case study on pneumonia for nurses

Learn about the nursing care management of patients with pneumonia .

Table of Contents

• What is Pneumonia? 

Community-Acquired Pneumonia

Hospital-Acquired Pneumonia

Pneumonia in the Immunocompromised Host

Aspiration pneumonia, pathophysiology, epidemiology.

• Clinical Manifestations 

Complications

Assessment and diagnostic findings, medical management, nursing assessment, nursing care planning & goals, nursing priorities, nursing interventions, discharge and home care guidelines, documentation guidelines, what is pneumonia.

Respiratory diseases are rampant today because it is easier spread in crowded areas. Pneumonia is one of the most common respiratory problems and it affects all stages of life.

• Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi , and viruses.
• Pneumonitis is a more general term that describes the inflammatory process in the lung tissue that may predispose and place the patient at risk for microbial invasion.

Classification

Pneumonia is classified into four: community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP), pneumonia in the immunocompromised host, and aspiration pneumonia .

• CAP occurs either in the community setting or within the first 48 hours after hospitalization .
• The causative agents for CAP that needs hospitalization include streptococcus   pneumoniae , H. influenza , Legionella , and Pseudomonas aeruginosa .
• Only in 50% of the cases does the specific etiologic agent become identified.
• Streptococcus pneumoniae is the most common cause of CAP in people younger than 60 years of age.
• Viruses are the most common cause of pneumonia in infants and children.
• HAP is also called nosocomial pneumonia and is defined as the onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission.
• HAP is the most lethal nosocomial infection and the leading cause of death in patients with such infections.
• Common microorganisms that are responsible for HAP include Enterobacter species , Escherichia coli , influenza , Klebsiella species , Proteus , Serratia marcescens , S. aureus , and S. pneumonia .
• The usual presentation of HAP is a new pulmonary infiltrate on chest x-ray combined with evidence of infection.
• Pneumonia in immunocompromised hosts includes Pneumocystis pneumonia, fungal pneumonias and Mycobacterium tuberculosis .
• Patients who are immunocompromised commonly develop pneumonia from organisms of low virulence .
• Pneumonia in immunocompromised hosts may be caused by the organisms also observe in HAP and CAP.
• Aspiration pneumonia refers to the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway.
• The most common form of aspiration pneumonia is a bacterial infection from aspiration of bacteria that normally reside in the upper airways.
• Aspiration pneumonia may occur in the community or hospital setting.
• Common pathogens are S. pneumonia , H.influenza , and S. aureus .

Having an idea about the disease process helps the patient understand the treatment regimen and its importance, increasing patient compliance .

• Pneumonia arises from normal flora present in patients whose resistance has been altered or from aspiration of flora present in the oropharynx.
• An inflammatory reaction may occur in the alveoli, producing exudates that interfere with the diffusion of oxygen and carbon dioxide.
• White blood cells also migrate into the alveoli and fill the normally air-filled spaces .
• Due to secretions and mucosal edema , there are areas of the lung that are not adequately ventilated and cause partial occlusion of the alveoli or bronchi .
• Hypoventilation may follow, causing ventilation -perfusion mismatch.
• Venous blood entering the pulmonary circulation passes through the under ventilated areas and travels to the left side of the heart deoxygenated.
• The mixing of oxygenated and poorly oxygenated blood can result to arterial hypoxemia .

Pneumonia has affected a lot of people, especially those who have a weak immune system. Learning statistics on pneumonia could give you an idea about how many has fallen victim to this respiratory disease.

• Pneumonia and influenza account for nearly 60,000 deaths annually .
• Pneumonia also ranks as the eighth leading cause of death in the United States.
• It is estimated that more than 915, 000 episodes of CAP occur in adults 65 years old and above in the United States.
• HAP accounts for 15% of hospital-acquired infections and is the leading cause of death in patients with such infections.
• The estimated incidence of HAP 4 to 7 episodes per 1000 hospitalizations.

Each type of pneumonia is caused by different and several factors.

• Streptococcus pneumoniae . This is the leading cause of CAP in people younger than 60 years of age without comorbidity and in those 60 years and older with comorbidity.
• H aemophilus influenzae.   This causes a type of CAP that frequently affects elderly people and those with comorbid illnesses.
• Mycoplasma pneumoniae. 
• Staphylococcus aureus . Staphylococcus pneumonia occurs through inhalation of the organism.
• Impaired host defenses. When the defenses of the body are down, several pathogens may invade the body.
• Comorbid conditions. There are several conditions that lower the immune system, causing bacteria to pool in the lungs and eventually result in pneumonia.
• Supine positioning . When the patient stays in a prolonged supine position, fluid in the lungs pools down and stays stagnant, making it a breeding place for bacteria.
• Prolonged hospitalization. The risk for hospital infections or nosocomial infections increases the longer the patient stays in the hospital.

Clinical Manifestations

Pneumonia varies in its signs and symptoms depending on its type but it is not impossible to diagnose a specific pneumonia through its clinical manifestations.

• Rapidly rising fever . Since there is inflammation of the lung parenchyma, fever develops as part of the signs of an infection.
• Pleuritic chest pain . Deep breathing and coughing aggravate the pain in the chest.
• Rapid and bounding pulse. A rapid heartbeat occurs because the body compensates for the low concentration of oxygen in the body.
• Tachypnea. There is fast breathing because the body tries to compensate for the low oxygen concentration in the body.
• Purulent sputum. The sputum becomes purulent because of the infection in the lung parenchyma which produced sputum-filled with pus.

It is better to prevent the occurrence of pneumonia instead of treating the disease itself. Here are several ways that can help prevent pneumonia.

• Pneumococcal vaccine. This vaccine can prevent pneumonia in healthy patients with an efficiency of 65% to 85%.
• Staff education. To help prevent HAP, the CDC (2004) encouraged staff education and involvement in infection prevention .
• Infection and microbiologic surveillance. It is important to carefully observe the infection so that there could be an appropriate application of prevention techniques.
• Modifying host risk for infection . The infection should never be allowed to descend on any host, so the risk must be decreased before it can affect one.

Pneumonia has several complications if left untreated or the interventions are inappropriate. These are the following complications that may develop in patients with pneumonia.

• Shock and respiratory failure. These complications are encountered chiefly in patients who have received no specific treatment and inadequate or delayed treatment.
• Pleural effusion . In pleural effusion , the fluid is sent to the laboratory for analysis, and there are three stages: uncomplicated, complicated, and thoracic empyema.

Assessment and diagnosis of pneumonia must be accurate since there are a lot of respiratory problems that have similar manifestations. The following are assessments and diagnostic tests that could determine pneumonia.

• History taking . The diagnosis of pneumonia is made through history taking, particularly a recent respiratory tract infection.
• Physical examination. Mainly, the number of breaths per minute and breath sounds is assessed during physical examination.
• Chest x-ray.  Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple abscesses/infiltrates, empyema (staphylococcus); scattered or localized infiltration (bacterial); or diffuse/extensive nodular infiltrates (more often viral). In mycoplasmal pneumonia, chest x-ray may be clear.
• Fiberoptic bronchoscopy .  May be both diagnostic (qualitative cultures) and therapeutic (re-expansion of lung segment).
• ABGs / pulse oximetry .  Abnormalities may be present, depending on extent of lung involvement and underlying lung disease.
• Gram stain/cultures.  Sputum collection; needle aspiration of empyema, pleural, and transtracheal or transthoracic fluids; lung biopsies and blood cultures may be done to recover causative organism. More than one type of organism may be present; common bacteria include Diplococcus pneumoniae, Staphylococcus aureus, a-hemolytic streptococcus, Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures may not identify all offending organisms. Blood cultures may show transient bacteremia.
• CBC.  Leukocytosis usually present, although a low white blood cell (WBC) count may be present in viral infection, immunosuppressed conditions such as AIDS , and overwhelming bacterial pneumonia. Erythrocyte sedimentation rate (ESR) is elevated.
• Serologic studies, e.g., viral or Legionella titers, cold agglutinins.  Assist in differential diagnosis of specific organism.
• Pulmonary function studies.  Volumes may be decreased ( congestion and alveolar collapse); airway pressure may be increased and compliance decreased. Shunting is present ( hypoxemia ).
• Electrolytes .   Sodium and chloride levels may be low.
• Bilirubin.  May be increased.
• Percutaneous aspiration /open biopsy of lung tissues.  May reveal typical intranuclear and cytoplasmic inclusions (CMV), characteristic giant cells ( rubeola ).

The management of pneumonia centers is a step-by-step process that zeroes on the treatment of the infection through identification of the causative agent.

• Blood culture . Blood culture is performed for identification of the causal pathogen and prompt administration of antibiotics in patients in whom CAP is strongly suspected.
• Administration of macrolides . Macrolides are recommended for people with drug-resistant S. pneumoniae .
• Hydration is an important part of the regimen because fever and tachypnea may result in insensible fluid losses.
• Administration of antipyretics . Antipyretics are used to treat fever and headache.
• Administration of antitussives . Antitussives are used for treatment of the associated cough .
• Bed rest. Complete rest is prescribed until signs of infection are diminished.
• Oxygen administration. Oxygen can be given if hypoxemia develops.
• Pulse oximetry. Pulse oximetry is used to determine the need for oxygen and to evaluate the effectiveness of the therapy.
• Aggressive respiratory measures. Other measures include administration of high concentrations of oxygen, endotracheal intubation, and mechanical ventilation .

Nursing Management

Nurses are expected to perform both dependent and independent functions for the patient to aid him or her towards the restoration of their well-being.

SEE ALSO: 11 Pneumonia Nursing Care Plans for a comprehensive nursing care plan and management guide

Nursing assessment is critical in detecting pneumonia. Here are some tips for your nursing assessment for pneumonia.

