NURSING PROCESS: THE PATIENT WITH PNEUMONIA
Nursing
assessment is critical in detecting pneumonia. A fever, chills, or night sweats
in a patient who also has respiratory symp-toms should alert the nurse to the
possibility of bacterial pneu-monia. A respiratory assessment will further
identify the clinical manifestations of pneumonia: pleuritic-type pain,
fatigue, tachyp-nea, use of accessory muscles for breathing, bradycardia or
relative bradycardia, coughing, and purulent sputum. It is important to
identify the severity, location, and cause of the chest pain, along with any
medications or procedures that provide relief. The nurse should monitor the
following:
• Changes in temperature and pulse
• Amount, odor, and color of secretions
• Frequency and severity of cough
• Degree of tachypnea or shortness of breath
• Changes in physical assessment findings
(primarily assessed by inspecting and auscultating the chest)
• Changes in the chest x-ray findings
In
addition, it is important to assess the elderly patient for unusual behavior,
altered mental status, dehydration, excessive fatigue, and concomitant heart
failure.
• Ineffective airway clearance related to copious tracheo-bronchial secretions
• Activity intolerance related to impaired respiratory function
• Risk for deficient fluid volume related to fever and dyspnea
• Imbalanced nutrition: less than body requirements
• Deficient knowledge about the treatment regimen and pre-ventive health measures
Based on the assessment data, collaborative problems or poten-tial complications that may occur include:
• Continuing symptoms after initiation of therapy
• Shock
• Respiratory failure
• Atelectasis
• Pleural effusion
• Confusion
• Superinfection
The
major goals for the patient may include improved airway patency, rest to
conserve energy, maintenance of proper fluid volume, maintenance of adequate
nutrition, an understanding of the treatment protocol and preventive measures,
and absence of complications.
Removing
secretions is important because retained secretions interfere with gas exchange
and may slow recovery. The nurse en-courages hydration (2 to 3 L/day) because
adequate hydration thins and loosens pulmonary secretions. Humidification may
be used to loosen secretions and improve ventilation. A high-humidity facemask
(using either compressed air or oxygen) deliv-ers warm, humidified air to the
tracheobronchial tree, helps to liquefy secretions, and relieves
tracheobronchial irritation. Cough-ing can be initiated either voluntarily or
by reflex. Lung expansion maneuvers, such as deep breathing with an incentive
spirometer, may induce a cough. A directed cough may be necessary to im-prove
airway patency. The nurse encourages the patient to perform an effective,
directed cough, which includes correct posi-tioning, a deep inspiratory
maneuver, glottic closure, contraction of the expiratory muscles against the
closed glottis, sudden glottic opening, and an explosive expiration. In some cases,
the nurse may assist the patient by placing both hands on the patient’s lower
rib cage (anteriorly or posteriorly) to focus the patient on a slow deep
breath, and then manually assisting the patient by applying exter-nal pressure
during the expiratory phase.
Chest
physiotherapy (percussion and postural drainage) is im-portant in loosening and
mobilizing secretions. Indications for chest physiotherapy include sputum
retention not responsive to spontaneous or directed cough, a history of
pul-monary problems previously treated with chest physiotherapy, continued
evidence of retained secretions (decreased or abnormal breath sounds, change in
vital signs), abnormal chest x-ray find-ings consistent with atelectasis or
infiltrates, or deterioration in oxygenation. The patient is placed in the
proper position to drain the involved lung segments, and then the chest is
percussed and vibrated either manually or with a mechanical percussor.
After
each position change, the nurse encourages the patient to breathe deeply and
cough. If the patient is too weak to cough effectively, the nurse may need to
remove the mucus by nasotra-cheal suctioning. It may take time for secretions
to mobilize and move into the central airways for expectoration. Thus, it is
important for the nurse to monitor the patient for cough and sputum production
after the completion of chest physiotherapy.
