PNEUMONIA

CHAPTER 5RESPIRATORY—PNEUMONIA

ACTIONS/INTERVENTIONS

(continued)

RATIONALE

(continued)

Provide information and encourage participation in support groups sponsored by the American Lung Association and public health department.

Refer for evaluation of home care if indicated. Provide a de- tailed plan of care and baseline physical assessment to home-care nurse as needed on discharge from acute care.

Assist client and SO in making arrangements for access to emergency assistance, such as a buddy system for getting help quickly, special phone numbers, and “panic button.”

Facilitate discussion about healthcare directives and end-of-life wishes as indicated.

These clients and their SOs may experience anxiety, depres- sion, and other reactions as they deal with a chronic disease that has an impact on their desired lifestyle. Support groups may be desired or needed to provide assistance, emotional support, and respite care.

Provides for continuity of care. May help reduce frequency of hospitalization.

Client with chronic respiratory condition should have access to prompt assistance when needed. This is both necessary and psychologically comforting for self-management.

Although many clients have an interest in discussing living wills, their wishes may be unspoken. In client with severe pulmonary disease, it is helpful to discuss preferences re- garding aggressive treatment, home care only, hospitaliza- tion for comfort care, and full life support. It is useful also to discuss the goals of care, such as functional independence or continuation of life support in an extended care nursing facility.

b.Distribution

i.CAP commonly caused by S. pneumoniae, Chlamydia

33.8 million new episodes of ALRI in children annually, 96% of these occurring in developing countries.

b.Mortality: In the United States, deaths attributed to pneu- monia in 2006 were over 55,000. Globally, pneumonia kills more than 1.5 million children younger than age 5 years (CDC) and is the leading cause of death in children world- wide (WHO, 2012). RSV is estimated to result in 53,000 to

199,000 deaths annually in young children (WHO, 2012;

Nair et al, 2011).

c.Cost:

i.CAP—annual cost exceeds $12.2 billion (Brar, 2011) ii.HCAP (non-VAP)—estimated $28,008 per incident

(Davis, 2012)

iii.VAP—estimated $39,828 per incident (Kollef, 2012)

Care Setting

Most clients are treated as outpatients in community settings;

however, persons at higher risk, such as children under 5, those older than 65, and persons with other chronic condi- tions such as chronic obstructive pulmonary disease (COPD), diabetes, cancer, and congestive heart failure, are treated in the hospital, as are those already hospitalized for other reasons and who have developed nosocomial, or healthcare- acquired, pneumonia.

Related Concerns

Acquired immunodeficiency syndrome (AIDS), page 689

Chronic obstructive pulmonary disease (COPD) and asthma, page 118

Pediatric considerations, page 872 Psychosocial aspects of care, page 729 Sepsis/septicemia, page 665

Surgical intervention, page 762

Adventitious breath sounds:Abnormal breath sounds heard

when listening to the chest. Adventitious sounds may include crackles or rales, rhonchi or wheezes, or pleural friction rubs.

Bronchial breath sounds:A harsh or blowing quality, made by air moving in the large bronchi and barely, if at all, mod- ified by the intervening lung; may be heard over a consoli- dated lung.

Community-acquired pneumonia (CAP):Acquired outside healthcare organizations, including hospitals, nursing homes, and other long-term care facilities; includes the first 2 days of hospitalization.

Crackles:An adventitious breath sound produced by air passing over airway secretions; a discontinuous sound, as opposed to a wheeze, which is continuous. Crackles are classified as

“fine” or “coarse”; also known as rales.

Empyema:A condition in which pus and fluid from infected tis- sue collects in a body cavity; most often used to refer to col- lections of pus in the space around the lungs (pleural cavity).

Fremitus:A palpable vibration, as felt by the hand placed on the chest during coughing or speaking.

G L O S S A R Y

Healthcare-associated pneumonia (HAP) (formerly called nosocomial pneumonia):Occurs 48 hours or longer after admission to a facility.

Percussion:An assessment method in which the surface of the body is struck with the fingertips to obtain sounds that can be heard or vibrations that can be felt. It can determine the posi- tion, size, and consistency of an internal organ. It is done over the chest to determine the presence of normal air content in the lungs.

