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Community-Acquired Pneumonia with Accurate Diagnosis, Patients Can Be Appropriately Treated in and out of the Hospital

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Community-Acquired Pneumonia with Accurate Diagnosis, Patients Can Be Appropriately Treated in and out of the Hospital Community-acquired pneumonia With accurate diagnosis, patients can be appropriately treated in and out of the hospital. By Shari J. Lynn, MSN, RN tive cough, anorexia, or confusion. within 14 days before symptom COMMUNITY -ACQUIRED PNEU - MONIA (CAP) is exactly what it onset sounds like—a lung infection ac - Risk factors • patient’s symptoms begin within quired while out and about in the Many factors contribute to an in - 4 days of hospital admission world. The cause may be a virus, creased chance of developing CAP. • patient doesn’t live in a long- bacteria, or fungus. (See CAP stats .) (See CAP risk factors .) Antibiotic term care facility. The estimated cost of treating treatment, chronic steroid use, and Bacterial pathogens and respira - CAP in the United States is about malnutrition increase the risk for tory viruses are common causes of $12.2 billion a year. Inpatient treat - CAP, as do comorbidities such as CAP. Bacterial organisms that are ment ranges from $7,500 to $10,227 chronic renal failure. In the elderly treatable in the outpatient setting per admission, whereas outpatient population, comorbidities as well as include Chlamydophila pneumoni - treatment ranges from $150 to $350 the effects of aging (such as re - ae, Haemophilus influenzae, Mo - per patient. This difference demon - duced mucociliary movement and rax ella catarrhalis, Mycoplasma strates the need for accurate diag - clearance, decreased cough reflex, pneumoniae , and Streptococcus nosis and appropriate treatment. increased potential for colonization pneumoniae . Respiratory viruses as - of gram-negative organisms, and sociated with outpatient treatment Immune response decreased immune response) in - of CAP include adenovirus, influen - A patient’s immune response to crease the risk for CAP. Additional za A and B, parainfluenza virus, CAP depends on the type of organ - risk factors include spleen removal, and respiratory syncytial virus. How - ism involved. Less noxious organ - HIV, hypogammaglobulinemia, and ever, any patient infected with isms typically are destroyed by sickle cell disease. these pathogens who shows severe macro phage engulfment, which re - symptoms may be admitted for in - sults in a moderate immune re - Classification and causes patient care as well as those infect - sponse. If the organism is highly CAP is just one classification of ed with anaerobes that are related virulent or is present in great num - pneumonia. (See CAP vs. HAP .) to aspiration and Legionella pneu - bers, a series of immune responses The criteria for CAP include: mophila . occur, including inflammation, cel - • patient hasn’t been hospitalized lular infiltration, and activation of Patient assessment the immune cascade. When the pa - Begin the patient assessment by tient can’t clear pulmonary secre - CNE identifying symptoms and their on - tions, a secondary infection may 1.51 contact set. Note symptom severity, includ - develop. (See Immune response .) hours ing characteristics of cough and In response to physiologic sputum, descriptions of pain level, changes, the patient’s respiratory LEARNING OBJECTIVES factors that relieve or aggravate rate may increase in an attempt to 1. Identify the causes of and risk fac - symptoms, treatments the patient improve oxygen levels, but eventu - tors for community-acquired has already tried, and how the pa - pneumonia (CAP). ally he or she becomes exhausted tient describes illness severity. 2. Describe the assessment of the from the work of tachypnea, and patient with CAP. Negative test results and negative the respiratory rate decreases, lead - 3. Discuss the management of the symptoms can help rule out other ing to hypoxemia and hypercapnia. patient with CAP. diagnoses. Ask about abdominal In addition, the patient may experi - pain, chest pain, hematuria, dys uria, The author and planners of this CNE activity have ence fever, pleuritic chest pain, disclosed no relevant financial relationships with edema, weight gain, and neurologi - coughing, dyspnea, and a general any commercial companies pertaining to this cal symptoms. In addition, gather activity. See the last page of the article to learn feeling of being unwell. In older how to earn CNE credit. information about the patient’s cur - adults, symptoms may not be as ob - rent medications (including pre - vious; they may have a less produc - scription and over-the-counter med - American Nurse Today Volume 12, Number 12 AmericanNurseToday.com 6 ications and herbal remedies); to - CAP stats bacco, alcohol, and illicit drug use; These statistics reveal the prevalence of community-acquired pneumonia (CAP) environmental