NAME: CHILDA MAE J.

BALILI

COMMUNITY-ACQUIRED PNEUMONIA

Pneumonia is an inflammatory condition of the lung affecting primarily the small air
sacs known as alveoli. Typically symptoms include some combination of productive or
dry cough, chest pain, fever, and trouble breathing. Severity is variable.

Pneumonia is usually caused by infection with viruses or bacteria and less commonly by
other microorganisms, certain medications and conditions such as autoimmune diseases. Risk
factors include other lung diseases such as cystic fibrosis, COPD, and asthma, diabetes, heart
failure, a history of smoking, a poor ability to cough such as following a stroke, or a weak
immune system.

Community-acquired pneumonia (CAP) refers to pneumonia (any of several

lung diseases) contracted by a person with little contact with the healthcare system. The chief
difference between hospital-acquired pneumonia (HAP) and CAP is that patients with HAP live
in long-term care facilities or have recently visited a hospital. CAP is common, affecting people
of all ages, and its symptoms occur as a result of oxygen-absorbing areas of the lung (alveoli)
filling with fluid. This inhibits lung function, causing dyspnea, fever, chest pains and cough.

CAP, the most common type of pneumonia, is a leading cause of illness and death
worldwide. Its causes include bacteria, viruses, fungi and parasites. CAP is diagnosed by
assessing symptoms, making a physical examination and on x-ray. Other tests, such
as sputum examination, supplement chest x-rays. Patients with CAP sometimes require
hospitalization, and it is treated primarily with antibiotics, antipyretics and cough
medicine. Some forms of CAP can be prevented by vaccination and by abstaining
from tobacco products.

Signs and symptoms

Common symptoms

 Coughing which produces greenish or yellow sputum

 A high fever, accompanied by sweating, chills
and shivering
 Sharp, stabbing chest pains
 Rapid, shallow, often-painful breathing

Less-common symptoms

 Coughing up blood (hemoptysis)

 Headaches, including migraines
 Loss of appetite
 Bluish skin (cyanosis)
 Excessive fatigue
 Nausea
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 Vomiting  Muscle aches (myalgia)

 Diarrhea  Rapid heartbeat
 Joint pain (arthralgia)  Dizziness or lightheadedness

In the elderly In infants

 Unusual sleepiness New or worsening confusion
 Yellowing of the skin (jaundice) Hypothermia
 Difficulty feeding Poor coordination, leading to falls

Risk factors

Some patients have an underlying problem which increases their risk of

infection. Some risk factors are:

 Obstruction: When part of the airway (bronchus) leading to the alveoli is

obstructed, the lung cannot eliminate fluid; this can lead to pneumonia. One
cause of obstruction, especially in young children, is inhalation of a foreign
object such as a marble or toy. The object lodges in a small airway, and
pneumonia develops in the obstructed area of the lung. Another cause of
obstruction is lung cancer, which can block the flow of air.
 Lung disease: Patients with underlying lung disease are more likely to develop
pneumonia. Diseases such as emphysema and habits such as smoking result in
more-frequent and more-severe bouts of pneumonia. In children, recurrent
pneumonia may indicate cystic fibrosis or pulmonary sequestration.
 Immune problems: Immune-deficient patients, such as those with HIV/AIDS,
are more likely to develop pneumonia. Other immune problems range from
severe childhood immune deficiencies, such as Wiskott–Aldrich syndrome, to
the less-severe common variable immunodeficiency.

Prognosis

Over 100 microorganisms can cause CAP, with most cases caused
by Streptococcus pneumoniae. Certain groups of people are more susceptible to CAP-
causing pathogens; for example, infants, adults with chronic conditions (such as chronic
obstructive pulmonary disease), senior citizens, alcoholics and others with
compromised immune systems are more likely to develop CAP from Haemophilus
influenzae or Pneumocystis jirovecii. A definitive cause is identified in only half the
cases. Short-term mortality is related to severity of illness. Mortality is < 1% in patients
who are candidates for outpatient treatment. Mortality in hospitalized patients is 8%.
Death may be caused by pneumonia itself, progression to sepsis syndrome, or
exacerbation of coexisting conditions. In patients hospitalized for pneumonia, risk of
death is increased during the year after hospital discharge.
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Mortality varies to some extent by pathogen. Mortality rates are highest with
gram-negative bacteria and CA-MRSA. However, because these pathogens are
relatively infrequent causes of pneumonia, S. pneumoniae remains the most common
cause of death in patients with community-acquired pneumonia. Atypical pathogens
such as Mycoplasma have a good prognosis. Mortality is higher in patients who do not
respond to initial empiric antibiotics and in those whose treatment regimen does not
conform with guidelines.

S. pneumoniae, H. influenzae, C. pneumoniae, and M. pneumoniae are the

most common bacterial causes. Pneumonias caused by chlamydia and mycoplasma are
often clinically indistinguishable from other pneumonias. Common viral agents include
respiratory syncytial virus (RSV), adenovirus, influenza viruses, metapneumovirus, and
parainfluenza viruses. Bacterial superinfection can make distinguishing viral from
bacterial infection difficult.

