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Friday, May 17, 2019

Pathophysiology of Pneumonia, types and diagnosis

Bsc(Anatomy),Dip.HSE,Masters of public health(Epidemiology) in-view

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Pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange. Pneumonia is caused by a bacterial or viral infection that is spread by droplets or by contact and is the sixth leading cause of death in the United States.

The prognosis is typically good for people who have normal lungs and adequate host defenses before the onset of pneumonia. Pneumonia is a particular concern in high-risk patients: persons who are very young or very old, people who smoke, bedridden, malnourished, hospitalized, immunocompromised, or exposed to MRSA.

Types of Pneumonia

There are two types of pneumonia: community-acquired pneumonia (CAP), or hospital-acquired pneumonia (HAP) or also known as nosocomial pneumonia.

Pneumonia may also be classified depending on its location and radiologic appearance. Bronchopneumonia (bronchial pneumonia) involves the terminal bronchioles and alveoli. Interstitial (reticular) pneumonia involves inflammatory response within lung tissue surrounding the air spaces or vascular structures rather than the area passages themselves. Alveolar (or acinar) pneumonia involves fluid accumulation in the lung’s distal air spaces. Necrotizing pneumonia causes the death of a portion of lung tissue surrounded by a viable tissue.
Pneumonia is also classified based on its microbiologic etiology – they can be viral, bacterial, fungal, protozoan, mycobacterial, mycoplasmal, or rickettsial in origin.

Aspiration pneumonia, another type of pneumonia, results from vomiting and aspiration of gastric or oropharyngeal contents into the trachea and lungs.

Signs and Symptoms

The main symptoms of pneumonia are coughing, sputum production, pleuritic chest pain, shaking chills, rapid shallow breathing, fever, and shortness of breath. If left untreated, pneumonia could complicate to hypoxemia, respiratory failure, pleural effusion, empyema, lung abscess, and bacteremia.
Here are ten (10) nursing diagnosis common to pneumonia care plans, they are as follows: 

1. Ineffective Airway Clearance

Ineffective Airway Clearance is a common NANDA nursing diagnosis for pneumonia nursing care plans. This diagnosis is related to excessive secretions and ineffective cough or nonproductive coughing. Inflammation and increased secretions in pneumonia make it difficult to maintain a patent airway.

Nursing Diagnosis

  • Ineffective Airway Clearance. Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

Related Factors

The following are the common related factors for the nursing diagnosis Ineffective Airway Clearance related to pneumonia:
  • Tracheal bronchial inflammation, edema formation, increased sputum production
  • Pleuritic pain
  • Decreased energy, fatigue
  • Aspiration

Defining Characteristics

Here are the common assessment cues that could serve as defining characteristics or “as evidenced by” for ineffective airway clearance secondary to pneumonia.
  • Changes in rate, depth of respirations
  • Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
  • Use of accessory muscles
  • Dyspnea, tachypnea
  • Cough, effective or ineffective; with/without sputum production
  • Cyanosis
  • Decreased breath sounds over affected lung areas
  • Ineffective cough
  • Purulent sputum
  • Hypoxemia
  • Infiltrates seen on chest x-ray film

Desired Outcomes

Below are the common expected outcomes for ineffective airway clearance secondary to pneumonia:
  • Patient will identify/demonstrate behaviors to achieve airway clearance.
  • Patient will display/maintain patent airway with breath sounds clearing; absence of dyspnea, cyanosis, as evidenced by keeping a patent airway and effectively clearing secretions.

