Respiratory: Pneumonia

You're listening to Nitty Gritty Nursing with Nurse M, where she breaks down the nitty-gritty basics of nursing concepts. Hello everyone and welcome back to the Nitty Gritty Nursing Podcast with Nurse Am. Today we're gonna talk about pneumonia and all things nursing related to pneumonia. And in order to do this, we're first gonna start out with basically the description of what pneumonia is, which

is just a respiratory tract infection that causes inflammation. And this is in an infection of the pulmonary tissue, including the interstitial spaces, along with the alveoli and the bronchioles. Because of this infection that causes the inflammation, there is also edema associated with this, which stiffens the lung. And because the lung becomes really stiff, it also then decreases the lung compliance and the vital capacity, which ultimately causes hypoxemia.

makes sense, right? If your lungs don't work, you're not gonna breathe adequately, which will equate itself to hypoxemia.

And this can actually be caused by multiple different things. So there's quite a few key players at large here. We have bacteria, viruses, and fungi that are potential culprits behind some sort of pneumonia. And it can also be community acquired, which is you know someone gets it outside of the hospital setting or it can be a hospital acquired pneumonia. like individuals on mechanical ventilation get a lot of pneumonia. We call it VAP ventilator associated pneumonia.

And that is frankly the worst type because there's the hospital's just littered with super bugs everywhere. And ultimately what happens is when an infection occurs and attacks the alveolar sac with whatever the culprit is, these alveolar sacs become super inflamed. As a result they fill with fluid.

And then that body senses that alteration and sends the troops basically to fight it. So your white blood cells show up. And then you start to have the buildup of not only fluid, but also white blood cells. and red blood cells and whatever the culprit is, bacteria, viruses or fungi, and the CO two can then not be filtered. So you basically get a buildup of CO two, which leads to hypoxemia.

Which equates to low O2 saturations and ultimately can lead to a respiratory acidosis. There are quite a few risk factors for developing pneumonia, so people who've had a prior infection and they've already been exposed to something like

having had the flu or maybe the cold. They're already ex they've because they've already been exposed to something, their immune system is stressed. So they are prone or at risk for the development of pneumonia. The same with individuals who have a really weak immune system. Maybe they're taking immunosuppressive drugs

uh because, you know, they've had a transplant of some sort, whether it was kidney, liver, bone marrow. Will those immunosuppressive drugs inhibit the normal function of their immune system? So they're not going to fight germs the same way. You know, individuals who are maybe really young or really old, they don't have developed immune systems, or they just have weaker systems, they're at risk for developing pneumonia. Same with anyone who's got like an autoimmune suppression going on.

Uh the next category is individuals who are immobile. So anyone who's had a stroke and has maybe got a deficit on one side of their body or they've got a decreased neurological status and maybe because of that they are now a risk for aspiration. these individuals will also be at risk for pneumonia for the obvious because if you're not moving around, you're not expanding and popping those alveoli open as you get up and ambulate. Similarly, like if you're an aspiration rest,

and you decide to inhale, you know, some pudding, well, you've just inhaled like a very sweet, sugary substance into a dark, cavernous cave of your lungs, and guess what? Bacteria love dark, wet, moist, sugary areas because the sugar feeds them and they get to thrive in those environments. And then anyone who with a history of lung problems like COPD or anyone who's a smoker, your lungs are already compromised.

So because of that, these p these people are also at risk for developing pneumonia. And then anyone postoperatively, especially if they've had any sort of abdominal or thoracic surgery, because these patients don't want to take a deep breath. And because they don't want to take a deep breath

The aviolae cannot stay popped open, they oftentimes then develop some sort of atolectasis, which can then predispose them to the development of pneumonia. I should also point out that they don't want to take a deep breath because they can't, but because they're in pain.

So be a good news and medicate them so that they take their deep breaths so that they don't develop the atolectasis, which then has the potential to lead to pneumonia. I will also say that bacterial causes are the most common cause.

of pneumonia, specifically Streptococcus pneumoniae, um, which we often see in like a community acquired setting, super, super common, uh, followed by a viral infection. So some patients who get an influenza infection or especially in the kiddos, RSV currently, um, they're gonna some kids are gonna get pneumonia because of RSV and the viral infections are really hard to treat because you use an antiviral medication with a bacterial pneumonia, you will use an antibacterial agent.

And then fungal pneumonia is the least common type of pneumonia that people can get and it affects people most often within a weakened immune system and

The vi the fungi that infect them are often found around plants and animals. So basically if you get pneumonia, what do you even look like? What do these people look like when they get them? I'm gonna tell you that they often have some sort of chills.

and they've got an elevated temperature, especially if it's bacterial. They can also have a pleuretic chest pain, they get that that pleurisy pain'cause there's a lot of inflammation going on in the thoracic cavity. They can become tachypnic and really have a rapid rate of a breathing pattern. Uh and oftentimes when you go to auscultate them you're also gonna hear ronkai and wheezes or like those coarse crackles that sound of like fluid or build up or like absolute gunk inside their lungs.