The
nurse administers and titrates oxygen therapy as pre-scribed. The effectiveness
of oxygen therapy is monitored by improvement in clinical signs and symptoms,
and adequate oxy-genation values measured by pulse oximetry or arterial blood
gas analysis.
The
nurse encourages the debilitated patient to rest and avoid overexertion and
possible exacerbation of symptoms. The patient should assume a comfortable
position to promote rest and breath-ing (eg, semi-Fowler’s) and should change
positions frequently to enhance secretion clearance and ventilation/perfusion
in the lungs. It is important to instruct outpatients not to overexert
themselves and to engage in only moderate activity during the initial phases of
treatment.
The
respiratory rate of a patient with pneumonia increases because of the increased
workload imposed by labored breathing and fever. An increased respiratory rate
leads to an increase in insensible fluid loss during exhalation and can lead to
dehydration. Therefore, it is important to encourage increased fluid intake (at
least 2 L/day), unless contraindicated.
Patients
with shortness of breath and fatigue often have a de-creased appetite and will
take only fluids. Fluids with electrolytes (commercially available drinks, such
as Gatorade) may help pro-vide fluid, calories, and electrolytes. Other
nutritionally enriched drinks or shakes may be helpful. In addition, fluids and
nutrients may be administered intravenously if necessary.
The
patient and family are instructed about the cause of pneu-monia, management of
symptoms of pneumonia, and the need for follow-up (discussed later). The
patient also needs informa tion about factors (both patient risk factors and
external factors) that may have contributed to developing pneumonia and
strate-gies to promote recovery and to prevent recurrence. If hospital-ized for
treatment, the patient is instructed about the purpose and importance of
management strategies that have been imple-mented and about the importance of
adhering to them during and after the hospital stay. Explanations need to be
given simply and in language that the patient can understand. If possible,
writ-ten instructions and information should be provided. Because of the
severity of symptoms, the patient may require that instructions and
explanations be repeated several times.
Patients
usually begin to respond to treatment within 24 to 48 hours after antibiotic
therapy is initiated. The patient is ob-served for response to antibiotic
therapy. The patient is moni-tored for changes in physical status
(deterioration of condition or resolution of symptoms) and for persistent
recurrent fever, which may be due to medication allergy (signaled possibly by a
rash); medication resistance or slow response (greater than 48 hours) of the
susceptible organism to therapy; superinfection; pleural effusion; or pneumonia
caused by an unusual organism, such as P.
carinii or Aspergillus fumigatus. Failure
of the pneumonia to re-solve or persistence of symptoms despite changes on the
chest x-ray raises the suspicion of other underlying disorders, such as lung
cancer. As described earlier, lung cancers may invade or com-press airways,
causing an obstructive atelectasis that may lead to a pneumonia.
In
addition to monitoring for continuing symptoms of pneu-monia, the nurse also
monitors for other complications, such as shock and multisystem failure,
atelectasis, pleural effusion, and superinfection, which may develop during the
first few days of antibiotic treatment.
The
nurse assesses for signs and symptoms of shock and respira-tory failure by
evaluating the patient’s vital signs, pulse oximetry values, and hemodynamic
monitoring parameters. The nurse re-ports signs of deteriorating patient status
and assists in administer-ing intravenous fluids and medications prescribed to
combat shock. Intubation and mechanical ventilation may be required if
respira-tory failure occurs.
The
patient is assessed for atelectasis, and preventive measures are initiated to
prevent its development. If pleural effusion develops and thoracentesis is
performed to remove fluid, the nurse assists in the procedure and explains it
to the patient. After thoracente-sis, the nurse monitors the patient for
pneumothorax or recur-rence of pleural effusion. If a chest tube needs to be
inserted, the nurse monitors the patient’s respiratory status.
The
patient is monitored for manifestations of superinfection (ie, minimal
improvement in signs and symptoms, rise in tempera-ture with increasing cough,
increasing fremitus and adventitious breath sounds on auscultation of the
lungs). These signs are reported, and the nurse assists in implementing therapy
to treat superinfection.