• Assess respiratory symptoms. Symptoms of fever, chills, or night sweats in a patient should be reported immediately to the nurse as these can be signs of bacterial pneumonia.
• Assess clinical manifestations. Respiratory assessment should further identify clinical manifestations such as pleuritic pain , bradycardia, tachypnea , and fatigue , use of accessory muscles for breathing, coughing, and purulent sputum.
• Physical assessment. Assess the changes in temperature and pulse; amount, odor, and color of secretions; frequency and severity of cough ; degree of tachypnea or shortness of breath ; and changes in the chest x-ray findings.
• Assessment in elderly patients. Assess elderly patients for altered mental status , dehydration , unusual behavior, excessive fatigue , and concomitant heart failure .

Through the data collected during assessment, the following nursing diagnoses are made:

• Ineffective airway clearance related to copious tracheobronchial secretions.
• Activity intolerance related to impaired respiratory function.
• Risk for deficient fluid volume related to fever and a rapid respiratory rate.

Planning is essential to establish the interventions that are appropriate for the patient’s condition.

• Improve airway patency .
• Rest to conserve energy.
• Maintenance of proper fluid volume.
• Maintenance of adequate nutrition .
• Understanding of treatment protocol and preventive measures.
• Absence of complications.
• Maintain/improve respiratory function.
• Prevent complications.
• Support recuperative process.
• Provide information about disease process, prognosis, and treatment.

These nursing interventions , if implemented appropriately, would result in the achievement of the goals of the management of pneumonia.

To improve airway patency:

• Removal of secretions. Secretions should be removed because retained secretions interfere with gas exchange and may slow recovery.
• Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions.
• Humidification may loosen secretions and improve ventilation.
• Coughing exercises. An effective, directed cough can also improve airway patency.
• Chest physiotherapy. Chest physiotherapy is important because it loosens and mobilizes secretions.

To promote rest and conserve energy:

• Encourage avoidance of overexertion and possible exacerbation of symptoms.
• Semi-Fowler’s position. The patient should assume a comfortable position to promote rest and breathing and should change positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion.

To promote fluid intake:

• Fluid intake. Increase in fluid intake to at least 2L per day to replace insensible fluid losses.

To maintain nutrition:

• Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
• Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also help restore proper nutrition.

To promote patient’s knowledge:

• Instruct patient and family about the cause of pneumonia, management of symptoms, signs, and symptoms, and the need for follow-up.
• Instruct patient about the factors that may have contributed to the development of the disease.

Expected patient outcomes include the following:

• Demonstrates improved airway patency.
• Rests and conserves energy by limiting activities and remaining in bed while symptomatic and then slowly increasing activities.
• Maintains adequate hydration.
• Consumes adequate dietary intake.
• States explanation for management strategies.
• Complies with management strategies.
• Exhibits no complications.
• Complies with treatment protocol and prevention strategies.

Patient education is crucial regardless of the setting because self-care is essential in achieving a patient’s well-being.

• Oral antibiotics. Teach the patient about the proper administration, potential side effects, and symptoms to report.
• Breathing exercises. Teach the patient breathing exercises to promote secretion clearance and volume expansion.
• Follow-up check up. Strict compliance to follow-up checkups is important to check the latest chest x-ray result or physical examination findings.
• Smoking cessation. Smoking should be stopped because it inhibits tracheobronchial ciliary action and irritates the mucous cells of the bronchi.  

Documentation of data must be accurate and up-to-date to avoid unnecessary legal situations that might occur.

• Document breath sounds, presence and character of secretions, use of accessory muscles for breathing.
• Document character of cough and sputum.
• Document respiratory rate, pulse oximetry/O2 saturation, and vital signs.
• Document plan of care and who is involved in planning .
• Document client’s response to interventions, teaching, and actions performed.
• Document if there is use of respiratory devices or airway adjuncts.
• Document response to medications administered.
• Document modifications to plan of care.

See also: Respiratory System NCLEX Practice Questions and Reviewer (220 Questions)

11 thoughts on “Pneumonia”

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Thanks very much for Nurseslabs

You’re very welcome for the Nurseslabs resources! I’m thrilled to hear that you found the information on pneumonia helpful. Can you share any personal tips or experiences in managing pneumonia cases that have helped you in your nursing studies or clinical practice? Sharing practical insights can be incredibly beneficial for fellow students and aspiring nurses. 🩺💬📚

This is very helpful.Thank you so much.

You wrote : Pneumonia is the most common cause of CAP Did you mean the other way around? thanks

Hi, thanks, this has been updated.

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Nursing Management of Pneumonia and Disease Process

Nurses play a pivotal role in improving patient outcomes. Nursing management of the pneumonia patient is critical to patient recovery. A thorough nursing assessment is necessary to establish nursing diagnoses, plan nursing care, set realistic goals, implement nursing interventions and to enable the evaluation process. This article discusses the nursing management of pneumonia and the associated disease process.

Pneumonia is defined as inflammation in one or both lungs, with the presence of consolidation and exudation. Inhaling infected droplets in the air from a cough or sneeze of an infected person is the mechanism in which pneumonia is commonly spread.

Incidence and classification

Pneumonia is characterized as a type of lung infection, most commonly caused by bacteria or a virus. Fungi and parasites can also a cause of pneumonia, however, these causes are less common. The differentiation between pneumonia and bronchitis is that bronchitis is a lower respiratory tract infection that does not affect the functional tissue of lungs also referred to as lung parenchyma.

Different types of pneumonia are classified into various groups. Pneumonia is classified based on the type of organisms responsible for the infection and the location where or the way in which the infection was acquired. For example, community-acquired pneumonia, hospital-acquired pneumonia, and ventilator-associated pneumonia also known as aspiration pneumonia.

Community-Acquired Pneumonia (CAP)

An acute infection of the lower respiratory tract, mostly caused by bacteria and occurring in a patient who has not resided in a hospital or healthcare facility in the previous 14 days (Johnson, Irving & Turnidge 2020). CAP is more likely to be caused by bacteria, however a number of viruses have been associated with community-acquired pneumonia.

Hospital-Acquired Pneumonia (HAP)

An acute lower respiratory tract infection that is acquired at least 48 hours after admission to the hospital and is not incubating at the time of admission (Forest 2020). Also referred to as nosocomial pneumonia.

Ventilator-Associated Pneumonia (VAP)

A form of HAP that develops in intensive care patients, occurring more than 48 hours after endotracheal intubation (Forest 2020).

Pneumonia can be contracted by people of any age or health status; however, pneumonia is more common in:

• the older population (particularly people over 65 years of age)
• cohorts with compromised immune systems such as cancer patients, those diagnosed with HIV, organ transplant patients and those who have damaged spleens or have had their spleen removed
• people with chronic conditions such as respiratory disorders, cardiac disease and diabetes
• indigenous populations particularly those over the age of 50 years and under the age of two years as well as indigenous people living in remote communities
• young children
• the homeless

Treatment for pneumonia is dependent on the individual, the classification and the organism responsible. However,  general pneumonia treatment includes:

• Increased fluid intake
• Simple pain relief to reduce fever and relieve pain
• Pathogen directed pharmacologic therapy
• Chest physiotherapy and coughing exercises

Most pneumonia cases can also be treated in the community, providing the patient access to good medical and nursing care. However, in serious cases of pneumonia, hospital admission may be required. International data suggests that approximately 30% of patients with pneumonia require hospitalization (Chung & Morgan 2015), with the instance of hospitalization increasing with age. A variety of admission criteria and assessment tools exist for patients presenting with pneumonia.

Each lung is made up of thousands of bronchi and alveoli. The bronchi are tiny tubes and alveoli are the small sacs at the end of the bronchi tube. The bronchi and alveoli are filled with capillaries that assist in adding oxygen to and removing carbon dioxide from the blood. This is known as gas exchange.

In the case of a patient with bacterial pneumonia, the alveoli in the affected lung or lungs become solid as they fill with exudate such as fluid or pus. The presence of exudate results in a less functional area for oxygen-carbon dioxide exchange, interfering with gas exchange and resulting in consolidation in the lung. The affected lung or lungs may also collapse.

Viral pneumonia does not result in consolidation. Viral pneumonia primarily infects the walls of the alveoli and the parenchyma of the lung.

Epidemiology of pneumonia

Pneumonia is responsible for substantial morbidity and mortality rates around the world. According to the World Health Organization (2019) pneumonia accounts for 15% of all deaths worldwide in children under the age of five years. 450 million cases of pneumonia are recorded every year; about 4 million people die from this illness (WHO 2004).

A study conducted in 2013 of 188 countries around the world, reported that lower respiratory tract infection was the second most common cause of death, with the incidence of pneumonia increasing with patient age.

In the United States pneumonia is the eighth most common cause of death (CDC 2018). However, when combined with influenza, pneumonia is the leading cause of death by infectious disease in the United States (Jones et al. 2014).

Pneumonia is caused by organisms, including microorganisms such as:

Signs and Symptoms 

The onset of pneumonia may be sudden or gradual. Symptoms of pneumonia vary and often individuals will present in different ways. Symptoms commonly associated with pneumonia include:

• flu-like illness
• difficulty breathing
• coughing (including a dry or mucus-producing cough)
• rapid breathing
• increased heart rate
• generally feeling unwell
• loss of appetite
• sweating and shivering
• crackling sounds in the chest (heard with a stethoscope)

Less common symptoms associated with pneumonia include:

• joint and muscle pain

In rare cases central cyanosis, caused by lack of oxygen may be present in the skin around the mouth.

Prevention is the key to protecting against infection.

• Good hygiene practices

Good hygiene practices, including following hand hygiene principles such as regular hand washing and the use of alcohol-based hand sanitizer, will help protect against respiratory infections that may lead to pneumonia.

• Smoking cessation

Smoking causes lung damage and results in the lungs being more suspectable to infection. Smoke cessation will help to prevent respiratory infections such as pneumonia.

