PNEUMONEA

Definition

Pneumonia is an inflammation of the lung parenchyma that is caused by a microbial agent.

Risk factors and Causes

 Conditions that produce mucus or bronchial obstruction and interfere with normal lung drainage
(eg, cancer, cigarette smoking,
 COPD)
 Immunosuppressed patients and those with a low neutrophil count
 (neutropenic)
 Smoking; cigarette smoke disrupts both mucociliary and
 macrophage activity
 Prolonged immobility and shallow breathing pattern
 Depressed cough reflex (due to medications, a debilitated state, or
 weak respiratory muscles); aspiration of foreign material into the
 lungs during a period of unconsciousness (head injury, anesthesia, depressed level of
consciousness), or abnormal swallowing
 mechanism
 Nothing-by-mouth (NPO) status; placement of nasogastric,
 orogastric, or endotracheal tube
 Antibiotic therapy (in very ill people, the oropharynx is likely to be
 colonized by gram-negative bacteria)
 Alcohol intoxication (because alcohol suppresses the body’s reflexes,
 may be associated with aspiration, and decreases white cell mobilization and tracheobronchial
ciliary motion)
 General anesthetic, sedative, or opioid preparations that promote
 respiratory depression, which causes a shallow breathing pattern
 and predisposes to the pooling of bronchial secretions and potential development of pneumonia
 Advanced age, because of possible depressed cough and glottic
 reflexes and nutritional depletion
 Respiratory therapy with improperly cleaned equipmen

Classification of pneumonea

1. community-acquired pneumonia

Community-acquired pneumonia (CAP) occurs either in the community setting or within the first 48 hours of
hospitalization or institutionalization. The need for hospitalization for CAP depends on the severity of the
pneumonia. The agents that most frequently cause CAP requiring hospitalization are S. pneumoniae, H.
influenzae, Legionella, Pseudomonas aeruginosa, and other gramnegative rods.

It is most prevalent during the winter and spring, when upper respiratory tract infections are most frequent. S.
pneumoniaeis a gram-positive, capsulated, nonmotile coccus that resides naturally in the upper respiratory
tract.
 2. hospitalacquired pneumonia
Health care associated pneumonia

Hospital-acquired pneumonia (HAP), also known as nosocomial pneumonia, is defined as the onset of
pneumonia symptoms more than 48 hours after admission to the hospital. HAP accounts for approximately 15%
of hospital-acquired infections but is the most lethal nosocomial infection.

Ventilator-associated pneumonia can be considered a type of nosocomial pneumonia that is associated with
endotracheal intubation and mechanical ventilation.

The common organisms responsible for HAP include the pathogens Enterobacter species, Escherichia coli,
Klebsiella species, Proteus, Serratia marcescens, P. aeruginosa, and methicillin-sensitive or methicillin-resistant
Staphylococcus aureus.

These respiratory infections occur when at least one of three conditions exists: host defenses are impaired, an
inoculum of organisms reaches the patient’s lower respiratory tract and overwhelms the host’s defenses, or a
highly virulent organism is present. Certain illnesses may predispose a patient to HAP because of impaired host
defenses. Examples include severe acute or chronic illness, a variety of comorbid conditions, coma, malnutrition,
prolonged hospitalization, hypotension, and metabolic disorders. The hospitalized patient is also exposed to
potential bacteria from other sources (eg, respiratory therapy devices and equipment, transmission of
pathogens by the hands of health care personnel).

Numerous interventionrelated factors also may play a role in the development of HAP (eg, therapeutic agents
leading to central nervous system depression with decreased ventilation, impaired removal of secretions, or
potential aspiration; prolonged or complicated thoracoabdominal procedures, which may impair mucociliary
function and cellular host defenses; endotracheal intubation; prolonged or inappropriate use of antibiotics; use
of nasogastric tubes). In addition, immunocompromised patients are at particular risk.

