nursing management

1. Ms. Amandeep Kaur
Nursing Tutor
MMCON

2. INTRODUCTION
 It is an inflammatory condition of the lung that is
caused by a microbial agent.
 “Pneumonitis” is a general term that describes an
inflammatory process in the lung tissue that may
predispose a patient to or place a patient at risk for
microbial invasion.
 It is the leading cause of death from the infectious
disease.

3. DEFINITION
“An inflammation of the lung
parenchyma (the respiratory bronchioles
and the alveoli) is known as Pneumonia”.
Pneumonia is mainly caused by
microorganisms which enter the lower
respiratory system and cause infection.
The microorganism includes bacteria,
mycobacteria, mycoplasma, fungi,
parasites, and viruses.

4. EPIDEMIOLOGY
 Common illness affecting approximately 450 million
people a year occurring in all part of the world, and 4
million death yearly .
 Rates are greater in children less than five years and
adult older than 75 years.
 It occurs five times more in the developing world than
in the developed world.

5. EPIDEMIOLOGY cont...
 It is the eighth leading cause of death in United States ,
resulting in almost 70,000 deaths per year. In persons
65 years of age and older, it is the fifth leading cause of
death.
 In India it is the single largest cause of death in
children, resulting in nearly 120 million cases a year.

6. CLASSIFICATION
 1. According to the causative organisms
(a) Bacterial :-
 Pneumococcal pneumonia caused by Streptococcus pneumonia**
 Staphylococcal pneumonia caused by Staphylococcus aureus
 Influenzal pneumonia caused by Haemophilus influenza
 Gram-negative bacterial pneumonia caused by Klebsiella
pneumonia
 Anaerobic bacterial pneumonia caused by normal oral flora.

7. CLASSIFICATION contd…
(b) Viral :-
 Rhinovirus, coronaviruses, influenza virus, respiratory sncytial virus(RSV),
adenovirus and parainfluenza.
 Herpes simplex virus rarely causes pneumonia in newborns, persons with
cancer, transplant recipients, and people with significant burns.
 People following organ transplantation or immunocompromised present
high rates of cytomegalovirus pneumonia.
(c) Fungal :-
 Fungal pneumonia caused by histoplasmosis , blastomycosis,
coccidioidomycosis, aspergillosis, candidiasis.

8. CLASSIFICATION cont…
(d) Parasitic :-
 Parasitic pneumonia (caused by protozoa, nematodes,
platyhelminthes); common organism is Pneumocystis
(carinii) firoveci

9. CLASSIFICATION cont…
2. According to the environment
 Community-acquired pneumonia.
 Hospital acquired pneumonia.
 Pneumonia in the immuno-compromised host.
 Ventilator acquired Pneumonia.(VAP)

10. CLASSIFICATION cont…
3. According to the areas of the lung involved/affected
 Lobar pneumonia
 Multilobar pneumonia
 Bronchial pneumonia
 Interstitial pneumonia
 Alveolar (acinar) pneumonia
 Necrotizing pneumonia
 Segmental pneumonia

11. CLASSIFICATION cont…
4. According to the cause
 Bronchiolitis obliterans organizing pneumonia (BOOP)/
cryptogenic organizing pneumonitis (COP).
 Eosinophilic pneumonia : occur in response to infection with
parasite.
 Chemical pneumonia
 Aspiration pneumonia
 Dust pneumonia
 Bilateral pneumonia.

12. ETIOLOY
There are many causes of pneumonia including
bacteria, viruses, mycoplasmas, fungal agents and
protozoa. It may also result from inhalation of toxic
or caustic chemicals, smoke, dusts or gases or
aspiration of food, fluids, or vomitus. Pneumonia may
complicate to chronic illnesses.

13. RISK FACTORS
 Age 60 or older
 Smoking
 Air pollution
 Altered consciousness : Alcoholism, head injury, anaesthesia,
drug overdose
 Tracheal intubation
 Upper Respiratory Tract Infection
 Chronic Disease : Chronic lung disease, Diabetes mellitus,
heart disease, cancer

14. RISK FACTORS contd…
 Immunosuppression.
 Malnutrition.
 Inhalation of noxious substances.
 Prolonged Bed rest and immobility
 Aspiration of fluid, liquid, foreign or gastric content.
 Prolonged hospital stay.
 Residence in institutional areas/setting where transmission is
prone.
 Fatigue

