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Chapter: Medical Surgical Nursing: Management of Patients With Chest and Lower Respiratory Tract Disorders

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Nursing Process: The Patient With Pneumonia

Nursing assessment is critical in detecting pneumonia.

NURSING PROCESS: THE PATIENT WITH PNEUMONIA

Assessment

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.

 

Diagnosis

 

NURSING DIAGNOSES

 Based on the assessment data, the patient’s major nursing diag-noses may include:


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


COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS


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

Planning and Goals

 

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.

 

Nursing Interventions

 

IMPROVING AIRWAY PATENCY

 

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.

 

PROMOTING REST AND CONSERVING ENERGY

 

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.

 

PROMOTING FLUID INTAKE

 

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.

MAINTAINING NUTRITION

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.

PROMOTING THE PATIENT’S KNOWLEDGE

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.

 

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

 

Continuing Symptoms After Initiation of Therapy

 

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.

 

Shock and Respiratory Failure

 

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.

 

Atelectasis and Pleural Effusion

 

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.

 

Superinfection

 

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.

 

Confusion

 

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.

 

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

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.

 

Continuing Care

 

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.

Evaluation

 

EXPECTED PATIENT OUTCOMES

 

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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