Aspiration pneumonia refers to the pulmonary consequences resulting from the entry of endogenous or
exogenous substances into the lower airway. The most common form of aspiration pneumonia is bacterial
infection from aspiration of bacteria that normally reside in the upper airways. Aspiration pneumonia may occur
in the community or hospital setting; common pathogens are S. pneumoniae, H. influenzae, and S. aureus. Other
substances may be aspirated into the lung, such as gastric contents, exogenous chemical contents, or irritating
gases. This type of aspiration or ingestion may impair the lung defenses, cause inflammatory changes, and lead
to bacterial growth and a resulting pneumonia.
Type Incidence c\m Treatment Complications
Community Highest occurrence in winter Abrupt onset, toxic Penicillins shock, pleural
Acquired months. Incidence greatest in the appearance, pleuritic chest Alternate antibiotic effusion,
Pneumonia elderly and in patients with COPD, pain. Usually involves one therapy, such as superinfections,
Streptococcal heart failure, alcoholism, asplenia, or more lobes. Lobar cefotaxime or pericarditis, and
pneumonia following influenza. Leading infiltrate common on chest ceftriaxone; otitis media.
(pneumococcal) infectious cause of illness x-ray or antipseudomonal
Streptococcus worldwide among young children, bronchopneumonia fluoroquinolones
pneumoniae persons with underlying chronic pattern. Bacteremia in 15% (levofloxacin,
health conditions, and the elderly. to 25% of all patients. gatifloxacin,
Death occurs in 14% of moxifloxacin).
hospitalized adults with invasive
disease.
Haemophilus Incidence greatest in alcoholics, Frequently insidious onset Ampicillin, lung abscess,
influenza the elderly, patients in chronic associated with upper 3rdgeneration pleural effusion,
care facilities and nursing homes, respiratory tract infection 2 cephalosporin, meningitis,
patients with diabetes or COPD. to 6 weeks before onset of macrolides arthritis,
illness. Fever, chills, (azithromycin, pericarditis,
productive cough. Usually clarithromycin), epigolottitis.
involves one or more lobes. fluoroquinoloneS
Bacteremia is common.
Infiltrate, occasional
bronchopneumonia pattern
on chest x-ray.
Legionella Highest occurrence in summer Flulike symptoms. High Erythromycin +/− Complications
pneumophila and fall. May cause disease fevers, mental confusion, rifampin (in include
sporadically or as part of an headache, pleuritic pain, severely hypotension,
epidemic. Incidence greatest in myalgias, dyspnea, compromised shock, and acute
middle-aged and older men, productive cough, patient) or renal failure.
smokers, and patients with hemoptysis, leukocytosis. clarithromycin, or a
chronic diseases, those receiving Bronchopneumonia, macrolide
immunosuppressive therapy, or unilateral or bilateral (azithromycin), or a
those in close proximity to disease, lobar fluoroquinolone
excavation sites. Accounts for 15% consolidation. (ofloxacin,
of communityacquired levofloxacin,
pneumonias. Mortality rate: 15% sparfloxacin)
to 50%
Mycoplasma Increase in fall and winter. Onset is usually insidious. Erythromycin; aseptic meningitis,
pneumoniae Responsible for epidemics of Patients not usually as ill as macrolide, meningoencephali
respiratory illness. Most common in other pneumonias. Sore fluoroquinolone or tis, transverse
type of atypical pneumonia. throat, nasal congestion, tetracycline myelitis, cranial
Accounts for 20% of ear pain, headache, nerve palsies,
communityacquired pneumonias. lowgrade fever, pleuritic pericarditis,
More common in children and pain, myalgias, diarrhea, myocarditis
young adults. erythematous rash,
pharyngitis. Interstitial
infiltrates on chest x-ray.
Influenza viruses Incidence greatest in winter Patchy infiltrate, small Amantadine; a superimposed
months. Epidemics occur every 2 pleural effusion on chest x- rimantadine; bacterial infection,
types A, B to 3 years. Most common ray. In majority of patients, oseltamivir bronchopneumoni
adenovirus, causative organisms in adults. influenza begins as an phosphate, a.
parainfluenza, Other organisms in children (eg, acute upper respiratory ribavirin aerosol.
cytomegalovirus cytomegalovirus and respiratory infection; others have Treated
, coronaviruS syncytial virus). Accounts for 20% bronchitis, pleurisy, etc., symptomatically.
