The winter months often see an influx of people suffering from colds and flu’s, as well as an increase in presentations to hospitals with respiratory illnesses such as pneumonia.
Worldwide, it has been estimated that 5 million people will die each year of pneumonia, with the most vulnerable populations being the very young and older individuals (Dunn 2005). Respiratory illnesses, including pneumonia, remain a major concern to hospitals worldwide, especially during the winter months when this influx of patients can put some hospitals into crisis mode.
What is Pneumonia?
Pneumonia arises from inflammation and infection of the lungs, specifically in the bronchioles and alveoli, which causes consolidation and interferes with gas exchange. Consolidation can be seen on both a chest x-ray as shadowing, and heard when auscultating the lungs as these alveolar spaces are filled with fluid instead of air (Better Health Channel 2015; Dunn 2005).
Pneumonia doesn’t discriminate across the lifespan and can affect any age group. Depending on the severity of the pneumonia, some people may not necessarily need a hospital admission, whilst others will. Generally those with more comorbidities or any problem that may exacerbate the pneumonia will require a hospital admission. However, pneumonia can also be treated in the community as long as the individual has access to good medical and nursing care.
There are many ways in which pneumonia may be classified or described including:
- Depending on the part of the lung affected, e.g. bronchial pneumonia or lower lobe pneumonia
- If it has been caused by bacterial, viral or less commonly, fungal infections
- According to the organism causing the infection
- Depending if the pneumonia is community acquired, or hospital acquired pneumonia (hospital acquired pneumonia occurs after the patient has been admitted for over 48 hours)
- If it is aspiration pneumonia which occurs as a result of aspiration which causes an inflammatory response in the affected area
- Ventilator-associated pneumonia
(Dunn 2005; Farrell & Dempsey 2013)
People with pneumonia can show a variety of symptoms and often individuals will present in different ways, therefore it is important for nurses to understand these symptoms to ensure prompt identification and treatment of pneumonia. Assessment of the patient and gaining a comprehensive patient history is vital in this diagnosis.
Symptoms of pneumonia can include:
- General malaise
- Persistent cough (it may or may not be productive)
- Chest pain
- Increased respiratory rate
- Breathing difficulties
- Decreased appetite
- Abdominal pain
(Better Health Channel 2015; Farrell & Dempsey 2013)
How is Pneumonia Diagnosed?
Pneumonia can be diagnosed by taking a detailed clinical history from the patient in adjunction with chest auscultation. However, for those with more serious cases, other tools can also be used such as a chest x-ray. For most, a simple chest x-ray will identify pneumonia, or specifically the degree of consolidation present and the presence of pleural effusions (Dunn 2005; Watson 2008).
However it is important to note, that some individuals with comorbidities may also have abnormal chest x-rays so other diagnostic tools are also needed. These can include sputum samples, blood tests including a full blood count, white cell count, blood cultures and in more severe cases, arterial blood gas levels (Dunn 2005; Farrell & Dempsey 2013; Watson 2008).
Further Learning: Complete the Interpretation of Arterial Blood Gases Video Course here!
How is Pneumonia Treated?
Pneumonia treatment depends on the severity of the pneumonia. A person may need oral antibiotics and can be treated in the community setting, or for more severe cases they may need admission to hospital and treatment with intravenous antibiotics, oxygen therapy and chest physiotherapy (Dunn 2005).
As pneumonia is an infection, antibiotic therapy should be started as soon as possible. Sometimes this can be before the causative organism has been determined, however the type of antibiotic can be changed if necessary, the main aim with antibiotic therapy is to be started immediately. Depending on the severity of the pneumonia, this can be in either an intravenous or oral form (Watson 2008).
Another important aspect of pneumonia treatment is oxygen therapy and maintaining adequate oxygen saturation levels. Depending on the patient, oxygen saturation levels should be above 93% with the oxygen concentrations also varying depending on the patient, their comorbidities and severity of the pneumonia. Humidified oxygen therapy can also be used in order to assist the patient with expectoration (Watson 2008).
While we are talking about oxygen saturation levels, sometimes pulse oximetry can be inaccurate on these patients, and this is where arterial blood gas levels play a role to ensure adequate oxygenation is being achieved. Some patients, even when receiving high flow oxygen, can still remain hypoxic, and therefore continuous positive airway pressure may be indicated (Farrell & Dempsey 2013; Watson 2008).
It is also important to remember that the patient with pneumonia may also be in pain. And if a patient with pneumonia is in pain, their lung expansion may be compromised which can further exacerbate their condition. Often this pain can be described as a pleuritic-type chest pain (Farrell & Dempsey 2013; Watson 2008).
For those with severe pneumonia, they may need the treatment of the multidisciplinary team, specifically physiotherapists. As part of the multidisciplinary team, physiotherapists can assist in not only any concurrent physical decline and chest physiotherapy, but also to help teach the patient effective breathing patterns and posture to promote lung expansion and expectoration (Watson 2008).
Other treatments for pneumonia should focus on ensuring the patient is adequately hydrated and if not, ensure IV fluids are commenced. Adequate hydration is important for the expectoration of secretions and will also help with any associated hypotension. The individual may also have an increased fluid loss occurring if they are febrile and continue to have an increased respiratory rate, therefore urinary output should also be monitored as this can flag deterioration in the patients condition (Dunn 2005; Watson 2008).
Another factor of treatment which can be easily overlooked is nutrition. People with severe pneumonia may also be experiencing nausea and therefore have a decreased appetite. And this is right at the time when they need a higher calorie intake to fight the infection, remembering that when a person has an infection, their calorific requirements increase (Watson 2008).
Pneumonia Monitoring and Complications
Prompt and effective treatment of pneumonia is also essential in order to decrease any complication from occurring. These complications include pleurisy, atelectasis, pleural effusion lung abscesses, bacteraemias, septicaemias and also death. If the patient deteriorates and goes into respiratory failure, they may also require ventilation (Farrell & Dempsey 2013; Watson 2008).
Therefore nurses need to ensure regular monitoring of the patient occurs which include:
- Monitoring hydration and elimination
- Observation of vital signs including oxygen saturation
- Providing oxygen therapy as needed
- Ensure patient is position in a way that ensures adequate ventilation
- Promote rest and conservation of energy
- Pressure area care
- Mouth care
- Monitor and maintain nutrition
- Pain assessment and management
- Educate the patient on infection control and hand washing
- Provide reassurance to the patient
(Dunn 2005; Farrell & Dempsey 2013)
Nurses play an important role not only in caring for the individual with pneumonia, but their assessments also contribute to the diagnosis of pneumonia in a patient and allow for early interventions to be implemented for any potential complications. Nurses contribute to all phases of the individual’s pneumonia journey and are vital in ensuring they receive the holistic care they need during this illness.
- Better Health Channel 2015, ‘Pneumonia’, available from: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pneumonia
- Dunn, L 2005, ‘ Pneumonia: Classification, diagnosis and nursing management’, Nursing Standard, vol. 19, no. 42, pp. 50-54, available from: http://journals.rcni.com/doi/pdfplus/10.7748/ns2005.06.19.42.50.c3901
- Farrell, M & Dempsey, J (eds) 2013, Smeltzer and Bare’s Textbook of Medical-Surgical Nursing’, 3rd edn, Lippincott Williams and Wilkins, Broadway
- Watson, D 2008, ‘Pneumonia 2: Effective nursing assessment and management’, Nursing Times, vol. 104, no. 5, pp. 30-31, available from: https://www.nursingtimes.net/clinical-archive/respiratory/pneumonia-2-effective-nursing-assessment-and-management/811709.article