Pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange. Primary pneumonia is caused by the patient’s inhaling or aspirating a pathogen. Secondary pneumonia ensues from lung damage caused by the spread of bacteria from an infection elsewhere in the body. Likely causes include various infectious agents, chemical irritants (including gastric reflux/aspiration, smoke inhalation), and radiation therapy. This plan of care deals with bacterial and viral pneumonias, e.g., pneumococcal pneumonia, Pneumocystis carinii, Haemophilus influenzae, mycoplasma, and Gram-negative microbes.
CARE SETTING
Most patients are treated as outpatients; however, persons at higher risk (e.g., with ongoing/chronic health problems) are treated in the hospital, as are those already hospitalized for other reasons.
RELATED CONCERNS
AIDS
Chronic obstructive pulmonary disease (COPD) and asthma
Psychosocial aspects of care
Sepsis/septicemia
Surgical intervention
Patient Assessment Database
ACTIVITY/REST
May report: Fatigue, weakness
Insomnia
May exhibit: Lethargy
Decreased tolerance to activity
CIRCULATION
May report: History of recent/chronic heart failure (HF)
May exhibit: Tachycardia
Flushed appearance or pallor
EGO INTEGRITY
May report: Multiple stressors, financial concerns
FOOD/FLUID
May report: Loss of appetite, nausea/vomiting
May exhibit: Distended abdomen
Hyperactive bowel sounds
Dry skin with poor turgor
Cachectic appearance (malnutrition)
NEUROSENSORY
May report: Frontal headache (influenza)
May exhibit: Changes in mentation (confusion, somnolence)
PAIN/DISCOMFORT
May report: Headache
Chest pain (pleuritic), aggravated by cough; substernal chest pain (influenza)
Myalgia, arthralgia
May exhibit: Splinting/guarding over affected area (patient commonly lies on affected side to restrict movement)
RESPIRATION
May report: History of recurrent/chronic URIs, tuberculosis or COPD, cigarette smoking
Progressive dyspnea
Cough: Dry hacking (initially) progressing to productive cough
May exhibit: Tachypnea; shallow grunting respirations, use of accessory muscles, nasal flaring
Sputum: Scanty or copious; pink, rusty, or purulent (green, yellow, or white)
Percussion: Dull over consolidated areas
Fremitus: Tactile and vocal, gradually increases with consolidation
Pleural friction rub
Breath sounds: Diminished or absent over involved area, or bronchial breath sounds over area(s) of consolidation; coarse inspiratory crackles
Color: Pallor or cyanosis of lips/nailbeds
SAFETY
May report: Recurrent chills
History of altered immune system: i.e., systemic lupus erythematosus (SLE), AIDS, steroid or chemotherapy use, institutionalization, general debilitation
Fever (e.g., 1028F–1048F/398C–408C)
May exhibit: Diaphoresis
Shaking
Rash may be noted in cases of rubeola or varicella
TEACHING/LEARNING
May report: History of recent surgery; chronic alcohol use; intravenous (IV) drug therapy or abuse; immunosuppressive therapy
Discharge plan
DRG projected mean length of inpatient stay: 4.3–8.3 days
Assistance with self-care, homemaker tasks.
Oxygen may be needed, especially if recovery is prolonged or other predisposing condition exists.
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Chest x-ray: Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple abscesses/infiltrates, empyema (staphylococcus); scattered or localized infiltration (bacterial); or diffuse/extensive nodular infiltrates (more often viral). In mycoplasmal pneumonia, chest x-ray may be clear.
Fiberoptic bronchoscopy: May be both diagnostic (qualitative cultures) and therapeutic (re-expansion of lung segment).
ABGs/pulse oximetry: Abnormalities may be present, depending on extent of lung involvement and underlying lung disease.
Gram stain/cultures: Sputum collection; needle aspiration of empyema, pleural, and transtracheal or transthoracic fluids; lung biopsies and blood cultures may be done to recover causative organism. More than one type of organism may be present; common bacteria include Diplococcus pneumoniae, Staphylococcus aureus, ahemolytic streptococcus, Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures may not identify all offending organisms. Blood cultures may show transient bacteremia.
CBC: Leukocytosis usually present, although a low white blood cell (WBC) count may be present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia. Erythrocyte sedimentation rate (ESR) is elevated.
Serologic studies, e.g., viral or Legionella titers, cold agglutinins: Assist in differential diagnosis of specific organism.
Pulmonary function studies: Volumes may be decreased (congestion and alveolar collapse); airway pressure may be increased and compliance decreased. Shunting is present (hypoxemia).
Electrolytes: Sodium and chloride levels may be low.
Bilirubin: May be increased.
Percutaneous aspiration/open biopsy of lung tissues: May reveal typical intranuclear and cytoplasmic inclusions
(CMV), characteristic giant cells (rubeola).