Nursing Interventions and Rationale

In this section are the ineffective airway clearance nursing interventions and actions for pneumonia together with its rationales or scientific explanations. The following nursing assessment for pneumonia and nursing interventions are measures to promote airway patency, increase fluid intake, and teaching and encouraging effective cough and deep-breathing techniques.
Nursing InterventionsRationale
Assess the rate, rhythm, and depth of respiration, chest movement, and use of accessory muscles.Tachypnea, shallow respirations and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung due to a compensatory response to airway obstruction. Altered breathing pattern may occur together with use of accessory muscles to increase chest excursion to facilitate effective breathing.
Assess cough effectiveness and productivityCoughing is the most effective way to remove secretions. Pneumonia may cause thick and tenacious secretions to patients.
Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes.Decreased airflow occurs in areas with consolidated fluid. Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasms and obstruction.
Observe the sputum color, viscosity, and odor. Report changes.Changes in sputum characteristics may indicate infection. Sputum that is discolored, tenacious, or has an odor may increase airway resistance and may warrant further intervention.
Assess the patient’s hydration status.Airway clearance is hindered with inadequate hydration and thickening of secretions.
Therapeutic Interventions
Elevate head of bed, change position frequently.Doing so would lower the diaphragm and promote chest expansion, aeration of lung segments, mobilization and expectoration of secretions.
Teach and assist patient with proper deep-breathing exercises. Demonstrate proper splinting of chest and effective coughing while in upright position. Encourage him to do so often.
  • Deep breathing exercises facilitates maximum expansion of the lungs and smaller airways, and improves the productivity of cough.
  • Coughing is a reflex and a natural self-cleaning mechanism that assists the cilia to maintain patent airways. It is the most helpful way to remove most secretions.
  • Splinting reduces chest discomfort and an upright position favors deeper and more forceful cough effort making it more effective.
Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway secretions.Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough or decreased level of consciousness. Note: Suctioning can cause increased hypoxemia; hyper oxygenate before, during, and after suctioning.
Maintain adequate hydration by forcing fluids to at least 3000 mL/day unless contraindicated (e.g., heart failure). Offer warm, rather than cold, fluids.Fluids, especially warm liquids, aid in mobilization and expectoration of secretions. Fluids help maintain hydration and increases ciliary action to remove secretions and reduces the viscosity of secretions. Thinner secretions are easier to cough out.
Assist and monitor effects of nebulizer treatment and other respiratory physiotherapy: incentive spirometer, IPPB, percussion, postural drainage.Perform treatments between meals and limit fluids when appropriate.
  • Nebulizers humidify the airway to thin secretions and facilitates liquefaction and expectoration of secretions.
  • Postural drainage may not be as effective in interstitial pneumonias or those causing alveolar exudate or destruction.
  • Incentive spirometry serves to improve deep breathing and helps prevent atelectasis.
  • Chest percussion helps loosen and mobilize secretions in smaller airways that cannot be removed by coughing or suctioning.
  • Coordination of treatments and oral intake reduces likelihood of vomiting with coughing, expectorations.
Encourage ambulation.Helps mobilize secretions and reduces atelectasis.
Administer medications as indicated:
  • Mucolytics increase or liquefy respiratory secretions.
  • Expectorants increase productive cough to clear the airways. They liquefy lower respiratory tract secretions by reducing its viscosity.
  • Bronchodilators are medications used to facilitate respiration by dilating the airways.
  • Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort and depress respirations.
Use humidified oxygen or humidifier at bedside.Increasing the humidity will decrease the viscosity of secretions. Clean the humidifier before use to avoid bacterial growth.
Monitor serial chest x-rays, ABGs, pulse oximetry readings.Follows progress and effects and extent of pneumonia. Therapeutic regimen, and may facilitate necessary alterations in therapy. Oxygen saturation should be maintain at 90% or greater. Imbalances in PaCO2 and PaO2 may indicate respiratory fatigue.
Assist with bronchoscopy and/or thoracentesis, if indicated.Bronchoscopy is occasionally needed to remove mucous plugs, drain purulent secretions, obtain lavage samples for culture and sensitivity.Thoracentesis is done to drain associated pleural effusions and prevent atelectasis.
Anticipate the need for supplemental oxygen or intubation if patient’s condition deteriorates.These measures are needed to correct hypoxemia. Intubation is needed for deep suctioning efforts and provide a source for augmenting oxygenation.
Urge all bedridden and postoperative patients to perform deep breathing and coughing exercises frequently.To promote full aeration and drainage of secretions.

2. Impaired Gas Exchange

This nursing diagnosis for pneumonia nursing care plans is usually written as Impaired Gas Exchange related to retained secretions and inflammatory pulmonary.


  • Impaired Gas Exchange: excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

Related Factors

The following are the common related factors for impaired gas exchange related to pneumonia:
  • Alveolar-capillary membrane changes (inflammatory effects)
  • Altered oxygen-carrying capacity of blood/release at cellular level (fever, shifting oxyhemoglobin curve)
  • Altered delivery of oxygen (hypoventilation)
  • Collection of mucus in airways
  • Inflammation of airways and alveoli
  • Fluid-filled alveoli

Defining Characteristics

The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
  • Dyspnea, Tachypnea
  • Pale, dusky, skin color
  • Cyanosis
  • Tachycardia
  • Restlessness, irritability, changes in mentation
  • Hypoxemia
  • Hypotension
  • Disorientation

Desired Outcomes

Common expected outcomes for the nursing diagnosis impaired gas exchange secondary to pneumonia:
  • Patient will demonstrate improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.
  • Patient will maintain optimal gas exchange.
  • Patient will participate in actions to maximize oxygenation.

