Nursing Management of Pneumonia and Disease Process

Nurses play a pivotal role in improving patient outcomes. Nursing management of the pneumonia patient is critical to patient recovery. A thorough nursing assessment is necessary to establish nursing diagnoses, plan nursing care, set realistic goals, implement nursing interventions and to enable the evaluation process. This article discusses the nursing management of pneumonia and the associated disease process.

Overview

Pneumonia is defined as inflammation in one or both lungs, with the presence of consolidation and exudation. Inhaling infected droplets in the air from a cough or sneeze of an infected person is the mechanism in which pneumonia is commonly spread.

Incidence and classification

Pneumonia is characterized as a type of lung infection, most commonly caused by bacteria or a virus. Fungi and parasites can also a cause of pneumonia, however, these causes are less common. The differentiation between pneumonia and bronchitis is that bronchitis is a lower respiratory tract infection that does not affect the functional tissue of lungs also referred to as lung parenchyma.

Different types of pneumonia are classified into various groups. Pneumonia is classified based on the type of organisms responsible for the infection and the location where or the way in which the infection was acquired. For example, community-acquired pneumonia, hospital-acquired pneumonia, and ventilator-associated pneumonia also known as aspiration pneumonia.

Community-Acquired Pneumonia (CAP)

An acute infection of the lower respiratory tract, mostly caused by bacteria and occurring in a patient who has not resided in a hospital or healthcare facility in the previous 14 days (Johnson, Irving & Turnidge 2020). CAP is more likely to be caused by bacteria, however a number of viruses have been associated with community-acquired pneumonia.

Hospital-Acquired Pneumonia (HAP)

An acute lower respiratory tract infection that is acquired at least 48 hours after admission to the hospital and is not incubating at the time of admission (Forest 2020). Also referred to as nosocomial pneumonia.

Ventilator-Associated Pneumonia (VAP)

A form of HAP that develops in intensive care patients, occurring more than 48 hours after endotracheal intubation (Forest 2020).

Pneumonia can be contracted by people of any age or health status; however, pneumonia is more common in:

• the older population (particularly people over 65 years of age)
• cohorts with compromised immune systems such as cancer patients, those diagnosed with HIV, organ transplant patients and those who have damaged spleens or have had their spleen removed
• people with chronic conditions such as respiratory disorders, cardiac disease and diabetes
• indigenous populations particularly those over the age of 50 years and under the age of two years as well as indigenous people living in remote communities
• young children
• smokers
• the homeless

Treatment

Treatment for pneumonia is dependent on the individual, the classification and the organism responsible. However,  general pneumonia treatment includes:

• Rest
• Increased fluid intake
• Simple pain relief to reduce fever and relieve pain
• Pathogen directed pharmacologic therapy
• Chest physiotherapy and coughing exercises

Most pneumonia cases can also be treated in the community, providing the patient access to good medical and nursing care. However, in serious cases of pneumonia, hospital admission may be required. International data suggests that approximately 30% of patients with pneumonia require hospitalization (Chung & Morgan 2015), with the instance of hospitalization increasing with age. A variety of admission criteria and assessment tools exist for patients presenting with pneumonia.

Pathophysiology

Each lung is made up of thousands of bronchi and alveoli. The bronchi are tiny tubes and alveoli are the small sacs at the end of the bronchi tube. The bronchi and alveoli are filled with capillaries that assist in adding oxygen to and removing carbon dioxide from the blood. This is known as gas exchange.

In the case of a patient with bacterial pneumonia, the alveoli in the affected lung or lungs become solid as they fill with exudate such as fluid or pus. The presence of exudate results in a less functional area for oxygen-carbon dioxide exchange, interfering with gas exchange and resulting in consolidation in the lung. The affected lung or lungs may also collapse.

Viral pneumonia does not result in consolidation. Viral pneumonia primarily infects the walls of the alveoli and the parenchyma of the lung.

Epidemiology of pneumonia

Pneumonia is responsible for substantial morbidity and mortality rates around the world. According to the World Health Organization (2019) pneumonia accounts for 15% of all deaths worldwide in children under the age of five years. 450 million cases of pneumonia are recorded every year; about 4 million people die from this illness (WHO 2004).

A study conducted in 2013 of 188 countries around the world, reported that lower respiratory tract infection was the second most common cause of death, with the incidence of pneumonia increasing with patient age.

In the United States pneumonia is the eighth most common cause of death (CDC 2018). However, when combined with influenza, pneumonia is the leading cause of death by infectious disease in the United States (Jones et al. 2014).

