ASKEP PNEUMONIA IN ENGLISH

CHAPTER 1

INTRODUCTION

1.1.       Background

Acute respiratory infections namely pneumonia cause up to 5 million deaths annually among children less than 5 years old in developing nations. Of the estimated total of 12.9 million deaths globally in 1990 in children under 5 years of age, over 3.6 million were attributed to acute respiratory infections mostly due to pneumonia. This represents 28% of all deaths in young children and places pneumonia as the largest single cause of childhood mortality. In Malaysia the prevalence of ARI in children below the age of 5 years is estimated to be 28% - 39.3%. Low birth weight, malnutrition, nasopharyngeal colonization, poor environmental factors and tobacco smoke are risk factors for developing pneumonia. Two local studies conducted in hospitalized children with acute lower respiratory tract infections identified the following factors as risks for developing pneumonia.

1.2.       Problem Question

How about the nursing process of pneumonia case?

1.3.       Objectives

a.       Explain about nursing process of pneumonia case.

b.      Explain about nursing care in pneumonia occurrence.

CHAPTER 2

STUDY LITERATURE

2.1.       Clinical definition

There is no single definition for pneumonia. It is a clinical illness defined in terms of symptoms and signs, and its course. WHO defines pneumonia in terms of febrile illness with tachypnea for which there is no apparent cause.

There are two clinical definitions of pneumonia:

1.      Bronchopneumonia which is a febrile illness with cough, respiratory distress with evidence of localized or generalized patchy infiltrates on chest x-ray

2.      Lobar pneumonia which is similar to bronchopneumonia except that the physical findings and radiographs indicate lobar consolidation.

2.2.2.           Physiology

A pressure gradient is required to generate flow. In spontaneous respiration inspiratory flow is achieved by creating a sub-atmospheric pressure in the alveoli (of the order of -5cmH2O during quiet breathing) by increasing the volume of the thoracic cavity under the action of the inspiratory muscles. During expiration the intra-alveolar pressure becomes slightly higher than atmospheric pressure and gas flow to the mouth results.

2.3.       Etiology

A specific etiological agent cannot be identified in 40% to 60% of cases. Viral pneumonia cannot be distinguished from bacterial pneumonia based on a combination of clinical findings. The majority of lower respiratory tract infections that present for medical attention in young children are viral in origin such as respiratory syncytial virus, influenza, adenovirus and influenza virus. Indicator of pathogens causing pneumonia

Age                             Bacterial Pathogens

Newborns                    Group B streptococcus, Escherichia coli, Klebsiella species, Enterobacteriaceae

1- 3 months                 Chlamydia trachomatis

Preschool                     Streptococcus pneumoniae, Haemophilus influenzae type b,

Staphylococcal aureus,

Less common: group A streptococcus, Moraxella catarrhalis, Pseudomonas aeruginosa

School                         Mycoplasma pneumoniae, Chlamydia pneumonia

2.5.       Signs And Symptoms

·         Hypotension; ·         Tachycardia; ·         Pyrexia; ·         Oliguria; ·         Dizziness; ·         Confusion; ·         Peripheral vasodilation; ·         Hypothermia; ·         Ischemia; ·         Tachypnea; ·         Metabolic acidosis;

·         Cough; ·         Hypoxia; ·         Rash; ·         Pallor; ·         Erratic blood glucose levels; ·         Sweats; ·         Rigors; ·         Dyspnea; ·         Vomiting; ·         Diarrhea.

2.6.       Clinical Features

The clinical diagnosis of pneumonia has traditionally been made using auscultatory findings such as bronchial breath sounds and crepitations in children with cough. However, the sensitivity of auscultation has been shown to be poor and varies between 33 %- 60% with an average of 50 % in children. Tachypnea is the best single predictor in children of all ages. Measurement of Tachypnea is better compared with observations of retractions or auscultatory findings. It is nonetheless important to measure respiratory rate accuratel. Respiratory rate should be counted by inspection for 60 seconds. However in the young infants, pneumonia may present with irregular breathing and hypopnea.