of communityacquired and still others develop Does not respond
pneumonias. gastrointestinal symptoms. to treatment with
currently available
antimicrobials.
Chlamydial Reported mainly in college Hoarseness, fever, chills, Tetracycline, reinfection and
pneumonia students, military recruits, and the pharyngitis, rhinitis, erythromycin, acute respiratory
elderly. May be a common cause nonproductive cough, macrolide, failure.
of communityacquired pneumonia myalgias, arthralgias. Single quinolone
or observed in combination with infiltrate on chest x-ray;
other pathogens. Mortality rate is pleural effusion possible
low as the majority of cases are
relatively mild. The elderly with
coexistent infections,
comorbidities, and reinfections
may require hospitalization.
Hospital-Acquired Pneumoni
Pseudomonas aeruginosa Incidence greatest in Diffuse consolidation on Aminoglycoside Complications
those with preexisting chest x-ray. Toxic and include lung
lung disease, cancer appearance: fever, chills, antipseudomonal cavitation. Has
(particularly leukemia); productive cough, relative agents (ticarcillin, capacity to invade
those with homograft bradycardia, leukocytosis. piperacillin, blood vessels,
transplants, burns; mezlocillin, causing
debilitated persons; and ceftazidine) hemorrhage and
patients receiving lung infarction.
antimicrobial therapy Usually requires
and treatments such as hospitalization.
tracheostomy,
suctioning, and in
postoperative settings.
Almost always of
nosocomial origin.
Accounts for 15% of
hospitalacquired
pneumonias.
Staphylococcal Incidence greatest in Severe hypoxemia, Nafcillin/oxacillin pleural
pneumonia immunocompromised cyanosis, necrotizing +/− rifampin or effusion/pneumot
Staphylococcus aureus patients, IV drug users, infection. Bacteremia is gentamicin; horax, lung
and as a complication of common. methicillinresistant abscess,
epidemic influenza. : vancomycin +/− empyema,
Commonly nosocomial in rifampin or meningitis,
 origin. Accounts for 10% gentamicin endocarditis.
to 30% of hospital- disease tends to
acquired pneumonias. destroy lung
tissue.
Klebsiella pneumonia Incidence greatest in the Tissue necrosis occurs Third-generation multiple lung
Klebsiella pneumoniae elderly; alcoholics; rapidly. Toxic appearance: cephalosporins abscesses with
(Friedlander’s bacillus- patients with chronic fever, cough, sputum (cefotaxime, cyst formation,
encapsulated gram- disease, such as diabetes, production, ceftriaxone) plus empyema,
negative aerobic bacillus) heart failure, COPD; bronchopneumonia, lung aminoglycoside, pericarditis,
patients in chronic care abscess. Lobar antipseudomonal pleural effusion.
facilities and nursing consolidation, penicillin, May be
homes. Accounts for 2% bronchopneumonia pattern monobactam fulminating,
to 5% of on chest x-ray. (aztreonam), or progressing to
communityacquired and quinolone. fatal outcome.
10% to 30% of hospital-
acquired pneumonias.
Pneumonia in Immunocompromised Host
Pneumocystis carinii Incidence greatest in Pulmonary infiltrates on Trimethoprim/ Complications
pneumonia (PCP) patients with AIDS and chest x-ray. Nonproductive sulfamethoxazole include
Pneumocystis carinii patients receiving cough, fever, dyspnea. (TMP-SMZ), respiratory failure
immunosuppressive dapsonetrimethopr
therapy for cancer, organ im, pentamidine,
transplants, and other primequine plus
disorders. Frequently clindamycin
seen with
cytomegalovirus
infection. Mortality rate
15% to 20% in
hospitalized and fatal if
not treated.
Fungal pneumonia Incidence greatest in Cough, hemoptysis, Flucytosine with Complications
Aspergillus fumigatus immunocompromised infiltrates, fungus ball on amphotericin B in include
and neutropenic chest x-ray. non-neutropenic dissemination to
patients. Mortality rate: patients, brain,
15% to 20%. amphotericin B, myocardium,
itraconazole, and/or thyroid
ketoconazole. gland
Lobectomy for
fungus ball.
Tuberculosis Incidence increased in Weight loss, fever, night Rifampin, reinfection and
Mycobacterium indigent, immigrant, and sweats, cough, sputum streptomycin, acute respiratory
tuberculosis prison populations, production, hemoptysis, ethambutol, INH infection
people with AIDS, and nonspecific infiltrate (lower (isoniazid),
the homeless. Mortality lobe), hilar node pyrazinamide
rate enlargement, pleural
effusion on chest x-ray
Pathophysiology

