Pneumonia Nursing CE Course

1.0 ANCC Contact Hours AACN Category A

Syllabus

Objectives

Upon completion of the CE activity, learners will be able to:

  1. Describe the pathophysiology and define types of pneumonia.
  2. Define the chief clinical manifestations, risk factors and preventive measures of pneumonia.
  3. Discuss the most common diagnostic tests related to pneumonia.
  4. Identify prevalence and significance of pneumonia across the life span.
  5. Articulate client care interventions to manage pneumonia.

This course is designed to help healthcare providers recognize and provide care for a client diagnosed with pneumonia effectively. 

Pneumonia is an inflammatory process in the lungs that produces excess fluid. Pneumonia is triggered by infectious organisms or by the aspiration of an irritant such as fluid or foreign object. The inflammatory process in the lung parenchyma results in edema and exudate that fills that alveoli. Pneumonia can be a primary disease or a complication of another disease or condition. It affects people of all ages, but young clients, older adult clients, and clients who are immunocompromised are more susceptible. Immobility is a contributing factor in the development of pneumonia (Hinkle & Cheever, 2018).

The acute infection of the lung parenchyma impairs gas exchange. Pneumonia may be caused by various microorganisms, including mycobacteria, bacteria, viruses, protozoa, and fungi.  Pneumonia may be classified by etiology, location in the lungs, or type of microorganisms. It could be also classified as community-acquired, health care-associated, hospital-acquired (nosocomial), ventilator associated, and aspiration pneumonia; also, as pneumonia that occurs in an immunocompromised host (Hinkle & Cheever, 2018). 

Incidence

In the United States between 2 to 5 million cases of pneumonia occur annually. Incidence and mortality rates are highest in elderly patients. In 2016, the number of visits to emergency departments with pneumonia as the primary diagnosis were 257,000. In 2016, the number of deaths due to pneumonia in U.S. were 48,632 (USDHHS, 2017b). Additionally, community acquired pneumonia is the infectious disease with the highest number of deaths worldwide (Pletz, Rohde, Welte, Kolditz, & Ott, 2016).

Anatomy and Physiology

The airway structures permit air to enter and provide adequate oxygenation and tissue perfusion. In pneumonia, the infectious organism enters the upper airway and multiplies in the epithelium, then spreads to the lungs via secretions or the blood. A gel-like substance forms within the lower airway structures such as bronchi, bronchioles, and alveoli as microorganisms and phagocytic cells fight against each other. Inflammation occurs within the alveoli, alveolar ducts, and interstitial spaces surrounding the alveolar walls. In lobar pneumonia, inflammation starts in one of the five lobes of the lungs and may extend to one or more additional lobes. In bronchopneumonia, it starts simultaneously in several areas, producing patchy, diffuse consolidation. In atypical pneumonia, inflammation is confined to the alveolar ducts and interstitial spaces (Lippincott Advisor for Education, 2019). 

Pneumonia affects both ventilation and diffusion. Areas of the lung are not adequately ventilated because of secretions and mucosal edema that cause partial occlusion of the bronchiole or alveoli, with a decrease in alveolar oxygen tension. Because of hypoventilation, a ventilation-perfusion (V/Q) mismatch occurs in the affected areas of the lung. An inflammatory reaction can occur in the alveoli, producing an exudate that interferes with the diffusion of oxygen and carbon dioxide. Venous blood entering the pulmonary circulation passes through poorly ventilated areas and travels to the left side of the heart poorly oxygenated. Poorly oxygenated blood eventually results in arterial hypoxemia (Hinkle & Cheever, 2018). 

Differentiation of Different Types of Pneumonia 

The National Heart, Lung, and Blood Institute (NHLBI) lists the following types of based on how and where it originated:

  • Community-acquired: Could be caused by bacteria or viruses; contracted outside of a healthcare setting in the community.
  • Healthcare –associated: Onset occurred less than 48 hours after admission to the hospital. 
  • Hospital-acquired: Onset occurred greater than 48 hours after admission to the hospital.
  • Ventilator-associated: Onset occurred with 48-72 hours after endotracheal intubation (USDHHS, 2018). 

