A nurse is assessing a client who has bacterial pneumonia

Pneumonia is an infection of one or both of the lungs caused by bacteria, viruses, or fungi. It is a serious infection in which the air sacs fill with pus and other liquid.

• Lobar pneumonia affects one or more sections (lobes) of the lungs.

• Bronchial pneumonia (also known as bronchopneumonia) affects patches throughout both lungs.

What causes pneumonia?

There are more than 30 different causes of pneumonia, and they’re grouped by the cause. The main types of pneumonia are:

• Bacterial pneumonia. This type is caused by various bacteria. The most common is Streptococcus pneumoniae. It usually occurs when the body is weakened in some way, such as by illness, poor nutrition, old age, or impaired immunity, and the bacteria are able to work their way into the lungs. Bacterial pneumonia can affect all ages, but you are at greater risk if you abuse alcohol, smoke cigarettes, are debilitated, have recently had surgery, have a respiratory disease or viral infection, or have a weakened immune system.

• Viral pneumonia. This type is caused by various viruses, including the flu (influenza), and is responsible for about one-third of all pneumonia cases. You may be more likely to get bacterial pneumonia if you have viral pneumonia.

• Mycoplasma pneumonia. This type has somewhat different symptoms and physical signs and is referred to as atypical pneumonia. It is caused by the bacterium Mycoplasma pneumoniae. It generally causes a mild, widespread pneumonia that affects all age groups.

• Other pneumonias. There are other less common pneumonias that may be caused by other infections including fungi.

Who is at risk for pneumonia?

Anyone can get pneumonia. However, the following groups are at the highest risk:

• Adults ages 65 and older

• Children younger than age 2

• People with certain medical conditions

• People that smoke

What are the symptoms of pneumonia?

The symptoms of bacterial pneumonia include:

• Bluish color to lips and fingernails

• Confused mental state or delirium, especially in older people

• Cough that produces green, yellow, or bloody mucus

• Fever

• Heavy sweating

• Loss of appetite

• Low energy and extreme tiredness

• Rapid breathing

• Rapid pulse

• Shaking chills

• Sharp or stabbing chest pain that’s worse with deep breathing or coughing

• Shortness of breath that gets worse with activity

Early symptoms of viral pneumonia are the same as those of bacterial pneumonia, which may be followed by:

• Headache

• Increasing shortness of breath

• Muscle pain

• Weakness

• Worsening of the cough

Mycoplasma pneumonia has somewhat different symptoms, which include a severe cough that may produce mucus.

How is pneumonia diagnosed?

Diagnosis is usually made based on your recent health history (such as surgery, a cold, or travel exposures) and the extent of the illness. Based on these factors, your healthcare provider may diagnose pneumonia simply on a thorough history and physical exam. The following tests may be used to confirm the diagnosis:

• Chest X-ray. This test takes pictures of internal tissues, bones, and organs, including the lungs.

• Blood tests. This test may be used to see whether infection is present and if infection has spread to the bloodstream (blood cultures). Arterial blood gas testing checks the amount of oxygen in your bloodstream.

• Sputum culture. This test is done on the material that is coughed up from the lungs and into the mouth. It’s often used to see if there’s an infection in the lungs.

• Pulse oximetry. An oximeter is a small machine that measures the amount of oxygen in the blood. A small sensor is taped or clipped onto a finger. When the machine is on, a small red light can be seen in the sensor. The test is painless and the red light does not get hot.

• Chest CT scan. This imaging procedure uses a combination of X-rays and computer technology to produce sharp, detailed horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than regular X-rays.

• Bronchoscopy. This is direct exam of the bronchi (the main airways of the lungs) using a flexible tube (called a bronchoscope). It helps to evaluate and diagnose lung problems, assess blockages, and take out samples of tissue and/or fluid for testing,

• Pleural fluid culture. In this test, a sample of a fluid sample is taken from the pleural space. This is the space between the lungs and chest wall. A long, thin needle is put through the skin between the ribs and into the pleural space. Fluid is pulled into a syringe attached to the needle. It is sent to the lab where it’s tested to find out which bacteria is causing the pneumonia.

