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Careplan

Pneumonia (Adult, --Obstetrics Inpatient)

Nov.19.2020

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 and deficit to determine goal-directed fluid therapy.
  • 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.

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 change from baseline
  • body temperature increased or decreased

Laboratory Values

  • ABG (arterial blood gas) abnormal
  • bands increased
  • blood glucose level abnormal
  • CRP (C-reactive protein) elevated
  • culture positive (urine, blood, sputum)
  • ESR (erythrocyte sedimentation rate) elevated
  • gram stain positive
  • influenza virus positive
  • serum lactate elevated
  • WBC (white blood cell) count change

Diagnostic Results

  • CXR (chest x-ray) 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 altered
  • breathlessness
  • confusion
  • cough impaired
  • cough increased
  • cyanosis
  • irritability
  • restlessness
  • shortness of breath
  • sputum 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

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 inhaled pharmacologic therapy (e.g., beta-2 agonist, mucolytic, corticosteroid, antimicrobial) to improve mucus clearance, inflammation, 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.
  • Anticipate noninvasive and invasive monitoring (e.g., pulse oximetry, end-tidal carbon dioxide, blood gases, cardiovascular).
  • Maintain optimal position to relieve discomfort, breathlessness and ventilation-perfusion mismatch.
  • Provide oxygen therapy judiciously to avoid hyperoxemia; adjust to achieve oxygenation goal.
  • Monitor fluid balance closely to minimize the risk of fluid overload.
  • Consider noninvasive or invasive 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

Population-Specific Considerations

Geriatric

  • Geriatric patients are at higher risk for aspiration pneumonia due decreased oropharyngeal swallow response.
  • Typical symptoms of pneumonia may be absent in the elderly patient. They may have an altered mental status, such as confusion, as the presenting sign of pneumonia.

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

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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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