NURSING PRIORITIES
1. Maintain/improve respiratory function.
2. Prevent complications.
3. Support recuperative process.
4. Provide information about disease process/prognosis and treatment.
DISCHARGE GOALS
1. Ventilation and oxygenation adequate for individual needs.
2. Complications prevented/minimized.
3. Disease process/prognosis and therapeutic regimen understood.
4. Lifestyle changes identified/initiated to prevent recurrence.
5. Plan in place to meet needs after discharge.
CARE SETTING
Most patients are treated as outpatients; however, persons at higher risk (e.g., with ongoing/chronic health problems) are treated in the hospital, as are those already hospitalized for other reasons.
RELATED CONCERNS
AIDS
Chronic obstructive pulmonary disease (COPD) and asthma
Psychosocial aspects of care
Sepsis/septicemia
Surgical intervention
Patient Assessment Database
ACTIVITY/REST
May report: Fatigue, weakness
Insomnia
May exhibit: Lethargy
Decreased tolerance to activity
CIRCULATION
May report: History of recent/chronic heart failure (HF)
May exhibit: Tachycardia
Flushed appearance or pallor
EGO INTEGRITY
May report: Multiple stressors, financial concerns
FOOD/FLUID
May report: Loss of appetite, nausea/vomiting
May exhibit: Distended abdomen
Hyperactive bowel sounds
Dry skin with poor turgor
Cachectic appearance (malnutrition)
NEUROSENSORY
May report: Frontal headache (influenza)
May exhibit: Changes in mentation (confusion, somnolence)
PAIN/DISCOMFORT
May report: Headache
Chest pain (pleuritic), aggravated by cough; substernal chest pain (influenza)
Myalgia, arthralgia
May exhibit: Splinting/guarding over affected area (patient commonly lies on affected side to restrict movement)
RESPIRATION
May report: History of recurrent/chronic URIs, tuberculosis or COPD, cigarette smoking
Progressive dyspnea
Cough: Dry hacking (initially) progressing to productive cough
May exhibit: Tachypnea; shallow grunting respirations, use of accessory muscles, nasal flaring
Sputum: Scanty or copious; pink, rusty, or purulent (green, yellow, or white)
Percussion: Dull over consolidated areas
Fremitus: Tactile and vocal, gradually increases with consolidation
Pleural friction rub
Breath sounds: Diminished or absent over involved area, or bronchial breath sounds over area(s) of consolidation; coarse inspiratory crackles
Color: Pallor or cyanosis of lips/nailbeds
SAFETY
May report: Recurrent chills
History of altered immune system: i.e., systemic lupus erythematosus (SLE), AIDS, steroid or chemotherapy use, institutionalization, general debilitation
Fever (e.g., 1028F–1048F/398C–408C)
May exhibit: Diaphoresis
Shaking
Rash may be noted in cases of rubeola or varicella
TEACHING/LEARNING
May report: History of recent surgery; chronic alcohol use; intravenous (IV) drug therapy or abuse; immunosuppressive therapy
Discharge plan
DRG projected mean length of inpatient stay: 4.3–8.3 days
Assistance with self-care, homemaker tasks.
Oxygen may be needed, especially if recovery is prolonged or other predisposing condition exists.
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Chest x-ray: Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple abscesses/infiltrates, empyema (staphylococcus); scattered or localized infiltration (bacterial); or diffuse/extensive nodular infiltrates (more often viral). In mycoplasmal pneumonia, chest x-ray may be clear.
Fiberoptic bronchoscopy: May be both diagnostic (qualitative cultures) and therapeutic (re-expansion of lung segment).
ABGs/pulse oximetry: Abnormalities may be present, depending on extent of lung involvement and underlying lung disease.
Gram stain/cultures: Sputum collection; needle aspiration of empyema, pleural, and transtracheal or transthoracic fluids; lung biopsies and blood cultures may be done to recover causative organism. More than one type of organism may be present; common bacteria include Diplococcus pneumoniae, Staphylococcus aureus, ahemolytic streptococcus, Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures may not identify all offending organisms. Blood cultures may show transient bacteremia.
CBC: Leukocytosis usually present, although a low white blood cell (WBC) count may be present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia. Erythrocyte sedimentation rate (ESR) is elevated.
Serologic studies, e.g., viral or Legionella titers, cold agglutinins: Assist in differential diagnosis of specific organism.
Pulmonary function studies: Volumes may be decreased (congestion and alveolar collapse); airway pressure may be increased and compliance decreased. Shunting is present (hypoxemia).
Electrolytes: Sodium and chloride levels may be low.
Bilirubin: May be increased.
Percutaneous aspiration/open biopsy of lung tissues: May reveal typical intranuclear and cytoplasmic inclusions
(CMV), characteristic giant cells (rubeola).
NURSING PRIORITIES
1. Maintain/improve respiratory function.
2. Prevent complications.
3. Support recuperative process.
4. Provide information about disease process/prognosis and treatment.
DISCHARGE GOALS
1. Ventilation and oxygenation adequate for individual needs.
2. Complications prevented/minimized.
3. Disease process/prognosis and therapeutic regimen understood.
4. Lifestyle changes identified/initiated to prevent recurrence.
5. Plan in place to meet needs after discharge.
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