2.7.       Diagnostic Assessment

Children with bacterial pneumonia cannot be reliably distinguished from those with viral disease on the basis of any single parameter; clinical, laboratory or chest radiograph findings.

2.7.1      Chest Radiograph

Chest radiograph is indicated when clinical criteria suggests pneumonia. It will not identify the etiological agent. However the chest radiograph is not always necessary if facilities are not available or the pneumonia is mild.

2.7.2      Complete White Blood Cell And Differential Count

This test may be helpful as an increased white blood count with predominance of polymorphonuclear cells may suggest bacterial cause. However, leucopenia can either suggest a viral cause or severe overwhelming infection.

2.7.3      Blood Culture

Blood culture remains the non-invasive gold standard for determining the precise etiology of pneumonia. However the sensitivity of this test is very low. Positive blood cultures are found only in 10% to 30% of patients with pneumonia. Even in 44% of patients with radiographic findings consistent with pneumonia, only 2.7% were positive for pathogenic bacteria. Blood culture should be performed in severe pneumonia or when there is poor response to the first line antibiotics.

2.7.4      Culture From Respiratory Secretions

It should be noted that bacteria isolates from throat swabs and upper respiratory tract secretions are not representative of pathogens present in the lower respiratory tract. Samples from the nasopharynx and throat have no predictive values. This investigation should not be routinely done.

2.7.5      Other Tests

Bronchoalveolar lavage is usually necessary for the diagnosis of Pneumocystis carini infections primarily in immunosuppressed children. It is only to be done when facilities and expertise are available. If there is significant pleural effusion diagnostic, pleural tap will be helpful.

Mycoplasma pneumoniae, Chlamydia, Legio nella and Moxarella catarrhalis are difficult organisms to culture, and thus serological studies should be performed in children with suspected  atypical pneumonia. An acute phase serum titre of more than 1:160 or paired samples taken 2-4 weeks apart showing four fold rise is a good indicator of Mycoplasma pneumoniae infection. 17 This test should be considered for children aged five years or older with pneumonia.

2.8.       Management

2.8.1.      Assessment of oxygenation

The best objective measurement of hypoxia is by pulse oximetry which avoids the need for arterial blood gases. It is a good indicator of the severity of pneumonia

2.8.2.      Criteria for hospitalization

Community acquired pneumonia can be treated at home. It is crucial to identify indicators of severity in children who may need admission as failure to do so may result in death. The following indicators can be used as a guide for admission.

1.      Children aged <3 months whatever the severity of pneumonia.

2.      Fever (>38.50 C), refusal to feed and vomiting

3.      Rapid breathing with or without cyanosis

4.      Systemic manifestation

5.      Failure of previous antibiotic therapy

6.      Recurrent pneumonia

7.      Severe underlying disorders (i.e. immunodeficiency, chronic lung disease)

2.8.3.      Antibiotic therapy

When treating pneumonia clinical, laboratory and radiographic findings should be considered. The age of the child, local epidemiology of respiratory pathogens and sensitivity of these pathogens to particular microbial agents and the emergence of antimicrobial resistance also determine the choice of antibiotic therapy. The severity of the pneumonia and drug costs have also a great impact on the selection of therapy.

The majority of childhood infections are caused by viruses and do not require any antibiotic. However, it is also very important to remember that we should be vigilant to choose appropriate antibiotics especially in the initial treatment to reduce further mortality and morbidity.

                                                   

Susceptibility (%) pattern of Streptococcus pneumonia  

Antibiotic                   Susceptible                 Intermediate              Resistance

Azithromycin                          98.1                                                                 1.9

Cefuroxime                             99.6                                                                 0.4

Chloramphenicol                     95.1                             1.5                               3.4

Chlindamycin                          9.2                               0.4                               0.4

Cotrimoxazole                         86.4                             3.9                               9.7

Erythromycin                          98.4                             0.4                               1.1

Penicillin                                 93.0                                                                 7.0

Tetracycline                             78.2                             0.8                               21.0

Predominant bacterial pathogens of children and the recommended antimicrobial agents to be used.

