Careplan

Pneumonia (Adult, --Obstetrics Inpatient)

Nov.08.2021

Pneumonia (Adult, Obstetrics Inpatient)

Clinical Description

Care of the hospitalized patient experiencing an infection of the pulmonary parenchyma that occurs as either a primary disease or as a complication of another condition.

Key Information

Knowledge of previous antimicrobial therapy exposure and drug resistance patterns in the patient’s local area may influence choice of empiric antimicrobial therapy (e.g., methicillin, beta-lactam, macrolide).

De-escalated (narrowing antibiotic therapy or changing from combination to monotherapy) rather than fixed antibiotic regimens are suggested for patients with hospital-acquired pneumonia and ventilator-associated pneumonia.

Viral infection may be present with community-acquired pneumonia. The mortality risk increases when dual bacterial and viral infections are present.

Severity scoring tools may assist in predicting mortality from community-acquired pneumonia.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:

Fluid Balance
Resolution of Infection Signs and Symptoms
Effective Oxygenation and Ventilation

B. Patient, family or significant other will teach back or demonstrate education topics and points:

Education: Overview
Education: Self Management
Education: When to Seek Medical Attention

Correlate Health Status

Correlate health status to:
- history, comorbidity
- age, developmental level
- sex, gender identity
- baseline assessment data
- physiologic status
- response to medication and interventions
- psychosocial status, social determinants of health
- barriers to accessing care and services
- health literacy
- cultural and spiritual preferences
- safety risks
- family interaction
- plan for transition of care

Fluid Imbalance

Signs/Symptoms/Presentation: Fluid Deficit

capillary refill delayed
lightheadedness
mental status altered
mucous membranes dry
muscle weakness
postural hypotension
skin turgor decreased
thirst
tongue dry
urinary output decreased
urine concentration increased

Signs/Symptoms/Presentation: Fluid Excess

acute weight gain
ascites
bounding pulses
breath sounds change
crackles in lungs
edema
neck and hand veins distended
positive fluid balance
restlessness
shortness of breath
wheezing

Vital Signs

heart rate increased or decreased
blood pressure increased or decreased

Laboratory Values

BUN (blood urea nitrogen) abnormal
Hct (hematocrit) abnormal
serum sodium abnormal
urine specific gravity abnormal

Problem Intervention

Monitor and Manage Fluid Balance

Assess fluid requirements to determine fluid therapy strategy.
Keep accurate intake, output and daily weight; monitor trends.
Monitor laboratory value trends and need for treatment adjustment.
Assess need for ongoing intravenous fluid therapy; encourage oral intake when able.
Assess neurologic status frequently due to risk of hyponatremia.

Associated Documentation

Fluid/Electrolyte Management

Infection

Signs/Symptoms/Presentation

appetite change
capillary refill delayed
chest discomfort
chills
diaphoresis
eating pattern and tolerance change
fatigue
irritability
lethargy
listless
lymphadenopathy
malaise
mental status change
night sweats
pallor
peripheral perfusion altered
respiratory pattern change
restlessness
shivering
skin cool and moist
skin flushed
skin mottled
skin warm
sleepiness
urinary output decreased

Vital Signs

heart rate increased
respiratory rate increased
blood pressure increased or decreased
SpO2 (peripheral oxygen saturation) decreased
body temperature increased or decreased

Laboratory Values

ABG (arterial blood gas) abnormal
CBC (complete blood count) with differential abnormal
blood glucose level abnormal
CRP (C-reactive protein) elevated
culture positive
ESR (erythrocyte sedimentation rate) elevated
gram stain positive
influenza virus positive
PCT (procalcitonin) increased
serum lactate elevated

Diagnostic Results

CXR (chest x-ray) abnormal
chest ultrasound abnormal

Problem Intervention

Prevent Infection Progression

Implement transmission-based precautions and isolation, as indicated, to prevent spread of infection.
Obtain cultures prior to initiating antimicrobial therapy when possible. Do not delay treatment for laboratory results in the presence of high suspicion or clinical indicators.
Administer ordered antimicrobial therapy promptly; reassess need regularly.
Monitor laboratory value, diagnostic test and clinical status trends for signs of infection progression.
Identify early signs of sepsis, such as increased heart rate and decreased blood pressure, as well as changes in mental state, respiratory pattern or peripheral perfusion.
Prepare for rapid sepsis management, including lactate level, intravenous access, fluid administration and oxygen therapy.
Provide fever-reduction and comfort measures.