• Healthy lifestyle

Keeping the immune system strong by staying healthy through adequate sleep, a healthy diet and regular exercise.

• Limit alcohol use

Alcohol misuse weakens the lungs’ natural defenses against infections (NHS 2019) making the patient more vulnerable to pneumonia.

• Immunization

Bacterial pneumonia

Bacterial pneumonia is commonly caused by the Streptococcus pneumoniae (pneumococcus) bacteria. The best protection against bacterial pneumonia is with immunization. The Pneumococcal vaccine helps to reduce the risk of bacterial pneumonia.

Viral pneumonia

Pneumonia is a common complication of influenza. As such, annual vaccination against influenza should be encouraged.

Medical Management 

Pharmacologic therapy .

Pharmacologic therapy for pneumonia differs depending on the causative agent, the type of infection as well as the age of the patient. Once appropriate pharmacologic treatment is commenced patients will generally recover in around seven to 10 days.

The choice of oral pharmacologic therapy or the use of intravenous therapy is dependent on several factors. More severe cases of pneumonia, where hospitalization occurs are likely to require intravenous (IV) antibiotic therapy. Switching from one therapy to another will be determined by the progress of the patient. For example, the hospitalized patient may commence on IV antibiotic therapy, but when discharged from the healthcare setting may commence oral antibiotics

Antibiotics also referred to as antibacterials, are the mainstay treatment for bacterial pneumonia. Antibiotics fight against the bacteria by:

• destroying the bacteria or
• inhibiting the growth of the bacteria

Destroying or inhibiting bacteria growth helps the body’s natural immune system to fight the bacterial infection. Different antibiotics work against different types of bacteria (NPS MedicineWise 2019).

Bacterial pneumonia 

Bacterial pneumonia is the most common type of pneumonia. Oral antibiotics are most commonly used to treat bacterial pneumonia.

In the absence of the causative bacteria being identified, empirical antibiotics or antibiotics are chosen to treat the likely pathogen causing bacterial pneumonia are often used. Within three to five days of commencing antibiotic treatment for bacterial pneumonia symptoms should start to improve.

If symptoms do not improve it is possible that the antibiotic treatment selected is not the right treatment for the pathogen causing bacterial pneumonia. Alternative antibiotic treatment that is pathogen directed will, therefore, be required.

The following are examples of antibiotics that may be used to treat bacterial pneumonia:

• Narrow-spectrum antibiotics such as glycopeptides

Narrow-spectrum antibiotics are effective in targeting specific types of bacteria. Vancomycin and flucloxacillin are both narrow-spectrum antibiotics used to treat bacterial pneumonia caused by methicillin-resistant Staphylococcus aureus (MRSA).

• Broad-spectrum antibiotics such as macrolides and penicillins 

Broad-spectrum antibiotics are effective in treating bacterial pneumonia caused by common causative bacteria. Azithromycin and Ceftriaxone are broad-spectrum antibiotics commonly prescribed to treat bacterial pneumonia.

Antibiotics do not treat viral pneumonia. Following diagnostic testing, if it is confirmed that the cause of the pneumonia is a viral infection, then antiviral therapy will be prescribed to treat viral pneumonia. Viral pneumonia is caused by viruses such as influenza A and B. The following antivirals are examples of those used to treat viral pneumonia:

• Oseltamivir used to treat the Influenza A virus
• Rimantadine used to treat various influenza viruses

Fungal pneumonia 

Fungi is the least common cause of pneumonia, however, Mattila et al. (2014) indicate that there is an increasing incidence of fungal pneumonia. Fungal pneumonia may be caused by a variety of different fungi including Histoplasma capsulatum and mucormycosis .

Antifungals are used to treat fungal pneumonia. Antifungals work by stopping the growth of fungi. The following are examples of antifungal treatments used to treat fungal pneumonia:

• Voriconazole
• Fluconazole
• Itraconazole

Supportive oxygen therapy will be required if the patient has oxygen saturations under 92%. The target saturation range for patients with acute medical conditions, pneumonia, asthma, and acute coronary syndrome is 92–96% (Pilcher & Beasley 2015). To assist the patient with expectoration, humidified oxygen therapy may be beneficial.

Assessment and Diagnosis

To determine a pneumonia diagnosis, the clinician must ascertain the absence or presence of pneumonia symptoms and obtain a detailed clinical history from the patient.

Physical assessment 

Physical assessment is key in the assessment of patients with respiratory complaints, such as pneumonia.  The components of a physical assessment should include:

• Chest inspection

The act of observing for visible external signs of respiratory function, reviewing chest symmetry and appearance and inspecting for accessory muscle usage

Palpation is the act of examination by touch.

The technique of tapping the surface of a body part to learn the condition of the parts beneath by the resultant sound

• Auscultation

Auscultation is the act of listening to sounds arising within organs, such as the lungs

Findings during physical examination of the pneumonia patient may include:

• Tachypnoea (abnormally rapid breathing)
• Tachycardia (rapid heart rate that may also be irregular)
• Decreased or bronchial breath sounds (tubular, hollow sounds which are heard when auscultating over the large airways)
• Egophony (increased resonance of voice sounds heard when auscultating the lungs) and tactile fremitus (assessment of the intensity of vibration felt in the chest wall or heard through auscultation)
• Crackles heard in affected regions of the lung
• Dullness on percussion

Diagnostic testing 

A variety of tests are available that assist in the diagnosis of pneumonia, including:

• Swabs from inside the nose or throat
• Bacterial sputum culture
• Oxygen saturation monitoring
• Chest x-rays
• Lung function tests
• Blood tests to identify inflammation markers
• Lung biopsy

Diagnosis is made based on the outcome of the physical assessment, patient history and the results of diagnostic testing.

Complications

Pneumonia complications commonly occur in young children, older people and those with pre-existing chronic health conditions, such as diabetes and cardiac conditions.

Complications of pneumonia include:

Pleurisy is a condition where the pleura (thin linings between the lungs and ribcage) becomes inflamed.

• Lung abscess 

Lung abscesses are rare any generally only occur in people with serious pre-existing illnesses and those who have a history of severe alcohol misuse

• Sepsis (also referred to as blood poisoning)

A rare but serious complication of pneumonia.

Admission to the hospital will be required if any of the above complications are present.

Nursing Management

Nursing management of patients with pneumonia is dependent on the needs of the individual, the symptoms and the targeted treatment required.

Nursing Assessment

Comprehensive nursing assessment is critical to the diagnosis of pneumonia and the ongoing management of the pneumonia patient.

The nursing assessment should include:

• Patient history
• General appearance
• Physical examination
• Focused assessments, including chest assessment and respiratory assessment
• Vital signs
• Assessment of clinical manifestations

Guidelines for your nursing assessment for pneumonia are as follows:

• Assessment of respiratory symptoms

Assess the airway for noises, secretions, cough and any artificial airways

Review breathing including, rhythm, work of breathing: – spontaneous/ labored/supported/ ventilator-dependent, oxygen requirement and delivery mode.

Assess bilateral air entry and movement, breath sounds and count the patients’ respiratory rate for one full minute and assess any respiratory distress.

Monitor oxygen saturation, noting oxygen requirement and delivery mode if required. Continue to monitor as clinically indicated.

Circulation

Check pulses (location, rate, rhythm and strength); temperature (peripheral and central), skin color and moisture, skin turgor, capillary refill time (central and Peripheral); skin, lip, oral mucosa and nail bed color.

Nursing Diagnosis

The clinical judgments made by the nurse based on the patient’s health conditions and needs form the nursing diagnosis. Nursing diagnoses reflect the potential causes and contributing factors of the health condition. The nursing care plan is based on the nursing diagnosis.

Based on the information gained through the nursing assessment the nursing diagnoses related to the patient with pneumonia include:

• Ineffective Airway Clearance
• Inability to clear the airway of secretions and obstructions due to
• Ineffective Breathing Pattern
• Activity Intolerance
• Deficit Fluid Intake
• Noncompliance

Nursing Care Planning & Goals

Nurses set to achieve goals in conjunction with the patient. These goals are based on the outcome of assessments and the diagnoses.

Examples of goals for the pneumonia patient are:

• Drink at least 2 liters of water daily

Maintaining adequate hydration is essential. Increased fluid intake assists with the expectoration of secretions.

• Conduct respiratory exercises (breathing, coughing and expulsion exercises) as directed

These exercises are crucial for clearing excess secretion, they improve lung function and help to strengthen the diaphragm and the accessory muscles around the lungs.

• Ensuring adequate nutrition

A balanced diet, including adequate servings of fruit and vegetables, promotes recovery from illness.

• Attend chest physical therapy

Chest physical therapy benefits mucus transport and assists in the expectoration of secretions.

• Adhere to medication regimen

Adherence with the prescribed medication regimen is key to recovery and preventing resurgence of pneumonia.

Nursing Interventions for Pneumonia

• Explain the pathophysiology of pneumonia appropriate to the patient’s level of health literacy and understanding. The use of teaching aids such as illustrations and models may be required
• Explain good hygiene practices to prevent the spread of infection, for example, hand hygiene practices and cough etiquette
• Provide education on the prevention of reoccurrence, including completing the full course of prescribed pharmacologic therapy, keeping follow up medical appointments and recommended immunizations
• Encourage rest to aid with recovery
• Promote adequate fluid intake
• Promote a healthy diet
• Encourage coughing exercises and chest physio
• Encourage simple pain relief to reduce fever and relieve pain, where clinically indicated

Nursing Evaluation

Nursing evaluation is the process whereby the success of the goals and outcomes are reviewed, and factors identified which are positively or negatively influencing the goal achievement. Using critical thinking and problem-solving skills the nurse makes clinical decisions and plans care for the patient accordingly. The nursing care plan should be modified as required.

