluid in Intertitial space -Consolidation -Hypoxemia

INFLAMMATION OF THE PLEURA

-Chest pain -Pleural Effusion -Dullness -Decrease breath sound -Decrease vocal fermitus
HYPOVENTILATION
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Clinical Manifestations
Pneumonia varies in its signs and symptoms depending on the patients underlying disease and organism. However regardless of the type of pneumonia a specific type of pneumonia cannot be diagnosed by clinical manifestation alone Click to edit Master subtitle style vFor example patients with Streptococcal/Pneumococcal pneumonia has a sudden onset of shaking chills, rapidly rising fever 38.5C-40.5C and aggravating pleuritic chest pain by deep breathing and coughing. vRusty blood tinge sputum may be expectorated with Streptococcal,Staphylococcal and Klebsiela 2/11/13 pneumonia.
v

v Differing signs occur in cancer patients or

those undergoing immunosuppresant treatment. Such patients have fever, crackles, and physical finding that indicates consolidation of the lung tissue including increase tactile fermitus-vocal vibration detected on palpation, percussion dullness, bronchial breath sounds, egophony-when auscultated, the spoken E, becomes a loud nasal sounding A. These changes occurs because sound transmitted better through solid or dense tissue |consolidation| than through normal air filled tissue. slight changes may be signs in of

v Purulent

sputum or respiratory symptoms 2/11/13

v Less common forms of pneumonia can cause

other symptoms; for instance, pneumonia caused by Legionella may cause abdominal pain and diarrhea, while pneumonia caused by tuberculosis or Pneumocystis may cause only weight loss and night sweats

v In elderly people, manifestations of

pneumonia are seldom typical. They may develop a new or worsening confusion (delirium) or may experience unsteadiness, leading to falls. Infants with pneumonia may have many of the symptoms above, but in many cases they are simply sleepy or have a 2/11/13 decreased appetite

Diagnostic Findings
Made by History particularly of recent

respiratory tract infection, physical examination, chest x-ray studies, blood culture bacteremia occur frequently and sputum examination. acute severe infection or immunocompromised patients when diagnosis cannot be made from an expectorated or induced specimen

Bronchoscopy is often used in patients with

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 A: Normal chest

x-ray.

B: Abnormal

chest x-ray with shadowing from pneumonia in the right lung (white area, left side of image).

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Treatment
Bacterial
Antibiotics

are used to treat bacterial pneumonia. The antibiotic choice depends on the nature of the pneumonia, the most common microorganisms causing pneumonia in the local geographic area, and the immune status and underlying health of the individual. Treatment for pneumonia should ideally be based on the causative microorganism and its known antibiotic sensitivity.

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Amoxicillin

and clarithromycin or erythromycin are the antibiotics selected for most patients with community-acquired pneumonia; patients allergic to penicillins are given erythromycin instead of amoxicillin. In where the "atypical" forms of communityacquired pneumonia are becoming more common, macrolides (such as azithromycin and clarithromycin), the fluoroquinolones, and doxycycline have displaced amoxicillin as firstline outpatient treatment for communityacquired pneumonia.The duration of treatment has traditionally been seven to ten days, but there is increasing evidence that 2/11/13 shorter courses (as short as three days) are

Antibiotics for hospital-acquired pneumonia

include third- and antibiotics are usually given intravenously. Multiple antibiotics may be administered in combination in an attempt to treat all of the possible causative microorganisms. pneumonia may require extra oxygen. Those who are extremely sick may require intensive care, including endotracheal intubation and artificial ventilation.

People who have difficulty breathing due to

Over the counter cough medicine has not been found to be helpful in pneumonia
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Viral
Viral pneumonia caused by influenza A may

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be treated with rimantadine or amantadine, while viral pneumonia caused by influenza A or B may be treated with oseltamivir or zanamivir. These treatments are beneficial only if they are started within 48 hours of the onset of symptoms. Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown resistance to rimantadine and amantadine. There are no known effective treatments for viral pneumonias caused by the SARS coronavirus, adenovirus, hantavirus, or parainfluenza virus.

Aspiration
There is no evidence to support the use of

antibiotics in chemical pneumonitis without bacterial superinfection. If infection is present in aspiration pneumonia, the choice of antibiotic will depend on several factors, including the suspected causative organism and whether pneumonia was acquired in the community or developed in a hospital setting. Common options include clindamycin, a combination of a beta-lactam antibiotic and metronidazole, or an aminoglycoside. Corticosteroids are commonly used in 2/11/13 aspiration pneumonia, but there is no

NURSING DIAGNOSIS
Ineffective airway clearance related to copious

tracheobronchial secretions

Objective: Diminish or adventitious breath sounds; sputum; ineffective or absent cough, restless, orthopnea, cyanosis Improving airway patency
1. Establish rapport 2. Auscultate breath sounds and assess air

movement- to ascertain status and note progress secretion

3. Encourage Hydration 2-3L/day loosen

pulmonary 2/11/13

3. Encourage deep breathing e.g with

incentive spirometry

4. Encourage coughing voluntarily or by

reflex to expectorate respiratory secretions and mobilizing secretions

5. Perform chest physiotherapy loosening 6. Monitor vital signs, blood pressure and

pulse changes to check status and improvement on therapy

7. Administer medication as ordered

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Activity Intolerance related to impaired

respiratory function

Subjective : Report fatigue or weakness, exertional discomfort or dyspnea Objective: Abnormal heart rate, blood pressure,use of accessory muscles for breathing Promoting Rest and Conserving Energy
1. Encourage patient Rest in comfortable

environment and ventilation to prevent exacerbation of symptoms semi-fowlers position to promote breathing and rest.

