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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$e Bacteria
H &aemophilus influen"a
H common cause of infection in children
H high mortality rate
H greenish colored sputum
H
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H most common gram negati$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$entilation(
Possi"ly e$i#ence# "y
Dyspnea! cyanosis
Tachycardia
RestlessnessEchanges in mentation
&ypo:ia
Desi!e# Outcomes
Demonstrate impro$ed $entilation and o:ygenation of tissues y #Bs within patient?s
acceptale range and asence of symptoms of respiratory distress.
Participate in actions to ma:imi"e o:ygenation.
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Nu!sin Inte!$entions Rationale
#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 $ital signs.
Nu!sin Inte!$entions Rationale
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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
Ris& facto!s may inclu#e
Increased metaolic needs secondary to fe$er and infectious process
#nore:ia associated with acterial to:ins! the odor and taste of sputum! and certain
aerosol treatments
#dominal distensionEgas associated with swallowing air during dyspneic episodes
Desi!e# Outcomes
Demonstrate increased appetite.
,aintainEregain desired ody weight.
Nu!sin Inte!$entions Rationale
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.
)$aluate general nutritional state! otain
aseline weight.
Presence of chronic conditions 'e.g.! COPD or
alcoholism( or financial limitations can
contriute to malnutrition! lowered resistance to
infection! andEor delayed response to therapy.
#cute Pain
Nu!sin Dianosis% Pain! acute
May "e !elate# to
Inflammation of lung parenchyma
Cellular reactions to circulating to:ins
Persistent coughing
Possi"ly e$i#ence# "y
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.
Nu!sin Inte!$entions Rationale
Determine pain characteristics! e.g.!
sharp! constant! staing. In$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
Possi"ly e$i#ence# "y
eral reports of wea+ness! fatigue! e:haustion
):ertional dyspnea! tachypnea
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Tachycardia in response to acti$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 $ital signs within patient?s acceptale range.
Nu!sin Inte!$entions Rationale
)$aluate patient?s response to acti$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$ery
phase. and demand.
,inimi"es e:haustion and helps alance o:ygen
supply and demand.
Ris+ for Infection
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Nu!sin Dianosis%Ris+ for Apread of Infection
Ris& facto!s may inclu#e
Inade4uate primary defenses 'decreased ciliary action! stasis of respiratory secretions(
Inade4uate secondary defenses 'presence of e:isting infection! immunosuppression(!
chronic disease! malnutrition
Desi!e# Outcomes
#chie$e timely resolution of current infection without complications.
Identify inter$entions to pre$entEreduce ris+Espread ofEsecondary infection.
Nu!sin Inte!$entions Rationale
,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.
Nu!sin Inte!$entions Rationale
Re$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!
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,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.