Pneumonia is caused by organisms, including microorganisms such as:

• Bacteria
• Viruses
• Fungi
• Parasites

Signs and Symptoms 

The onset of pneumonia may be sudden or gradual. Symptoms of pneumonia vary and often individuals will present in different ways. Symptoms commonly associated with pneumonia include:

• flu-like illness
• difficulty breathing
• coughing (including a dry or mucus-producing cough)
• fever
• rapid breathing
• fatigue
• chest pain
• increased heart rate
• generally feeling unwell
• loss of appetite
• sweating and shivering
• crackling sounds in the chest (heard with a stethoscope)

Less common symptoms associated with pneumonia include:

• fatigue
• wheezing
• joint and muscle pain
• headaches

In rare cases central cyanosis, caused by lack of oxygen may be present in the skin around the mouth.

Prevention

Prevention is the key to protecting against infection.

• Good hygiene practices

Good hygiene practices, including following hand hygiene principles such as regular hand washing and the use of alcohol-based hand sanitizer, will help protect against respiratory infections that may lead to pneumonia.

• Smoking cessation

Smoking causes lung damage and results in the lungs being more suspectable to infection. Smoke cessation will help to prevent respiratory infections such as pneumonia.

• Healthy lifestyle

Keeping the immune system strong by staying healthy through adequate sleep, a healthy diet and regular exercise.

• Limit alcohol use

Alcohol misuse weakens the lungs’ natural defenses against infections (NHS 2019) making the patient more vulnerable to pneumonia.

• Immunization

Bacterial pneumonia

Bacterial pneumonia is commonly caused by the Streptococcus pneumoniae (pneumococcus) bacteria. The best protection against bacterial pneumonia is with immunization. The Pneumococcal vaccine helps to reduce the risk of bacterial pneumonia.

Viral pneumonia

Pneumonia is a common complication of influenza. As such, annual vaccination against influenza should be encouraged.

Medical Management 

Pharmacologic Therapy 

Pharmacologic therapy for pneumonia differs depending on the causative agent, the type of infection as well as the age of the patient. Once appropriate pharmacologic treatment is commenced patients will generally recover in around seven to 10 days.

The choice of oral pharmacologic therapy or the use of intravenous therapy is dependent on several factors. More severe cases of pneumonia, where hospitalization occurs are likely to require intravenous (IV) antibiotic therapy. Switching from one therapy to another will be determined by the progress of the patient. For example, the hospitalized patient may commence on IV antibiotic therapy, but when discharged from the healthcare setting may commence oral antibiotics

Antibiotics also referred to as antibacterials, are the mainstay treatment for bacterial pneumonia. Antibiotics fight against the bacteria by:

• destroying the bacteria or
• inhibiting the growth of the bacteria

Destroying or inhibiting bacteria growth helps the body’s natural immune system to fight the bacterial infection. Different antibiotics work against different types of bacteria (NPS MedicineWise 2019).

Bacterial pneumonia 

Bacterial pneumonia is the most common type of pneumonia. Oral antibiotics are most commonly used to treat bacterial pneumonia.

In the absence of the causative bacteria being identified, empirical antibiotics or antibiotics are chosen to treat the likely pathogen causing bacterial pneumonia are often used. Within three to five days of commencing antibiotic treatment for bacterial pneumonia symptoms should start to improve.

If symptoms do not improve it is possible that the antibiotic treatment selected is not the right treatment for the pathogen causing bacterial pneumonia. Alternative antibiotic treatment that is pathogen directed will, therefore, be required.

The following are examples of antibiotics that may be used to treat bacterial pneumonia:

• Narrow-spectrum antibiotics such as glycopeptides

Narrow-spectrum antibiotics are effective in targeting specific types of bacteria. Vancomycin and flucloxacillin are both narrow-spectrum antibiotics used to treat bacterial pneumonia caused by methicillin-resistant Staphylococcus aureus (MRSA).

• Broad-spectrum antibiotics such as macrolides and penicillins 

Broad-spectrum antibiotics are effective in treating bacterial pneumonia caused by common causative bacteria. Azithromycin and Ceftriaxone are broad-spectrum antibiotics commonly prescribed to treat bacterial pneumonia.

Viral pneumonia

Antibiotics do not treat viral pneumonia. Following diagnostic testing, if it is confirmed that the cause of the pneumonia is a viral infection, then antiviral therapy will be prescribed to treat viral pneumonia. Viral pneumonia is caused by viruses such as influenza A and B. The following antivirals are examples of those used to treat viral pneumonia:

• Oseltamivir used to treat the Influenza A virus
• Rimantadine used to treat various influenza viruses

Fungal pneumonia 

Fungi is the least common cause of pneumonia, however, Mattila et al. (2014) indicate that there is an increasing incidence of fungal pneumonia. Fungal pneumonia may be caused by a variety of different fungi including Histoplasma capsulatum and mucormycosis.