How is pneumonia treated?

Treatment depends on the type of pneumonia you have. Most of the time, pneumonia is treated at home, but severe cases may be treated in the hospital. Antibiotics are used for bacterial pneumonia. Antibiotics may also speed recovery from mycoplasma pneumonia and some special cases. Most viral pneumonias don’t have specific treatment. They usually get better on their own.

Other treatment may include eating well, increasing fluid intake, getting rest, oxygen therapy, pain medicine, fever control, and maybe cough-relief medicine if cough is severe.

Can pneumonia be prevented?

Check with your healthcare provider about getting immunizations. The flu is a common cause of pneumonia. Because of that, getting a flu shot every year can help prevent both the flu and pneumonia.

There is also a pneumococcal vaccine. It will protect you from a common form of bacterial pneumonia. Children younger than age 5 and adults ages 65 and older should get this shot.

The pneumococcal shot is also recommended for all children and adults who are at increased risk of pneumococcal disease due to other health conditions.

What are the complications of pneumonia?

Most people with pneumonia respond well to treatment, but pneumonia can be very serious and even deadly.

You are more likely to have complications if you are an older adult, a very young child, have a weakened immune system, or have a serious medical problem like diabetes or cirrhosis. Complications may include:

• Acute respiratory distress syndrome (ARDS). This is a severe form of respiratory failure.

• Lung abscesses. These are pockets of pus that form inside or around the lung. They may need to be drained with surgery

• Respiratory failure. This requires the use of a breathing machine or ventilator.

• Sepsis. This is when the infection gets into the blood. It may lead to organ failure.

Key points about pneumonia

• Pneumonia is an infection of one or both of the lungs caused by bacteria, viruses, or fungi.

• There are more than 30 different causes of pneumonia, and they’re grouped by the cause. The main types of pneumonia are bacterial, viral, and mycoplasma pneumonia.

• A cough that produces green, yellow, or bloody mucus is the most common symptom of pneumonia. Other symptoms include fever, shaking chills, shortness of breath, low energy, and extreme tiredness.

• Pneumonia can often be diagnosed with a thorough history and physical exam. Tests used to look at the lungs, blood tests, and tests done on the sputum you cough up may also be used.

• Treatment depends on the type of pneumonia you have. Antibiotics are used for bacterial pneumonia. It may also speed recovery from mycoplasma pneumonia and some special cases. Most viral pneumonias don’t have a specific treatment and just get better on their own. Other treatment may include a healthy diet, more fluids, rest, oxygen therapy, and medicine for pain, cough, and fever control.

• Most people with pneumonia respond well to treatment, but pneumonia can cause serious lung and infection problems. It can even be deadly.

Learn about the nursing care management of patients with pneumonia.

What is Pneumonia? 

Respiratory diseases are rampant today because it is easier spread in crowded areas. Pneumonia is one of the most common respiratory problems and it affects all stages of life.

• Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses.
• Pneumonitis is a more general term that describes the inflammatory process in the lung tissue that may predispose and place the patient at risk for microbial invasion.

Classification

Pneumonia is classified into four: community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP), pneumonia in the immunocompromised host, and aspiration pneumonia.

Community-Acquired Pneumonia

• CAP occurs either in the community setting or within the first 48 hours after hospitalization.
• The causative agents for CAP that needs hospitalization include streptococcus pneumoniae, H. influenza, Legionella, and Pseudomonas aeruginosa.
• Only in 50% of the cases does the specific etiologic agent become identified.
• Pneumonia is the most common cause of CAP in people younger than 60 years of age.
• Viruses are the most common cause of pneumonia in infants and children.

Hospital-Acquired Pneumonia

• HAP is also called nosocomial pneumonia and is defined as the onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission.
• HAP is the most lethal nosocomial infection and the leading cause of death in patients with such infections.
• Common microorganisms that are responsible for HAP include Enterobacter species, Escherichia coli, influenza, Klebsiella species, Proteus, Serratia marcescens, S. aureus, and S. pneumonia.
• The usual presentation of HAP is a new pulmonary infiltrate on chest x-ray combined with evidence of infection.