Predisposing factors

Inflammatory reactions in the alveoli

Formation of exudates

Interfere in diffusion of gases

Neutrophils migrate to alveoli and occupy air filled spaces

Mucosal secretions and edema

Interfere in normal ventilation process

Partial occlusion of bronchi / alveoli

Decreased alveoli O2 tension

Hypoventilation

Ventilation – perfusion mismatch

aspiration of flora present in the oropharynx. It may also result from bloodborne organisms that enter the
pulmonary circulation and are trapped in the pulmonary capillary bed, becoming a potential source of
pneumonia. Pneumonia often affects both ventilation and diffusion. An inflammatory reaction can occur in the
alveoli, producing an exudate that interferes with the diffusion of oxygen and carbon dioxide. White blood cells,
mostly neutrophils, also migrate into the alveoli and fill the normally air-containing spaces. Areas of the lung are
not adequately ventilated because of secretions and mucosal edema that cause partial occlusion of the bronchi
or alveoli, with a resultant decrease in alveolar oxygen tension. Bronchospasm may also occur in patients with
reactive airway disease. Because of hypoventilation, a ventilation–perfusion mismatch occurs in the affected
area of the lung. Venous blood entering the pulmonary circulation passes through the underventilated area and
exits to the left side of the heart poorly oxygenated. The mixing of oxygenated and unoxygenated or poorly
oxygenated blood eventually results in arterial hypoxemia. If a substantial portion of one or more lobes is
involved, the disease is referred to as “lobar pneumonia.” The term “bronchopneumonia” is used to describe
pneumonia that is distributed in a patchy fashion, having originated in one or more localized areas within the
bronchi and extending to the adjacent surrounding lung parenchyma.
Clinical Manifestations

 Pneumonia varies in its signs and symptoms depending on the organism and the patient’s
underlying disease.
streptococcal (pneumococcal) pneumonia
 a sudden onset of shaking chills, rapidly rising fever (38.5° to 40.5°C [101° to 105°F])
 pleuritic chest pain that is aggravated by deep breathing and coughing
 tachypnea (25 to 45 breaths/min)
 accompanied by other signs of respiratory distress (eg, shortness of breath, use of accessory
muscles in respiration).
 The pulse is rapid and bounding, and it usually increases about 10 beats/min for every degree of
temperature (Celsius) elevation.
 A relative bradycardia for the amount of fever may suggest viral infection, mycoplasma
infection, or infection with a Legionella organism.
 Some patients exhibit an upper respiratory tract infection (nasal congestion, sore throat), and the
onset of symptoms of pneumonia is gradual and nonspecific.
 The predominant symptoms may be headache, low-grade fever, pleuritic pain, myalgia, rash, and
pharyngitis.
 After a few days, mucoid or mucopurulent sputum is expectorated
 Sputum is often purulent; this is not a reliable indicator of the etiologic agent. Rusty, blood-
tinged sputum may be expectorated with streptococcal (pneumococcal), staphylococcal, and
Klebsiella pneumonia
 In severe pneumonia, the cheeks are flushed and the lips and nailbeds demonstrate central
cyanosis (a late sign of poor oxygenation [hypoxemia]).
 Orthopnea, he or she prefers to be propped up in bed leaning forward (orthopneic position),
trying to achieve adequate gas exchange without coughing or breathing deeply.
 Appetite is poor
 diaphoretic and tires easily

Assessment and Diagnostic Findings

The diagnosis of pneumonia is made by history (particularly of a recent respiratory tract infection)
physical examination
 fever, crackles, and physical findings that indicate consolidation of lung tissue, including
increased tactile fremitus (vocal vibration detected on palpation), percussion dullness, bronchial
breath sounds, egophony (when auscultated, the spoken “E” becomes a loud, nasal-sounding
“A”), and whispered pectoriloquy (whispered sounds are easily auscultated through the chest
wall). These changes occur because sound is transmitted better through solid or dense tissue
(consolidation) than through normal air-filled tissue;
chest x-ray studies may reveal multilobar, patchy bronchopneumonia or areas of consolidation (tissue that
solidifies as a result of collapsed alveoli or pneumonia).
blood culture (bloodstream invasion, called bacteremia, occurs frequently)
sputum examination
 The sputum sample is obtained by having the patient:
(1) rinse the mouth withn water to minimize contamination by normal oral flora
(2) breathe deeply several times
(3) cough deeply
(4) expectorate the raised sputum into a sterile container.
More invasive procedures may be used to collect specimens. Sputum may be obtained by nasotracheal
or orotracheal suctioning with a sputum trap or by fiberoptic bronchoscopy.
Bronchoscopy
bronchoscopy is often used in patients with acute severe infection, patients with chronic or refractory
infection, or immunocompromised patients when a diagnosis cannot be made from an expectorated or
induced specimen.

