Chapter 62 Pneumonia
PATHOPHYSIOLOGY
Pneumonia is an inflammation or infection of the pulmonary parenchyma. Pneumonia is attributable to one or more agents: viruses, bacteria (e.g., Mycoplasma pneumoniae, Streptococcus pneumoniae, Staphylococcus aureus), fungi, parasites, or aspirated foreign substances. The pattern of the illness depends on the following: (1) causative agent, (2) age of the child, (3) child’s reaction, (4) extent of lesions, and (5) degree of bronchial obstruction. The clinical features of viral, mycoplasmal, and other bacterial pneumonias are listed in Box 62-1.
Box 62-1 Clinical Features of Bacterial, Viral, and Mycoplasmal Pneumonia
Bacterial Pneumonia
Chlamydia trachomatis, Chlamydia pneumoniae, staphylococcal, streptococcal (90% of bacterial cases), and pneumococcal pneumonia occur most frequently.
Progresses to Abrupt Onset
Productive cough, diminished breath sounds, rales on auscultation
Rapid and shallow respirations (50 to 80 breaths/min), dyspnea
Nasal flaring, retractions, expiratory grunt
Increased white blood cell count, predominantly PMNs
Younger than 2 years of age—vomiting and mild diarrhea
Older than 5 years of age—headache and chills, often complaint of chest and abdominal pain
Viral Pneumonia
Causative viruses include RSV (usually in infants 2 to 5 months old), influenza virus, parainfluenza virus, adenovirus, and enterovirus.
Progresses to Insidious or Abrupt Onset
Range of symptoms—mild fever, slight cough, and malaise to high fever, severe cough, cyanosis and respiratory fatigue
Tachypnea, although infants with RSV infection may have apnea; retractions, nasal flaring
Scattered rales, rhonchi, wheezing
Normal or slight elevation in white blood cell count, with lymphs predominant
Chest radiographic finding of diffuse or focal lobar infiltrates; hyperinflation due to air trapping is common
PMNs, polymorphonuclear cells; RSV, respiratory syncytial virus.
INCIDENCE
1. Pneumonia accounts for 10% to 15% of all respiratory infections, especially during the fall and winter months. The incidence in children younger than 5 years of age is 34 to 40 in 1000; in children 9 to 15 years of age, the incidence drops to 9 in 1000.
2. Viral pneumonia occurs more frequently than bacterial pneumonia, representing about 70% to 80% of all cases. Respiratory syncytial virus (RSV) accounts for 50% of all pneumonia cases.
3. Pneumonia is more severe and more common in infancy and early childhood.
4. Of children with bacterial pneumonia, 25% to 75% have a concurrent viral infection.
CLINICAL MANIFESTATIONS
Major clinical signs include the following (see Box 62-1 for specific clinical manifestations):
4. Decreased or absent breath sounds
5. Retractions of chest wall: intercostal, substernal, diaphragmatic, or supraclavicular
7. Paroxysmal cough simulating pertussis (common in smaller children)
8. Abdominal pain (caused by irritation of diaphragm by adjacent infected lung)
COMPLICATIONS
Respiratory: chronic interstitial pneumonia, chronic segmental or lobar atelectasis, airway damage, pleural effusion, pulmonary calcification, pulmonary fibrosis, obliterative bronchitis and bronchiolitis, and persistent atelectasis
LABORATORY AND DIAGNOSTIC TESTS
Refer to Appendix D for normal values and ranges of laboratory and diagnostic tests.
1. Pulse oximetry—to assess oxygen saturation in children with respiratory distress, significant tachypnea or pallor
2. Mucus/sputum sample—to rapidly test for RSV, influenza, adenovirus, and so on
3. Chest radiographic studies—to assess for air trapping, infiltrates, consolidation
4. Complete blood count with differential—to detect presence of respiratory infection
5. Blood culture and Gram stain—to identify causative agents
6. Tuberculin skin test—to rule out tuberculosis if child does not respond to treatment; uses purified protein derivative; is nonreactive in 10% of children with pulmonary tuberculosis (false negative result)
7. Gram stain and culture of sputum, if available—to rule out tuberculosis; usually done for children older than 10 years of age; if tuberculosis is suspected, morning gastric aspirate collection may be ordered in children unable to produce sputum
8. Culture of pleural fluid—to obtain specimen of fluid from pleural space to identify causative agents such as bacteria and viruses
9. Bronchoscopy—to visualize and manipulate main branches of tracheobronchial tree; tissue obtained for diagnostic testing, therapeutically used to identify and remove foreign bodies
10. Lung biopsy—performed during thoracotomy; lung tissue is excised for diagnostic studies
MEDICAL MANAGEMENT
Medical treatment is primarily supportive and includes improving oxygenation with oxygen and respiratory treatments. Antibiotics are used to treat bacterial pneumonia based on culture and sensitivity testing. Hospitalization depends on the severity of the illness, the child’s age, the need for supplemental oxygen, the suspected organism, and the adequacy of the home environment. If pleural effusion occurs, thoracentesis or chest tube drainage may be warranted.
NURSING ASSESSMENT
1. See the Respiratory Assessment section in Appendix A.
3. Assess for signs of respiratory distress and response to oxygen therapy. Monitor oxygen saturation levels.
4. Assess for signs of dehydration.
5. Assess child’s response to medications.
6. Assess family’s ability to manage home treatment regimen.
NURSING INTERVENTIONS
1. Monitor airway and maintain patency.
2. Monitor for signs of respiratory distress and response to oxygen therapy.
3. Monitor for and maintain optimal hydration status.
4. Monitor child’s therapeutic response to and side effects from antibiotics.
5. Control fever with antipyretics.
6. Teach parents how to care for infant on IV and oxygen therapy.
Discharge Planning and Home Care
CLIENT OUTCOMES
1. Child’s respiratory rate, oxygen saturation, and arterial blood gas levels will be within age-acceptable parameters without use of supplemental oxygen.
2. Child will have adequate hydration.
3. Child’s temperature will remain within normal range.
4. Child will participate in self-care activities with minimal to no complaints of breathing difficulty.
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