Pneumonia in the Immunocompromised Host

• Pneumonia in immunocompromised hosts includes Pneumocystis pneumonia, fungal pneumonias and Mycobacterium tuberculosis.
• Patients who are immunocompromised commonly develop pneumonia from organisms of low virulence.
• Pneumonia in immunocompromised hosts may be caused by the organisms also observe in HAP and CAP.

Aspiration Pneumonia

• Aspiration pneumonia refers to the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway.
• The most common form of aspiration pneumonia is a 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. pneumonia, H.influenza, and S. aureus.

Pathophysiology

Having an idea about the disease process helps the patient understand the treatment regimen and its importance, increasing patient compliance.

• Pneumonia arises from normal flora present in patients whose resistance has been altered or from aspiration of flora present in the oropharynx.
• An inflammatory reaction may occur in the alveoli, producing exudates that interfere with the diffusion of oxygen and carbon dioxide.
• White blood cells also migrate into the alveoli and fill the normally air-filled spaces.
• Due to secretions and mucosal edema, there are areas of the lung that are not adequately ventilated and cause partial occlusion of the alveoli or bronchi.
• Hypoventilation may follow, causing ventilation-perfusion mismatch.
• Venous blood entering the pulmonary circulation passes through the under ventilated areas and travels to the left side of the heart deoxygenated.
• The mixing of oxygenated and poorly oxygenated blood can result to arterial hypoxemia.

Epidemiology

Pneumonia has affected a lot of people, especially those who have a weak immune system. Learning statistics on pneumonia could give you an idea about how many has fallen victim to this respiratory disease.

• Pneumonia and influenza account for nearly 60,000 deaths annually.
• Pneumonia also ranks as the eighth leading cause of death in the United States.
• It is estimated that more than 915, 000 episodes of CAP occur in adults 65 years old and above in the United States.
• HAP accounts for 15% of hospital-acquired infections and is the leading cause of death in patients with such infections.
• The estimated incidence of HAP 4 to 7 episodes per 1000 hospitalizations.

Causes

Each type of pneumonia is caused by different and several factors.

Community-Acquired Pneumonia

• Streptococcus pneumoniae. This is the leading cause of CAP in people younger than 60 years of age without comorbidity and in those 60 years and older with comorbidity.
• Haemophilus influenzae.  This causes a type of CAP that frequently affects elderly people and those with comorbid illnesses.
• Mycoplasma pneumoniae. 

Hospital-Acquired Pneumonia

• Staphylococcus aureus. Staphylococcus pneumonia occurs through inhalation of the organism.
• Impaired host defenses. When the defenses of the body are down, several pathogens may invade the body.
• Comorbid conditions. There are several conditions that lower the immune system, causing bacteria to pool in the lungs and eventually result in pneumonia.
• Supine positioning. When the patient stays in a prolonged supine position, fluid in the lungs pools down and stays stagnant, making it a breeding place for bacteria.
• Prolonged hospitalization. The risk for hospital infections or nosocomial infections increases the longer the patient stays in the hospital.

Clinical Manifestations 

Pneumonia varies in its signs and symptoms depending on its type but it is not impossible to diagnose a specific pneumonia through its clinical manifestations.

• Rapidly rising fever. Since there is inflammation of the lung parenchyma, fever develops as part of the signs of an infection.
• Pleuritic chest pain. Deep breathing and coughing aggravate the pain in the chest.
• Rapid and bounding pulse. A rapid heartbeat occurs because the body compensates for the low concentration of oxygen in the body.
• Tachypnea. There is fast breathing because the body tries to compensate for the low oxygen concentration in the body.
• Purulent sputum. The sputum becomes purulent because of the infection in the lung parenchyma which produced sputum-filled with pus.

Prevention

It is better to prevent the occurrence of pneumonia instead of treating the disease itself. Here are several ways that can help prevent pneumonia.