2. Placed patient on comfortable position ,

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3. Turn to sides q2 to enhance clearance of secretion and ventilation of lungs

4. Instruct patient not to overexert and engage

in moderate activity during initial phases of treatment.

5. Plan care periods between activities to

reduce fatigue

6. Give client information that provides

evidence of daily progress to sustain motivation

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Risk for deficient fluid volume related to fever

and dyspnea

1. Assess clinical signs of dehydration 2. Instruct patient to increase fluid intake

2L/day, unless contraindicated

3. Weight daily or as ordered and evaluate

changes as to relate to fluid status

4. Measure and record I and O to monitor

hydration status

5. Administer IV fluids as prescribed

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Imbalance nutrition less than body

requirements

Subjective: Reported inadequate food intake, abdominal pain/cramping, lack of interest in food, shortness of breath Objective: Body weight 20% or more under the ideal, weakness of muscle required for swallowing and mastication, poor muscle tone Maintaining Nutrition
1. Ascertain understanding of individual

nutritional needs to determine what information to provide

2. Provide pleasant and relaxing environment

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3. Consult dietician and provide diet

modification e.g increase protein and carbohydrates as indicated to implement team work Avoid foods that increase intolerance or gastric motility like hot/cold, spicy foods, caffeinated beverages according to individual needs early satiety

4.

5. Limit fiber/bulk as indicated. It may lead to 6. Provide oral care before and after meals 7. Weigh weekly and document results to

monitor 2/11/13

effectiveness

Complications
Acute respiratory distress syndrome (ARDS),

which results from a combination of infection and inflammatory response. The lungs quickly fill with fluid and become very stiff. This stiffness, combined with severe difficulties extracting oxygen due to the alveolar fluid, create a need for mechanical ventilation.

Sepsis and septic shock- Sepsis occurs when

microorganisms enter the bloodstream and the immune system responds by secreting cytokines. Sepsis most often occurs with 2/11/13 bacterial pneumonia; Streptococcus

Pleural effusion. Chest x-ray showing a pleural effusion. The A arrow indicates "fluid layering" in the right chest. The B arrow indicates the width of the right lung. The volume of useful lung is reduced because of the collection of fluid around the lung.

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Empyema- If the microorganisms themselves

are present in the pleural cavity, the fluid collection a pocket of infected fluid . Lung abscesses can usually be seen with a chest x-ray or chest CT scan. Abscesses typically occur in aspiration pneumonia and often contain several types of bacteria. Antibiotics are usually adequate to treat a lung abscess, but sometimes the abscess must be drained by a surgeon or radiologist.

Lung abscess- bacteria in the lung will form

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Prevention
Appropriately treating underlying illnesses

(such as AIDS) can decrease a person's risk of pneumonia

Smoking cessation Testing pregnant women for

Group B Streptococcus and Chlamydia trachomatis, and then giving antibiotic treatment if needed, reduces pneumonia in infants. meconium-stained amniotic fluid

Suctioning the mouth and throat of infants

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Vaccination - Hib vaccine is now widely used

around the globe. Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae in the first year of life have greatly reduced the role these bacteria play in causing pneumonia in children. Vaccinating children against Streptococcus pneumoniae has also led to a decreased incidence of these infections in adults because many adults acquire infections from children.

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Who should consider pneumococcal vaccination?

Pneumococcal vaccination should be

considered by people in the following groups:

Adults 65 years of age and older. Persons > 2 years of age with chronic

heart or lung disorders including congestive heart failure, diabetes mellitus , chronic liver disease, alcoholism, spinal fluid leaks, cardiomyopathy, chronic bronchitis or emphysema (COPD) or emphysema. dysfunction (such as sickle cell disease)

Persons > 2 years of age with spleen 2/11/13

BIBLIOGRAPHY
Doenges, M. E., Moorehouse, M. F. and

Geissler, A. C. Nursing Care Plans: Guidelines for Planning and Documenting Patient Care. 3rd ed. Philadelphia: F. A. Davis Co. 1993. Textbook of Medical-Surgical Nursing. 9th ed. Philadelphia: Lippincott Williams and Wilkins. 2000.

Smeltzer, Suzzane C. and Bare, Brenda G.

Udan, J. Q. Medical-Surgical Nursing:

Concepts and Clinical Application. 1st ed. Philippines: Educational Publishing House. 2/11/13 2002.

End
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