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The following course content

Introduction   

Pneumonia is a common acute medical condition diagnosed in children and adults. People with certain medical conditions or in specific age groups are at an increased risk of developing pneumonia.  

Patients do not always have the same symptoms for pneumonia. Thus, it can make it sometimes challenging to initially diagnose patients. It’s important for nurses to understand the signs and symptoms of pneumonia and its potential complications.  

The purpose of this course is to equip learners with knowledge related to pneumonia. This course reviews the epidemiology, etiology, and pathophysiology of pneumonia. It also describes the signs and symptoms of pneumonia, treatment, and complications. The course also discusses collaboration of care with speech therapy and prevention strategies for aspiration pneumonia. Last, it reviews patient and family education.  

Statistical Evidence/Epidemiology 

This section will discuss the statistical evidence and epidemiology behind pneumonia. 

According to the Centers for Disease Control and Prevention (CDC), there are around 41,000 deaths per year from pneumonia in the United States (U.S.). This equates to 12.4 deaths per 100,000 people (3). The CDC posts an annual publication of the leading causes of death each year in the U.S. and in 2019, pneumonia and influenza were the ninth leading cause of mortality (9). Additionally, a research study published in 2018, found that the rate of community-acquired pneumonia (CAP) hospitalizations was around 847 per 100,000 people in 2015 (1). 

Another report by the National Hospital Care Survey (NHCS), released in January 2022, studied hospitalized patients with pneumonia in 2016. The NHCS found that 35% of patients with pneumonia died within one year of discharge or during their hospital stay. This percentage reflects around 77,000 adults who contributed to the survey across 97 U.S. hospitals (14). 

A research study published in 2018 found that pneumonia-associated hospitalizations in the United States were more prevalent amongst infants, older adults (age 65 years and older), and people who are immunocompromised. Also, people with lower socioeconomic status and certain races and ethnicities were more impacted. The study reported that non-Hispanic African Americans had the highest rate of pneumonia-associated hospitalizations. Non-Hispanic American Indians and Alaskan Natives had a higher prevalence as well (8). 

Additional modifiable risk factors for developing pneumonia include smoking, and drug and alcohol use. People who have had a stroke, head injury, or other neurological conditions that affect their swallowing ability are also at increased risk. Risk also increases with lung problems, like asthma and cystic fibrosis, and people who have diabetes, kidney disease, and other serious chronic health conditions (12).  

Etiology/Causes in Older Adults 

This section reviews the different underlying causes and organisms of pneumonia. 

Pneumonia can occur from various underlying causes or etiologies. The three organisms are bacteria, viruses, and fungi (12). In the United States, Streptococcus pneumoniae is the most common bacteria that causes pneumonia (17). Haemophilus influenzae and Staphylococcus aureus are the second and third most common bacterial causes of community-acquired pneumonia, respectively (19). Additionally, Mycoplasma pneumoniae is oftentimes the cause of “walking pneumonia” (12). Many other bacteria strains can cause pneumonia, but these are considered atypical (10).  

Viruses can also cause pneumonia, like influenza and SARS-CoV-2 (COVID-19). Respiratory syncytial virus, or RSV, is the most common cause in young children. Also, the virus that causes the common cold, rhinovirus, can lead to pneumonia (12).  

Fungi infections in the lungs can also contribute to pneumonia. In patients who are immunocompromised or have human immunodeficiency virus (HIV), the common fungi causing pneumonia is Pneumocystis jjrovecii (12). Other common fungi are Aspergillus and Cryptococcus. Aspergillus is a common cause of ventilator-associated pneumonia (VAP) (20). 

Types of Pneumonia 

This section discusses the different types of pneumonia. 

There are three different types of pneumonia, usually depending on where the initial source of infection occurred. Community-acquired pneumonia (CAP) is when the source is in a community setting and not inside the hospital. Patients who reside in assisted living, rehabilitation, and other non-inpatient facilities who develop pneumonia are classified under the CAP umbrella (10). 

Conversely, hospital-acquired pneumonia (HAP) develops when a patient is inside the hospital or inpatient setting. HAP is only considered when a patient develops pneumonia at least 48 hours after admission and was not already present or developing upon the time of admission (10). 

Ventilator-associated pneumonia (VAP) occurs 48 hours after an endotracheal tube is inserted (10). Aspiration pneumonia occurs when fluid from oropharyngeal secretions or the gastrointestinal tract enters the lower respiratory tract. This can occur in any setting, causing a certain type of pneumonia, depending on the setting where it occurred.  

Aspiration pneumonia often occurs in patients who have difficulty swallowing, dementia, or other conditions affecting their swallowing ability, such as gastroesophageal reflux disease (GERD). Aspiration can also occur after general anesthesia, during nasogastric tube insertion, and in patients who have a tracheostomy (16). 

