ACTIONS/INTERVENTIONS (continued)
Facilitate discussion about healthcare directives and end- of- life wishes as indicated.
Client with chronic respiratory condition should have access to prompt assistance when needed. This is both neces- sary 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 regarding aggressive treatment, home care only, hospitalization for comfort care, and full life support. It is useful also to discuss the goals of care, such as functional in de pen dence or continuation of life support in an extended- care nursing fa cil i ty.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of com- plications, personal resources, and life responsibilities)
•Self- Care deficit, [specify]— fatigue, weakness, severe anxiety
•impaired Home Maintenance— condition impacting ability to maintain home; insufficient support system or finances; insufficient knowledge of neighborhood resources
•risk for Infection— chronic illness, inadequate vaccination; inadequate primary defenses (e.g., decrease in ciliary action, smoking);
increased environmental exposure to pathogens
I. Pathophysiology
a. Infl ammation of the lung parenchyma associated with alveolar edema and congestion that impairs gas exchange b. Common pathogens
i. Viruses (CDC, 2016a)
1. Common causative organisms include respiratory syncytial virus (RSV) (most common virus causing pneumonia in children): Infl uenza (most common virus causing pneumonia in adults) and human parainfl uenza viruses (HPIVs); human metapneu- movirus (HMV).
2. Viruses account for approximately half of all cases of community- acquired pneumonia (CAP).
ii. Bacteria
1. Divided into typical and aty pi cal types.
2. Gram- positive Streptococcus pneumoniae, Haemophilus, and Staphylococcus most common typical bacterial causes.
3. Aty pi cal bacterial causes include Legionella, mycoplasma, and chlamydia (National Heart, Lung, and Blood Institute [NHLB], 2016).
iii. Fungus
1. Most common causes Histoplasma capsulatum and Coccidioides immitis.
2. Pneumocystis jirovecii (formerly carinii) and cytomegalovirus (CMV) often occur in immuno- compromised persons.
iv. Chemical: Infl ammation of lung tissue is from poisons or toxins. Many substances can cause chemical pneumonia, including liquids, gases, and small particles, such as dust or fumes. Note: Aspiration pneumonia is a type of chemical pneumonia.
II. Types (NHLB, 2016)
i. Community- acquired pneumonia (CAP): Commonly caused by S. pneumoniae, Chlamydia pneumoniae, Haemophilus infl uenzae, RSV, and occasionally aty pi cal pathogens.
ii. Hospital- acquired pneumonia (HAP): Pneumonia that occurs 48 hours or more after hospital admission and that was not pres ent at the time of admission.
iii. Ventilator- assisted pneumonia (VAP): Often caused by Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus, and both methicillin- sensitive and methicillin- resistant S. aureus (MRSA).
iv. Aspiration pneumonia: Caused by inhaling food, drink, vomit, or saliva from the mouth into the lungs.
Aspiration may occur when something disturbs the normal gag refl ex, such as a brain injury, swallowing prob lem, or excessive use of alcohol or drugs.
III. Etiology
i. Primary pneumonia is caused by the client’s inhalation or aspiration of a pathogen (microaspiration).
ii. Secondary pneumonia ensues from lung damage caused by the spread of an infectious agent—
bacterial, viral, or fungal— from another site in the body or from vari ous chemical irritants (including gastric refl ux and aspiration, smoke inhalation) or radiation therapy.
iii. Risk factors: Comorbidities, such as heart or lung disease, compromised immune system, diabetes mellitus, liver or renal failure, malnutrition, smoking, previous antibiotic therapy, abdominal or thoracic surgical procedures, endotracheal intubation with mechanical ventilation.
Globally, pneumonia killed more than 900,000 children younger than age 5 years in 2015 and is the leading cause of death of infectious diseases in children worldwide (World Health Organ ization [WHO], 2016).
c. Cost:
i. A study published in 2015 with data gleaned from 2007—2011 reported that pneumonia- related medical costs in the post- Prevnar-13 period (2011) showed a 22% decrease compared with the pre- Prevnar-13 period (2007—2009), although these differences were not statistically signifi cant (Park et al, 2015).
ii. CAP: In the United States, annual healthcare costs associated with CAP range from $10.6 to $17 billion and are expected to grow as the proportion of older persons increases. Inpatient care accounts for more than 90% of pneumonia- related health expenditures (Kaysen & Viera, 2016).
IV. Statistics
a. Morbidity: Hospital discharges in the United States attributed to pneumonia in 2013 were 674,000 (CDC, 2017a). Pneumonia accounts for 13% of all infectious illnesses in infants younger than 2 years. However, deaths occur almost exclusively in children with under lying conditions, such as chronic lung disease of prematurity, congenital heart disease, and immunosuppression (Bennett
& Domachowske, 2017).
Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory infections (ALRIs) in children.