Chief Clinical Manifestations 

The nurse, in evaluating a patient with suspected pneumonia, should be aware of common signs and symptoms. These include:

  • Anxiety.
  • Fatigue.
  • Weakness.
  • Chest discomfort due to coughing.
  • Confusion (most common symptom in older adults).
  • Fever.
  • Chills.
  • Flushed face.
  • Diaphoresis.
  • Difficulty breathing.
  • Tachypnea.
  • Sharp, pleuritic chest pain.
  • Purulent, blood-tinged, green, or yellow sputum production.
  • Crackles and wheezes.
  • Dull chest percussion over areas of consolidation.
  • Decreased oxygen saturation level (Lippincott Advisor for Education, 2019).

Risk Factors 

The American Lung Association (ALA, 2019) lists the following risk factors for pneumonia:

  • Advanced age.
  • Debilitation.
  • Nasogastric (NG) tube feedings aspiration.
  • Aspiration related to impaired gag reflex.
  • Poor oral hygiene.
  • Decreased level of consciousness.
  • Immobility.
  • History of smoking.
  • Close living quarters (Mycoplasma pneumonia). 
  • Multiple medical comorbidities.
  • Residency in a long-term care facility.
  • Recent or overuse of broad-spectrum antibiotic therapy. 
  • Prolonged intubation. 
  • General anesthesia.
  • Transmission of organism from health care providers. 
  • Alcoholism.
  • Immunosuppressive therapy.
  • Exposure to a child who attends a daycare setting (ALA, 2019).

Preventive Measures

Pneumonia can sometimes be prevented with certain preventive actions. For example, urge bedridden and postoperative patients to perform coughing and diaphragmatic breathing exercises frequently. Position these patients properly to promote full aeration and secretion drainage. Advise patients to avoid using antibiotics indiscriminately for minor infections. Doing so could produce upper airway colonization with antibiotic-resistant bacteria. If pneumonia develops, the causative organisms may require treatment with more toxic antibiotics. Take steps to prevent aspiration during NG feedings; if the patient has aspiration pneumonia due to difficulty swallowing, institute aspiration precautions (Lippincott Advisor for Education, 2019).

The nurse should encourage high-risk patients to obtain an annual influenza vaccination and pneumococcal pneumonia vaccination if appropriate. Annual influenza vaccine helps to prevent flu which in turn helps to prevent pneumonia. Further, there are two pneumonia vaccines available, pneumococcal polysaccharide (PPSV23) and pneumococcal conjugate vaccine (PCV13). The pneumococcal conjugate vaccine (PCV13 or Prevnar 13®) protects against 13 types of pneumococcal bacteria. The Centers for Disease Control and Prevention (CDC) recommends PCV13 for use in infants and young children and adults 65 years or older. Older children and adults younger than 65 years old who are at increased risk for getting pneumococcal disease may also need a dose of PCV13. Before the vaccine, there were about 700 cases of meningitis, 13,000 bloodstream infections, and 200 deaths from pneumococcal disease each year among children younger than 5 years old. After children started getting this vaccine, these numbers dropped drastically. The pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax®) protects against 23 types of pneumococcal bacteria. CDC recommends it for all adults 65 years or older (USDHHS, 2017a).

The nurse can also help patients with secondary prevention measures by discussing ways to avoid spreading the infection to others. The nurse should remind patients to sneeze and cough into tissues and to dispose of tissues in a plastic bag. The nurse should also advise patients to perform hand hygiene regularly, especially after handling contaminated tissues (Lippincott Advisor for Education, 2019).

Diagnostic Tests 

The diagnosis of pneumonia is made by history (recent respiratory tract infection), physical examination, chest x-ray, blood culture, and sputum examination. in the setting of pneumonia, chest x-ray may show consolidation of lung tissue, and pulse ox may show hypoxemia. The next critical step to diagnosing pneumonia is a sputum specimen collection. The sputum sample is obtained by having patients do the following: (1) rinse the mouth with water to minimize contamination by normal oral flora, (2) breathe deeply several times, (3) cough deeply, and (4) expectorate the raised sputum into a sterile container. Sputum may also be obtained by nasotracheal or orotracheal suctioning or bronchoscopy. Bronchoscopy or transtracheal aspiration specimens should be obtained in patients with acute severe infection, chronic or refractory infections, and in mechanically ventilated patients. Sputum culture and sensitivity is usually obtained before starting antibiotics therapy. In the setting of pneumonia, elevated WBC count (may not be present in older adult client), and abnormal serum electrolytes are often present due to dehydration (Lippincott Advisor for Education, 2019). 