That is basically consolidating and we can hear that. And they're oftentimes also going to have a lot of sputum production, so they'll be able to cough stuff up. Some people might have accessory muscles that they'll be utilizing for breathing, and then others might have mental status changes because of an oxygenation issue. If you're hypoxemic, Your brain is also not getting oxygen. If your brain is not getting oxygen, then you become altered and you get an altered mental status.

The way we'll d typically diagnose is we do a chest x-ray and we'll also do sputum cultures if we can to really determine what the bacteria is so that we can do a targeted therapy, especially if we need a specific antibiotic to target a specific bacteria. Now look, if you're also gonna want like the classic signs and symptoms These patients who develop pneumonia are gonna have that productive cough with a pleuretic pain. Every time they cough, it's gonna hurt.

They m are likely to also have neurological changes. Again, frequently seen in the elderly population, along with fatigue and an increased respiratory rate, because they're just not transporting enough oxygen because they are hypoxemic from that fluid buildup which is trapping in the CO two and not exchanging it for the oxygen. In terms of their lab values, they're likely to go figure, have an elevated CO two level and an increased white blood cell count.

They'll usually have unusual breath sounds, so you're gonna hear crackles, ronchi, etcetera. They're likely to have a h mild to high fever. the oxygen saturation is gonna vary and they might need supplementary oxygen. Some patients also get nausean vomiting and again we're gonna see an increase in heart rate and respiratory rate as a compensatory mechanism to try to accommodate for the lack of oxygen and hypoxemia and then oftentimes they're gonna be achy all over because they feel like garbage.

And they'll have some degree of activity intolerance with shortness of breath. So when they get up and they try to move around, guess what? They get short of breath.

And they get fatigued because they don't have the oxygen to make their muscles do the things that they need to. So here's what's up from a nursing perspective, the interventions that you're gonna do with someone who's got pneumonia. Is follow the ABCs, alright? Make sure they've got an airway and that they're breathing adequately. This may mean that we need to give them some sort of supplementation of oxygen in a nasal cannula.

and monitor their respiratory status. Always assess your patient. Never trust the monitor. Your assessment skills as a nurse are what are gonna carry you through. We're gonna monitor that respiratory status and we're gonna watch for whether or not they're having laboured respirations. Maybe they're a little bit cyanotic, maybe their skin is cold and clammy, again.

News flash, not enough oxygen in their system. And we really want to encourage these patients to cough and deep breathe and use an incentive spirometer. And that incentive spirometer Is really designed to kind of help ex inflate the lungs and try to pop some of those aviat oli open so that they've got the surface area to do the CO2O2 examination.

exchange. Oftentimes in terms of positioning we really want them in a semi fallows position, uh so sitting upright to facilitate that breathing and lung expansion. And then we wanna really try to provide suctioning if we need it. Use a pulse oximetry, you know, make sure that you're monitoring their heart rate and O two levels. And then record uh if they've got a lot of speedum, record what it looks like and how often. We also push

Fluids, as long as it's applicable. I mean, if you've got someone with CHF and they've got a terrible heart and they're fluid overloaded to begin with, don't push a bunch of fluids on them. You also have to think about like how much fluid is in the antibiotics that I'm giving them and take that into account because we don't want to fluid overload them because that will just compound the inflammatory issue in the fluid flowing into the alveoli.

You then also want to make sure that you're giving them medications to fix the symptoms that they're having. So if they've got a fever, give them an antipyrotic. Everyone feels like garbage when they're running a fever, so give them something for that. Additionally, you might want you might consider giving them a bronchodilator. to help kind of open up the alveoli, maybe a cough suppressant especially if they've been coughing a lot. some sort of mucolytic agent that might, you know, loosen or

uh liquefy the mucus secretions that they've got and then expectorints as prescribed. And then the other big thing that you want to do is treat whatever the culprit is. So if you've got a bacterial infection, give them their antibiotics. If they've got a viral infection, give them an antiviral. Again, you know, if they've got a fungal infection, make sure you're giving them the antifungal agent that will ultimately

nicks this issue in the bud. Now, from an education perspective, we do want to encourage the use of the In Center Sparometer, which is that device that you might have seen in nursing school. with a blue tube that comes out of it and it's called a mouthpiece. It's not a device you blow into, it's a device that you inhale slowly into with different tidal volume goals.

And ideally, like I think the literature says you would want to encourage your patient to use it ten times every one to two hours while they're awake. Don't wake'em up if they're in the middle of the night. To be like, you didn't use your IS machine, no, we don't do that. But you also want to encourage fluid.

uh stay hydrated because it keeps the production, the speed in production that they've got going, it keeps it liquid so that they can actually get it up. And then If your patient is actually immobile and cannot get out of bed, we really want to try to keep that head of bed at greater than 30 degrees and then turn them frequently.

and then ultimately like keep them up to date on their vaccines, whether it's an annual flu vaccine, whether it's the pneumax vaccine, and then encourage them to, you know, stop smoking if they're a smoker or You know, if they've got a weakened immune system, n encourage them to avoid sick people or crowds during that flu season and ultimately like wash your damn hands. Wash'em.

Wash em, it prevents so much spread of infection. So that's the nitty gritty on pneumonia that I can think of. So go forth and keep learning.