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

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    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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