Nursing Interventions and Rationales

Here are the nursing interventions and rationales to address the nursing diagnosis impaired gas exchange secondary to pneumonia. They are mostly measures to maintain oxygen saturations above 90%.
Nursing InterventionsRationale
Assess respirations: note quality, rate, rhythm, depth, use of accessory muscles, ease, and position assumed for easy breathing.Manifestations of respiratory distress are dependent on/and indicative of the degree of lung involvement and underlying general health status as patients will adapt their breathing patterns to facilitate effective gas exchange.Rapid, shallow breathing patterns and hypoventilation directly affects gas exchange. Hypoxia is associated with signs of increased breathing effort. Tripod positioning is an evidence of significant dyspnea.
Observe color of skin, mucous membranes, and nail beds, noting presence of peripheral cyanosis (nail beds) or central cyanosis (circumoral).As oxygenation and perfusion become impaired, peripheral tissues become cyanotic. Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (“warm membranes”) is indicative of systemic hypoxemia.
Assess mental status, restlessness, and changes in level of consciousness.Restlessness, irritation, confusion, and somnolence may reflect hypoxemia and decreased cerebral oxygenation and may require further intervention. Check pulse oximetry results with any mental status changes in older adults.
Assess anxiety level and encourage verbalization of feelings and concerns.Anxiety is a manifestation of psychological concerns and physiological responses to hypoxia. Providing reassurance and enhancing sense of security can reduce the psychological component, thereby decreasing oxygen demand and adverse physiological responses.
Monitor heart rate and rhythm and blood pressure.Tachycardia is usually present as a result of fever and/or dehydration but may represent a response to hypoxemia. Initial hypoxia and hypercapnia increases BP and HR. As hypoxia becomes more severe, BP may drop while HR tends to continue to be rapid with dysrhythmias.
Monitor body temperature, as indicated. Assist with comfort measures to reduce fever and chills: addition or removal of bedcovers, comfortable room temperature, tepid or cool water sponge bath.High fever (common in bacterial pneumonia and influenza) greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation.
Observe for deterioration in condition, noting hypotension, copious amounts of bloody sputum, pallor, cyanosis, change in LOC, severe dyspnea, and restlessness.Shock and pulmonary edema are the most common causes of death in pneumonia and require immediate medical intervention.
Monitor ABGs, pulse oximetry.Follows progress of disease process and facilitates alterations in pulmonary therapy. Pulse oximetry detects changes in oxygenation. O2 sats should be at 90% or greater.
Therapeutic Interventions
Maintain bedrest by planning activity and rest periods to minimize energy use. Encourage use of relaxation techniques and diversional activities.Prevents over exhaustion and reduces oxygen demands to facilitate resolution of infection. Relaxation techniques helps conserve energy that can be used for effective breathing and coughing efforts.
Elevate head and encourage frequent position changes, deep breathing, and effective coughing.These measures promote maximum chest expansion, mobilize secretions and improve ventilation.
Administer oxygen therapy by appropriate means: nasal prongs, mask, Venturi mask.The purpose of oxygen therapy is to maintain PaO2 above 60 mmHg. Oxygen is administered by the method that provides appropriate delivery within the patient’s tolerance. Note: Patients with underlying chronic lung diseases should be given oxygen cautiously.

3. Ineffective Breathing Pattern

In this case, the nursing diagnosis Ineffective Breathing Pattern is related to compensatory tachypnea due to an inability to meet metabolic demands. It is experienced by many clients with pneumonia. Changes in breathing pattern occur because affected alveoli cannot effectively exchange oxygen and carbon dioxide, as a result of chest pain, and increased body temperature.

Nursing Diagnosis

  • Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation.

Related Factors

Common related factors for ineffective breathing pattern:
  • Alteration of patient’s O2/CO2 ratio
  • Anxiety
  • Hypoxia
  • Decreased lung expansion
  • Inflammatory process
  • Pain

Defining Characteristics

The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
  • Changes in rate, depth of respirations
  • Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
  • Use of accessory muscles
  • Dyspnea, tachypnea
  • Cough, effective or ineffective; with/without sputum production
  • Cyanosis
  • Decreased breath sounds over affected lung areas
  • Ineffective cough
  • Purulent sputum
  • Hypoxemia
  • Infiltrates seen on chest x-ray film
  • Reduced vital capacity

Desired Outcomes

Common goals and outcomes for ineffective breathing pattern:
  • Patient maintains an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnea.
  • Patient’s respiratory rate remains within established limits.