Medical Management

The treatment of pneumonia includes administration of the appropriate antibiotic as determined by the
results of the Gram stain.
CAP
 who have no cardiopulmonary disease or other modifying factors include a macrolide
(erythromycin, azithromycin [Zithromax], or clarithromycin [Biaxin]), doxycycline
(Vibramycin), or a fluoroquinolone (eg, gatifloxacin [Tequin], levofloxacin [Levaquin]) with
enhanced activity against S. pneumoniae. Erythromycin should be avoided in areas where H.
influenzae and S. aureus are more prevalent.

 For those outpatients who have cardiopulmonary disease or other modifying factors, treatment
should include a beta-lactam (oral cefpodoxime [Vantin], cefuroxime [Zinacef, Ceftin], high
dose amoxicillin or amoxicillin/clavulanate [Augmentin, Clavulin]) plus a macrolide or
doxycycline. Also, a beta-lactam plus an antipneumococcal fluoroquinolone can be used.

 For patients with CAP who are hospitalized and do not have cardiopulmonary disease or
modifying factors, management consists of intravenous azithromycin (Zithromax) or
monotherapy with an antipneumococcal fluoroquinolone.
 For inpatients with cardiopulmonary disease or modifying factors, the treatment involves an
intravenous beta-lactam plus an intravenous or oral macrolide or doxycycline. An intravenous
antipneumococcal fluoroquinolone may also be used alone.

 For acutely ill patients admitted to the intensive care unit, management includes an intravenous
beta-lactam plus either an intravenous macrolide or fluoroquinolone.

Assessment
Nursing assessment is critical in detecting pneumonia.
A fever, chills, or night sweats in a patient who also has respiratory symptoms should alert the nurse to
the possibility of bacterial pneumonia.
A respiratory assessment will further identify the clinical manifestations of pneumonia: pleuritic type
pain, fatigue, tachypnea, use of accessory muscles for breathing, bradycardia or relative bradycardia,
coughing, and purulent sputum. It is important to identify the severity, location, and cause of the chest
pain, along with any medications or procedures that provide relief.
The nurse should monitor the following: • Changes in temperature and pulse • Amount, odor, and color
of secretions • Frequency and severity of cough • Degree of tachypnea or shortness of breath • Changes
in physical assessment findings (primarily assessed by inspecting and auscultating the chest) • Changes
in the chest x-ray findings In addition, it is important to assess the elderly patient for unusual behavior,
altered mental status, dehydration, excessive fatigue, and concomitant heart failure.
Nursing diagnoses
• Ineffective airway clearance related to copious tracheobronchial secretions
• Activity intolerance related to impaired respiratory function
• Risk for deficient fluid volume related to fever and dyspnea
• Imbalanced nutrition: less than body requirements
• Deficient knowledge about the treatment regimen and preventive health measures

Collaborative problems/ potential complications Based

• Continuing symptoms after initiation of therapy
• Shock
• Respiratory failure
• Atelectasis
• Pleural effusion
• Confusion
• Superinfection

The major goals for the patient may include improved airway patency, rest to conserve energy,
maintenance of proper fluid volume, maintenance of adequate nutrition, an understanding of the
treatment protocol and preventive measures, and absence of complications.