The nurse must ensure the following:

• that abnormal findings are identified, and appropriate action is taken
• that the airway patency is maintained
• secretions are cleared and explored where necessary
• continuous assessment of the client occurs to identify any changes in condition
• assessment details and clinical notes are documented accordingly

Discharge and Home Care Guidelines 

Discharge planning should commence on admission. It is important that the multidisciplinary team are involved in the discharge planning process to ensure that all discharge needs and priorities are identified.

The following aspects are key to the discharge process and home care guidelines:

• Patient education

Providing patients with education is integral to the discharge process. Patient education is essential to ensuring satisfactory health outcomes.

• Pharmacologic Therapy

It is essential that the patient is aware of their medication regimen and understands the importance of medication compliance, administration processes and potential side effects

Referrals to appropriate health professionals and other relevant organizations should be made and communicated to the patient

• Follow-up appointments

It is imperative that the patient is aware of any follow-up appointments and that the patient is encouraged to maintain any follow-up appointments in order to gain the best health outcomes

In order to improve the capacity of the lungs and promote clearance of secretions breathing exercises should be provided for the patient. An exercise regimen may also need to be provided. This should be developed in conjunct with the multidisciplinary team

• Health promotion and harm reduction activities

If applicable the patient should be encouraged to cease smoking as a continuation of smoking with inhibiting recovery from pneumonia as smoking impacts the capacity of the lungs to take up oxygen and damages the cilia. Limiting alcohol consumption should also be encouraged

Nursing Documentation  

The nurse should ensure that all the necessary information has been collected, is complete, and has been documented appropriately. Healthcare documentation must provide an accurate description of each patient’s care and contact with health staff, including nurses.

Nursing documentation should include:

• Vital signs 

Heart rate, respiratory rate, oxygen saturation rate and temperate should also be accurately documented in the health record

With pneumonia patients, it is important that the details of breath sounds including the presence and characteristics of secretions and accessory muscles usage are recorded

• Characteristics of sputum

The color and consistency of sputum should be recorded and monitored on an ongoing basis

A plan for each patient’s care should be documented. The care plan must outline the details of the multidisciplinary team and their involvement in care. The care plan should be updated as required

• Use of devices, aids and equipment

The use of any airway or respiratory devices should be recorded as should any aids or equipment

• Medication administration

Administration of medications should be clearly documented including the patient’s response to medication and any adverse reactions

• Bailliere’s Nurses’ Dictionary (25th ed.) 2009. Elsevier Limited.
• Centre for Disease Control (CDC). Leading causes of death and numbers of deaths, by sex, race, and Hispanic origin: United States, 1980 and 2017 .2018< https://www.cdc.gov/nchs/data/hus/2018/006.pdf
• Chung Y, Morgan L. Pneumonia Who is at risk in your practice? Medicine Today. 2015; 16(8): 35-42< https://medicinetoday.com.au/sites/default/files/cpd/MT2015-08-035-CHUNG.pdf >
• Johnson PDR, Irving LB, Turnidge JD. Community-acquired pneumonia . Med J Aust 2002; 176 (7): 341-347.
• Forest WA. Hospital-acquired pneumonia. British Medical Journal (BMJ) Best Practice. 2020< https://bestpractice.bmj.com/topics/en-us/720 >
• Mattila JT, Fine MJ, Limper AH, Murray PR, Chen BB, Lin PL. Pneumonia: Treatment and diagnosis. Ann Am Thor Soc. 2014;11 Suppl 4: S189–92.
• NPS MedicineWise. Antibiotics, explained. 2019. < https://www.nps.org.au/consumers/antibiotics-explained#how-do-antibiotics-work ?>
• Pilcher J, Beasley R. Acute use of oxygen therapy. Aust Prescr. 2015; 38:98-100. < https://www.nps.org.au/australian-prescriber/articles/acute-use-of-oxygen-therapy#article >
• The National Health Service (NHS). Overview: Pneumonia. 2019. < https://www.nhs.uk/conditions/pneumonia/ >
• World Health Organization (WHO). Revised global burden of disease 2002 estimates . 2004. < http://www.who.int/healthinfo/global_burden_disease/estimates_regional_2002_revised/en/ >
• World Health Organization (WHO). Pneumonia . 2019. < https://www.who.int/health-topics/pneumonia/#tab=tab_1 >

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Pneumonia: Nursing Diagnoses, Care Plans, Assessment & Interventions

Pneumonia is an infection of the lungs caused by a bacteria, virus, or fungus . In healthy individuals, pneumonia is not usually life-threatening and does not require hospitalization. Those at higher risk, such as the very young or old, patients with compromised immune systems, or who already have a respiratory comorbidity, may require inpatient care and treatment.

Hospital-acquired pneumonia (HAP) , which presents after the patient has been admitted for 48 hours, is often attributed to antibiotic resistance. Healthcare-associated pneumonia (HCAP) develops in patients in other healthcare settings, such as nursing homes. Patients admitted to intensive care units receiving ventilator support are at risk for ventilator-associated pneumonia (VAP) . These critically ill patients have a high mortality rate of 25-50%.

Community-acquired pneumonia (CAP) occurs outside of the hospital or facility setting. Droplets often spread the bacteria or virus through coughing or sneezing, which the person then inhales. Touching an infected object and touching your nose or mouth can also transfer the germs.

In this article:

• Nursing Process
• Review of Health History
• Physical Assessment
• Diagnostic Procedures
• Nursing Interventions
• Impaired Gas Exchange
• Impaired Spontaneous Ventilation
• Ineffective Airway Clearance
• Ineffective Breathing Pattern
• Risk For Infection

Pneumonia is one of the most frequent infections the nurse will encounter and treat. The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment.

Nurses also play a role in preventing pneumonia through education. Patients with compromised immune systems, such as those with COPD , HIV , or autoimmune diseases, should be educated on their risks and how to protect themselves. Smoking further increases the risk of developing pneumonia and should be avoided. Nurses should assess for and encourage pneumonia vaccines for eligible populations.

Nursing Assessment

The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to pneumonia.

1. Assess the patient’s general symptoms. Symptoms may vary depending on the cause, patient’s age, and overall health. These include:

• Productive cough with yellowish to greenish sputum
• Excessive sweating
• Sharp chest pain during breathing or coughing
• Nausea and vomiting in children
• Confusion in older patients

2. Identify the patient’s risk. The following patient populations have a higher risk of contracting pneumonia:

• Adults over age 65
• Babies and children two years old or younger
• Those with a compromised immune system

3. Consider sources of possible exposure. Legionnaires’ disease is a type of pneumonia caused by contaminated water sources. Some fungi sources found in soil may also cause pneumonia. Assess potential causes by inquiring about:

• Recent travel
• Occupation or living situation (military barracks, prison systems, nursing homes)
• Environmental exposures (air pollution or fumes)
• Animal exposure (birds may carry and transmit bacteria to humans)

4. Determine the patient’s risk of aspiration. Patients at risk for aspiration have a higher rate of developing pneumonia. The risk of aspiration may be related to:

• Altered mental status
• Anatomic defect
• Difficulty swallowing (dysphagia)
• Gastroesophageal reflux disease (GERD)
• Seizure disorders

5. Review the medical history. Conduct a comprehensive review of the patient’s medical conditions that increase the risk for pneumonia, such as:

• Cystic fibrosis
• Heart failure
• Sickle cell disease
• Compromised immune system

6. Check the medication list. Bacteria resistant to antibiotics, such as methicillin-resistant Staphylococcus aureus (MRSA) , is a common cause of HAP and HCAP. 

7. Track the patient’s past surgeries. Postoperative pneumonia is the third most prevalent complication of all surgical procedures. Risk factors include older age, COPD, emergency surgery, prolonged ventilation, low albumin levels, and bed rest.

1. Monitor the vital signs. Note the following vital sign alterations, such as:

• Tachypnea (respiratory rate >20 breaths per minute)
• Tachycardia (pulse rate >100 beats per minute)
• Fever (100.4 F (38 C) or greater)

Note: Patients who are immunocompromised may not present with a fever.

2. Assess the respiratory status. Observe the following physical findings:

• Palpation: increased tactile fremitus
• Percussion: dullness 
• Auscultation: decreased breath sounds or rales, crackles, rhonchi, or wheezes

3. Note systemic signs and symptoms. Pneumonia may also cause:

• Anorexia (loss of appetite)
• Muscle pain (myalgia)
• Altered mentation
• Dehydration (diarrhea, vomiting, headache)

4. Observe the sputum characteristics. Purulent or (rarely) blood-tinged sputum is a sign of bacterial pneumonia. Watery or occasionally mucopurulent sputum is a characteristic of viral pneumonia.

5. Assess the gag reflex. Aspiration occurs when food, drink, vomit, or saliva enters the lungs. Elicit the glossopharyngeal nerve to test the gag reflex by gently touching the back of the tongue with a cotton swab or tongue blade. 

1. Obtain blood for testing. Blood tests assess severity, inflammation, and other complications. Blood testing may include:

• Complete blood count with differential
• Coagulation studies
• Serum electrolytes
• Renal panel
• Liver panel
• Serum lactate level
• C-reactive protein (CRP) level
• Procalcitonin

2. Assess blood and sputum cultures. Obtain blood (and sputum cultures when possible) before initiating antibiotic therapy.

3. Investigate the oxygenation of the blood. Blood gas analysis assesses the degree of respiratory compromise, gas exchange, and acid-base balance in the blood. 

4. Obtain lower respiratory secretions if needed. Ventilator-associated pneumonia (VAP) develops several days after admission. Taking airway samples for stains and cultures may help guide antibiotic therapy. Nowadays, fiberoptic bronchoscopy is used instead of transtracheal aspiration to acquire lower respiratory secretions.

5. Prepare the patient for imaging scans. Chest radiography (X-ray) is the standard approach to diagnose the presence of the following:

• Infiltrates
• Pleural effusion
• Parapneumonic pleural fluid

Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with pneumonia.