Treatment 

The treatment of pneumonia includes: (1) positioning client in a semi to high fowler’s position to maximize ventilation and prevent further fatigue, (2) encouraging coughing  diaphragmatic breathing exercises, and incentive spirometry; if the patient has copious secretions, perform chest physiotherapy, (3) administering breathing treatments and medications such as antibiotics, bronchodilators, and anti-inflammatories as prescribed, (4) auscultating lung sounds regularly to monitor for adventitious breath sounds such as crackles and wheezes, (5) encouraging and assisting with early mobilization, (6) providing a high-calorie, high-protein diet to fight against infection, (7) providing a quiet, calm environment with frequent rest periods; clustering activities to minimize energy expenditure and decrease oxygen demand, (8) giving supplemental oral feedings; if the patient can't ingest foods and fluids orally, anticipate enteral tube feedings or parenteral nutrition, if needed, and (9) applying antiembolism stockings or sequential compression stockings to prevent venous thromboembolism (VTE). It is critical to include the patient in care decisions whenever possible, allowing the verbalization of feelings and concerns; provide emotional support; and assist the patient in anxiety-reduction techniques and the use of positive coping strategies. The nurse should promote adequate hydration (two to three liters/day) unless contraindicated due to another condition such as renal failure or congestive heart failure (USDHHS, 2018; Lippincott Advisor for Education, 2019). 

Pneumonia treatment also involves certain multidisciplinary interventions. For example, respiratory services need to be consulted for inhalers, breathing treatments, suctioning, and chest physiotherapy. Providers will prescribe antibiotics (targeted at specific pathogen as soon as known), such as clarithromycin (Biaxin), azithromycin (Zithromax), doxycycline (Vibramycin), levofloxacin (Levaquin), or moxifloxacin hydrochloride (oral; injection) (Avelox) may be ordered for bacterial pneumonia. Further, erythromycin (E.E.S.), clarithromycin (Biaxin), or azithromycin (Zithromax) are often used for Mycoplasma pneumonia.  Additionally, piperacillin sodium-tazobactam sodium (Zosyn), imipenem-cilastatin sodium (Primaxin), clindamycin phosphate (injection) (Cleocin), or metronidazole hydrochloride (Flagyl) and a respiratory fluoroquinolone and ceftriaxone sodium (Rocephin) are common treatments for aspiration pneumonia. Pneumonia may cause cough which needs to be treated by antitussives such as dextromethorphan and benzonatate. Analgesics and antipyretics, such as acetaminophen (Tylenol), or nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil) are used to treat body aches caused by pneumonia. Bronchodilators, such as albuterol sulfate (AccuNeb), may be given for wheezing. Lastly, intravenous fluids may be prescribed to maintain hydration in pneumonia patients. (Lippincott Advisor for Education, 2019). 

Future Research/Directions

Community acquired pneumonia is the infectious disease with the highest number of deaths worldwide. Nevertheless, the importance of this disease is often underestimated. The challenge for the future is to implement current knowledge into clinical practice to reduce the number of community acquired pneumonia cases by vaccination, and the number of deaths by adequate diagnostics and treatment. National and international societies should establish community acquired pneumonia audits to oversee management and to give clinicians constructive feedback about their daily clinical practice (Pletz et al., 2016). 

Case Study 1: 

A 67-year-old male patient is admitted to the medical-surgical unit with the diagnosis of acute community-acquired pneumonia. The patient smoked two packs per day of cigarettes for 55 years and quit five years ago. The patient has a history chronic obstructive pulmonary disease, and diabetes controlled with insulin. 

The patient presents with confusion as to time and place, which his family states is a new change for him. The admission vital signs are as follows: 

  • Blood pressure: 92/54 mm Hg, 
  • Heart rate: 110 bpm, 
  • Respiratory rate: 26 breaths/min, 
  • Temperature: 102.5°F,
  • Pulse oximeter on room air: 86%. 

The CBC is as follows: 

  • White blood cell count (WBC): 12,000, 
  • Platelets 250,000, 
  • Hematocrit (HCT): 30%,
  • Hemoglobin (Hgb): 10 g/dL. 

Chest x-ray results reveal right lower lobe consolidation, flattened diaphragm, and a small pleural effusion in the right lower lobe. Arterial blood gases show: 

  • pH 7.28, 
  • Partial pressure of oxygen (PaO2): 50, 
  • Partial pressure of carbon dioxide (PaCO2): 55, 
  • Bicarbonate (HCO3): 24. 

