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Careplan

Pneumonia (Pediatric Inpatient)

Nov.19.2020

Pneumonia (Pediatric Inpatient)

Clinical Description

  • Care of the hospitalized child 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.

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, congenital anomaly
    • 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
    • child and family/caregiver:
      • 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
  • eyes sunken
  • fatigue
  • fontanel sunken (infant)
  • irritability
  • listless
  • mucous membranes dry
  • peripheral pulse strength decreased
  • skin turgor decreased
  • tearing decreased or absent
  • thirst
  • urinary output decreased
  • urine concentration increased

Signs/Symptoms/Presentation: Fluid Excess

  • acute weight gain
  • 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 fluid therapy goal.
  • 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.
  • Evaluate causes and potential sources that may lead to imbalance, such as illness severity, organ failure, mental status, mobility limitations, swallowing difficulties, intravenous fluid and medication side effects.
  • 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
  • fatigue
  • diaphoresis
  • eating pattern and tolerance change
  • irritability
  • lethargic
  • listless
  • lymphadenopathy
  • malaise
  • mental status change
  • night sweats
  • pallor
  • 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 elevated

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
  • 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 or temperature, 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
  • feeding difficulty
  • 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

Age-Related

  • Blood cultures may not be reliable in the diagnosis of pneumonia in children.

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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