Manage the Infection

1. Identify the type of pneumonia. The first step in managing pneumonia is through identifying its type. CAP, VAP, and HAP have different treatment approaches depending on the severity and risk. Consider the following:

• Outpatient treatment
• Need for hospitalization
• Admission to ICU

2. Administer antibiotic therapy as ordered. The cornerstone of treatment for bacterial pneumonia is antibiotic therapy. Administer empiric treatment as recommended. Tailor antibiotic therapy if the pathogen is known. 

3. Provide oxygen as recommended. Supplemental oxygen may be necessary for patients who are hypoxic or experiencing dyspnea. 

4. Start fluid resuscitation. Volume depletion is common among patients with pneumonia. Patients who are hypotensive may need intravenous therapy. Take caution when administering IV fluids to patients with heart disease or kidney failure .

5. Administer medications as prescribed.

• Corticosteroids
• Pain and fever reducers (aspirin, NSAIDs, or acetaminophen)
• Cough suppressants and/or expectorants

6. Collaborate with respiratory therapy. Collaborate with the respiratory therapist in administering breathing treatments, chest physiotherapy, oxygen, or ventilatory support.

7. Mobilize secretions. Breathing exercises, movement, and devices aid in loosening and expelling secretions. The following strategies can help strengthen the lungs:

• Diaphragmatic breathing
• Deep breathing and coughing
• Use of spirometry or flutter valves
• Early ambulation

8. Encourage moisture and fluids. Encourage patients with pneumonia to increase fluid intake, especially warm liquids, and to use a humidifier or steamy shower/bath to open the airways and make breathing easier. 

Prevent Pneumonia

1. Avoid smoking. Smoking harms the lungs and increases the chance of lung infection. This also includes avoiding secondhand smoke. 

2. Encourage vaccination. Pneumonia vaccines are recommended for anyone over age 65 or those younger than age 65 who are at increased risk for pneumonia. The patient should also receive other recommended vaccines against influenza, COVID-19, or respiratory syncytial virus, as these respiratory infections can develop into pneumonia.

3. Reduce the risk of exposure. Teach the patient about proper handwashing and the use of hand sanitizer. Avoid contact with those who are ill, and consider a mask if traveling or in crowded areas. Boost the immune system through a healthy diet, exercise, and regular sleep.

4. Implement aspiration precautions. If the patient is at risk for aspiration , implement the following measures to reduce the risk of aspiration and subsequent pneumonia:

• Encourage small bites when eating
• Avoid distractions during meals
• Allow plenty of time for chewing and swallowing
• Ensure the patient is sitting upright when eating
• Do not lay the patient down for 30 minutes after meals
• Monitor for pocketing of food or pills in the mouth
• Monitor for choking or gagging while eating
• Consider thickened liquids or pureed diets
• Request evaluation by a speech therapist

Reduce the Risk of Ventilator-Acquired Pneumonia (VAP)

1. Provide oral hygiene. Patients on a ventilator must receive frequent oral care to reduce the risk of bacterial growth.

2. Suction as needed. Secretions can pool in the mouth and lead to aspiration. The nurse and respiratory therapist can provide subglottic suctioning to prevent aspiration.

3. Position appropriately. Elevate the head of the bed by 30 to 45 degrees to prevent reflux and VAP. 

4. Ambulate as tolerated. If the patient isn’t sedated, assist in ambulating, sitting on the side of the bed, or marching in place to reduce VAP.

Nursing Care Plans

Once the nurse identifies nursing diagnoses for pneumonia, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for pneumonia.

Impaired gas exchange is closely tied to Ineffective airway clearance. Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation.

Nursing Diagnosis: Impaired Gas Exchange

Related to:

• Inflammation 
• Fluid and mucus in the alveoli 
• Hypoventilation causing a lack of oxygen delivery 

As evidenced by:

• Dyspnea 
• Hypoxemia 
• Confusion 
• Restlessness 
• Lethargy 
• Alterations in breathing pattern  

Expected outcomes:

• Patient will display appropriate oxygenation through ABGs within normal limits.
• Patient will demonstrate appropriate actions to promote ventilation and oxygenation.

Assessment:

1. Assess lung sounds and vital signs. Assess breath sounds, respiratory rate and depth, sp02, blood pressure and heart rate, and capillary refill to monitor for signs of hypoxia and changes in perfusion.

2. Assess for mental status changes. Poor oxygenation leads to decreased perfusion to the brain resulting in a decreased level of consciousness, restlessness, agitation, and lethargy.

3. Monitor ABGs and oxygen saturation. Decreasing sp02 signifies hypoxia. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. If abnormal, the lungs are not oxygenating adequately causing poor perfusion of the tissues.

Interventions:

1. Encourage rest and limit exertion. Patients may not be able to tolerate too much activity. Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption.

2. Use narcotics and sedatives with caution. Narcotics for pain control or anti-anxiety medications should be monitored closely as they can further suppress the respiratory system.

3. Administer oxygen. Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels.

Severe cases of pneumonia may deteriorate to respiratory failure and the inability to breathe independently.

Nursing Diagnosis: Impaired Spontaneous Ventilation

• Underlying conditions (COPD, asthma, HIV)
• Respiratory muscle fatigue
• Tachycardia
• Restlessness
• Accessory muscle use
• Nasal Flaring
• Abnormal ABGs
• Patient will maintain ABGs within acceptable parameters.
• Patient will be free of signs of respiratory distress such as cyanosis, restlessness, or hypoxia.
• Patient will maintain a patent airway.

1. Assess for signs of respiratory distress. Worsening dyspnea, tachypnea, retractions, accessory muscle use, or cyanosis require immediate intervention.

2. Monitor ABG results. Blood gas analysis can detect changes in oxygenation and acid-base balance, allowing the healthcare team to plan interventions and intervene before respiratory failure occurs.

3. Identify factors that may complicate the respiratory status. Chronic conditions such as COPD, asthma, heart failure, cirrhosis, and more may complicate the patient’s breathing abilities and require advanced interventions.

1. Discuss intubation and ventilation. Explain the process of noninvasive and invasive ventilation to prepare the patient and family and reduce anxiety .

2. Consider the use of noninvasive positive pressure ventilation (NPPV) first. BiPAP is a type of NPPV that provides noninvasive ventilation with a lower risk of ventilator-associated pneumonia (VAP) than intubation and mechanical ventilation.

3. Reposition as needed. If not sedated, assist with ambulation. A rotational bed can help with turning to prevent atelectasis and VAP.

4. Implement techniques to reduce VAP. Keep the head of the bed elevated 30-45 degrees, provide frequent oral care, and suction secretions to prevent aspiration and VAP.

Pneumonia may increase sputum production causing difficulty in clearing the airways.

Nursing Diagnosis: Ineffective Airway Clearance

• Poor cough reflex 
• Secretions in the bronchi or alveoli 
• Excessive mucus  
• Comorbidities: COPD, asthma, cystic fibrosis 
• Shortness of breath  
• Diminished lung sounds or crackles/rhonchi 
• Ineffective cough 
• Observed sputum production 
• Orthopnea 
• Changes in respiratory rate and rhythm 
• Patient will demonstrate appropriate airway clearance techniques.
• Patient will display improvement in airway clearance as evidenced by clear breath sounds and an even and unlabored respiratory rate.

1. Monitor for respiratory changes. Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop.

2. Assess the ability and effectiveness of cough. Pneumonia infection causes inflammation and increased sputum production. The patient needs to be able to effectively remove these secretions to maintain a patent airway. Patients who are weak or lack a cough reflex may not be able to do so. This also increases the risk for aspiration pneumonia.

3. Obtain a sputum sample for culture. If the patient can cough, have them expectorate sputum for testing. If they cannot, sputum can be obtained via suctioning. Sputum samples can be cultured to appropriately treat the type of bacteria causing infection.

1. Assist with respiratory devices and techniques. Flutter valves mobilize secretions facilitating airway clearance while incentive spirometers expand the lungs. The nurse should instruct on how to properly use these devices and encourage their use hourly. The nurse can also teach coughing and deep breathing exercises.

2. Suction as needed. Patients who have a tracheostomy may need frequent suctioning to keep airways clear. Patients who are weak or fatigued with an ineffective cough can be taught how to suction themselves.

3. Administer nebulizer treatments and other medications. Nebulizer treatments can loosen secretions in the lungs while mucolytics and expectorants can help thin mucus and make it easier to cough up.

4. Encourage movement and positioning. Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. Immobile patients or those who need assistance should be turned every 2 hours, assisted into an upright position, or transferred into a chair to promote lung expansion.

Pneumonia is an infection of the lungs that can alter respiratory patterns, preventing adequate ventilation.

Nursing Diagnosis: Ineffective Breathing Pattern

• Increased sputum production
• Pleuritic pain
• Poor body positioning
• Chronic lung diseases
• Changes in the rate and depth of respirations
• Abnormal breath sounds
• Use of accessory muscles
• Productive cough
• Patient will demonstrate effective respirations while in a position of comfort.
• Patient will maintain an even and unlabored breathing pattern.

1. Monitor and measure the respiratory status. Assess the patient’s respiratory rate, depth, and pattern. Monitor closely for accessory muscle use, nasal flaring, grunting, or orthopnea.

2. Auscultate lung fields. Inflammation or mucus accumulation in the lungs may cause wheezing, crackles, or rhonchi, disrupting the respiratory pattern.

3. Assess for pain with breathing. Pneumonia can cause pleuritic chest pain or pain with breathing or coughing that inhibits normal breathing.

1. Elevate the head of the bed and encourage ambulation. This encourages optimal chest expansion and the mobilization of secretions.

2. Administer oxygen as indicated. Supplemental oxygen may be necessary to address hypoxia and improve oxygenation. Administer and adjust oxygen therapy per the prescribed orders or guidelines.

