CRITICAL NURSING CARE PLAN FOR: Pneumonia



Pneumonia is an acute infection of the lung's terminal alveolar spaces and/or the interstitial tissues which results in gas exchange problems. The major challenge is identification of the source of the infection. Pneumonia ranks as the sixth most common cause of death in the United States.

When the infection is limited to a portion of the lung, it is known as segmental or lobular pneumonia; when the alveoli adjacent to the bronchioles are involved, it is known as bronchopneumonia, and when the entire lobe of the lung is involved, it is known as lobar pneumonia. Pneumonia may be caused by bacteria, viruses, mycoplasma, rickettsia’s, or fungi. The causative organism gains entry by aspiration of oropharyngeal or gastric contents, inhalation of respiratory droplets, from others who are infected, by way of the blood stream, or directly with surgery or trauma.

types of Pneumonia

Viral types are more common in some areas, but identification of causative organisms may be difficult with limited technology.
Patients who develop bacterial pneumonia usually are immunosuppressed or compromised by a chronic disease, or have had a recent viral illness.


The most common type of bacterial pneumonia is pneumococcal pneumonia, in which the organism reaches the lungs via the respiratory passageways and result in the collapse of alveoli. The inflammatory response that this generates causes protein-rich fluid to migrate into the alveolar spaces and provides culture media for the organism to proliferate and spread. Frequently pneumonia is predisposed by upper respiratory infections, chronic illness, cancer, surgery, atelectasis, chronic obstructive pulmonary disease, asthma, cystic fibrosis, bronchiectasis, influenza, malnutrition, smoking, alcoholism, immunosuppressive therapy, aspiration, sickle cell disease, head injury or coma.

Pneumonia pathway
Pathway Pneumonia

Aspiration pneumonia occurs after aspiration of gastric or oropharyngeal contents, or other chemical irritants into the trachea and lungs. Stomach acid damages the respiratory endothelium and may result in non-cardiogenic pulmonary edema, hemorrhage, destruction of surfactant-producing cells, and hypoxemia. The pH of the aspirated material determines the severity of the injury with pH less than 2.5 causing severe damage. Morbidity is high even with treatment.
In pneumonia's early stages, pulmonary vessels dilate and erythrocytes spread into the alveoli and cause a reddish, liver-like appearance, or red hepatization, in the lung consolidation area. Polymorphonuclear cells then enter the alveolar spaces and the consolidation increases to a grey hepatization. The leukocytes trap bacteria against the alveolar walls or other leukocytes so that more organisms are found in the increasing margins of the consolidation. The macrophage reaction occurs when mononuclear cells advance into the alveoli and phagocytize the exudate debris.
Diagnosis may be assisted with the observation of sputum characteristics, with bacterial pneumonia
having mucopurulent sputum, viral and mycoplasmic pneumonias having more watery secretions, pneumococcal pneumonia having rust-colored sputum, and Klebsiella noting dark red mucoid secretions.
The initial signs/symptoms are sudden onset of shaking chills, fever, purulent sputum, pleuritic chest pain that is worsened with respiration or coughing, tachycardia, tachypnea, and use of accessory muscles.
Staphylococcal pneumonia is frequently noted after influenza or in hospitalized patients with a nosocomial superinfection following surgery, trauma, or immunosuppression. Pleural pain, dyspnea, cyanosis, and productive coughing with copious pink secretions are common symptoms. Streptococcal pneumonia occurs rarely with the exception as a complication after measles or influenza. Klebsiella pneumonia is virulent and necrotizing, and is usually seen with alcoholic or severely debilitated patients. Pneumonia that is caused by Hemophilus influenzae occurs after viral upper respiratory infections, or concurrently with bronchopneumonia, bronchitis, and bronchiolitis. Sputum is usually yellow or green, and patients have fever, cough, cyanosis, and arthralgias. Viral pneumonia may be caused by influenza, adenoviruses, respiratory syncytial virus, rhinoviruses, cytomegalovirus, herpes simplex virus, and childhood diseases; it is usually milder. Symptoms include headache, anorexia, and occasionally mucopurulent sputum that is bloody.
MEDICAL CARE
Laboratory: white blood cell count may be normal or low but usually is elevated with poly- morphonuclear neutrophils; cultures of sputum, blood, and CSF may be obtained to identify the causative organism and antimicrobial agent best suited for eradication; electrolytes may show decreased sodium and chloride levels; serology and cold agglutinins may be done for identification of viral titers; sedimentation rate is usually elevated
Pulmonary function studies: used to evaluate ventilation/perfusion problems; volumes may be decreased due to alveolar collapse; airway pressures may be increased; lung compliance may be decreased
Arterial blood gases: to evaluate adequacy of oxygen and respiratory therapies, as well as to identify acid-base imbalances and acidotic/alkalotic states
Chest x-ray: used to demonstrate small effusions and abscesses, pulmonary consolidations, and empyema; may be clear with mycoplasma pneumonia
Oxygen: used to supplement room air, and to treat hypoxemia that may occur
Antibiotics: used in the treatment after culture results are obtained to eradicate the infective organism
Thoracentesis: used to remove fluid if pleural fluid is present; assists in the diagnosis of pleural empyema
Surgery: may be required for open lung biopsy or treatment of effusions and empyema; bronchoscopy with bronchial brushing may be indicated for progressive pneumonias that are unresponsive to medical treatment
Nerve blocks: intercostal blocks may be required to control pleuritic pain
NURSING CARE PLANS
Ineffective airway clearance
Related to: inflammation, edema, increased secretions, fatigue
Defining characteristics: adventitious breath sounds, use of accessory muscles, cyanosis, dyspnea, cough with or without production
Outcome Criteria
Patient will maintain patency of airway, have clear breath sounds, and will be able to effectively clear secretions.