15. PATHOPHYSIOLOGY
Infectious agent, Foreign substance, blood borne organisms
that enter the blood circulation or Aspiration of gastric content
Mucosal edema of
alveolar membrane occur
The alveoli fills with
exudates
Cause inflammation of pulmonary tissue affecting both
ventilation and diffusion

16. PATHOPHYSIOLOGY
interferes with the
diffusion of oxygen and
carbon dioxide
causing occlution of
alveoli resulting in
decrease alveolar oxygen
tension
Hypoxia occur with retention of
carbon dioxide, Shortness of
breath, Fatigue ,Crackles in
lungs Or decrease Breath
sounds

17. CLINICAL MANIFESTATION
 Fever
 Chills and sweating
 Productive cough
 Shortness of breath
 Pleuritic chest pain
 Hypoxemia
 Fatigue
 Tachypnea

18. CLINICAL MANIFESTATION
CONTD…
 Hemoptysis
 Dyspnea
 Tachypnea
 Headache
 Crackling sounds over affected area
 Dullness on percussion on affected area
 Decrease in breath sounds
 Unequal chest expansion

19. CLINICAL MANIFESTATION CONT…
SYMPTOMS FREQUENCY
SYMPTOM FREQUENCY
Cough 79–91%
Fatigue 90%
Fever 71–75%
Shortness of breath 67–75%
Sputum 60–65%
Chest pain 39–49%

20. DIAGNOSTIC EVALUATION
 Physical examination.
 Chest X-ray.
 Gram stain and culture and sensitivity tests of sputum.
 Blood culture.
 Immunologic test to detect microbial antigens.
 CT Scan thorax.
 Transtracheal aspirate.
 Fiberoptic bronchoscopy or transcutaneous needle aspiration
/biopsy.
 Transcutaneous oxygen level analysis or ABG.

22. MANAGEMENT
 Antimicrobial therapy
CAUSATIVE
ORGANISM
ANTIBIOTIC OF
CHOICE
ALTERNATE ANTIBIOTICS
Streptococcus
Pneumonia
Penicillin G or Penicillin
V, or amoxicillin
clavulanate (Augmentin),
Trimethoprim
sulfamethoxazole (TMP-
SMZ).
Macrolide antibiotics such as
azithromycin (Zithromax) or
clarithromycin (Biaxin);
doxycycline; oral beta lactams
such as cefuroxime (Ceftin),
Linozolid.
Staphylococcus
Aureus
Penicillin. Cephalosporins; vancomycin
(Vancocin) for methicillin-
resistant S. aureus.
Haemophilus
Influenza
2nd/3rdgeneration
cephalosporins, β lactam-
β- lactamase inhibitor,
doxycycline.
Azithromycin, TMP-SMZ

23. MANAGEMENT cont…
CAUSATIVE
ORGANISM
ANTIBIOTIC OF
CHOICE
ALTERNATE
ANTIBIOTICS
Mycoplasma
Pneumonia
Doxycycline, macrolides,
Fluoroquinolone
Klebsiella
Pneumonia
3rd generation cephalosporin
with or without
aminiglycoside, carbapenams
Aztreonam, β lactam-β-
lactamase inhibitor,
fluoroquinolone
Legionella
Pneumonia
Macrolide + rifampin,
fluoroquinolone
Doxycycline + rifampin
Pneumocystis
TMP-SMZ, pentamidine +
prednisone.
Dapsone + trimethoprim +
Clindamycin + primaquine +
Trimetrexate

24. MANAGEMENT cont…
 Oxygen therapy
 Nutritional support
 Fluid and electrolyte management
 Bronchodilators medications: albuterol sulphate, metaproterenol
or methylxanthines.
 Deep breathing exercises and spirometry
 Chest physiotherapy
 Percussion & Vibration
 Postural drainage
 Nasotracheal suctioning

25. FIG:- Patient positions for postural drainage.

26. COMPLICATION
 Empyema.
 Lung Abscess.
 Bronchiolitis Obliterans.
 Acute Respiratory Distress
Syndrome (ARDS).
 Sepsis.
 Bacterimia.
 Hypotension and shock,
especially in gram negative
bacterial disease, particularly in
elderly patients.
 Atelectasis.
 Pleural effusion.
 Pericarditis.

27. PROGNOSIS
With treatment, most types of bacterial pneumonia
will stabilize in 3–6 days. It often takes a few
weeks before most symptoms resolved. In persons
requiring hospitalization, mortality may be as high
as 10%, and in those requiring intensive care it may
reach 30–50%.

