Pneumonia Review Notes

Definition: a lower respiratory tract infection that causes inflammation of the alveoli sacs

Key Players: Germs: Bacteria, Virus, Fungi

 Lung Parenchyma: Alveoli, Alveolar Ducts, and Bronchioles (the trio in gas exchange)
Process of normal gas exchange: oxygen is inhaled through the upper respiratory systemdown
through trachea, the bronchus (right and left primary bronchi) which splits at the carina and enters
into the lungs at the hilum and branches into the

 Secondary Bronchi (also called Lobar Bronchi)

 Tertiary Bronchi (also called Segmental Bronchi)
then into smaller branches called bronchioles to the alveolar ducts to the alveolar sacs which inflate
and deflate to allow gas exchange.

During this process, there is the transfer of oxygen from inhalation into the bloodstream and transfer of
carbon dioxide out of the blood through the lungs which is exhaled. This happens in the alveoli capillary
wall. Then the fresh oxygenated blood is taken back to the heart through the pulmonary vein and is
pumped through the heart to the body.

How does Pneumonia develop?

Normally, the respiratory system can “fight off” these type of germs by filtering the air taken in through the
nose and airway BUT certain conditions can damage the body’s ability to do this and make the body
more susceptible to developing PNA.

These risk factors include:

 Prior infection: flu or cold

 Weak immune system: Elderly, infants, HIV, autoimmune medications
 Immobile: strokes or any other condition that causes decrease mental awareness or restrict ability
to move
 Lung problems: COPD, asthma, smokers
 Post-opt patient: not coughing deep breathing
These germs get into the lungs by inhalation, aspiration, or from the blood and attack the alveoli
sacs. These sacs become very inflamed and fill with fluid, body’s immune defense cell RBCs and WBCs,
and bacteria.
 This causes the sac to lose the ability to inflate and deflate
which allows proper gas exchange. Therefore, the patient will start to experience HYPOXEMIA (low
oxygen in the blood) because oxygen cannot transfer across capillary wall to attach to RBCs to supply
the body with oxygen and the body keeps the CO2 (carbon dioxide) which leads to RESPIRATORY
ACIDOSIS!

Arterial Blood Gase Values due to Respiratory Acidosis:

 ABGs: PO2: <90 mmHg

 pH: lower 7.35 mmHg
 PCO2: higher than 45 mmHg
 **To compensate for this the Kidneys start to conserve bicarbonate (HCO3) to hopefully increase
the blood’s pH back to normal…..so HCO3 becomes >26 mEq/L
Further look at the Germs that Cause Pneumonia:

 Bacteria: most common cause of pneumonia especially in community-acquired is caused

by Streptococcus pneumoniae
 Atypical Bacteria: Mycoplasma pneumoniae that causes “walking pneumonia” which is a milder
form of pneumonia that isn’t severe enough to require complete bed rest
 Virus: influenza, RSV most common causes of PNA in children
 Fungi: least common…most likely to affect people with severe suppressed immune system and
typically is contracted from outside in nature from plants, animals etc.
Types of Pneumonia

 Community-acquired Pneumonia (most occurring): patient obtains the germs that causes the
pneumonia OUTSIDE of the healthcare system hence in the community.
 Hospital-acquired Pneumonia: patients who are on mechanical ventilation at major risk…it is
hard to treat because the bacteria tend to be resistant to antibiotics and more likely a bacteria
cause. Criteria: patient must have developed 48-72 hours after admission
Diagnosed:
  Notice: abnormal lungs sound when auscultating with stethoscope may hear coarse crackles,
rhonchi (type of wheezing) or bronchial breath sounds which should be noted only in the tracheal
area and this represents lung consolidation.
 Chest x-ray, sputum culture
Signs & Symptoms of Pneumonia

Remember the word: PNEUMONIA

Productive cough, Pleuritic pain (chest pain that is caused by coughing, breathing etc.)

Neuro changes (especially ELDERLY patients…may not even have a fever but fatigue and increased
respiratory rate)

Elevated labs: PCO2 >45 (retaining carbon dioxide because it can’t pass capillary of alveoli sac),
increased WBC (represents infection…body is trying to fight infection off)

Unusual breath sounds: coarse crackles, rhonchi, or bronchial in the peripheral lung fields

Mild to high Fever (bacteria cause produces highest fever….. greater than 104’F)

Oxygen saturation decreased (want >90%) will need supplementary oxygen

Nausea and vomiting (won’t feel like eating)

Increase heart rate and respirations

Aching all over with joint pain, Activity intolerance with shortness of breath

Nursing Interventions for Pneumonia

Monitor respiratory system:

 Lung Sounds
 Respiratory rate/vital signs
 Oxygen Saturation >95%
 ABGS (if ordered)
 Sputum (collect for culture)
 Suction as needed
Encourage usage of incentive spirometer for deep breathing and encourage coughing and deep breathing

Encourage 2-3 L of fluid (unless on fluid restriction as with patients who have heart failure)…fever causes
dehydration, lose water through breathing (300-400 mL), and patient is too sick to have the urge to drink

Education on prevention: Up-to-date Vaccinations (Pneumovax every 5 years for patients 65+ and 19-64
years old with risk factors and annual flu shot)

Education about stop smoking, avoid people who are sick, hand-washing
Keeping head of bed elevated greater than 30 degree for immobile patients to prevent aspiration
especially while eating and after meals along with frequent turning.

Breathing treatments and other respiratory therapy treatments (usually by respiratory therapy
department). These will be schedule or PRN (as needed).

Treatments include: Bronchodilators, chest percussion etc.

Medications:

Administering per doctor’s order: fluids, antipyretics, antivirals (if a viral cause), and antibiotics (if a
bacterial cause)

Antibiotics Groups for BACTERIAL Pneumonia

Remember the mnemonic: Various Medications Frequently Treat Pneumonia Cases

Antibiotics used depend on the bacteria type that is causing the infection, the patient’s ability to tolerate
etc.

Vancomycin: used to treat severe cases and is one of the few that can treat bacteria that may be resistant
to other antibiotics….watch for HEARING LOSS “ototoxicity”

Macrolides: “Zithromax (Z-Pak)” used in patients with Penicillin allergy….narrow-spectrum targets

mainly gram positive bacteria

Tetracylines: “Doxycycline” broad-spectrum that targets gram positive and negative bacteria. Side
effects: not for pregnant women or 8 years or younger due to growth retardation and teeth
discoloration, photosensitivity of the skin and decreases effectiveness of birth control, no antacids or milk
product while taking this medication because it affects absorption.

Fluroquinolones: “Levaquin” broad-spectrum (targets gram-negative and positive)…treatment for severe

infection that are found in the hospital that are resistant. Side effects: c. diff infection, tendon rupture,
cardiac arrhythmias such as QT interval prolonged

Cephalosporins: “Keflex, Rocephin” watch with patients who are allergic to penicillin(can also be allergic
to cephalosporin)…great for community acquired pneumonia… ( 3rd and 4th generations of
cephalosporins broad-spectrum)

Penicillin: “Penicillin G”…narrow-spectrum…target gram positive bacteria…. monitor if patient is allergic

to cephalosporins, decreases effectiveness of birth control

Education about antibiotics: Take medications as prescribed and don’t stop in the middle of
treatment….even if feeling better which helps decrease resistance

Viral Cases: May be prescribed an antiviral of the virus that is causing the pneumonia ex: Tamiflu