The goal of this NCLEX review is to help you understand the respiratory infection, pneumonia. After this review, you will have a clearer understanding of pneumonia’s pathophysiology, its complications, signs and symptoms, risk factors, types, how it is diagnosed, the antibiotics used for the treatment, and the corresponding nursing interventions.
What Is Pneumonia?
Pneumonia is a lower respiratory lung infection where the air sacs of one or both lungs are inflamed. The alveolar sacs are filled with fluid or purulent material such as pus. The fluids cause the patient to cough with phlegm accompanied by fever and difficulty breathing.
The nursing diagnosis for patients with pneumonia is impaired gas exchange, and for severe cases, it will require mechanical ventilation. The nurse must recognize the signs and symptoms of pneumonia for further diagnostic tests for confirmation.
There are two types of pneumonia:
- Community-acquired pneumonia: This is the most widely occurring pneumonia obtained from germs outside of the hospital or acquired in the community.
- Hospital-acquired pneumonia: This is the type of pneumonia acquired in the hospital, especially by post-op patients, in mechanical ventilators, bedridden or immobile patients. It is classified as hospital-acquired pneumonia when the patient developed pneumonia 48-72 hours after admission. Hospital-acquired pneumonia is hard to treat because it may become resistant to antibiotics.
What Happens During Gas Exchange in Pneumonia?
In a normal gas exchange, the oxygen is transported from the lungs into the bloodstream. At the same time, the carbon dioxide is passed from the blood to the lungs. The gas exchange occurs between the capillaries (tiny blood vessels) and the alveoli. When a person has pneumonia, the alveoli sacs are filled with fluid or pus. As a result, oxygen intake is limited, and the person experiences difficulty breathing.
The Development of Pneumonia: In normal circumstances, the respiratory system filters the germs or microorganisms through the nose and airway. However, there are events when the respiratory system can’t fight off these germs. When the lungs cannot fight off these germs, the bacteria, virus, or fungi enter the lungs through aspiration, inhalation, or the bloodstream. As a result, the sacs become inflamed with fluids, RBC and WBC (immune cells to fight off the infection), and bacteria.
Alveoli Sacs Are Filled With Fluids: Since the alveoli sacs are filled with fluids, they cannot inflate or deflate normally. As a result, there is no proper gas exchange, so the patient will experience hypoxemia (low oxygen levels in the blood). Hypoxemia occurs because the oxygen cannot attach to the RBC, and the carbon dioxide is retained, which also results in respiratory acidosis.
Arterial Blood Gas Values of a Person With Pneumonia:
- PO2 <90 mmHg
- pH less than 7.35 mmHg
- PCO2 greater than 45 mmHg
- HCO3 greater than 26 mEq/L
- The kidneys compensate to increase the pH of the blood to normal. This is done by conserving HCO3 (bicarbonate)
What Causes Pneumonia?
Bacteria, viruses, and fungi cause pneumonia. Pneumonia has different types, and it is classified according to the causative agent. Here are some of the most common microorganisms that cause pneumonia:
- Bacteria: Streptococcus pneumoniae (most common), Mycoplasma pneumoniae, Legionella pneumophila, Haemophilus influenzae
- Virus: respiratory syncytial virus, influenza, rhinoviruses
- Fungi: Pneumocystis jirovecii, Histoplasmosis species, Cryptococcus species
Who Are at Risk of Acquiring Pneumonia?
Anyone can be affected by pneumonia, however, there are those who are more susceptible compared to others.
- Children younger than two years old
- Older people, usually above 65 years old
- Those who had a prior infection like flu
- Immunocompromised persons (e.g., people with HIV or undergoing chemotherapy)
- Immobile persons (e.g., stroke or bedridden patients)
- Existing respiratory illness like asthma and COPD
- After an operation where the patient cannot cough or practice deep breathing
- Being hospitalized exposes you to pneumonia (hospital-acquired pneumonia)
What Are the Signs and Symptoms of Pneumonia?
It is the nurse’s responsibility to closely monitor all high-risk patients for the signs and symptoms of pneumonia. It must be reported to the doctor once these signs and symptoms appear for confirmation and further diagnostic tests. These are the signs and symptoms to look for–remember the acronym PNEUMONIA:
- P – Productive cough (with phlegm) and Pleural pain (chest pain caused by breathing or coughing)
- N – Neurological changes like confusion or changes in mental awareness, especially in elderly patients
- E – Elevated laboratory values (increased WBC and PCO2 greater than 45)
- U – Unusual breathing (presence of coarse rhonchi, crackles, or bronchial sounds in the peripheral area upon auscultation)
- M – Mild or high fever
- O – O2 saturation may decrease, and the patient may need supplementary oxygen.
- N – Nausea or sometimes vomiting that may lead to loss of appetite
- I – Increased respiration and increased heart rate.
- A – Aches (muscle pain or aching joints) and activity intolerance due to shortness of breath
How Is Pneumonia Diagnosed?
Pneumonia is diagnosed through the following tests:
- Chest X-Ray
- Chest CT Scan
- Blood Cultures
- ABG Values
- Sputum culture
What Are the Nursing Interventions for Pneumonia?
- P – Practice deep breathing, coughing exercises or use an incentive spirometer
- N – Never forget to frequently change the patient’s position, keep the head of the bed elevated at least 30 degrees, prevent aspiration while eating or after meals.
- E – Encourage fluid intake (2-3 liters a day) unless contraindicated.
- U – Use suction and perform chest percussion as needed.
- M – Monitor respiratory status, lungs, songs, and vital signs. Medications include bronchodilators, antipyretics, antivirals, or antibiotics as per the doctor’s order.
- O – Oxygen saturation must be >95%
- N – No smoking and no exposure to people who are sick
- I – Inform about vaccinations for pneumonia and flu.
- A – ABG tests or sputum collection as ordered
What Are the Antibiotics Used to Treat Pneumonia?
As mentioned earlier, pneumonia can be caused by different kinds of bacteria strains. There are other people who are allergic to penicillin, and some may develop resistance to antibiotics. That is why further diagnostic tests are important to determine the causative agent, especially sputum cultures.
For bacterial pneumonia the antibiotics that may be prescribed by the physician are:
- Vancomycin: For severe cases and those who are resistant to other antibiotics. Watch out for ototoxicity (loss of hearing).
- Macrolides (Zithromax): Prescribed for patients with allergy to penicillin. Macrolides are narrow-spectrum antibiotics that mainly target gram-positive bacteria.
- Tetracycline (Doxycycline): Broad-spectrum antibiotics that target gram-negative and gram-positive bacteria. This is contraindicated for pregnant women and children eight years old and younger.
- Fluoroquinolones (Levaquin): Treatment for severe hospital-acquired pneumonia that has developed resistance to other antibiotics.
- Cephalosporin: Prescribed for community-acquired pneumonia. Watch out for patients who are also allergic to penicillin.
- Penicillin: A narrow-spectrum antibiotic that targets gram-positive bacteria only. Those patients who are allergic to cephalosporin may be allergic to penicillin too.
Looking for more study materials on respiratory diseases? Check out these 53 Respiratory Memes You Need for the NCLEX.