INTERVENTIONS
RATIONALES
Monitor respiratory status for changes, increased work of breathing, use of accessory muscles, and nasal flaring.
Tachypnea and hyperpnea are frequently noted with pneumonia.

Observe for symmetrical chest expansion.
Unilateral pneumonia will result in asymmetrical chest movement due to decreased lung compliance on the affected side and because of pleuritic pain.
Observe for cyanosis and/or mental status changes.
May indicate impending or present hypoxemia. 
Assess vocal fremitus.
Increased fremitus is noted over consolidated areas in pneumonia.
Decreased or absent fremitus may indicate that a foreign body is obstructing a large bronchus.
Percuss chest for changes.
Percussion may be dull over consolidated areas or in areas of atelectasis.
Auscultate lung fields.
Fine crackles or bronchial breath sounds are noted in lobar pneumonia; in other types of pneumonia, bronchial sounds are rarely heard. Wheezes may indicate aspiration of a solid object. Inspiratory stridor may indicate the presence of an obstruction to a large bronchus.
Assist with bronchoscopy as warranted.
May be required to remove mucous plugs and prevent or improve atelectasis.
Assist with thoracentesis as warranted.
May be required to drain purulent fluid.

Impaired gas exchange
[See Mechanical Ventilation]
Related to: inflammation, infection, ventilation/perfusion mismatching, fever, changes in oxyhemoglobin dissociation curve
Defining characteristics: dyspnea, tachycardia, cyanosis, hypoxia, hypoxemia, abnormal arterial blood gases
Alteration in comfort
[See MI]
Related to: inflammation, dyspnea, fever, coughing
Defining characteristics: pleuritic chest pain worsened with respiration or cough, muscle aches, joint pain, restlessness, communication of pain/discomfort
Risk for altered nutrition: less than body requirements
[See Mechanical Ventilation]
Related to: increased metabolic demands, fever, infection, abnormal taste sensation, anorexia, abdominal distention, nausea, vomiting
Defining characteristics: actual inadequate food intake, altered taste, altered smell sensation, weight loss, anorexia, nausea, vomiting, abdominal distention, decreased muscle mass and tone
Risk for fluid volume deficit
[See ARDS]
Related to: fluid loss from fever, diaphoresis, or vomiting, decreased fluid intake
Defining characteristics: decreased blood pressure, oliguria, anuria, low pulmonary artery wedge pressures
Risk for fluid volume excess
[See ARDS]
Related to: inflammatory response, pulmonary edema
Defining characteristics: rales, crackles, wheezing, pink frothy sputum, abnormal arterial blood gases
Knowledge deficit
Related to: lack of information, competing stimuli, misinterpretation of information
Defining characteristics: request for information, failure to improve, development of preventable complications
Outcome Criteria
Patient will be able to verbalize and demonstrate understanding of information.
INTERVENTIONS
RATIONALES
Instruct on need for vaccines for influenza and pneumonia.
Influenza increases the chance of secondary pneumonia infection; vaccinations help to prevent the occurrence and spread of infective process.
Instruct in continued need for coughing and deep breathing.
Patient is at risk for recurrence of pneumonia for 6-8 weeks following discharge.
Instruct in importance of continuing with follow-up medical care.
Helps prevent complications and recurrence of pneumonia.
Instruct in need to quit or avoid smoking.
Smoking destroys the action of the cilia and impairs the lungs’ first line of defense against infection.

Discharge or Maintenance Evaluation
  •  Patient will be able to accurately verbalize understanding of all instructions.

   Patient will be compliant in avoiding smoking.
  • Patient will not have preventable complications from illness.



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