3. Encourage deep, controlled breathing and splinting of the chest. The patient with pleuritic chest pain may be hesitant to cough or breathe normally. Help ease the pain by encouraging deep, slow breaths and using a pillow to splint the chest when breathing or coughing.

4. Promote adequate rest periods and sleep. Encourage active participation in activities of daily living (ADLs), but remind patients not to overdo themselves. Limit interruptions so the patient receives adequate sleep .

Pneumonia is an infection itself but a risk for infection nursing diagnosis is appropriate as untreated pneumonia can progress into a secondary infection or sepsis.

Nursing Diagnosis: Risk For Infection

• Inadequate primary defenses: decreased ciliary action, respiratory secretions 
• Invasive procedures: suctioning, intubation 
• Presence of existing infection 
• Worsening in condition leading to immobility , immunosuppression, and malnutrition  

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.

• Patient will not develop a secondary infection or sepsis.
• Patient will display improvement in infection evidenced by vital signs and lab values within normal limits.

1. Monitor for worsening signs of infection or sepsis. Dropping blood pressure, hypothermia or hyperthermia , elevated heart rate, and tachypnea are signs of sepsis that require immediate attention.

2. Assess lab values. An elevated white blood count is indicative of infection. This is an expected finding with pneumonia, but should not continue to rise with treatment. If sepsis is suspected, a blood culture can be obtained.

3. Consider sources of infection. Any inserted lines such as IVs, urinary catheters, feedings tubes, suction tubing, or ventilation tubes are potential sources of infection. Remove unnecessary lines as soon as possible. Surgical incisions and any skin breakdown should be monitored for redness, warmth, drainage, or odor that signals an infection.

1. Administer antibiotics. A diagnosis of pneumonia will warrant antibiotic treatment. If the patient’s condition worsens or lab values do not improve, they may not be receiving the correct antibiotic for the bacteria causing infection.

2. Encourage fluid intake and nutrition. Hydration is vital to prevent dehydration and supports homeostasis. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. Encouraging oral fluids will mobilize respiratory secretions. Proper nutrition promotes energy and supports the immune system.

3. Implement precautions to prevent infection. Proper handwashing is the best way to prevent and control the spread of infection. The patient may have a limit to visitors to prevent the transmission of infections. Always maintain sterility or aseptic techniques when performing any invasive procedure.

4. Promote skin integrity. The skin is the body’s first barrier against infection. Skin breakdown allows pathogens to enter the body. If a patient is immobile they must be repositioned every 2 hours to maintain skin integrity . Keep skin clean and dry through frequent perineal care or linen changes.

• American Lung Association. (2023, September 26). Pneumonia treatment and recovery. Retrieved October 2023, from https://www.lung.org/lung-health-diseases/lung-disease-lookup/pneumonia/treatment-and-recovery
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• Bacterial pneumonia workup: Approach considerations, routine laboratory tests, blood studies. (2023, June 30). Diseases & Conditions – Medscape Reference. Retrieved October 2023, from https://emedicine.medscape.com/article/300157-workup#c18
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• Yang, Fang1#; Yang, Yi1#; Zeng, Lingchan2; Chen, Yiwei1; Zeng, Gucheng1 Nutrition Metabolism and Infections, Infectious Microbes & Diseases: September 2021 – Volume 3 – Issue 3 – p 134-141 doi: 10.1097/IM9.0000000000000061 (Pneumonia: Symptoms, Treatment, Causes & Prevention, 2020)

Nursing Care Plan (NCP) for Pneumonia

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In this lesson, you will learn pathophysiology and etiology of pneumonia, the subjective and objective data of a nursing care plan, and nursing interventions and rationales. You will also learn how to write a nursing care plan for pneumonia. This includes making an assessment, the concepts of making a diagnosis, formulating a care plan, writing an implementation list, and making a proper evaluation.

After completing this lesson, nursing students will be able to:

• Define the pathophysiology of pneumonia
• Differentiate between different types of commonly occurring pneumonia
• List signs and symptoms of pneumonia
• Identify the risk factors and complications associated with pneumonia
• List common causes of pneumonia
• State the desired outcome for a pneumonia patient
• Write a Nursing Care Plan for pneumonia
• Describe how to do an assessment on a pneumonia patient
• Determine the nursing diagnosis of a pneumonia patient
• Create a plan and goals for a pneumonia patient
• Write a nursing implementation list for a pneumonia patient
• Evaluate the effectiveness of a nursing care plan for pneumonia
• Understand and explain the nursing interventions and rationales associated with a pneumonia nursing care plan

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Pathophysiology of Pneumonia

Pneumonia is an infection that causes inflammation of the small air sacs of the lungs, called alveoli, and the surrounding tissue. The inflamed alveoli will fill with purulent material (fluid or pus) impairing their ability to exchange gases with the surrounding capillaries.

Any infectious organism, bacteria, or fungus that reaches the alveoli is likely to be very hostile and will cause them to inflame and fill with fluid. As these fluids build, the lungs ability to exchange oxygen and carbon dioxide is restricted.

In response to the inflammation and fluid build-up the patient will experience:

• Falling oxygen levels
• Rising carbon dioxide levels
• Increased respiratory rate
• Increased heart rate
• Labored breathing
• Vital organs being deprived of oxygen

The first picture below depicts a normal, unobstructed gas exchange. In the second picture, the alveoli have an accumulation of fluid in them which impairs the gas exchange that occurs with the capillaries and provides appropriate oxygenation into circulation.

Types of Pneumonia

As a nurse, knowing the type of pneumonia is essential for creating a care plan. Pneumonia can be classified in three different ways:

• The setting where it develops
• The part of the lung it affects
• The pathogen that causes the infection (see Etiology of Pneumonia)

Pneumonia by Setting

There are four generally recognized kinds of pneumonia based on the setting where they occur:

Pneumonia by Location

There are three general types of pneumonia based on the location in the lung where they occur:

Signs and Symptoms of Pneumonia

Symptoms of pneumonia begin when the inflammation and fluid-filled alveoli cause coughing (often producing phlegm), fever, chills, chest pain or pain when coughing, and cold or flu-like symptoms. These symptoms can vary from mild to severe. Mild signs are often similar to a long-lasting cold or flu. More severe cases can include high fevers, organ failure, and even death.

Symptoms of Pneumonia

• A cough that may produce green, yellow, or bloody phlegm
• Shortness of breath
• Mild or severe fatigue
• Chest pain when breathing or coughing
• Shaking chills
• Muscle pain or weakness
• Nausea, vomiting or diarrhea
• Lips and fingernails that appear blue
• Loss of appetite
• Low energy and extreme tiredness
• Rapid breathing
• Rapid pulse

Signs of Pneumonia

• Elevated temperature
• Lower body temperature
• Elevated White Blood Count (WBC)
• Low oxygen level
• Rhonchi or wheezing

Risk Factors

Pneumonia can affect anyone, however those with the following conditions are at greater risk:

• Those over the age of 65
• Children who are 2 years old or younger
• Immunocompromised, for example those with HIV/AIDS or undergoing chemotherapy
• Lung diseases such as COPD, cystic fibrosis, bronchiectasis
• History of Smoking
• Cardiac and/or liver disease
• Recent viral respiratory infection (common cold, laryngitis, influenza)
• Difficulty swallowing due to neurological conditions like stroke, dementia, or Parkinson’s disease
• Living in a nursing facility
• Malnutrition
• Medications that decrease gastric pH such as H2 receptor blockers
• Those in hospital intensive care units, especially those on a ventilator

Complications

Complications of untreated or under-treated pneumonia include respiratory failure, sepsis, metastatic infections, empyema, lung abscess, and multi-organ dysfunction.

Etiology of Pneumonia

Pneumonia can be caused by a virus, bacteria, fungus, or from inhaling something (chemical, inhalant, or aspirating on food or fluid).

Common Causes of Viral Pneumonia

• Influenza: most common for adults
• Respiratory Syncytial Virus (RSV): most common in young children
• SARS-CoV-2 (the virus that causes COVID-19)

Common Causes of Bacterial Pneumonia

• Streptococcus Pneumoniae (Pneumococcus)
• Haemophilus influenzae

Common Causes of Fungal Pneumonia

• Pneumocystis
• Cryptococcus
• Aspergillus

Desired Outcome

Resolve the infection, optimize gas exchange, minimize impact from the impaired gas exchange.

Writing a Nursing Care Plan for Pneumonia

A Nursing Care Plan (NCP) for pneumonia is one of the most common assignments in nursing college. They start immediately after a patient is admitted and document all activities and changes in the patient’s condition. These plans are intended to help enhance quality outcomes and consistent health care delivery. They can also be used as a communication tool among nurses, other healthcare professionals, the patient and their families.

The goal of an NCP is to create a treatment plan that is individualized for the specific patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.

Performing an Assessment

Making an individualized assessment begins by focusing on the available background information of the patient: health history, current health status, psychological state, and other available data.

Subjective Data

Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by interview. In the case of pneumonia, a patient might report feeling:

• Labored breathing (Dyspnea)
• Altered Mental State (AMS)

Objective Data:

Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of pneumonia, a patient may present with:

• Low Oxygen Rate
• Rhonchi or Wheezes

Making a Diagnosis

A nursing diagnosis is the basis for establishing and carrying out a nursing care plan. After performing a proper assessment, formulate a nursing diagnosis based on problems associated with pneumonia. This will be your clinical judgment about the patient’s health conditions or needs.

Select the appropriate nursing diagnostic label from the NANDA-I list of approved nursing diagnostic statements that best identify with pneumonia. One or more nursing diagnoses may be given.

Creating a Plan

Care plan goals form the basis of a nursing intervention. These goals are best thought of as “what the patient will do” and should be a clearly stated, easy to measure, realistic description of the patient’s expected outcomes.