• Pneumococcal vaccine. This vaccine can prevent pneumonia in healthy patients with an efficiency of 65% to 85%.
• Staff education. To help prevent HAP, the CDC (2004) encouraged staff education and involvement in infection prevention.
• Infection and microbiologic surveillance. It is important to carefully observe the infection so that there could be an appropriate application of prevention techniques.
• Modifying host risk for infection. The infection should never be allowed to descend on any host, so the risk must be decreased before it can affect one.

Complications

Pneumonia has several complications if left untreated or the interventions are inappropriate. These are the following complications that may develop in patients with pneumonia.

• Shock and respiratory failure. These complications are encountered chiefly in patients who have received no specific treatment and inadequate or delayed treatment.
• Pleural effusion. In pleural effusion, the fluid is sent to the laboratory for analysis, and there are three stages: uncomplicated, complicated, and thoracic empyema.

Assessment and Diagnostic Findings

Assessment and diagnosis of pneumonia must be accurate since there are a lot of respiratory problems that have similar manifestations. The following are assessments and diagnostic tests that could determine pneumonia.

• History taking. The diagnosis of pneumonia is made through history taking, particularly a recent respiratory tract infection.
• Physical examination. Mainly, the number of breaths per minute and breath sounds is assessed during physical examination.
• Chest x-ray. Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple abscesses/infiltrates, empyema (staphylococcus); scattered or localized infiltration (bacterial); or diffuse/extensive nodular infiltrates (more often viral). In mycoplasmal pneumonia, chest x-ray may be clear.
• Fiberoptic bronchoscopy. May be both diagnostic (qualitative cultures) and therapeutic (re-expansion of lung segment).
• ABGs/pulse oximetry. Abnormalities may be present, depending on extent of lung involvement and underlying lung disease.
• Gram stain/cultures. Sputum collection; needle aspiration of empyema, pleural, and transtracheal or transthoracic fluids; lung biopsies and blood cultures may be done to recover causative organism. More than one type of organism may be present; common bacteria include Diplococcus pneumoniae, Staphylococcus aureus, a-hemolytic streptococcus, Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures may not identify all offending organisms. Blood cultures may show transient bacteremia.
• CBC. Leukocytosis usually present, although a low white blood cell (WBC) count may be present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia. Erythrocyte sedimentation rate (ESR) is elevated.
• Serologic studies, e.g., viral or Legionella titers, cold agglutinins. Assist in differential diagnosis of specific organism.
• Pulmonary function studies. Volumes may be decreased (congestion and alveolar collapse); airway pressure may be increased and compliance decreased. Shunting is present (hypoxemia).
• Electrolytes. Sodium and chloride levels may be low.
• Bilirubin. May be increased.
• Percutaneous aspiration/open biopsy of lung tissues. May reveal typical intranuclear and cytoplasmic inclusions (CMV), characteristic giant cells (rubeola).

Medical Management

The management of pneumonia centers is a step-by-step process that zeroes on the treatment of the infection through identification of the causative agent.

• Blood culture. Blood culture is performed for identification of the causal pathogen and prompt administration of antibiotics in patients in whom CAP is strongly suspected.
• Administration of macrolides. Macrolides are recommended for people with drug-resistant S. pneumoniae.
• Hydration is an important part of the regimen because fever and tachypnea may result in insensible fluid losses.
• Administration of antipyretics. Antipyretics are used to treat fever and headache.
• Administration of antitussives. Antitussives are used for treatment of the associated cough.
• Bed rest. Complete rest is prescribed until signs of infection are diminished.
• Oxygen administration. Oxygen can be given if hypoxemia develops.
• Pulse oximetry. Pulse oximetry is used to determine the need for oxygen and to evaluate the effectiveness of the therapy.
• Aggressive respiratory measures. Other measures include administration of high concentrations of oxygen, endotracheal intubation, and mechanical ventilation.

Nursing Management

Nurses are expected to perform both dependent and independent functions for the patient to aid him or her towards the restoration of their well-being.

Nursing Assessment

Nursing assessment is critical in detecting pneumonia. Here are some tips for your nursing assessment for pneumonia.