Case Study  

A 56-year-old patient was admitted to the medical unit for pneumonia three days ago. Prior to the patient’s admission, they were living in an assisted living facility.  

• What type of pneumonia (CAP, HAP, VAP) does this patient have? 

Pathophysiology 

This section reviews the pathophysiology of developing pneumonia. 

Like many other body systems, the respiratory tract has a balance of bacteria and other organisms. The body’s immune system also acts as a defense mechanism and responds whenever a foreign pathogen is present.  

When pneumonia occurs, foreign pathogens enter the alveoli of the lungs and macrophages respond. Macrophages clear or engulf the pathogens and signal to other molecules, like interleukins IL-8, IL-1, and other cytokines. Then white blood cells act on the site of infection developing and T cells trigger an immune response. This immune response creates inflammation in the lungs and increases the permeability of the capillaries. Thus, causing pneumonia to develop (10).  

Signs and Symptoms 

This section discusses the signs, symptoms, and physical exam findings of pneumonia.  

Initially diagnosing pneumonia can sometimes be difficult for the healthcare provider. Thus, nurses must recognize and understand the potential signs and symptoms of pneumonia. If the patient has difficulty swallowing, the nurse should look for signs of aspiration since this can cause pneumonia as well. Initial signs of any type of pneumonia typically include: 

• Fever, chills, or sweats 
• Lack of appetite 
• Body aches 
• Fatigue or weakness 
• Cough with or without sputum 
• Shortness of breath  

(10) 

However, sometimes very few of these symptoms will be present and can vary from patient to patient. Less common symptoms are altered mental status and chest or abdominal pain. Additionally, the nurse should recognize potential physical exam findings of pneumonia when performing their physical assessment.  

Some of these findings might include: 

• Increased heart rate 
• Increased respiratory rate and/or decreased oxygen saturation 
• Diminished or abnormal breath sounds  
• Fever  

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The nurse may also notice an elevated white blood cell count. If a recent chest x-ray was completed, it would show infiltrates (10).  

The image below shows ventilator-associated pneumonia (VAP) and aspiration pneumonia: 

(10) 

Treatment 

This section discusses the diagnostic tests and treatment options for pneumonia. It also reviews nursing interventions.  

If the nurse suspects a patient has developed pneumonia, they should alert the healthcare provider immediately. Typically, the healthcare provider will order a chest x-ray, which would reveal infiltrates.  

The healthcare provider might also order blood work, including: 

• Blood cultures 
• Complete blood count (CBC) 
• Basic or comprehensive metabolic panel (BMP or CMP) 
• Procalcitonin 
• C-reactive protein (CRP) 

In addition, the healthcare provider should order a sputum culture or bronchial aspirate, depending on if the patient is intubated. A sputum culture helps determine the underlying organism for treatment (10).  

The healthcare provider will start the patient on empiric intravenous (IV) antibiotics. Usually, the patient is started on piperacillin/tazobactam, cefepime, and levofloxacin. Alternatively, the patient might be started on an aminoglycoside, like azithromycin, and another antibiotic, such as imipenem.  

However, the initial treatment regimen is selected by the healthcare provider and may also depend on the facility’s protocol. The nurse should plan to administer these medications, pending the blood and sputum culture results. Once the cultures return, the healthcare provider may adjust the medications (10). Depending on the results, the nurse may also need to implement droplet, contact, or airborne precautions. 

The nurse will also provide other nursing interventions when caring for a patient with pneumonia. They will promote hydration by administering IV fluids and measuring any oral intake. In addition, they will carefully monitor urinary output and document it in the medical record.  

The nurse may perform oral suctioning when necessary and routine oral care. If the patient has pain or a cough, the nurse may administer medications prescribed by the healthcare provider. Also, the nurse should promote proper nutrition, including increasing fluid and protein intake, and rest. If the patient’s oxygen saturation is low, they will administer oxygen as ordered. Additionally, nurses should educate patients and their families on pneumonia, medications, and prevention strategies (18).  

Pneumonia can lead to many other health complications, and the nurse should alert the healthcare provider of any changes in the patient’s status immediately. If the patient is not already admitted to an intensive care unit (ICU) for treatment, they may need to be transferred to a higher level of care if their health status is deteriorating. 

Case Study  

A 64-year-old patient was admitted to the medical unit with pneumonia. They are currently on 10 liters high-flow nasal cannula. The nurse enters the patient’s room and notices they are having difficulty breathing and tachycardic. The patient’s oxygen saturation is 88%.   

• Which immediate nursing interventions should the nurse take in this case study? 

Complications 

This section reviews the potential complications of pneumonia.  

Pneumonia can lead to a variety of complications, especially if left untreated. The nurse must look for slight changes in the patient’s health status, which may indicate signs of deterioration. Some complications are respiratory failure, lung abscesses, and empyema, which is a collection of pus in the pleural cavity (10).  