Nursing Interventions
Improving airway patency
 Removing secretions is important because retained secretions interfere with gas exchange and
may slow recovery.
 Encourages hydration (2 to 3 L/day) because adequate hydration thins and loosens pulmonary
secretions. Humidification may be used to loosen secretions and improve ventilation. A
highhumidity facemask (using either compressed air or oxygen) delivers warm, humidified air to
the tracheobronchial tree, helps to liquefy secretions, and relieves tracheobronchial irritation.
 Coughing can be initiated either voluntarily or by reflex.
 Lung expansion maneuvers, such as deep breathing with an incentive spirometer, may induce a
cough. A directed cough may be necessary to improve airway patency. The nurse encourages the
patient to perform an effective, directed cough, which includes correct positioning, a deep
inspiratory maneuver, glottic closure, contraction of the expiratory muscles against the closed
glottis, sudden glottic opening, and an explosive expiration.
 In some cases, the nurse may assist the patient by placing both hands on the patient’s lower rib
cage (anteriorly or posteriorly) to focus the patient on a slow deep breath, and then manually
assisting the patient by applying external pressure during the expiratory phase.
 Chest physiotherapy (percussion and postural drainage) is important in loosening and mobilizing
secretions.
 Indications for chest physiotherapy include sputum retention not responsive to spontaneous or
directed cough, a history of pulmonary problems previously treated with chest physiotherapy,
 continued evidence of retained secretions (decreased or abnormal breath sounds, change in vital
signs), abnormal chest x-ray findings consistent with atelectasis or infiltrates, or deterioration in
oxygenation. The patient is placed in the proper position to drain the involved lung segments,
and then the chest is percussed and vibrated either manually or with a mechanical percussor.
After each position change, the nurse encourages the patient to breathe deeply and cough. If the
patient is too weak to cough effectively, the nurse may need to remove the mucus by
nasotracheal suctioning. It may take time for secretions to mobilize and move into the central
airways for expectoration. Thus, it is important for the nurse to monitor the patient for cough and
sputum production after the completion of chest physiotherapy.
 The nurse administers and titrates oxygen therapy as prescribed.
Promoting rest and conserving energy
The nurse encourages the debilitated patient to rest and avoid overexertion and possible exacerbation of
symptoms.
The patient should assume a comfortable position to promote rest and breathing (eg, semi-Fowler’s) and
should change positions frequently to enhance secretion clearance and ventilation/perfusion in the lungs.
It is important to instruct outpatients not to overexert themselves and to engage in only moderate activity
during the initial phases of treatment.
Promoting fluid intake
The respiratory rate of a patient with pneumonia increases because of the increased workload imposed
by labored breathing and fever. An increased respiratory rate leads to an increase in insensible fluid loss
during exhalation and can lead to dehydration. Therefore, it is important to encourage increased fluid
intake (at least 2 L/day), unless contraindicated.
Maintaining nutrition
Patients with shortness of breath and fatigue often have a decreased appetite and will take only fluids.
Fluids with electrolytes (commercially available drinks, such as Gatorade) may help provide fluid,
calories, and electrolytes. Other nutritionally enriched drinks or shakes may be helpful. In addition,
fluids and nutrients may be administered intravenously if necessary.
Promoting the patient’s knowledge
 The patient and family are instructed about the cause of pneumonia, management of symptoms
of pneumonia, and the need for follow-up (discussed later).
 The patient also needs information about factors (both patient risk factors and external factors)
that may have contributed to developing pneumonia and strategies to promote recovery and to
prevent recurrence. If hospitalized for treatment, the patient is instructed about the purpose and
importance of management strategies that have been implemented and about the importance of
adhering to them during and after the hospital stay.
 Explanations need to be given simply and in language that the patient can understand. If
possible, written instructions and information should be provided. Because of the severity of
symptoms, the patient may require that instructions and explanations be repeated several times.
Monitoring and managing potential complications
 Continuing Symptoms After Initiation of Therapy Patients usually begin to respond to treatment
within 24 to 48 hours after antibiotic therapy is initiated.
 The patient is observed for response to antibiotic therapy.
 The patient is monitored for changes in physical status (deterioration of condition or resolution
of symptoms) and for persistent recurrent fever, which may be due to medication allergy
(signaled possibly by a rash); medication resistance or slow response (greater than 48 hours) of
 the susceptible organism to therapy; superinfection; pleural effusion; or pneumonia caused by an
unusual organism, such as P. carinii or Aspergillus fumigatus.
 Failure of the pneumonia to resolve or persistence of symptoms despite changes on the chest x-
ray raises the suspicion of other underlying disorders, such as lung cancer. As described earlier,
lung cancers may invade or compress airways, causing an obstructive atelectasis that may lead to
a pneumonia.
 In addition to monitoring for continuing symptoms of pneumonia, the nurse also monitors for
other complications, such as shock and multisystem failure, atelectasis, pleural effusion, and
superinfection, which may develop during the first few days of antibiotic treatment.