The
patient with pneumonia is assessed for confusion and other more subtle changes
in cognitive status. Confusion and changes in cognitive status resulting from
pneumonia are poor prognos-tic signs. Confusion may be related to hypoxemia,
fever, dehy-dration, sleep deprivation, or developing sepsis. The patient’s
underlying comorbid conditions may also play a part in the de-velopment of
confusion. Addressing the underlying factors and ensuring the patient’s safety
are important nursing interventions.
Depending
on the severity of the pneumonia, treatment may occur in the hospital or in the
outpatient setting. Patient educa-tion is crucial regardless of the setting,
and the proper adminis-tration of antibiotics is important. In some instances,
the patient may be initially treated with intravenous antibiotics as an
inpa-tient and then be discharged to continue the intravenous anti-biotics in
the home setting. It is important that a seamless system of care be maintained
for the patient from hospital to home; this includes communication between the
nurses caring for this pa-tient in both settings. In addition, if oral
antibiotics are pre-scribed, it is important to teach the patient about their
proper administration and potential side effects.
After
the fever subsides, the patient may gradually increase ac-tivities. Fatigue and
weakness may be prolonged after pneumo-nia, especially in the elderly. The
nurse encourages breathing exercises to promote secretion clearance and volume
expansion. It is important to instruct the patient to return to the clinic or
caregiver’s office for a follow-up chest x-ray and physical exami-nation. Often
improvement in chest x-ray findings lags behind improvement in clinical signs
and symptoms.
The
nurse encourages the patient to stop smoking. Smoking inhibits tracheobronchial
ciliary action, which is the first line of defense of the lower respiratory
tract. Smoking also irritates the mucous cells of the bronchi and inhibits the
function of alveolar macrophage (scavenger) cells. The patient is instructed to
avoid stress, fatigue, sudden changes in temperature, and excessive al-cohol
intake, all of which lower resistance to pneumonia. The nurse reviews with the
patient the principles of adequate nutri-tion and rest, because one episode of
pneumonia may make the patient susceptible to recurring respiratory tract
infections.
Patients who are severely debilitated or who cannot care for them-selves may require referral for home care. During home visits, the nurse assesses the patient’s physical status, monitors for compli-cations, assesses the home environment, and reinforces previous teaching. The nurse evaluates the patient’s adherence to the ther-apeutic regimen (ie, taking medications as prescribed, perform-ing breathing exercises, consuming adequate fluid and dietary intake, and avoiding smoking, alcohol, and excessive activity). The nurse stresses to the patient and family the importance of monitoring for complications. The nurse encourages the patient to obtain an influenza vaccine at the prescribed times, because influenza increases susceptibility to secondary bacterial pneu-monia, especially that caused by staphylococci, H. influenzae, and S. pneumoniae. The nurse also encourages the patient to seek medical advice about receiving the vaccine (Pneumovax) against S. pneumoniae.
Expected
patient outcomes may include:
1.
Demonstrates improved airway
patency, as evidenced by adequate oxygenation by pulse oximetry or arterial
blood gas analysis, normal temperature, normal breath sounds, and effective
coughing
2.
Rests and conserves energy by
limiting activities and re-maining in bed while symptomatic and slowly
increasing activities
3.
Maintains adequate hydration, as
evidenced by an adequate fluid intake and urine output and normal skin turgor
4.
Consumes adequate dietary intake, as
evidenced by main-tenance or increase in body weight without excess fluid gain
5.
States explanation for management
strategies
6.
Complies with management strategies
7.
Exhibits no complications
i.
Has normal vital signs, pulse
oximetry, and arterial blood gas measurements
ii.
Reports productive cough that
diminishes over time
iii.
Has absence of signs or symptoms of
shock, respiratory failure, or pleural effusion
iv.
Remains oriented and aware of
surroundings
v.
Maintains or increases weight
8.
Complies with treatment protocol and
prevention strategies
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