Lung auscultation by the nurse reveals crackles and expiratory wheezes with severely diminished breath sounds in the right lower lobe. The patient complains of fatigue, shortness of breath and dyspnea on exertion. The nurse notes that the patient becomes extremely diaphoretic while ambulating to the bathroom and pulse oximetry decreases from 86% to 82% on room air. The patient’s nail beds indicate clubbing and capillary refill is sluggish. The patient is using accessory muscles and attempts to cough weakly, but he does not raise any sputum (Hinkle & Cheever, 2018). 

  1. What nursing assessment findings support the diagnosis of pneumonia?
  2. What diagnostic findings support the diagnosis of pneumonia?
  3. Write three priority nursing diagnoses for the patient?
  4. What overall interventions and teaching should the nurse provide?

Case 1 Answers: 

  1. What nursing assessment findings support the diagnosis of pneumonia?

Confusion

Low Blood Pressure

High Heart Rate

High Respiratory Rate

Wheezing

Crackles

Diminished Lung Sounds

Low Oxygen Saturation

Fever

Weak Cough

Shortness of breath

Nail Clubbing

Sluggish Capillary Refill

Dyspnea on Exertion

  1. What diagnostic test findings support the diagnosis of pneumonia?

Elevated WBCs

Chest x-ray results reveal right lower lobe consolidation, flattened diaphragm, and a small              pleural effusion in the right lower lobe. 

  1. Write three priority nursing diagnoses for the patient?
  1. Ineffective airway clearance related to weak cough
  1. Impaired gas exchanged related to Pneumonia
  1. Ineffective breathing pattern related to Pneumonia
  1. What overall interventions and teaching should the nurse provide?
  1. Maintain and protect airway 
  • Elevate head of bed to semi-Fowler or high fowler's to promote oxygenation.
  • Apply warm, humidified oxygen and titrate as ordered. 
  • Monitor pulse oximetry and arterial blood gases
  • Assess and monitor continuously respiratory rate, rhythm, and regularity, and status for response. 
  • Reduce respiratory secretions via breathing treatments (bronchodilators) and nasal/oral suctioning if patient is unable to cough out secretions. 
  • Monitor the sputum for amount, color, odor, and consistency.
  • Encourage use of incentive spirometer every hour and assess effectiveness by auscultating lung sounds. 
  1. Obtain cultures as ordered before beginning antibiotics. The cultures may include blood and sputum cultures. Administer antibiotics full course per prescription to treat pneumonia. Administer IV fluids per prescription. Encourage the patient to consume oral fluids (two to three liters/day) unless contraindicated to maintain adequate fluid and electrolyte status. Monitor intake and output. 
  1. Place patient on high calorie and protein diabetic diet. Provide oral care after each meal and at bed time. 
  1. Encourage ambulation so bodily secretions can mobilize unless contraindicated by another condition.
  1. Provide antipyretic/analgesic as ordered for fever.
  1. Report abnormal physical findings, laboratory results, and diagnostic test results to the physician and receive orders.
  1. Provide patient/family education on ways to decrease their risk for pneumonia, which includes proper handwashing, adequate nutrition, annual influenza immunization, pneumococcal immunization, and avoiding persons with upper respiratory infections or crowds in the winter months.

References

American Lung Association. (2019). Lung Health and Diseases. Retrieved from https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/pneumonia/what-causes-pneumonia.html

Hinkle, J.L., & Cheever, K.H. (2018). Management of patients with chest and lower respiratory tract disorders. In Brunner & Suddarth (14th Eds.), Textbook of Medical-Surgical Nursing (pp. 583-633). Philadelphia, PA: Wolters Kluwer. 

Lippincott Advisor for Education. (2019). Pneumonia. Retrieved from https://advisor-edu.lww.com/lna/document.do?did=737990

Pletz, M. W., Rohde, G. G., Welte, T., Kolditz, M., & Ott, S. (2016). Advances in the prevention, management, and treatment of community-acquired pneumonia. F1000Research, 5, F1000 Faculty Rev-300. doi:10.12688/f1000research.7657.1

US Department of Health and Human Services (USDHHS), The Center for Disease Control and Prevention (CDC). (2017a). Pneumococcal Disease. Retrieved from https://www.cdc.gov/pneumococcal/vaccination.html

US Department of Health and Human Services (USDHHS), The Centers for Disease Control and Prevention (CDC). (2017b). Pneumonia Facts. Retrieved from https://www.cdc.gov/nchs/fastats/pneumonia.htm

US Department of Health and Human Services (USDHHS), National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI). (2018). Pneumonia. Retrieved from https://www.nhlbi.nih.gov/health-topics/pneumonia