Pathogens                                                       Antimicrobial agent

Beta- lactam susceptible

Streptococcus pneumonia                               Penicillin, Cephalosporins

Haemophilus influenzae type b                       Ampicillin,Chloramphenicol,

Cephalosporins

Staphylococcus aureus                                    Cloxacillin

Group A Sreptococcus                                    Penicillin,Cephalosporin

Mycoplasma pneumoniae                               Macrolides such as erythromycin and

Azithromycin

Chlamydia pneumoniae                                  Macrolides such as erythromycin and

Azithromycin

Bordetella pertussis                                         Macrolides such as erythromycin and

Azithromycin

Commonly used antibiotics and their dosages

Intravenous Antibiotics                                            Dosages

Amoxycillin-Clavulanate Acid                       10-25mg/kg/dose 8 hrly

Ampicillin -sulbactam                                     10-25 mg/kg/dose 8 hrly

Ampicillin                                                       100mg/kg/day 6 hrly

C. Penicillin                                                     25,000-50,000U/kg/dose 6 hourly

Cefuroxime                                                     10-25 mg/kg/dose 8 hrly

Cefotaxime                                                     25-50mg/kg/dose 8 hrly

Cloxacillin                                                       25-50mg/kg/dose 6hrly

Co-trimoxazole (trimethoprim )                      4 mg/kg/dose 12 hrly

Erythromycin                                                  7.5mg kg/dose 6 hrly

Oral Antibiotis                                                           Dosages

Azithromycin                                                  10-15 mg/kg/day daily dose

Augmentin                                                      114 mg 12 hourly (less than 2 years)

228 mg 12 hourly (> 2 years)

Cefuroxime                                                     125 mg 12 hourly (less than 2 years)

250 mg 12 hourly (> 2 years)

Cotrimoxazole                                                 4 mg/kg/dose 12 hourly

Cloxacillin                                                       50mg/kg /dose 6 hourly

Erythromycin Estolate                                    7.5 mg/kg/dose 12 hour ly

Penicillin V                                                     7.5 - 15 mg/kg/dose 6 hourly

2.9.            Nursing Diagnosis

a.       Ineffective Airway Clearance

b.      Impaired Gas Exchange

c.       Imbalanced Nutrition: Less Than Body Requirements

d.      Acute Pain

e.       Hyperthermia

f.       Anxiety

g.      Ineffective Coping

h.      Risk For Deficient Fluid Volume

i.        Risk For Infection

CHAPTER 3

DISCUSSION

CASE STUDY

3.1.       Nursing Assessment

Mrs. Inem is a 39-year-old secretary who was admitted to the hospital with an elevated temperature, fatigue, rapid, labored respirations; and mild dehydration. The nursing history reveals that she has had a “bad cold” for several weeks that just wouldn’t go away. She has been dieting for several months and skipping meals. She mentions that in addition to her fulltime job as a secretary she is attending college classes two evenings a week. She has smoked one package of cigarettes per day since she was 18 years old. Chest x-ray confirms pneumonia.

3.2.       Physical Examination

Height                         : 167.6 cm (5′6′′)

Weight                                    : 54.4 kg (120 lb)

Temperature                : 39.4°C (103°F)

Pulse                            : 68 BPM

Respirations                : 24/minute

Blood pressure            : 118/70 mm Hg

Skin pale; cheeks flushed; chills; use of accessory muscles; inspiratory crackles with diminished breath sounds right base; expectorating thick, yellow sputum.