• Assess respiratory symptoms. Symptoms of fever, chills, or night sweats in a patient should be reported immediately to the nurse as these can be signs of bacterial pneumonia.
• Assess clinical manifestations. Respiratory assessment should further identify clinical manifestations such as pleuritic pain, bradycardia, tachypnea, and fatigue, use of accessory muscles for breathing, coughing, and purulent sputum.
• Physical assessment. Assess the changes in temperature and pulse; amount, odor, and color of secretions; frequency and severity of cough; degree of tachypnea or shortness of breath; and changes in the chest x-ray findings.
• Assessment in elderly patients. Assess elderly patients for altered mental status, dehydration, unusual behavior, excessive fatigue, and concomitant heart failure.

Diagnosis

Through the data collected during assessment, the following nursing diagnoses are made:

Nursing Care Planning & Goals

Main article: Pneumonia Nursing Care Plans

Planning is essential to establish the interventions that are appropriate for the patient’s condition.

• Improve airway patency.
• Rest to conserve energy.
• Maintenance of proper fluid volume.
• Maintenance of adequate nutrition.
• Understanding of treatment protocol and preventive measures.
• Absence of complications.

Nursing Priorities

1.  Maintain/improve respiratory function.
2. Prevent complications.
3. Support recuperative process.
4. Provide information about disease process, prognosis, and treatment.

Nursing Interventions

These nursing interventions, if implemented appropriately, would result in the achievement of the goals of the management of pneumonia.

To improve airway patency:

• Removal of secretions. Secretions should be removed because retained secretions interfere with gas exchange and may slow recovery.
• Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions.
• Humidification may loosen secretions and improve ventilation.
• Coughing exercises. An effective, directed cough can also improve airway patency.
• Chest physiotherapy. Chest physiotherapy is important because it loosens and mobilizes secretions.

To promote rest and conserve energy:

• Encourage avoidance of overexertion and possible exacerbation of symptoms.
• Semi-Fowler’s position. The patient should assume a comfortable position to promote rest and breathing and should change positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion.

To promote fluid intake:

• Fluid intake. Increase in fluid intake to at least 2L per day to replace insensible fluid losses.

To maintain nutrition:

• Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
• Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also help restore proper nutrition.

To promote patient’s knowledge:

• Instruct patient and family about the cause of pneumonia, management of symptoms, signs, and symptoms, and the need for follow-up.
• Instruct patient about the factors that may have contributed to the development of the disease.

Evaluation

Expected patient outcomes include the following:

• Demonstrates improved airway patency.
• Rests and conserves energy by limiting activities and remaining in bed while symptomatic and then slowly increasing activities.
• Maintains adequate hydration.
• Consumes adequate dietary intake.
• States explanation for management strategies.
• Complies with management strategies.
• Exhibits no complications.
• Complies with treatment protocol and prevention strategies.

Discharge and Home Care Guidelines

Patient education is crucial regardless of the setting because self-care is essential in achieving a patient’s well-being.

• Oral antibiotics. Teach the patient about the proper administration, potential side effects, and symptoms to report.
• Breathing exercises. Teach the patient breathing exercises to promote secretion clearance and volume expansion.
• Follow-up check up. Strict compliance to follow-up checkups is important to check the latest chest x-ray result or physical examination findings.
• Smoking cessation. Smoking should be stopped because it inhibits tracheobronchial ciliary action and irritates the mucous cells of the bronchi. 

Documentation Guidelines

Documentation of data must be accurate and up-to-date to avoid unnecessary legal situations that might occur.

• Document breath sounds, presence and character of secretions, use of accessory muscles for breathing.
• Document character of cough and sputum.
• Document respiratory rate, pulse oximetry/O2 saturation, and vital signs.
• Document plan of care and who is involved in planning.
• Document client’s response to interventions, teaching, and actions performed.
• Document if there is use of respiratory devices or airway adjuncts.
• Document response to medications administered.
• Document modifications to plan of care.

Practice Quiz: Pneumonia

1. CAP occurs either in the community setting or within the first _____ hours after hospitalization.

A. 24. B. 48. C. 72.

D. 36.