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:
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
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.
- 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.
- 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.
- 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.
- Airway/Ventilation Management
- Head of Bed (HOB) Positioning
Education
Overview
description
signs/symptoms
When to Seek Medical Attention
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
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.