Shock and Respiratory Failure
The nurse assesses for signs and symptoms of shock and respiratory failure by evaluating the patient’s
vital signs, pulse oximetry values, and hemodynamic monitoring parameters.
The nurse reports signs of deteriorating patient status and assists in administering intravenous fluids and
medications prescribed to combat shock.
Intubation and mechanical ventilation may be required if respiratory failure occurs.
Atelectasis and Pleural Effusion
The patient is assessed for atelectasis, and preventive measures are initiated to prevent its development.
If pleural effusion develops and thoracentesis is performed to remove fluid, the nurse assists in the
procedure and explains it to the patient. After thoracentesis, the nurse monitors the patient for
pneumothorax or recurrence of pleural effusion. If a chest tube needs to be inserted, the nurse monitors
the patient’s respiratory status
Superinfection
The patient is monitored for manifestations of superinfection (ie, minimal improvement in signs and
symptoms, rise in temperature with increasing cough, increasing fremitus and adventitious breath sounds
on auscultation of the lungs). These signs are reported, and the nurse assists in implementing therapy to
treat superinfection.
Confusion
The patient with pneumonia is assessed for confusion and other more subtle changes in cognitive status.
Confusion and changes in cognitive status resulting from pneumonia are poor prognostic signs.
Confusion may be related to hypoxemia, fever, dehydration, sleep deprivation, or developing sepsis. The
patient’s underlying comorbid conditions may also play a part in the development of confusion.
Addressing the underlying factors and ensuring the patient’s safety are important nursing interventions.
Promoting home and community-based care
 Teaching Patients Self-Care Depending on the severity of the pneumonia, treatment may occur in
the hospital or in the outpatient setting.
 Patient education is crucial regardless of the setting, and the proper administration of antibiotics
is important. In some instances, the patient may be initially treated with intravenous antibiotics
as an inpatient and then be discharged to continue the intravenous antibiotics in the home setting.
It is important that a seamless system of care be maintained for the patient from hospital to
home; this includes communication between the nurses caring for this patient in both settings. In
addition, if oral antibiotics are prescribed, it is important to teach the patient about their proper
administration and potential side effects.
 After the fever subsides, the patient may gradually increase activities. Fatigue and weakness may
be prolonged after pneumonia, especially in the elderly.
 The nurse encourages breathing exercises to promote secretion clearance and volume expansion.
  It is important to instruct the patient to return to the clinic or caregiver’s office for a follow-up
chest x-ray and physical examination. Often improvement in chest x-ray findings lags behind
improvement in clinical signs and symptoms.
 The nurse encourages the patient to stop smoking. Smoking inhibits tracheobronchial ciliary
action, which is the first line of defense of the lower respiratory tract. Smoking also irritates the
mucous cells of the bronchi and inhibits the function of alveolar macrophage (scavenger) cells.
 The patient is instructed to avoid stress, fatigue, sudden changes in temperature, and excessive
alcohol intake, all of which lower resistance to pneumonia.
 The nurse reviews with the patient the principles of adequate nutrition and rest, because one
episode of pneumonia may make the patient susceptible to recurring respiratory tract infections.
 Continuing Care Patients who are severely debilitated or who cannot care for themselves may
require referral for home care. During home visits, the nurse assesses the patient’s physical
status, monitors for complications, assesses the home environment, and reinforces previous
teaching.
 The nurse evaluates the patient’s adherence to the therapeutic regimen (ie, taking medications as
prescribed, performing breathing exercises, consuming adequate fluid and dietary intake, and
avoiding smoking, alcohol, and excessive activity).
 The nurse stresses to the patient and family the importance of monitoring for complications.
 The nurse encourages the patient to obtain an influenza vaccine at the prescribed times, because
influenza increases susceptibility to secondary bacterial pneumonia, especially that caused by
staphylococci, H. influenzae, and S. pneumoniae.
 The nurse also encourages the patient to seek medical advice about receiving the vaccine
(Pneumovax) against S. pneumonia.

Prevention measures

 Promote coughing and expectoration of secretions.

 Encourage smoking cessation.
 Initiate special precautions against infection.
 Encourage smoking cessation.
 Reposition frequently and promote lung expansion exercises and coughing.
 Initiate suctioning and chest physical therapy if indicated.
 Reposition frequently to prevent aspiration and administer medications judiciously,
particularly those that increase risk for aspiration.
 Perform suctioning and chest physical therapy if indicated.
 Promote frequent oral hygiene.
 Minimize risk for aspiration by checking placement of tube and proper positioning of
patient.
 Encourage reduced or moderate alcohol intake (in case of alcohol stupor, position patient
to prevent aspiration).
 Observe the respiratory rate and depth during recovery from general anesthesia and
before giving medications. If respiratory depression is apparent, withhold the medication
and contact the physician.
 Promote frequent turning, early ambulation and mobilization, effective coughing,
breathing exercises, and nutritious diet.
 Make sure that respiratory equipment is cleaned properly; participate in continuous
quality improvement monitoring with the respiratory care department.