Associated Documentation

Fever Reduction/Comfort Measures
Infection Management
Isolation Precautions

Respiratory Compromise

Signs/Symptoms/Presentation

breath sounds abnormal
breathing pattern ineffective
breathlessness
confusion
cough impaired
cough increased
cyanosis
irritability
restlessness
retractions
shortness of breath
sputum (amount, color or consistency) change
swallow function impaired
work of breathing increased

Vital Signs

heart rate increased
respiratory rate increased
SpO2 (peripheral oxygen saturation) decreased

Laboratory Values

ABG (arterial blood gas) abnormal

Diagnostic Results

CXR (chest x-ray) abnormal
chest ultrasound abnormal

Problem Intervention

Promote Airway Secretion Clearance

Assess the effectiveness of pulmonary hygiene and ability to perform airway clearance techniques.
Promote early mobility or ambulation; match activity to ability and tolerance.
Encourage deep breathing and lung expansion therapy to prevent atelectasis; adjust treatment to patient’s response.
Anticipate the need to splint chest or abdominal wall with cough to minimize discomfort; assist if needed.
Initiate cough-enhancement and airway-clearance techniques with instruction.
Consider pharmacologic therapy, such as beta-2 agonist, mucolytic, corticosteroid, antimicrobial, that may improve inflammation, mucus clearance, cough response and air flow.

Associated Documentation

Breathing Techniques/Airway Clearance
Cough And Deep Breathing

Problem Intervention

Optimize Oxygenation and Ventilation

Assess and monitor airway, breathing and circulation for effective oxygenation and ventilation; consider oxygenation and ventilation parameters and goal.
Maintain head of bed elevation with regular position changes to minimize ventilation-perfusion mismatch and breathlessness; consider prone positioning to maximize alveolar recruitment.
Provide oxygen therapy judiciously to avoid hyperoxemia; adjust to achieve oxygenation goal.
Monitor fluid balance closely to minimize the risk of fluid overload.
Consider positive pressure ventilation to enhance oxygenation and ventilation, as well as reduce work of breathing.

Associated Documentation

Airway/Ventilation Management
Head of Bed (HOB) Positioning

Education

CPG-Specific Education Topics

Overview

description
signs/symptoms

Self Management

activity
fluid/food intake
immunizations
infection prevention
medication management
pulmonary hygiene
tobacco use, smoke exposure
VTE prevention

When to Seek Medical Attention

unresolved/worsening symptoms
VTE symptoms

General Education Topics

General Education

admission, transition of care
orientation to care setting, routine
advance care planning
diagnostic tests/procedures
diet modification
opioid medication management
oral health
medication management
pain assessment process
safe medication disposal
tobacco use, smoke exposure
treatment plan

Safety Education

call light use
equipment/home supplies
fall prevention
harm prevention
infection prevention
MDRO (multidrug-resistant organism) care
personal health information
resources for support

Quality Measures

NQF 0279 Community-Acquired Pneumonia Admission Rate (PQI 11)
Admissions with a principal diagnosis of bacterial pneumonia per 1,000 population, ages 18 years and older. Excludes sickle cell or hemoglobin-S admissions, other indications of immunocompromised state admissions, obstetric admissions, and transfers from other institutions.
Steward: Agency for Healthcare Research and Quality
Care Setting: Inpatient/Hospital
National Quality Forum-endorsed measure; CMS188v6
Last Edited: 03/27/2018

References

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Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

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