In the case of pneumonia, a plan may include:

• Patient movement
• Taking medications
• Receiving fluids
• Understanding their condition and treatment

Writing an Implementation

Implementations are actions and activities you will take to achieve the nursing plan goals.

These interventions should take into account:

• The patient’s beliefs, values, and culture
• The patient’s condition, health, and age
• Coordination with other therapies and interventions
• Available resources and time constraints

In the case of pneumonia an implementation may include:

• Encourage movement
• Administer medications as prescribed
• Provide fluids
• Educate the patient

Evaluating Goals

The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. The evaluation helps determine whether to continue, stop, or change the selected interventions.

In our pneumonia example, our evaluation might include:

• Patient moved 3 times a day
• Patient took medications
• Patient received fluids
• Patient understood information about their care

Nursing Interventions and Rationales

Related Courses & Lessons

• Pneumonia Concept Map
• Center for Disease Control and Prevention (CDC)
• American Lung Association
• National Heart, Lung, and Blood Institute
• MedlinePlus
• UptoDate – Pneumonia in adults
• Ohio State University College of Medicine – Community Acquired Pneumonia
• Cleveland Clinic – Hospital acquired pneumonia, healthcare acquired pneumonia, ventilator associated pneumonia

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Example Nursing Diagnosis for Pneumonia

• Ineffective Airway Clearance: Pneumonia can lead to airway congestion and impaired mucus clearance. This diagnosis focuses on airway management.
• Risk for Infection Spread: Pneumonia is contagious. This diagnosis emphasizes infection prevention and education on hygiene and transmission.
• Altered Gas Exchange: Pneumonia can result in poor oxygen exchange. This diagnosis addresses the need for oxygen support and monitoring.

View the FULL Transcript

Nursing care plans.

How do I write a Nursing Care Plan? Why and how do we even use Nursing Care Plans ? This course is going to expand on that for you and show you the most effective way to write a Nursing Care Plan and how to use Nursing Care Plans in the clinical setting . PLUS, we are going to give you examples of Nursing Care Plans for all the major body systems and some of the most common disease processes. When you complete this course, you will be able to write and implement powerful and effective Nursing Care Plans.

0 – Nursing Care Plans Course Introduction

1 – understanding nursing care plans.

• 16 Questions

Cardiovascular (Cardiac, CVD) Care Plans

• 5 Questions
• 6 Questions
• 10 Questions
• 3 Questions
• 8 Questions
• 1 Questions
• 4 Questions

Eyes, Ears, Nose, Throat (EENT) Care Plans

• 7 Questions

Gastrointestinal (GI) Care Plans

• 2 Questions

Genitourinary (Renal) (Kidney) (Nephrotic) Care Plans

Hematology (blood, labs), oncology (cancer) & immunology (immunity) care plans, integumentary (skin) care plans, mental health care plans, metabolic & endocrine care plans.

• 9 Questions

Neurological Care Plans

Obstetrics (ob) & pediatrics (peds) care plans, respiratory care plans.

• 11 Questions

Sepsis (Septic) & Shock Care Plans

Musculoskeletal and skeletal (osteo) (bones) care plans.

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A case report on management of severe childhood pneumonia in low resource settings

Yasmin jahan.

a Graduate School of Biomedical & Health Sciences, Hiroshima University, Japan

Atiqur Rahman

b School of Health, University of New England, Australia

Associated Data

Pneumonia is a major cause of child mortality among children under five years, worldwide. Pneumonia infection may be caused by bacteria, viruses, or fungi in single or in both lungs. According to recent criteria developed by World Health Organization (WHO) in September (2013), pneumonia can be classified into severe pneumonia, pneumonia and no pneumonia. Most of the deaths occur from severe pneumonia and management of severe childhood pneumonia requires early identification, prompt referral and the availability of intensive quality of care. This case study aimed to represent the actual scenario of severe childhood pneumonia case management at community clinic. Considering that circumstances, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) developed an innovative day care management approach as safe, effective and less expensive alternative to hospital management of severe childhood pneumonia. A twenty-seven months old boy came to the Health & Family Welfare Centre (HFWC) with severe breathing difficulty, cough, history of fever. The management described below was continued daily until there was clinical improvement; no fever, no fast breathing, no lower chest wall indrawing, no danger signs, no rales on auscultation and no hypoxemia. Considering the WHO case management protocol for severe pneumonia, day care management approach on community clinic recommends that diagnosis of severe pneumonia should be based primarily on visible clinical parameters. On that basis, severe childhood pneumonia can be successfully managed at community clinics including for children with hypoxemia who is required prolong (4–6 hours) oxygen therapy.

1. Introduction

Globally, Pneumonia sustains as the leading cause of death among under five years old children [ 1 ]. The recent World Health Organization (WHO) global report (2013) deemed that pneumonia accounts for approximately 120 million cases every year [ 2 ], among which 14 million (12%) progress to severe pneumonia [ 3 ]; and developing countries belong into the most vulnerable vicinity (95%) [ 1 ]. Reported deaths in a year of this age group was 0.9 million which represents about 17% of all deaths among children under five [ 4 ]. More than 99% of all pneumonia deaths occur in low- and middle-income countries (LMIC). For instance, South Asia and sub-Saharan Africa, specifically, suffer more than two-third of worldwide pneumonia burden; 13% of which covers children from Bangladesh [ 5 ].

According to WHO guideline, successful management of severe childhood pneumonia requires hospitalization for supportive treatment, such as suctioning, oxygen therapy, fluid and nutritional management, and close monitoring [ [6] , [7] , [8] , [9] ]. In Bangladesh, inadequacy of pediatric hospital beds for severe pneumonia patients is a major challenge. A prospective observational study has resulted that, day care facility based modified primary care management for severe pneumonia is more successful and cost-effective as an alternative in respect to hospitalization [ 10 ]. Previous research indicated positive outcomes (both efficacy and safety) of a day care-based management at community clinic. The International Centre for Diarrheal Disease Research, Bangladesh (icddr, b) by following the outcomes, developed an innovative model of day care-based management approach as a safer and less expensive alternative to hospital management of severe childhood pneumonia. The fundamental theme of this model urges initiating patient management in the community clinics for those severe patients who can not be hospitalized. This will be applicable for both in the urban outpatient clinics, such as Comprehensive Reproductive Health Centres (CRHCs) and in the rural clinics such as Health & Family Welfare Centres (HFWCs). As a consequence, day care managment at community clinics has become a validated approach to free up hospital beds in LMIC [ 11 ].

2. Case report

A twenty-seven months old boy came from the rural site of Bangladesh and presented with a history breathing difficulty, cough and fever for two days. His physical examination revealed the past case history of grunting, very severe chest wall indrawing and hypoxemia (SpO2 (peripheral capillary oxygen saturation) 82% without O2) and head nodding. He was clinically diagnosed with severe pneumonia. On admission, his temperature was 37.4 ○ C, RR 74 breaths/min, PR 176 beats/min, and SpO2 was 82% without O2. Patient was dyspneic and irritated. On Auscultation, crepitation was present in both lung fields (right upper zone and left lower zone) and rhonchi was present on upper and middle side of left lung field. He was admitted in a HFWC in day care management basis and treated as a severe pneumonia patient immediately. In HFWC, there is an out-patient facility providing space, trained staff members (doctors, nurses), beds, and the necessary equipment's like antibiotics, oxygen therapy, nebulization, nasopharyngeal suction etc. as needed.

Treatment and diet that the patient received (According to the body weight):

• 1. Diet- Breast feeding + Milk Suji 12ml/kg/feed
• 2. Oxygen inhalation: 2L/min - Stat and SOS
• 3. Inj. Ceftriaxone: 1gm I/M once daily for 5 days
• 4. Syp. Levosalbutamol: 1 ½ TSF P/O 12 hourly for 7 days
• 5. Syp. Paracetamol: 1 TSF P/O 8 hourly (for fever more than or equal to 38° C)

No investigations were done due to inadequate facilities.

2.1. Expected outcome of the treatment plan

Clinical improvement of the patient; no fever, no hypoxemia, no fast breathing and no tachycardia after the 5th day of treatment.

2.2. Actual outcome

2.2.1. on day 0 (admission day).

The patient was diagnosed with following physical conditions: age specific fast breathing, severe lower chest wall indrawing, grunting and hypoxemia, temperature (37.4° C, not fever), respiratory rate (74 breaths/min), SpO2 (82%; without O2) and Pulse rate (176 beats/min). SpO2 improved after providing 5 hours of continuous oxygen supply. With provision of O2, SpO2 was 95%, 89%, 93% and 94% respectively at the beginning and after 2 mins, 15 mins and 1 hour of removing O2. Respiratory rate was 50 breaths/min, temp was 37° C.

2.2.2. On day 1

There was age specific fast breathing, tachycardia and chest wall indrawing. Temp was 36.8° C, Respiratory rate was 44 breaths/min, SpO2 was 97% without O 2 though the child was kept without O2 for overnight and Pulse rate was 157 beats/min.

2.2.3. On day 2

There was mild chest indrawing but no age specific fast breathing, no fever and no hypoxemia. Temp was 36.2° C, respiratory rate was 36 breaths/min, SpO2 was 95% without O2 and Pulse rate was 136 beats/min.

2.2.4. On day 3

Patient started improving clinically but there was age specific fast breathing but no chest indrawing, no fever, no tachycardia and no hypoxemia. Temp was 36.3° C. respiratory rate was 41 breaths/min, SpO2 was 98% without O2 and pulse rate was 132 beats/min.

2.2.5. On day 4

Patient was clinically improved and there was no hypoxemia, no fever, no age specific fast breathing and no tachycardia. Temp was 36.5° C. Respiratory rate was 36 breaths/min, Pulse rate was 134 beats/min, SpO2 was 99% without O2.

