28/10/2009 1

Pneumonia
Dr Ibrahim Bashayreh, RN, PhD.
28/10/2009 2
Pneumonia
Acute inflammation of lung (lower
respiratory tract) caused by
microorganism, comes with fever,
focal chest symptoms, shadowing
on CXR
Leading cause of death until 1936
Discovery of sulfa drugs and
penicillin
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Classification
Community Acquired Pneumonia
Occur within 48 hrs of admission or in
patients who havent been hospitalized in the
last 2 wks
Strep pneumonia, mycoplasma pneumonia,
influenza A, Haemophilus influenza, and
Legionella are more common pathogens
Patients with chronic diseases are more prone
to Klebsiella and other gram negative
organisms
Highest incidence in winter
Smoking important risk factor

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Types of Pneumonia
Hospital-acquired pneumonia (HAP) (Nasocomial Infection)

Develops 2 or more days after admission
Gram negative bacilli (Klebsiella, Pseudomonas, E coli,
Proteus) or Staphylococcus are more common pathogens
Aspiration around an ETT/reduced consciousness or
difficulty swallowing allows pathogens in the oropharynx to
colonize the lungs
Ventilator-associated pneumonia (VAP): in patients on
ventilators
Aspiation: follows aspiration of gastric contents
Immunosuppression: chemotherapy/bone marrow
transplant/HIV patients susceptible to fungi and viral
infections as well as other pathogen
Highest mortality rate of nosocomial infections

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Causes of HAP
Pseudomonas
Enterobacter
S. aureus
S. pneumoniae
Immunosuppressive therapy
General debility
Endotracheal intubation
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Aging, 65 years or older
Male
Children under 2
Having HIV or AIDS
Increased frequency of gram- negative bacilli
(leukemia, diabetes, alcoholism)
Smoking
Being around certain chemicals
Living in certain parts of the country
Being hospitalized in ICU & having ETT
Pollution
Malnutrition

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Acquisition of Organisms
Aspiration from nasopharynx,
oropharynx
Inhalation of microbes
Hematogenous spread from
primary infection elsewhere
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Signs & Symptoms
Symptoms
Dyspnea
Pleurisy
Cough
Discolored sputum
Signs
Cyanosis
Tachycardia
Tachypnea
Dull percussion
Crepitus
Bronchial breath sounds
Pleural rub
Sweating, cold clammy skin
Non-respiratory features
Confusion, fatigue
Diarrhea, N&V.
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Clinical Manifestations
CAP symptoms
Sudden onset of fever
Chills
Cough productive of purulent
sputum
Pleuritic chest pain


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Pathophysiology:
Pneumococcal Pneumonia
Congestion from outpouring of
fluid into alveoli
Microorganisms multiply and spread
infection, interfering with lung
function
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Pathophysiology:
Pneumococcal Pneumonia
Red hepatization
Massive dilation of capillaries
Alveoli fill with organisms,
neutrophils, RBCs, and fibrin
Causes lungs to appear red and
granular, similar to liver


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Complications
Pleurisy (pain with breathing)
Pleural effusion
Usually is sterile and reabsorbed in 1-2
weeks or requires thoracentesis
Atelectasis
Usually clears with cough and deep
breathing

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Complications
Delayed resolution
Persistent infection seen on x-ray as
residual consolidation
Lung abscess (pus-containing lesions)
Empyema (purulent exudate in pleural
cavity)
Requires antibiotics and drainage of
exudate
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Complications
Pericarditis
From spread of microorganism
Arthritis
Systemic spread of organism
Exudate can be aspirated
Meningitis
Patient who is disoriented, confused, or
somnolent should have lumbar puncture
to evaluate meningitis
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Complications
Endocarditis
Microorganisms attack endocardium and
heart valves
Manifestations similar to bacterial
endocarditis
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Diagnostic Tests
History
Physical exam
Chest x-ray
Gram stain of sputum
Sputum culture and sensitivity
Pulse oximetry or ABGs
CBC, differential, chems
Blood cultures
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Collaborative Care
Antibiotic therapy
Oxygen for hypoxemia
Analgesics for chest pain
Antipyretics
Influenza drugs
Influenza vaccine
Fluid intake at least 3 L per day
Caloric intake at least 1500 per day
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Collaborative Care
Pneumococcal vaccine
Indicated for those at risk
Chronic illness such as heart and lung
disease, diabetes mellitus
Recovering from severe illness
65 or older
In long-term care facility
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Nursing Assessment
History of Predisposing/Risk Factors
Lung cancer
COPD
Diabetes mellitus
Debilitating disease
Malnutrition
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Nursing Assessment
History of Predisposing/Risk Factors
AIDS
Use of antibiotics, corticosteroids,
chemotherapy, immunosuppressants
Recent abdominal or thoracic
surgery
Smoking, alcoholism, respiratory
infections
Prolonged bed rest

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Nursing Assessment
Clinical Manifestations
Dyspnea
Nasal congestion
Pain with breathing
Sore throat
Muscle aches
Fever

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Nursing Assessment
Clinical Manifestations
Restlessness or lethargy
Splinting affected area
Tachypnea
Asymmetric chest movements
Use of accessory muscles
Crackles
Green or yellow sputum

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Nursing Assessment
Clinical Manifestations
Tachycardia
Changes in mental status
Leukocytosis
Abnormal ABGs
Pleural effusion
Pneumothorax on CXR