Antifungals are used to treat fungal pneumonia. Antifungals work by stopping the growth of fungi. The following are examples of antifungal treatments used to treat fungal pneumonia:

• Voriconazole
• Fluconazole
• Itraconazole

O2 Therapy

Supportive oxygen therapy will be required if the patient has oxygen saturations under 92%. The target saturation range for patients with acute medical conditions, pneumonia, asthma, and acute coronary syndrome is 92–96% (Pilcher & Beasley 2015). To assist the patient with expectoration, humidified oxygen therapy may be beneficial.

Assessment and Diagnosis

To determine a pneumonia diagnosis, the clinician must ascertain the absence or presence of pneumonia symptoms and obtain a detailed clinical history from the patient.

Physical assessment 

Physical assessment is key in the assessment of patients with respiratory complaints, such as pneumonia.  The components of a physical assessment should include:

• Chest inspection

The act of observing for visible external signs of respiratory function, reviewing chest symmetry and appearance and inspecting for accessory muscle usage

• Palpation 

Palpation is the act of examination by touch.

• Percussion

The technique of tapping the surface of a body part to learn the condition of the parts beneath by the resultant sound

• Auscultation

Auscultation is the act of listening to sounds arising within organs, such as the lungs

Findings

Findings during physical examination of the pneumonia patient may include:

• Tachypnoea (abnormally rapid breathing)
• Tachycardia (rapid heart rate that may also be irregular)
• Decreased or bronchial breath sounds (tubular, hollow sounds which are heard when auscultating over the large airways)
• Egophony (increased resonance of voice sounds heard when auscultating the lungs) and tactile fremitus (assessment of the intensity of vibration felt in the chest wall or heard through auscultation)
• Crackles heard in affected regions of the lung
• Dullness on percussion

Diagnostic testing 

A variety of tests are available that assist in the diagnosis of pneumonia, including:

• Swabs from inside the nose or throat
• Bacterial sputum culture
• Oxygen saturation monitoring
• Chest x-rays
• Lung function tests
• Blood tests to identify inflammation markers
• Lung biopsy

Diagnosis 

Diagnosis is made based on the outcome of the physical assessment, patient history and the results of diagnostic testing.

Complications

Pneumonia complications commonly occur in young children, older people and those with pre-existing chronic health conditions, such as diabetes and cardiac conditions.

Complications of pneumonia include:

• Pleurisy 

Pleurisy is a condition where the pleura (thin linings between the lungs and ribcage) becomes inflamed.

• Lung abscess 

Lung abscesses are rare any generally only occur in people with serious pre-existing illnesses and those who have a history of severe alcohol misuse

• Sepsis (also referred to as blood poisoning)

A rare but serious complication of pneumonia.

Admission to the hospital will be required if any of the above complications are present.

Nursing Management

Nursing management of patients with pneumonia is dependent on the needs of the individual, the symptoms and the targeted treatment required.

Nursing Assessment

Comprehensive nursing assessment is critical to the diagnosis of pneumonia and the ongoing management of the pneumonia patient.

The nursing assessment should include:

• Patient history
• General appearance
• Physical examination
• Focused assessments, including chest assessment and respiratory assessment
• Vital signs
• Assessment of clinical manifestations

Guidelines for your nursing assessment for pneumonia are as follows:

• Assessment of respiratory symptoms

Airway

Assess the airway for noises, secretions, cough and any artificial airways

Breathing 

Review breathing including, rhythm, work of breathing: – spontaneous/ labored/supported/ ventilator-dependent, oxygen requirement and delivery mode.

Assess bilateral air entry and movement, breath sounds and count the patients’ respiratory rate for one full minute and assess any respiratory distress.

Monitor oxygen saturation, noting oxygen requirement and delivery mode if required. Continue to monitor as clinically indicated.

Circulation

Check pulses (location, rate, rhythm and strength); temperature (peripheral and central), skin color and moisture, skin turgor, capillary refill time (central and Peripheral); skin, lip, oral mucosa and nail bed color.

Nursing Diagnosis

The clinical judgments made by the nurse based on the patient’s health conditions and needs form the nursing diagnosis. Nursing diagnoses reflect the potential causes and contributing factors of the health condition. The nursing care plan is based on the nursing diagnosis.