28. NURSING MANAGEMENT Nursing Assessment
 Take a careful history to help establish etiologic diagnosis.
 Assess the elderly patient for unusual behavior, altered mental
status, dehydration, excessive fatigue, and concomitant heart
failure.
 Observe for anxious, flushed appearance, shallow respirations,
splinting of affected side, confusion, disorientation.
 Auscultate for crackles overlying affected region, and for
bronchial breath sounds when consolidation (filling of airspaces
with exudate) is present.

29. NURSING MANAGEMENT cont…
NURSING DIAGNOSIS AND INTERVENTIONS
1. Impaired gas exchange related to inflammatory pulmonary
infection evidenced by presence of retained secretions,
Changes in respiratory rate diminished/adventitious breath
sounds, dyspnea, cyanosis Ineffective cough
INTERVENTION
 Assess rate, depth of respirations and chest movement.
 Auscultate lung fields.
 Elevate head of bed.
 Assist and demonstrate client with frequent deep-breathing
exercises, splinting the chest and coughing.
 Suctioning is done as indicated.
 Force fluids to at least 2500 mL per day, unless
contraindicated, as in HF

30. NURSING MANAGEMENT cont…
 Assist with and monitor effects of nebulizer treatments and
other respiratory physiotherapy, such as incentive spirometer,
percussion, and postural drainage.
 Administer medications, as indicated, for example, mucolytics,
expectorants, bronchodilators, and analgesics.
 Provide supplemental fluids such as IV, humidified oxygen,
and room humidification.
 Monitor serial chest x-rays, ABGs, and pulse oximetry
readings.

31. 2. Impaired Gas Exchange related t oAlveolar-capillary
membrane changes Ventilation-perfusion imbalance, possibly
evidenced By dyspnea, abnormal skin color (e.g., pale,
dusky)tachycardia, restlessness, confusion ,Hypoxia
INTERVENTION
 Assess the respiratory status, skin colour, mental status, heart rhythm and
body temperature.
 Elevate head and encourage frequent position changes, deep breathing, and
effective coughing. And maintain bedrest
 Observe for deterioration in condition, noting hypotension, copious amounts
of pink or bloody sputum, pallor, cyanosis, change in level of
consciousness, severe dyspnea, and restlessness.
 Monitor ABGs and pulse oximetry.
 Administer oxygen therapy by appropriate .

32. 3. Risk for Infection related to inadequate primary defenses due to
decreased ciliary action, stasis of body fluids [respiratory
secretions]; Inadequate secondary defenses due to [presence of
existing infection], immunosuppression; chronic disease,
malnutrition, possibly evidenced By presence of signs and
symptoms establishes an actual diagnosis.
INTERVENTION
 Monitor vital signs closely, especially during initiation of
therapy.
 Instruct client concerning the disposition of secretions
reporting changes in color, amount, and odor of secretions.
 Change position frequently and provide good pulmonary toilet,.
 perform proper suctioning technique for ventilated clients as
appropriate.
 Limit visitors, and institute isolation precautions as
individually appropriate.

33. NURSING INTERVENTION cont…
 Promote adequate nutritional intake.
 Investigate sudden changes or deterioration in condition,
such as increasing chest pain, extra heart sounds, altered
sensorium, recurring fever, and changes in sputum
characteristics
 Administer antimicrobials, as indicated, by results of
sputum and blood cultures.

34. 4. Activity Intolerance related To Imbalance between oxygen
supply and demand, General weakness, possibly evidenced by
report of weakness, fatigue, exertional dyspnea , Tachypnea,
Abnormal heart rate response to activity.
INTERVENTION
 Evaluate client’s response to activity. Note reports of dyspnea,
increased weakness and fatigue, and changes in vital signs
during and after activities
 Provide a quiet environment and limit visitors during acute
phase and encourage use of stress management and diversional
activities as appropriate.
 Explain importance of rest in treatment plan and necessity for
balancing activities with rest.
 Assist with self-care activities as necessary.

35. 5. Acute Pain related to Injuring agents (e.g., biological—
inflammation of lung parenchyma, cellular reactions to
circulating toxins; physical—persistent coughing) possibly
evidenced by Verbal/coded report [pleuritic chest pain,
headache, muscle or joint pain] and guarded behavior,
expressive behavior—restlessness.
INTERVENTION
 Determine pain characteristics, Investigate changes in
character, location, and intensity of pain.
 Monitor vital signs.
 Provide comfort measures, such as back rubs, change of
position, and quiet music or conversation. Encourage use of
relaxation and breathing exercises.
 Instruct and assist client in chest-splinting techniques
during coughing episodes.
 Administer analgesics and antitussives, as indicated.