C. pneumoniae accounts for 2 to 5% of community-acquired pneumonia and is

the 2nd most common cause of lung infections in healthy people aged 5 to 35 yr. C.
pneumoniae is commonly responsible for outbreaks of respiratory infection within
families, in college dormitories, and in military training camps. It causes a relatively
benign form of pneumonia that infrequently requires hospitalization. Chlamydia

P. aeruginosa is an especially common cause of pneumonia in patients with

cystic fibrosis, neutropenia, advanced AIDS, and/or bronchiectasis.

A host of other organisms causes lung infection in immunocompetent patients.

In patients with pneumonia, a thorough history of exposures, travel, pets, hobbies, and
other exposures is essential to raise suspicion of less common organisms.

Q fever, tularemia, anthrax, and plague are uncommon bacterial syndromes

in which pneumonia may be a prominent feature. Tularemia, anthrax,
and plague should raise the suspicion of bioterrorism.

Adenovirus, Epstein-Barr virus, and coxsackievirus are common viruses that

rarely cause pneumonia. Seasonal influenza can rarely cause a direct viral pneumonia
but often predisposes to the development of a serious secondary bacterial pneumonia.
Varicella virus and hantavirus cause lung infection as part of adult chickenpox and
hantavirus pulmonary syndrome. A coronavirus causes severe acute respiratory
syndrome(SARS) and the Middle East respiratory syndrome (MERS).

Common fungal pathogens include Histoplasma capsulatum (histoplasmosis)

and Coccidioides immitis (coccidioidomycosis). Less common fungal pathogens
include Blastomyces dermatitidis (blastomycosis) and paracoccidioides
braziliensis (paracoccidioidomycosis). Pneumocystis jirovecii commonly causes
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pneumonia in patients who have HIV infection or are immunosuppressed

(see Pneumonia in Immunocompromised Patients).

Pathogen identification

Identification of the pathogen can be useful to direct therapy and verify bacterial
susceptibilities to antibiotics. However, because of the limitations of current diagnostic
tests and the success of empiric antibiotic treatment, experts recommend limiting
attempts at microbiologic identification (eg, cultures, specific antigen testing) unless
patients are at high risk or have complications (eg, severe pneumonia,
immunocompromise, asplenia, failure to respond to empiric therapy).

Chest x-ray findings generally cannot distinguish one type of infection from
another, although the following findings are suggestive:

Multilobar infiltrates suggest S. pneumoniae or Legionella pneumophila infection.

Interstitial pneumonia (on chest x-ray, appearing as increased interstitial markings,

subpleural reticular opacities that increase from the apex to the bases of the lungs, and
peripheral honeycombing) suggests viral or mycoplasmal etiology.

Cavitating pneumonia suggests S. aureus or a fungal or mycobacterial etiology.

Sputum testing can include Gram stain and culture for identification of the
pathogen, but the value of these tests is uncertain because specimens often are
contaminated with oral flora and overall diagnostic yield is low. Regardless,
identification of a bacterial pathogen in sputum cultures allows for susceptibility
testing. Obtaining sputum samples also allows for testing for viral pathogens via direct
fluorescence antibody testing or PCR, but caution needs to be exercised in
interpretation because 15% of healthy adults carry a respiratory virus or potential
bacterial pathogen. In patients whose condition is deteriorating and in those
unresponsive to broad-spectrum antibiotics, sputum should be tested with
mycobacterial and fungal stains and cultures.

Sputum samples can be obtained noninvasively by simple expectoration or

after hypertonic saline nebulization (induced sputum) for patients unable to produce
sputum. Alternatively, patients can undergo bronchoscopy or endotracheal suctioning,
either of which can be easily done through an endotracheal tube in mechanically
ventilated patients. Otherwise, bronchoscopic sampling is usually done only for patients
with other risk factors (eg, immunocompromise, failure of empiric therapy).

Urine testing for Legionella antigen and pneumococcal antigen is now widely
available. These tests are simple and rapid and have higher sensitivity and specificity
than sputum Gram stain and culture for these pathogens. Patients at risk
of Legionella pneumonia (eg, severe illness, failure of outpatient antibiotic treatment,
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presence of pleural effusion, active alcohol abuse, recent travel) should undergo testing
for urinary Legionella antigen, which remains present long after treatment is initiated,
but the test detects only L. pneumophila serogroup 1 (70% of cases).

The pneumococcal antigen test is recommended for patients who are severely ill; have
had unsuccessful outpatient antibiotic treatment; or who have pleural effusion, active
alcohol abuse, severe liver disease, or asplenia. This test is especially useful if adequate
sputum samples or blood cultures were not obtained before initiation of antibiotic
therapy. A positive test can be used to tailor antibiotic therapy, though it does not
provide antimicrobial susceptibility.