exposure to possible and why outpatient treatment is preferred when possible. lung irritants; and immunizations. • All age groups are susceptible to CAP, but the greatest morbidity and mortality Note allergies and past medical can be found in young patients under 6 years old and older patients over 75 history as well as social and family years old. histories. Ask about any comorbidi - • The incidence of CAP increases exponentially in patients over age 50 in indus - ties, such as cancer, autoimmune trialized countries. disease, and chronic respiratory is - • Even with the discovery of antibiotics, pneumonia is still prevalent on a global sues. Also note the patient’s resi - level and remains an economic burden on the healthcare system. dence (for example, home or long- • According to the World Health Organization, 1.4 million people die every year term care facility). from pneumonia, and it’s a predominant cause of death in children. Examine all body systems to • In the United States, CAP is the eighth leading cause of death and the most determine infection severity, the common cause of death from an infectious agent. probability of CAP, and other ill - • The death rate for patients being treated in the outpatient setting is less than 5%. nesses that may have contributed • The death rate may increase to 10% and go as high as 30% for patients admit - to CAP. A head, ears, eyes, nose, ted to the intensive care unit. and throat exam may reveal an up - • The most prevalent reasons for death related to CAP are complications, such per-respiratory infection related to as refractory hypoxemia, multi-organ failure, sepsis, and shock. nasal congestion, ocular discharge, mouth breathing, nasal flaring, or otitis media. Dullness and dryness of the lips, eyes, and mucosa may be signs of dehydration. Immune response Pulmonary auscultation and physical examination may reveal A patient’s immune response to the organism causing community-acquired pneumonia includes vasodilation of the pulmonary capillaries, resulting in permeability and leaking dull percussion, chest tenderness, of protein-rich exudate into the interstitial space and eventually reaching the alveoli. As increased tactile fremitus, broncho - the alveoli fill with exudate, they stick together and inhibit gas exchange. ph ony, egophony, and whispered The formation of neutrophils, as part of the inflammatory response, may damage the pectoriloquy. You also may hear lung tissue and lead to fibrosis or pulmonary edema. The tissue of the alveoli is delicate wheezes, rhonchi, or crackles, and and can be damaged easily by the normal inflammatory response, which can be exac - the patient may have pleuritic chest erbated if the patient has underlying protective mechanism issues such as overproduc - pain that’s more severe on deep in - tion of mucous, immune deficiencies, and diminished ciliary action. spiration. Cardiovascular effects of CAP in - clude poor perfusion, prolonged capillary refill, and tachycardia. Be - cause of dehydration and cyanosis caused by hypoxia, the patient’s skin may tent, and he or she may experience men tal status changes. Changes in mental status, loss of appetite, and falls (related to confu - sion and dizziness as a result of hy - poxia) also can be factors that are part of a CAP diagnosis. Diagnostic tools Many tools (including the pneu - Pneumonia severity index Diagnosis of CAP includes a chest monia severity index, CURB-65 and The pneumonia severity index x-ray. Viral pneumonia commonly CRB-65, SMART-COP, and the Amer - (PSI) was developed to classify presents with interstitial infiltrates i can Thoracic Society criteria) are patients suspected of having CAP on x-ray; bacterial infection pres - available to help determine if the (goo.gl/Yk5JLH ). This tool, which ents with alve olar infiltrates. Viral patient with CAP can be treated has been used in emergency de - and bacterial infections can occur successfully as an outpatient or if partments, nursing homes, and simultaneously. hospital admission is required. community hospitals, looks at pa - AmericanNurseToday.com December 2017 American Nurse Today 7 CAP risk factors CAP vs HAP Several factors place patients at risk This chart from the Wexner Medical Center of the Ohio State University College of for community-acquired pneumonia Medicine differentiates community-acquired pneumonia (CAP) and hospital- (CAP), including comorbidities, acquired pneumonia (HAP). lifestyle, and patient characteristics. CAP HAP Comorbidities Presentation • Altered mental state • Asthma Necessary features for diagnosis: Variable clinical features: • Cough • Fever • Bronchiectasis • Fever • Leukocytosis • Chronic obstructive pulmonary • Chest x-ray infiltrates • Increased respiratory secretions disease • Chest x-ray infiltrates • Cystic fibrosis Risk factors • Diabetes • Age extremes • Aspiration risks: • Heart disease • Alcohol misuse • supine positioning
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