Nursing Interventions and Rationales

The following are nursing actions to address ineffective breathing pattern. These interventions include: positioning the client to facilitate effective breathing (raising head of bed to 45 degrees), teaching how to splint chest wall with a pillow, and use of incentive spirometry.
Nursing InterventionsRationales
Assess and record respiratory rate and depth at least every 4 hours.The average rate of respiration for adults is 10 to 20 breaths per minute. It is important to take action when there is an alteration in the pattern of breathing to detect early signs of respiratory compromise.
Assess ABG levels, according to facility policy.This monitors oxygenation and ventilation status.
Observe for breathing patterns.Unusual breathing patterns may imply an underlying disease process or dysfunction. Cheyne-Stokes respiration signifies bilateral dysfunction in the deep cerebral or diencephalon related with brain injury or metabolic abnormalities. Apneusis and ataxic breathing are related with failure of the respiratory centers in the pons and medulla.
Auscultate breath sounds at least every four (4) hours.This is to detect decreased or adventitious breath sounds.
Assess for use of accessory muscle.Work of breathing increases greatly as lung compliance decreases.
Monitor for diaphragmatic muscle fatigue or weakness (paradoxical motion).Paradoxical movement of the abdomen (an inward versus outward movement during inspiration) is indicative of respiratory muscle fatigue and weakness.
Observe for retractions or flaring of nostrils.These signs signify an increase in respiratory effort.
Therapeutic Interventions
Place patient with proper body alignment for maximum breathing pattern.A sitting position permits maximum lung excursion and chest expansion.
Encourage sustained deep breaths by:
  • Using demonstration: highlighting slow inhalation, holding end inspiration for a few seconds, and passive exhalation
  • Utilizing incentive spirometer
  • Requiring the patient to yawn
These techniques promotes deep inspiration, which increases oxygenation and prevents atelectasis. Controlled breathing methods may also aid slow respirations in patients who are tachypneic. Prolonged expiration prevents air trapping.
Encourage diaphragmatic breathing for patients with chronic disease.This method relaxes muscles and increases the patient’s oxygen level.
Maintain a clear airway by encouraging patient to mobilize own secretions with successful coughing.This facilitates adequate clearance of secretions.
Suction secretions, as necessary.This is to clear blockage in airway.
Stay with the patient during acute episodes of respiratory distress.This will reduce the patient’s anxiety, thereby reducing oxygen demand.
Ambulate patient as tolerated with doctor’s order three times daily.Ambulation can further break up and move secretions that block the airways.
Encourage frequent rest periods and teach patient to pace activity.Extra activity can worsen shortness of breath. Ensure the patient rests between strenuous activities.
Encourage small frequent meals.This prevents crowding of the diaphragm.
Help patient with ADLs, as necessary.This conserves energy and avoids overexertion and fatigue.
Avail a fan in the room.Moving air can decrease feelings of air hunger.
Educate patient or significant other proper breathing, coughing, and splinting methods.These allow sufficient mobilization of secretions.
Teach patient about:
  • pursed-lip breathing
  • abdominal breathing
  • performing relaxation techniques
  • performing relaxation techniques
  • taking prescribed medications (ensuring accuracy of dose and frequency and monitoring adverse effects)
  • scheduling activities to avoid fatigue and provide for rest periods
These measures allow patient to participate in maintaining health status and improve ventilation.

4. Risk for Infection

The NANDA nursing diagnosis Risk for Infection is chosen to prevent the spread of infection.

Nursing Diagnosis

  • Risk for [Spread] of Infection: at increased risk for being invaded by pathogenic organisms.

Risk Factors

The following are the common risk factors:
  • Inadequate primary defenses (decreased ciliary action, stasis of respiratory secretions)
  • Inadequate secondary defenses (presence of existing infection, immunosuppression), chronic disease, malnutrition

Desired Outcomes

Goals and expected outcomes for Risk for Infection secondary to pneumonia.

6. Activity Intolerance

The nursing diagnosis Activity Intolerance is related to decreased oxygen levels for metabolic demands. For these pneumonia nursing care plans, energy reserves are also depleted due to insufficient intake of food during periods of dyspnea.

Nursing Diagnosis

  • Activity Intolerance: Insufficient physiologic or physiological energy to endure or complete required or desired activity.

Related Factors

Common related factors for activity intolerance secondary to pneumonia:
  • Imbalance between oxygen supply and demand
  • General weakness
  • Exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing, and dyspnea

Defining Characteristics

The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
  • Verbal reports of weakness, fatigue, exhaustion
  • Exertional dyspnea, tachypnea
  • Tachycardia in response to activity
  • Development/worsening of pallor/cyanosis

Desired Outcomes

Common goals and expected outcomes:
  • Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs within patient’s acceptable range.

Nursing Interventions and Rationales

Nursing interventions for activity intolerance in this pneumonia nursing care plan should include assessment of the client’s baseline activity level and response to activity and noting how well the client tolerates activity. Next is to schedule activities after treatment or medications and providing emotional support and a quiet environment to reduce anxiety and promote rest.

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