36. 6. Deficient Knowledge regarding condition, treatment, self-care, and discharge
needs, related to lack of exposure , information misinterpretation, lack of
recall possibly evidenced by reports the problem, inaccurate follow-through of
instructions.
INTERVENTION
 Assess the level of understanding of the patient and knowledge.
 Explain about the disease condition, its signs and symptoms and treatment
modalities.
 Explain and demonstrate about the importance of effective coughing and deep
breathing exercises.
 Stress necessity of continuing antimicrobial therapy.
 Explain about balanced rest and activity, avoiding smoking, well-rounded diet,
program of aerobic exercise or strength training (particularly elderly
individuals), and avoidance of crowds during cold and flu season and of
persons with upper respiratory infections.
 Stress importance of continuing medical follow-up and obtaining vaccinations
and immunizations as appropriate for both children and adults.

37. EXPECTED OUTCOME
The client will be able to :-
 Airway with breath sounds is clear and absence of
dyspnea and cyanosis.
 Improved ventilation and oxygenation of tissues by
ABGs within client’s acceptable range.
 Participate in actions to maximize oxygenation
 Achieve timely resolution of current infection without
complications.

38. EXPECTED OUTCOME cont...
 Identify interventions to prevent and reduce risk and
spread of a secondary infection.
 Report and demonstrate a measurable increase in
tolerance to activity.
 Verbalize understanding of disease condition
participate in treatment program.

39. PATIENT EDUCATION AND HEALTH
MAINTENANCE
 Advise patient to complete entire course of antibiotics.
 Once clinically stable, encourage gradual increase in activities to
bring energy level back to pre-illness stage.
 Encourage breathing exercises.
 Explain that a chest X-ray is usually taken 4 to 6 weeks after
recovery .
 Advise smoking cessation .
 Advise patient to keep up natural resistance with good nutrition and
adequate rest.
 Instruct patient to avoid fatigue, sudden extremes in temperature, and
excessive alcohol intake.
 Advice patient to practice frequent handwashing, especially after
contact with others.

40. RESEARCH INPUT
1. Oral health and ventilator-associated pneumonia among
critically ill patients: a prospective study.
Saensom D, Merchant AT, wara-Aswapati N, Ruaisungneon w, Pitiphat W
OBJECTIVE:- To evaluate the association between oral health and ventilator
associated pneumonia (VAP) among critically ill patients.
METHODS:- A prospective cohort study was conducted among 162 critically
ill patients who are newly intubated and treated with mechanical ventilator
in one tertiary hospital in Thailand. Oral health status was assessed using
Oral Health Assessment Tool (OHAT), Plaque Index (PI), and number of
teeth. VAP, defined as Clinical Pulmonary Infection Score>6, was assessed
on Day 4 after intubation. Hazard ratios and 95% confidence intervals (CIs)
were calculated using Cox proportional hazards regression adjusted for
confounders.

41. RESEARCH INPUT contd..
 RESULTS:-
 Critically ill patients had deteriorating oral health status after
intubation.
 Early-onset VAP developed in 69 patients (42.6%), with VAP
incidence of 117 episodes per 1000 ventilator-days.
 Patients with moderate-to-very poor oral hygiene assessed by
PI had increased VAP risk of 1.66-folds .The number of teeth
was not associated with VAP development.
 CONCLUSIONS:- There is a strong association between poor
oral health and increased risk for early-onset VAP. Routine oral
care possibly prevents VAP development among critically ill
patients treated with mechanical ventilator.

42. SUMMARY

43. CONCLUSION

44. REFERENCES
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pneumonia and diarrhea, Lancet, 2013.
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Shannon. Medical Surgical Nursing : Assessment and Management of
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601.
 Lemone Priscilla, Karen Burke. Medical Surgical Nursing: Critical
Thinking in Client Care. 4th Edition. New Delhi: Published by Dorling
Kindersley (India) Pvt, Ltd. 2003.p.1267-1276.
 Smeltzer C Suzanne, Bare G Brenda, Hinkle L Jainice, Cheever H Kerry.
Brunner and Suddharth textbook of Medical-Surgical Nursing. 11th
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