Pleural effusion:Accumulation of fluid in the space between the membrane encasing the lung and lining the thoracic cavity.

Pleural friction rub:An abrasive sound that is synchronous with the respiratory movements, made by the rubbing together of two acutely inflamed serous surfaces, as in acute pleurisy.

Respiratory syncytial virus (RSV):A highly contagious virus and the leading cause of lower respiratory disease (e.g., bron- chiolitis and pneumonia) in children ages 2 and under. RSV infection is primarily a disease of winter or early spring, with waves of illness sweeping through a community. There is cur- rently no vaccine against RSV.

Client Assessment Database

D I A G N O S T I C D I V I S I O N M AY R E P O R T

A

^CTIVITY

/R

^EST

•Fatigue, weakness

•Insomnia

•Prolonged immobility and bedrest

C

IRCULATION

•History of recent or chronic heart failure (HF)

F

^OOD

/F

^LUID

•Loss of appetite

•Nausea, vomiting

•Lethargy

•Decreased tolerance to activity

•Tachycardia

•Flushed appearance, pallor, central cyanosis

•Distended abdomen

•Hyperactive bowel sounds

M AY E X H I B I T

CHAPTER 5RESPIRATORY—PNEUMONIA

D I A G N O S T I C D I V I S I O N

M AY R E P O R T

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•May be receiving intestinal, gastric feedings

N

EUROSENSORY

•Frontal headache (influenza)

P

^AIN

/D

^ISCOMFORT

•Headache

•Chest pain (pleuritic) aggravated by cough

•Substernal chest pain (influenza)

•Myalgia, arthralgia

•Abdominal pain

R

ESPIRATION

•History of recurrent or chronic upper respiratory infections (URIs), tuberculosis, COPD, cigarette smoking

•Progressive shortness of breath

•Presence of tracheostomy, endotracheal tube

•Current treatment with mechanical ventilator

•Cough is dry and hacking (initially), progressing to productive cough

S

^AFETY

•Recurrent chills

•History of altered immune system, such as systemic lupus erythematosus (SLE), AIDS, active malignancies, neurological disease, HF, diabetes, steroid or chemotherapy use; institution- alization, general debilitation

T

^EACHING

/L

^EARNING

•Recent surgery, chronic alcohol use or long history of alco- holism, intravenous (IV) drug therapy or abuse, chemotherapy or other immunosuppressive therapy

•Use of herbal supplements, such as garlic, ginkgo, licorice, onion, turmeric, horehound, marshmallow, mullein, wild cherry bark, astragalus, echinacea, elderberry, goldenseal, Oregon grape root

D

^ISCHARGE

P

^LAN

C

ONSIDERATIONS

•Assistance with self-care, homemaker tasks

•Supplemental oxygen, especially if recovery is prolonged or other predisposing condition exists

ÁRefer to section at end of plan for postdischarge considerations.

•Dry skin with poor turgor

•Cachectic appearance (malnutrition)

•Changes in mentation, such as confusion, somnolence

•Changes in behavior, such as irritability, restlessness, lethargy

•Splinting, guarding over affected area

•Position—commonly lies on affected side to restrict movement

•Respirations: Tachypnea, shallow grunting respirations

•Use of accessory muscles, nasal flaring

•Breath sounds are diminished or absent over involved area

• Bronchial breath sounds over area(s) of consolidation

• Coarse inspiratory crackles

•Color:Pallor or cyanosis of lips or nailbeds

•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

• Signs of respiratory distress (Bradley et al, 2011)

•Tachypnea—respiratory rate, breaths/min

•Age 0–2 months: >60

•Age 2–12 months: >50

•Age 1–5 years: >40

•Age 5 years: >20

•Dyspnea

•Retractions (suprasternal, intercostals, or subcostal); nasal flaring

•Grunting

•Apnea

•Altered mental status

•Pulse oximetry measurement 90% room air

•Diaphoresis

•Shaking

•Rash, in cases of rubeola or varicella

•Fever of 102°F to 104°F (39°C to 40°C)

M AY E X H I B I T

(continued)

T E S T

W H Y I T I S D O N E