The patient may also develop pericarditis, which is an inflammation surrounding the heart, or an endobronchial obstruction. Atelectasis, which is a collapse within the lung, is another common complication.  

Pneumonia can also lead to a bloodstream infection, called bacteriemia. It can also cause a severe bloodstream infection, called sepsis. Sepsis can lead to further complications like kidney or multi-organ failure (2). Another severe, life-threatening complication is acute respiratory distress syndrome (ARDS). If the patient develops severe complications from pneumonia, it can also lead to death (16).   

Considerations for Aspiration Pneumonia 

This section reviews the different nursing considerations, prevention strategies, and collaboration with speech therapy regarding aspiration pneumonia. 

Aspiration pneumonia occurs when fluid from oropharyngeal secretions or the gastrointestinal tract enters the lower respiratory tract. When caring for patients, there are several nursing interventions and prevention strategies that nurses should consider for aspiration pneumonia.  

Collaborating with Speech Therapy 

The nurse collaborates with the speech therapist to evaluate a patient’s swallowing. Depending on the facility, this typically involves an initial bedside swallowing screening by the nurse. If the nurse notices a patient has difficulty swallowing (dysphagia) or has aspirated, they should not allow the patient to have anything by mouth, or NPO, until further evaluation.  

Steps depend on the healthcare facility’s protocol. However, this usually entails the nurse notifying the healthcare provider and placing a referral to speech therapy for a swallow evaluation. Patients with medical conditions that can lead to difficulty swallowing, like stroke, typically have a speech therapy order placed by the healthcare provider upon admission (4).   

After the initial evaluation by the speech therapist, they make dietary recommendations for the patient. Patients may be placed on thickened liquids, pureed and soft foods, or other specific foods. Nurses may need to crush oral medications and place them in the patient’s food for ease of swallowing.  

The speech therapist may also recommend feeding assistance or place a referral to nutrition. Sometimes nutritional supplements are ordered with meals, like protein shakes, to promote a balanced diet. The nurse will continuously work with the speech therapist in advances to diet, when able, and notify the speech therapist of any changes in the patient’s condition. 

How Speech Therapy Assesses for Aspiration 

There are different strategies that the speech therapist can use to assess aspiration. However, this sometimes depends on the healthcare facility’s policies and protocols. Typically, the speech therapist will perform a bedside swallowing screening, which involves a questionnaire and a water swallow test (5).  If a patient has been recently extubated, the Gugging Swallowing Screen (GUSS)-ICU is another valuable tool (21).   

If the speech therapist suspects the patient is aspirating, the patient is placed on NPO until further diagnostic testing is completed. Some additional tests may include a barium swallow x-ray, endoscopy, or fiber-optic endoscopic evaluation of swallowing (FEES) (21).  

Aspiration Prevention Strategies 

There are many strategies that nurses and patients can take to prevent aspiration pneumonia. If the patient is hospitalized or living in a nursing home, the nurse and healthcare staff should take certain precautions to prevent aspiration. Some of these include promoting a quiet environment that is free from distractions and has adequate lighting.  

Feeding assistance should be offered, especially for patients with dementia and dysphagia. Patients should be positioned properly, seated in an upright position, and instructed on correct maneuvers for swallowing. Using the chin-tuck maneuver, which involves tucking the chin towards the chest, when swallowing can prevent food from entering the airway when swallowing (4).  

Patients who are receiving tube feedings via a nasogastric tube should always have the head of the bed elevated. If they are being turned or the head of the bed lowered, the nurse should pause the tube feedings. Another strategy is serving food at either hot or cold temperatures, instead of a normal temperature since it stimulates the swallow reflex more readily. Liquids should be thickened whenever recommended as well.  

Oral care is another pneumonia prevention strategy since it keeps oral bacteria levels low (6). Providing routine oral care for patients on a ventilator has been shown to reduce the rate of ventilator-acquired pneumonia (7).  

If the patient has any difficulty swallowing, the speech therapist should be consulted, and the patient should start early dysphagia rehabilitation. Early dysphagia rehabilitation has been associated with shorter hospital stays and improved patient outcomes for patients with potential aspiration pneumonia (11).  

Case Study  

A 67-year-old patient in the intensive care unit was receiving respiratory support via a ventilator. About 30 minutes ago, the patient was extubated.  

• What nursing interventions should the nurse immediately implement to prevent aspiration pneumonia? 

Conclusion

If pneumonia is left untreated, it can lead to additional health complications, including death. Nurses and healthcare providers need to recognize the signs and symptoms of pneumonia and understand the available treatments.  

If a nurse suspects or witnesses a patient with difficulty swallowing, they should alert the healthcare provider immediately and recommend a speech therapy consult. In addition, nurses should provide patients and family members with education on pneumonia prevention techniques whenever possible. 

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