Nurse’s role
Nurses play a key role in patient recovery from CAP. Administering antibiotics
as prescribed helps ensure positive patient responses. Once every shift and before
administering antibiotics, check the I.V. site for patency and integrity. Monitor the
patient’s response to antibiotic therapy by checking temperature, oxygen saturation,
respiratory rate, and adventitious breath sounds.

To improve a patient’s respiratory status, nurses and respiratory therapists work

together. Respiratory therapists give drugs used to break up congestion, facilitate
secretion removal, and ensure adequate oxygenation. To reduce the spread of
respiratory infections from patients with a cough in outpatient settings and EDs, use
respiratory hygiene measures, such as hand hygiene and masks or tissues (strong
recommendation, Level III evidence). For hospitalized patients, infection-control
measures depend on the pathogen.

Assisting with and encouraging patient mobility improves respiratory function,

including chest expansion and airway clearance, and aids other body systems.
Discomfort may adversely affect a patient’s respiratory status, so assess the patient for
pain and intervene, as appropriate. Throughout treatment, teach the patient strategies
for avoiding a recurrence as well as the importance of adhering to prescribed regimens
and following up after discharge.

Switching to oral antibiotics

The switch from I.V. to oral antibiotics depends on the patient’s clinical
stability, which includes hemodynamic stability, clinical improvement, ability to ingest
oral drugs, and normal GI function (moderately recommended, Level II evidence). (See
Determining clinical stability by clicking on the download now button below.) With
nonsevere CAP, the switch typically takes place after 2 or 3 days. Clinical guidelines
may outline other indicators, such as being afebrile or having a consistently improving
fever over a 24-hour period and having a normalizing white blood cell count. Keep in
mind that an early transition to the oral route has been linked to increased survival in
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retrospective investigations. Also, some studies suggest that, in immunocompetent

patients, oral antibiotics are as effective as I.V. antibiotics.

Nursing Interventions and Rationales:

1. Obtain appropriate labs (antibiotic troughs, sputum cultures, ABGs, etc.)

o Gives us a baseline; identifies pathogens, and enables us to evaluate if
interventions are effective
2. Complete a full respiratory assessment to detect changes or further
decompensation as early as possible, and notify MD as indicated
o Enables quicker interventions and may change them (for example,
wheezing noted on auscultation would potentially indicate steroids and a
breathing treatment, while crackles could require suctioning,
repositioning, and potential fluid restriction)
3. Promote normothermia (warm patient if hypothermic, cool patient and
administer antipyretics if hyperthermic)
o Normothermia optimizes oxygen consumption
4. Cluster care
o Activity intolerance is common because of decreased gas exchange;
cluster your care to conserve your patient’s energy for essential tasks
like ambulation, coughing and deep breathing, and eating
5. Promote airway clearance
o We want to encourage coughing to remove phlegm; do not suppress
cough unless clinically indicated. If patient is able to clear their own
airway, continue to encourage this. If not, suction frequently and
consider an advanced airway to ensure a patent airway, which
ultimately maximizes gas exchange. Getting phlegm out is important.
6. Optimize fluid balance
o Patients with pneumonia may not be consuming adequate oral intake
due to fatigue or not feeling well, but hydration is essential to healing.
Patients may need IV fluids if PO intake is inadequate.
7. Assess and treat pain
o If patients are not coughing because of pain, it will only allow fluid to
continue to build. Treat pain appropriately and encourage them to
cough to clear phlegm.
8. Encouraging coughing and deep breathing
o Coughing and deep breathing encourages expectoration, which enables
better gas exchange
9. Promote nutrition
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o Patients with pneumonia typically tire easily and have poor appetites,
but need appropriate nutrition and hydration to heal
10. Administer supplemental oxygen as appropriate
o Due to the impaired gas exchange, oxygen doesn’t make it into
circulation as easily. Providing additional oxygen supports this as much
as possible. Use caution in patients with underlying lung conditions.
11. Ensure patent airway
o If a patient has unmanageable secretions or is unable to maintain
consciousness and keep their airway clear, they must be supported
(positioning, advanced airway, etc) to ensure adequate oxygen delivery
12. Promote rest
o Energy conservation is essential; patients should focus on breathing,
providing self care, coughing/deep breathing, and ambulation. Patients
cannot adequately participate in these important activities if they are not
maximizing their time to rest. Appropriate sleep promotes healing.
13. Administer antibiotics in a timely fashion, draw troughs appropriately
o Patients may be on antibiotics, therefore it’s essential to ensure they are
administered at the appropriate time and not delayed, as this will impair
their efficacy. Also, trough levels will most likely to be ordered to assess
if the patient is getting too much, too little, or just enough of the
antibiotic. The timing of these labs related to administration times are
essential for accuracy.
14. Prevent further infection
o Patients may have invasive lines like a internal urinary catheter, central
venous catheter, endotracheal tube, and so forth. It is essential to care
for these devices properly to prevent further infection.
15. Educate patient and loved ones on the importance of energy conservation,
effective airway clearance, nutrition, as well as coughing and deep
breathing
o Patients must be aware of how these aspect of recovery are pertinent so
they will be more likely to participate and remain compliant.