Based on the information gained through the nursing assessment the nursing diagnoses related to the patient with pneumonia include:

• Ineffective Airway Clearance
• Inability to clear the airway of secretions and obstructions due to

• • • Ineffective Breathing Pattern
    • Activity Intolerance
    • Deficit Fluid Intake
    • Noncompliance

Nursing Care Planning & Goals

Nurses set to achieve goals in conjunction with the patient. These goals are based on the outcome of assessments and the diagnoses.

Examples of goals for the pneumonia patient are:

• Drink at least 2 liters of water daily

Maintaining adequate hydration is essential. Increased fluid intake assists with the expectoration of secretions.

• Conduct respiratory exercises (breathing, coughing and expulsion exercises) as directed

These exercises are crucial for clearing excess secretion, they improve lung function and help to strengthen the diaphragm and the accessory muscles around the lungs.

• Ensuring adequate nutrition

A balanced diet, including adequate servings of fruit and vegetables, promotes recovery from illness.

• Attend chest physical therapy

Chest physical therapy benefits mucus transport and assists in the expectoration of secretions.

• Adhere to medication regimen

Adherence with the prescribed medication regimen is key to recovery and preventing resurgence of pneumonia.

Nursing Interventions for Pneumonia

• Explain the pathophysiology of pneumonia appropriate to the patient’s level of health literacy and understanding. The use of teaching aids such as illustrations and models may be required
• Explain good hygiene practices to prevent the spread of infection, for example, hand hygiene practices and cough etiquette
• Provide education on the prevention of reoccurrence, including completing the full course of prescribed pharmacologic therapy, keeping follow up medical appointments and recommended immunizations
• Encourage rest to aid with recovery
• Promote adequate fluid intake
• Promote a healthy diet
• Encourage coughing exercises and chest physio
• Encourage simple pain relief to reduce fever and relieve pain, where clinically indicated

Nursing Evaluation

Nursing evaluation is the process whereby the success of the goals and outcomes are reviewed, and factors identified which are positively or negatively influencing the goal achievement. Using critical thinking and problem-solving skills the nurse makes clinical decisions and plans care for the patient accordingly. The nursing care plan should be modified as required.

The nurse must ensure the following:

• that abnormal findings are identified, and appropriate action is taken
• that the airway patency is maintained
• secretions are cleared and explored where necessary
• continuous assessment of the client occurs to identify any changes in condition
• assessment details and clinical notes are documented accordingly

Discharge and Home Care Guidelines 

Discharge planning should commence on admission. It is important that the multidisciplinary team are involved in the discharge planning process to ensure that all discharge needs and priorities are identified.

The following aspects are key to the discharge process and home care guidelines:

• Patient education

Providing patients with education is integral to the discharge process. Patient education is essential to ensuring satisfactory health outcomes.

• Pharmacologic Therapy

It is essential that the patient is aware of their medication regimen and understands the importance of medication compliance, administration processes and potential side effects

• Referrals

Referrals to appropriate health professionals and other relevant organizations should be made and communicated to the patient

• Follow-up appointments

It is imperative that the patient is aware of any follow-up appointments and that the patient is encouraged to maintain any follow-up appointments in order to gain the best health outcomes

• Exercises

In order to improve the capacity of the lungs and promote clearance of secretions breathing exercises should be provided for the patient. An exercise regimen may also need to be provided. This should be developed in conjunct with the multidisciplinary team

• Health promotion and harm reduction activities

If applicable the patient should be encouraged to cease smoking as a continuation of smoking with inhibiting recovery from pneumonia as smoking impacts the capacity of the lungs to take up oxygen and damages the cilia. Limiting alcohol consumption should also be encouraged

Nursing Documentation  

The nurse should ensure that all the necessary information has been collected, is complete, and has been documented appropriately. Healthcare documentation must provide an accurate description of each patient’s care and contact with health staff, including nurses.

Nursing documentation should include:

• Vital signs 

Heart rate, respiratory rate, oxygen saturation rate and temperate should also be accurately documented in the health record

• Breathing 

With pneumonia patients, it is important that the details of breath sounds including the presence and characteristics of secretions and accessory muscles usage are recorded

• Characteristics of sputum

The color and consistency of sputum should be recorded and monitored on an ongoing basis

• Care plan

A plan for each patient’s care should be documented. The care plan must outline the details of the multidisciplinary team and their involvement in care. The care plan should be updated as required

• Use of devices, aids and equipment

The use of any airway or respiratory devices should be recorded as should any aids or equipment

• Medication administration

Administration of medications should be clearly documented including the patient’s response to medication and any adverse reactions

References

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