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Definition:Pneumonia is an inflammatory process, involving the terminal airways and alveoli of the lung, caused by infectious agents (Table 9-1). It is classified according to its causative agent.

Path physiology / Etiology:1. The organism gains access to the lungs through aspiration of oropharyngeal contents, by inhalation of respiratory secretions from infected individuals, via the bloodstream, or from direct spread to the lungs from surgery or trauma. 2. Patients with bacterial pneumonia may have an underlying disease that

impairs host defense; pneumonia arises from endogenous flora of the person whose resistance has been altered, or from aspiration of oropharyngeal secretions. a. Immunocompromised patients include those receiving corticosteroids

or immunosuppressants, those with cancer, those being treated with chemotherapy or radiotherapy, those undergoing organ transplantation, alcoholics, intravenous (IV) drug abusers, and those with human immunodeficiency virus (HIV) disease and acquired immunodeficiency syndrome (AIDS). b. infection. c. Infectious agents include aerobic and anaerobic gram-negative bacilli, These people have an increased chance of developing overwhelming

Staphylococcus, Nocardia, fungi, Candida, viruses such as cytomegalovirus (CMV), Pneumocystis carinii, reactivation of tuberculosis, and others. 3. When bacterial pneumonia occurs in a healthy person, there usually is

a history of preceding viral illness. 4. Other predisposing factors include conditions interfering with normal

drainage of the lung such as tumor, general anesthesia and postoperative immobility, depression of the central nervous system from drugs, neurologic disorders, or other conditions, and intubation or respiratory instrumentation.

5. a.

Pneumonia may be divided into three groups: Community-acquired, due to a number of organisms, including

Streptococcus pneumoniae. b. Hospital or nursing home acquired (nosocomial), due primarily to

gram-negative bacilli and staphylococci. c. 6. Pneumonia in the immunocompromised person. Persons over 65 have a high mortality rate, even with appropriate

antimicrobial therapy.

Recurring pneumonia often indicates underlying disease such as cancer of the lung or multiple myeloma.

Clinical Manifestations
(For most common forms of bacterial pneumonia.) 1. Sudden onset; shaking chill; rapidly rising fever of 39.5° to 40.5°C.

(101° to 105°F) 2. 3. 4. Cough productive of purulent sputum. Pleuritic chest pain aggravated by respiration/coughing. Tachypnea accompanied by respiratory grunting, nasal flaring, use of

accessory muscles of respiration. 5. Rapid, bounding pulse.

Diagnostic Evaluation
1. 2. Chest x-ray to show presence/extent of pulmonary disease. Gram’s stain, culture, and sensitivity studies of sputum—may indicate

offending organism.


Blood culture to detect bacteremia (bloodstream invasion) occurring

with bacterial pneumonia. 4. and urine. Immunologic test for detecting microbial antigens in serum, sputum,

1. Antimicrobial therapy—depends on laboratory identification of causative organism and sensitivity to specific antimicrobials. 2. Oxygen therapy if patient has inadequate gas exchange.

1. 2. Pleural effusion. Sustained hypotension and shock, especially in gram-negative bacterial

disease, particularly in the elderly. 3. 4. 5. 6. Superinfection: pericarditis, bacteremia, meningitis. Delirium—this is considered a medical emergency. Atelectasis—due to mucous plugs. Delayed resolution.

Nursing Assessment
1. a. b. c. d. 2. Take a careful history to help establish etiologic diagnosis. History of recent respiratory illness? Mode of onset? Presence of fever, chills, chest pain? Any family illness? Medications? Alcohol, tobacco, or IV drug use? Observe for anxious, flushed appearance, shallow respirations,

splinting of affected side, confusion, disorientation. 3. Auscultate for crackles overlying affected region, and for bronchial

breath sounds when consolidation (filling of airspaces with exudate) is present.

Nursing Diagnoses
A. Impaired gas exchange related to decreased ventilation secondary to inflammation and infection involving distal airspaces B. secretions C. Pain related to inflammatory process and dyspnea Ineffective airway clearance related to excessive tracheobronchial

Nursing Interventions
A. Improving Gas Exchange 1. Observe for cyanosis, dyspnea, hypoxia, and confusion, indicating

worsening condition. 2. therapy. 3. Administer oxygen at concentration to maintain PaO2 at acceptable Follow ABGs to determine oxygen need and response to oxygen

level—hypoxemia may be encountered because of abnormal ventilation–perfusion ratios in affected lung segments. 4. Avoid high concentrations of oxygen in patients with COPD; use of

high oxygen concentrations may worsen alveolar ventilation by removing the patient’s only remaining ventilatory drive. 5. Place patient in a fairly upright position to obtain greater lung

expansion to improve aeration.