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Nursing Diagnoses
Ineffective breathing pattern
Ineffective airway clearance
Acute pain
Imbalanced nutrition: less than body
requirements
Activity intolerance
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Planning
Goals: Patient will have
Clear breath sounds
Normal breathing patterns
No signs of hypoxia
Normal chest x-ray
No complications related to pneumonia
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Nursing Implementation
Teach nutrition, hygiene, rest, regular
exercise to maintain natural resistance

Prompt treatment of URIs
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Nursing Implementation
Encourage those at risk to obtain
influenza and pneumococcal
vaccinations
Reposition patient q2h
Assist patients at risk for aspiration
with eating, drinking, and taking meds

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Nursing Implementation
Assist immobile patients with turning
and deep breathing
Strict asepsis
Emphasize need to take course of
medication(s)
Teach drug-drug interactions

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Evaluation
Dyspnea not present
SpO
2
> 95
Free of adventitious breath sounds
Clears sputum from airway
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Evaluation
Reports pain controlled
Verbalizes causal factors
Adequate fluid and caloric intake
Performs ADLs
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Tuberculosis
Famous people who have had TB
Fredric Chopin*
Eleanor Roosevelt*
Nelson Mandela
Ringo Starr
Tom J ones
Tina Turner
*Died of TB
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What is tuberculosis (TB)?
Disease caused by bacteria called
Mycobacterium tuberculosis
Chronic bacterial infection
Was once the leading cause of death in US
The number of cases declined in the 1940s
when drugs were developed to treat TB
TB is still a problem worldwide
8 million people develop TB yearly
3 million die
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Tuberculosis
5-10% become
active
Only contagious
when active
Primarily affect
lungs but
Kidneys
Liver
Brain
Bone

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How is TB spread?
Through the air from person to
person by coughing
Usually attacks lungs
Two stages
Latent TB
asymptomatic and not contagious
can take medication to prevent development
of disease
Active TB Disease
May spread to others
May have abnormal chest x-ray
Usually have positive skin test
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Symptoms of TB
Chills
Fever
Weakness or fatigue
Sweating while sleeping, Night sweats
Cough that lasts longer than 2 weeks
Pain in chest
Coughing up blood or sputum
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Risk Factors
Close contact with someone who is infected
with TB
Traveling to a country where TB is common
Foreign-born individuals and minorities
have a higher incidence of developing TB
2002: 50% of US cases were in foreign-
born individuals.
2002: 80% of all US TB cases were in
ethnic and racial minorities.
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Risk Factors

Immunocompromise
Substance abuse
Indigent (POVERTY)
Living in overcrowded, substandard housing
Health care workers performing high risk
activities

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Multi-drug resistant TB (MDR TB)
Bacteria become resistant to antibiotics
Arose from improper use of antibiotics in the
treatment of TB
Treatment of one case can cost up to $1.3 million
45 states and Washington, DC have confirmed cases
of MDR TB
Treatment is difficult and costly
Can develop from not taking proper course of
antibiotics for TB
MDR TB can be spread by an infected person
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How to protect yourself
BCG vaccine for TB is given in many countries
Not recommended for healthcare workers
unless a high percentage of patients are
infected with MDR TB
PPD test if exposure is suspected
USE proper PPE when in contact with patients
who may have TB
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PPD Skin Test Procedure
Intradermal administration of PPD
L forearm
Must be read between 48 and 72 hours
To accurately read
Visual inspection for erythema
Tactile inspection to monitor size of
induration
10 mm or > area of induration
Consider positive and must be referred
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Tuberculosis
Diagnostic exams
PPD
Mantoux skin test
> 10mm in diameter
induration
Indicates:
Latent TB
Read
48-72 after
Intradermal: 15-degrees
Do not rub

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Confirmation of Disease
Positive reaction does not
necessarily mean active disease.
May indicate exposure to TB
Diagnosis confirmed by:
Positive smear for AFB and
Sputum culture of
Mycobacterium tuberculosis
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Interventions
Combination drug
therapy
Isoniazid
Rifampicin
Pyrazinamide
Ethambutol or
streptomycin
Education
Must follow
exact drug
regimen
Proper
nutrition
Reverse weight
loss and lethargy
About disease
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Tuberculosis Treatment

INH
Isonicotinyl Hydrazine
Isoniazid
Toxic to the liver
Rifampicin
Turns urine red
Streptomycin
Causes 8th cranial nerve
damage
Acoustic nerve



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CLASSIFICATION
Class 0no exposure
Class 1exposure, no infection
Class 2latent infection; no disease (positive
PPD but no evidence of active TB
Class 3disease; clinically active
Class 4disease; not clinically active
Class 5suspected disease; diagnosis
pending
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MEDICAL MANAGEMENT
Treated with chemotherapeutic agents for 6-
12 months
Resistance increasing. May be primary,
secondary, or multidrug resistant.
Primaryresistance to one of first line drugs
in those who have not had prior treatment
Secondaryresistance to one or more anti-
TB drugs in patients undergoing tx
Multidrug resistanceresistance to two
agents, INH and Rifampicin.
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Tuberculosis
Complications
Pleurisy
Pericarditis
Meningitis
Bone infections
Malnutrition
Drug-toxicity
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Tuberculosis
Nursing Dx
Impaired gas exchange
Ineffective airway clearance
Anxiety
Knowledge deficit
Alt. nutrition

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Tuberculosis
Preventative measures
Clean well ventilated living areas
Resp. isolation
Vaccine?
BCG
Does not prevent TB
Causes a + PPD
If exposed take
INH
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Tuberculosis Summary
Chronic bacterial infection
spread through the air
Fever, chills, sweating while
sleeping, persistent cough,
coughing up blood or sputum
Multi-drug-resistant tuberculosis
MDR TB
Use proper PPE and get PPD test
if exposed