Studies conducted using molecular diagnostic assays confi rmed that RSV accounts for over 50% of bronchiolitis (see Glossary) in young children requiring hospitalization b. Mortality: In the United States, deaths attributed to
pneumonia in 2014 were over 55,000 and listed as the eighth leading cause of death (Kochanek et al, 2016).
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, modifi ed by the intervening lung; may be heard over a consolidated lung.
Bronchiolitis : Involves infl ammation of small airways, which is a common condition in children. Patients with bronchiolitis pres ent with features close to pneumonia.
Cough, sputum, fever, and pleuritic- type chest pain are some of the clinical features of bronchiolitis. Most of the cases have a mixture of features of pneumonia and obstructive airway disease. Note: It is not common for pneumonia to pro gress into bronchiolitis while the reverse is very common.
Community- acquired pneumonia (CAP): Acquired outside healthcare organ izations, including hospitals, nursing homes, and other long- term care facilities; includes the fi rst 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 classifi ed as “fi ne” or “coarse” and are also known as rales.
Empyema: A condition in which pus and fl uid from infected tissue collect in a body cavity; most often used to refer to
collections 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.
Healthcare- associated pneumonia (HCAP) (also may be called hospital- acquired pneumonia [HAP] or nosocomial pneumonia): Occurs 48 hours or longer after admission to a fa cil i ty.
Percussion: An assessment method in which the surface of the body is struck with the fi ngertips to obtain sounds that can be heard or vibrations that can be felt. It can deter- mine the position, 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 fl uid 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 infl amed serous surfaces, as in acute pleurisy.
Respiratory syncytial virus (RSV): A highly contagious virus and the leading cause of lower respiratory disease (e.g., bronchiolitis 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 currently no vaccine against RSV.
G L O S S A R Y
CARE SETTING
Most clients are treated as outpatients in community settings.
Persons at higher risk (such as children under 5, those older than 65, and persons with other chronic conditions such as chronic obstructive pulmonary disease [COPD], diabetes, cancer, and congestive heart failure) are treated in the hospi- tal, as are those already hospitalized for other reasons and who have developed healthcare- acquired pneumonia.
RELATED CONCERNS
Acute lung injury/acute respiratory distress syndrome, page 177
Acquired immunodefi ciency syndrome (AIDS), page 800 Chronic obstructive pulmonary disease (COPD) and
asthma, page 132
Pediatric considerations, page 993 Psychosocial aspects of care, page 835
Respiratory failure/ventilatory assistance, page 187
D I A G N O S T I C D I V I S I O N
M A Y R E P O R T M A Y E X H I B I T
Activity/Rest
• Fatigue, weakness • Lethargy
• Insomnia • Decreased tolerance to activity
• Prolonged immobility and bedrest
Circulation
• History of recent or chronic heart failure (HF) • Tachycardia
• Flushed appearance, pallor, central cyanosis
Food/Fluid
• Loss of appetite • Cachectic appearance (malnutrition)
• Nausea, vomiting • Distended abdomen
• May be receiving intestinal, gastric feedings • Hyperactive bowel sounds
• Dry skin with poor turgor
Neurosensory
• Changes in mentation, such as confusion, somnolence
• Changes in be hav ior, such as irritability, restlessness, lethargy
Pain/Discomfort
• Headache
• Substernal chest pain (infl uenza) • Splinting, guarding over affected area
• Chest, rib and/or back pain (pleuritic) aggravated by cough • Position— commonly lies on affected side to restrict movement
Respiration
• Progressive or sudden shortness of breath • Respirations: Tachypnea, shallow grunting respirations
• Use of accessory muscles, nasal fl aring
• Breath sounds are diminished or absent over involved area
• Bronchial breath sounds over area(s) of consolidation
• Coarse inspiratory crackles
• Pleural friction rub
• Color: Pallor or cyanosis of lips or nailbeds
• Percussion: Dull over consolidated areas
• Fremitus: Tactile and vocal, gradually increases with consolidation
• Signs of respiratory distress (Bradley et al, 2011)
• Tachypnea— respiratory rate, breaths/min
• Age 0 to 2 months: >60
• Age 2 to 12 months: >50
• Age 1 to 5 years: >40
• Age 5 years: >20
• Dyspnea
• Retractions (suprasternal, intercostal, or subcostal); nasal fl aring
• Grunting
• Apnea
• Altered mental status
• Cough: dry and hacking (initially), progressing to productive cough
• Sputum: Scanty or copious; pink, rusty, or purulent (green, yellow, or white)
• Presence of tracheostomy, endotracheal tube; current treatment with mechanical ventilator
• History of recurrent or chronic upper respiratory infections (URIs), tuberculosis, COPD, cigarette smoking
C L I E N T A S S E S S M E N T D A T A B A S E
(continues on page 150)
CHAPTER 3 Respiratory: Pneumonia
T E S T
W H Y I T I S D O N E W H A T I T T E L L S M E