3.3.       Diagnostic Data

Chest x-ray      : right lobar infiltration WBC               : 14,000 pH                   : 7.49 PaCO2             : 33 mm Hg

HCO3–             : 20 mEq/L PaO2                : 80 mm Hg O2 sat              : 88%

3.4.       Nursing diagnosis

Ineffective Airway Clearance related to thick sputum, secondary to pneumonia (as evidenced by rapid respirations, diminished and adventitious breath sounds, thick yellow sputum)

3.5.       Desired Outcome

Respiratory Status       : Airway Patency as evidenced by not compromised

·         Respiratory rate

·         Moves sputum out of airway

·         No adventitious breath Sounds

3.6.       Nursing Interventions

Nursing Interventions	Rationale
Assist Ms. Singh to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed.	Lying flat causes the abdominal organs to shift toward the chest, crowding the lungs and making it more difficult to breathe.
Encourage her to take several deep breaths.	Deep breathing promotes oxygenation before controlled coughing.
Encourage her to take a deep breath, hold for 2 seconds, and cough two or three times in succession.	Controlled coughing is accomplished by closure of the glottis and the explosive expulsion of air from the lungs by the work of abdominal and chest muscles.
Encourage use of incentive spirometry, as appropriate.	Breathing exercises help maximize ventilation.
Promote systemic fluid hydration, as appropriate. Encourage her to take several deep breaths.	Adequate fluid intake enhances liquefaction of pulmonary secretions and facilitates expectoration of mucus.
Monitor rate, rhythm, depth, and effort of respirations.	Provides a basis for evaluating adequacy of ventilation.
Note chest movement, watching for symmetry, use of accessory muscles, and supraclavicular and intercostal muscle retractions.	Presence of nasal flaring and use of accessory muscles of respirations may occur in response to ineffective ventilation.
Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds.	As fluid and mucus accumulate, abnormal breath sounds can be heard including crackles and diminished breath sounds owing to fluid-filled air spaces and diminished lung volume.
Auscultate lung sounds after treatments to note results.	Assists in evaluating prescribed treatments and client outcomes.
Monitor client’s ability to cough effectively.	Respiratory tract infections alter the amount and character of secretions. An ineffective cough compromises airway clearance and prevents mucus from being expelled.
Monitor client’s respiratory secretions.	People with pneumonia commonly produce rust-colored, purulent sputum.
Institute respiratory therapy treatments (e.g., nebulizer) as needed.	A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions.
Monitor for increased restlessness, anxiety, and air hunger.	These clinical manifestations would be early indicators of hypoxia.
Note changes in SpO2, tidal volume, and changes in arterial blood gas values, as appropriate.	Evaluates the status of oxygenation, entilation, and acid–base balance.

CHAPTER 4

CONCLUSIONS AND RECOMMENDATIONS

4.1.            Conclusions

Pneumonia is a potentially serious and sometimes life-threatening condition. It carries a significant mortality rate, especially in vulnerable or at-risk patients. Those who are at risk should be offered preventive treatment if appropriate, such as vaccination. Healthcare professionals caring for at-risk groups in hospital should ensure that patients are nursed carefully to minimize exposure to infection. It is vital that nurses are aware of the signs and symptoms of pneumonia, to facilitate early diagnosis and interventions. They should also know the signs and symptoms of sepsis, and understand the criteria.

4.2.       Recommendations

As a professional nurse, we must understand about pneumonia and that nursing process, so we should provide the best intervention.

REFERENCES

Acute Respiratory infections in children: Case management in small hospitals in developing countries. A manual for doctors and other senior health workers. WHO/ARI/90.5 website: www.who.int

Bellamy, R. 2006. Pneumocystis pneumonia in people with HIV. Clinical Evidence; 15: 982–985.

Clinical Practice Guidelines on Pneumonia and Respiratory Tract Infections in Children WHO/ARI/90.5 website: www.who.int

Laterre, P.F. et al (2005) Severe community-acquired pneumonia as a cause of severe sepsis: data from the PROWESS study. Critical Care Medicine; 35: 5,952–961.