Pneumonia

Pneumonia

An inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange due to virus (more common in children) or bacteria (especially Streptococcus pneumonia) and rarely fungi with symptoms including high fever (over 102⁰ F), chills, headaches, muscle aches, shortness of breath, coughing that produces phlegm (discolored yellowish or greenish or some blood spot), increased breathing rate, and sharp chest pain is the pneumonia.  During pneumonia the air sacs may be filled with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing.  Pneumonia is a sixth leading cause of death overall.  When a person breathes in small droplets that contain pneumonia-causing organisms and or when bacteria or viruses that are normally present in the mouth, nose and throat, enter the lungs, pneumonia can occur.  Viral pneumonia tends to develop slowly over a number of days, whereas bacterial pneumonia usually develops quickly, often over a day.  With the use of antibiotics pneumonia can usually be treated successfully at home but in some cases, it may require hospitalization and can result in loss of life.  Pneumonia vaccines are available against some of the more common infectious agents.

Some other symptoms would also be seen in the skin, lips and nail beds where they become dusky or bluish which indicates lungs not being able to deliver enough oxygen to the body which is vital situation and required urgent medical assistance.

In babies and children, symptoms may be less specific and they may not show clear signs of a chest infection. Commonly they will have a high fever, appear very unwell, and become lethargic. they may also have noisy or rattly breathing, have difficulty with feeding and make a grunting sound with breathing.

Right lung has three lobes while as the left one has two lobes only.  Pneumonia can affect all the lungs or only one lobe and the condition are classified by the area of the lung affected and by the cause of the infection.

Anyone can develop pneumonia, but certain groups are with higher risk which include babies and toddlers (particularly those born prematurely), people with recent viral infection, asthma, bronchitis, bronchiectasis, immunocompromised, swallowing, or coughing problem following stroke or brain injury, smokers, drinkers, people aged above 65, etcetera. 

Diagnosis

Upon suspicion of pneumonia the doctor will take a medical history and will conduct a physical examination. During the examination the doctor will listen to the chest with a stethoscope. Coarse breathing, crackling sounds, wheezing and reduced breath sounds in a particular part of the lungs can indicate pneumonia.

Confirmed diagnosis is made via chest x-ray where the affected lung area by the pneumonia can be seen.  Blood tests along with the sputum sample be tested in laboratory.

Pathophysiology of pneumonia

Pneumonia can be transmitted with inhalation of airborne microbe from an infected individual. However, in many cases, pneumonia are attributable to self-infection with one or more types of microbes that are present in the nose and mouth. In healthy people, typical upper airway there is a presence of bacteria such as Streptococcus pneumoniae (“pneumococcus”) and Hemophilus influenzae which are culprit for most common bacteria causing community-acquired pneumonia. Hospital-acquired pneumonia is usually caused by more resistant bacteria, such as Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli.

Individuals with an extreme low immune system become susceptible to pneumonia caused by so-called “opportunistic” microbes, such as certain fungi, viruses, and bacteria related to tuberculosis (mycobacteria), that would not ordinarily cause disease in normal individuals.

To cope with its constant exposure to potentially infectious microbes, the lung depends on a hierarchy of defense mechanisms. Physical mechanisms that can prevent microbes from reaching the alveoli include the structure of the upper airway, the branching of the bronchial tree, the sticky mucus layer lining the airways, the hair-like cilia that propel mucus upward, and the cough reflex. The microbes that do manage to reach the alveoli are usually destroyed by a variety of immune cells, which is why most pneumonias occur in people with one or more deficiencies in either their mechanical or immune defense mechanisms.

 

 

Treatment

Most cases of pneumonia can be treated at home but untreated pneumonia could complicate to hypoxemia, respiratory failure, pleural effusion, empyema, lung abscess, and bacteremia.  However, babies, children, elderly people, and people with severe pneumonia may need hospital admit.  Pneumonia is usually treated with antibiotics, irrespective of viral pneumonia as there might be a degree of bacterial infection. The type of antibiotic used and the way it is given will be determined by the severity and cause of the pneumonia.  Mostly, azithromycin and cefixime is antibiotic of choice.  Home treatment would include antibiotics by mouth, pain killer, paracetamol and proper rest while as hospital treatment would use IV antibiotics, oxygen therapy (in case of low O₂), intravenous fluid (to hydrate in case of dysphagia) and physiotherapy (to clear sputum from lungs).

Recovery

Severe weeks is required for full recovery from Pneumonia for clearance of sputum from lung.  Some fatigue and reduced exercise tolerance may also be experienced.  In case of worsened cough and fever lasting several weeks a doctor consultation is required and smokers should to have a chest x-ray after six weeks to confirm complete clearance of the lungs.

Prevention

Prevention is always better than cure as, person cured are not healthy as person prevented.  Breastfeeding baby (bossing immune system), smoking cessation, making home warm and well-ventilated, vaccination for pneumococcal disease, whooping cough, haemophilus influenza and influenza, good hand hygiene, avoiding contact with patient with cold and flu would be some steps that could be taken for prevention from pneumonia. 

Nursing Care Plans

Nursing care for patients with pneumonia should include supportive measures like humidified oxygen therapy for hypoxemia, mechanical ventilation for respiratory failure, a high calorie diet and adequate fluid intake. Interventions should include bed rest and analgesic to relieve pleuritic chest pain.

Nursing care plan for pneumonia should include these major eight issues:

1. Ineffective Airway Clearance.  Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
2. Ineffective Breathing Pattern/ Impaired Gas Exchange
3. Risk for Deficient Fluid Volume
4. Risk for Imbalanced Nutrition: Less Than Body Requirements
5. Acute Pain
6. Activity Intolerance
7. Risk for Infection

• Hyperthermia

Nursing Interventions	Rationale
Assess the rate and depth of respirations and chest movement.	Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung.
Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes.	Decreased airflow occurs in areas with consolidated fluid. Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasms and obstruction.
Elevate head of bed, change position frequently.	Doing so would lower the diaphragm and promote chest expansion, aeration of lung segments, mobilization and expectoration of secretions.
Teach and assist patient with proper deep-breathing exercises. Demonstrate proper splinting of chest and effective coughing while in upright position. Encourage him to do so often.	Deep breathing exercises facilitates maximum expansion of the lungs and smaller airways. Coughing is a reflex and a natural self-cleaning mechanism that assists the cilia to maintain patent airways. Splinting reduces chest discomfort and an upright position favors deeper and more forceful cough effort.
Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway secretions.	Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough or decreased level of consciousness.
Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer warm, rather than cold, fluids.	Fluids, especially warm liquids, aid in mobilization and expectoration of secretions.
Assist and monitor effects of nebulizer treatment and other respiratory physiotherapy: incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate.	Nebulizers and other respiratory therapy facilitates liquefaction and expectoration of secretions. Postural drainage may not be as effective in interstitial pneumonias or those causing alveolar exudate or destruction. Coordination of treatments and oral intake reduces likelihood of vomiting with coughing, expectorations.
Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics.	Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort and depress respirations.
Provide supplemental fluids: IV.	Room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection.
Monitor serial chest x-rays, ABGs, pulse oximetry readings.	Followers progress and effects of the disease process, therapeutic regimen, and may facilitate necessary alterations in therapy.
Assist with bronchoscopy and/or thoracentesis, if indicated.	Occasionally needed to remove mucous plugs, drain purulent secretions, and/or prevent atelectasis.
Urge all bedridden and postoperative patients to perform deep breathing and coughing exercises frequently.	To promote full aeration and drainage of secretions.