Enhancing Airway Clearance 1. Obtain freshly expectorated sputum for Gram’s stain and culture, as

directed. Instruct the patient as follows: a. b. c. 2. Rinse mouth with water to minimize contamination by normal flora. Breathe deeply several times. Cough deeply and expectorate raised sputum into sterile container. Encourage patient to cough—retained secretions interfere with gas

exchange. Suction as necessary. 3. Encourage increased fluid intake, unless contraindicated, to thin mucus

and promote expectoration and replace fluid losses due to fever, diaphoresis, dehydration, and dyspnea. 4. ventilation. Humidify air or oxygen therapy to loosen secretions and improve


Employ chest wall percussion and postural drainage when appropriate

to loosen and mobilize secretions. 6. 7. Auscultate the chest for crackles. Administer cough suppressants when coughing is nonproductive,

debilitating, and when coughing paroxysms cause serious hypoxemia. C. Relieving Pleuritic Pain 1. Place in a comfortable position (semi-Fowler’s) for resting and

breathing; encourage frequent change of position to prevent pooling of secretions in lungs. 2. 3. 4. Demonstrate how to splint the chest while coughing. Avoid suppressing a productive cough. Administer prescribed analgesic agent to relieve pain. Avoid narcotics

in patients with a history of COPD.

Sedatives, narcotics, and cough suppressants are generally contraindicated in the elderly, because of their tendency to suppress cough and gag reflexes and respiratory drive.

Restlessness, confusion, aggressiveness may be due to cerebral hypoxia. In such instances, sedatives are inappropriate. 5. 6. 7. 8. Apply heat and/or cold to chest as prescribed. Assist with intercostal nerve block for pain relief. Encourage modified bedrest during febrile period. Watch for abdominal distention or ileus, which may be due to

swallowing of air during intervals of severe dyspnea. Insert a nasogastric or rectal tube as directed.


Monitoring for Complications


Remember that fatal complications may develop during the early

period of antimicrobial treatment. 2. Monitor temperature, pulse, respiration, and blood pressure at regular intervals to assess the patient’s response to therapy. 3. Listen to lungs and heart. Heart murmurs or friction rub may indicate

acute bacterial endocarditis, pericarditis, or myocarditis. 4. conditions: a. Alcoholism, COPD, immunosuppression; these persons, as well as Employ special nursing surveillance for patients with the following

elderly patients, may have little or no fever. b. Chronic bronchitis; it is difficult to detect subtle changes in condition,

because the patient may have seriously compromised pulmonary function. c. d. Epilepsy—pneumonia may result from aspiration after a seizure. Delirium, which may be caused by hypoxia, meningitis, delirium

tremens of alcoholism. (1) (2) (3) (4) 5. Prepare for lumbar puncture; meningitis may be lethal. Ensure adequate hydration and give mild sedation. Give oxygen. Delirium must be controlled to prevent exhaustion and cardiac failure. Assess these patients for unusual behavior, alterations in mental status,

stupor, and congestive heart failure. 6. Assess for resistant fever or return of fever, indicating bacterial

resistance to antibiotics.

Patient Education/Health Maintenance
1. Advise patient that fatigue, weakness, and depression may be prolonged after pneumonia. 2. Encourage chair rest after fever subsides; gradually increase activities

to bring energy level back to preillness stage. 3. Encourage breathing exercises to clear lungs and promote full

expansion and function after the fever subsides. 4. Explain that a chest x-ray is taken 4 to 6 weeks after recovery to

evaluate lungs for clearing and detect any tumor or underlying cause.








tracheobronchial cilial action, which is the first line of defense of lungs; also irritates mucosa of bronchi and inhibits function of alveolar scavenger cells (macrophages). 6. Advise the patient to keep up natural resistance with good nutrition,

adequate rest—one episode of pneumonia may make the individual susceptible to recurring respiratory infections. 7. Instruct the patient to avoid fatigue, sudden extremes in temperature,

and excessive alcohol intake, which lower resistance to pneumonia. 8. Encourage the yearly influenza immunization and immunization for S.

pneumoniae, if indicated, a major cause of bacterial pneumonia. 9. Advise avoidance of contact with people who have upper respiratory

infections for several months after pneumonia and resolves.

A. B. C. Cyanosis and dyspnea reduced; ABGs improved Coughing effectively; absence of crackles Appears more comfortable; free of pain

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