2.2.6. On day 5

Patient was clinically stable, and his Temperature was 36.4° C. Respiratory rate was 34 breaths/min, SpO2 was 100% without O2 and Pulse rate was 118 beats/min.

As the child was clinically improved and there was no fever, no hypoxemia, no fast breathing and no tachycardia, he was discharged from the HFWC (See Table 1 ).

Clinical evaluation during day care-based management at community clinic.

3. Discussion

Management of severe childhood pneumonia in low resource settings health facilities is pertinent where referral is difficult or impossible. In most developing countries, more health resources are available in cities and towns than in rural areas. Children with severe pneumonia need to be referred due to difficult breathing, hypoxemia, stridor, convulsion like danger signs. In countries with a high burden of pneumonia, implementation of the WHO revised guidelines will increase the proportion of children receiving care at the outpatient or community levels reduce the need for referrals and improve treatment outcomes [ 12 ].

According to the WHO revised treatment guideline, child age 2–59 months with cough and/or difficult breathing with fast breathing and/or chest indrawing, pneumonia should be treated with oral amoxicillin and home advice and child age 2–59 months with cough and/or difficult breathing with general danger signs (not able to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor in a calm child or severe malnutrition), severe pneumonia or very severe disease should be treated with first dose antibiotic and referral to facility for injectable antibiotic/supportive therapy [ 13 ]. According to the WHO/United Nations Children's Fund (UNICEF) joint statement, management of pneumonia in community settings recommends the training and deployment of Community Health Workers (CHWs) as an important strategy to increase access to quality care for pneumonia [ 13 ]. Research showed that educated community members could be trained to detect and manage fast breathing pneumonia in their communities, Large-scale studies showed that the sensitivity, specificity, and overall agreement rates in pneumonia diagnosis and treatment were high among CHWs who had intensive basic training and routine supervision [ 13 ]. Thus, the need for referrals to higher-level facilities is decreased and the probability of hospitalization and thus the risk of nosocomial and injection-borne diseases is reduced.

Case management in a low resource setting, we will be able to assess the effectiveness of severe childhood pneumonia treatment at community health clinics. This case management proved that, children with severe pneumonia can be treated at community clinic, as effectively as in the hospital. Generally, chain of management of a severe childhood pneumonia is increasing management of patients at first-level facilities [ [14] , [15] , [16] , [17] ], improving emergency triage assessment and treatment [ 18 , 19 ], and appropriately managing severely ill children in hospitals [ [20] , [21] , [22] ]. Along this chain of management of sick children, the referral of a sick child from a rural first-level health facility to a hospital at the district level often is a bottleneck. So, this case report is to explore the possibility of managing children locally. The additional things will be cost effectiveness compare to hospital as parents do not need to pay hospital related fees. Furthermore, they do not need to stay overnight at the hospital, thus they can save their time.

The findings can be easily replicated also in most urban and rural outpatient clinics in developing countries through provided proper training and motivation of staff members and provision of logistic support are guaranteed. Moreover, the case report findings may have a significant impact on the treatment of severe childhood pneumonia, particularly in countries with poor resources and limited hospital beds.

4. Conclusions

Day care management at community clinics might be a feasible method of applying scarce hospital beds in developing countries more proficiently by selecting day care treatment for children with severe pneumonia. The solution could be executed followed by WHO guideline in those hospitals which have been identified as requiring hospitalization. This practical approach would be effective for both developing and other developed and/or underdeveloped countries where similar health resources and infrastructures are available. In such manner, the health care providers would be familiar with clinical manifestations to comprehend the presence of danger signs of pneumonia like hypoxemia. This case study suggests for upgrading the existing day care facilities by promoting training to service providers, procurement of modern equipment and create friendly and secure atmosphere for the clients. Moreover, integrating day care management at community clinics in health promotion strategy will benefit to develop new healthcare policy and particularly the cost-effectiveness will assist to increase client's interest.

Ethical approval

Our institutions do not require ethical approval for reporting individual cases or case series.

Conflicts of interest

The authors declare that they have no competing interests.

Informed consent

Written informed consent was obtained from the legally authorized representative(s) for anonymized patient information to be published in this article.

Authors’ contribution

YJ wrote the initial text and AR reviewed and complemented it. All authors critically reviewed the manuscript and approved the final version submitted for publication.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

I would like to express my appreciation to my co-authors for their full-time cooperation.

Appendix A Supplementary data related to this article can be found at https://doi.org/10.1016/j.rmcr.2018.08.024 .

Appendix A. Supplementary data

The following is the supplementary data related to this article:

Pneumonia Nursing Diagnosis and Care Plan

Last updated on January 27th, 2024 at 04:10 pm

Table of Contents

Signs and symptoms, subjective:, related factors and at-risk population, nursing diagnosis for pneumonia.

Below are five nursing diagnoses that can be used for Pneumonia Nursing Care Plans.

Nursing Interventions for Pneumonia

Nursing care plan for pneumonia, ineffective airway clearance.

Related factors/causes:

Impaired Gas Exchange

Nursing Diagnosis: Impaired gas exchange related to alveolar consolidation and decreased oxygen diffusion secondary to pneumonia.

Nursing Interventions with Rationales:

Nursing Test Questions for Pneumonia

Rationale: Crackles on auscultation indicate the presence of secretions in the alveoli, which is consistent with pneumonia. Fever is a systemic response to infection. The other options are not specific signs of pneumonia.

Rationale: Smoking and COPD are significant risk factors for pneumonia because they compromise the lung’s defense mechanisms. The other individuals do not have factors that increase their risk to the same extent.

Rationale: While all the options are essential interventions for a patient with pneumonia, timely administration of the prescribed antibiotic is crucial to effectively treat the infection and prevent complications.

Rationale: Pneumonia is primarily a respiratory condition wherein microorganisms cause infection and inflammation within the alveoli. The alveoli become filled with pus and other liquid, making oxygen exchange difficult.

Rationale: Deep breathing and coughing exercises help in mobilizing and expectorating secretions, improving airway clearance. The other options would potentially worsen the patient’s condition or are not directly related to improving airway clearance.

Nursing References

Eshwara, Vandana Kalwaje1,; Mukhopadhyay, Chiranjay1; Rello, Jordi2,3. Community-acquired bacterial pneumonia in adults: An update. Indian Journal of Medical Research 151(4):p 287-302, April 2020. | DOI: 10.4103/ijmr.IJMR_1678_19

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier. 

Silvestri, L. A. (2020).  Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier. 

Best Nursing Books and Resources

The Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care

NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023

It contains more than 200 care plans that adhere to the newest evidence-based recommendations.

The medical information on this site is provided as an information resource only and is not to be used or relied on for diagnostic or treatment purposes.

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Article Contents

Case presentation, acknowledgments.

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Scenario 1: A Patient with Mild Community-Acquired Pneumonia—Introduction to Clinical Trial Design Issues

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David N. Gilbert, Scenario 1: A Patient with Mild Community-Acquired Pneumonia—Introduction to Clinical Trial Design Issues, Clinical Infectious Diseases , Volume 47, Issue Supplement_3, December 2008, Pages S121–S122, https://doi.org/10.1086/591391

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A prototypical patient is presented to introduce important design issues for clinical trials of antibacterials in the treatment of community-acquired pneumonia.

Of the 4 million or more patients in the United States treated annually for community-acquired pneumonia (CAP), ∼80% are cared for on an outpatient basis [ 1 , 2 ]. Admittedly, the patient population is heterogeneous. However, 2 subgroups constitute a significant percentage of the total.

The first subgroup consists of young, otherwise-healthy individuals who are nonsmokers aged <40 years. “Atypical” pathogens, such as Mycoplasma pneumoniae or Chlamydia pneumoniae , are identified frequently as the etiologic organism. Streptococcus pneumoniae may be the etiologic organism, especially during or after viral tracheobronchitis.

In contrast, individuals in the second group are older. Often, they have used tobacco products for years and meet clinical criteria for chronic bronchitis and/or emphysema.

To focus on clinical trial design issues pertinent to the population of patients with mild pneumonia, a typical clinical-trial candidate patient is described below.

Present illness. A 35-year-old male resident of Boston, Massachusetts, presents with fever and cough. He was well until 3 days earlier, when he suffered the onset of nasal stuffiness, mild sore throat, and a cough productive of small amounts of clear sputum. Today, he decided to seek physician assistance because of an increase in temperature to 38.3°C and spasms of coughing that produce purulent secretions. On one occasion, he noted a few flecks of bright-red blood in his sputum.

Other pertinent history. It is March. He lives in a home in the city with his wife and 3 children, aged 7, 9, and 11 years. The children are fully immunized. The 11-year-old child is recovering from a “nagging” cough that has persisted for 10–14 days.

The family has a pet parakeet who is 5 years old and appears to be well. The patient has not traveled outside the city in the past year. He is an office manager.

The patient smokes 1 pack/day and has done so since the age of 15 years. Several times a month, especially during the winter, on arising from sleep, he produces ∼1 tablespoon of purulent sputum.

Medical history. The patient has no history of familial illness, hospitalizations, or trauma. There are no drug allergies or intolerance. The only medication he takes is acetaminophen occasionally, for headaches. He drinks beer or wine in moderation.

Physical examination. His body temperature is 38.9°C (100°F), his pulse is 110 beats/min and regular, and his respiratory rate is 18 breaths/min. His oxygen saturation is 93% while breathing room air. There is mild erythema of the mucosa of the nose and posterior oropharynx. Inspiratory “rales” are heard at the right lung base.

Laboratory and radiographic findings. His hemoglobin level is 12.5 g/dL, with a hematocrit of 36%. His WBC count is 13,500 cells/µL, with 82% polymorphonuclear cells, 11% band forms, and 7% lymphocytes. His platelet count is 180,000 cells/µL. The results of a multichemistry screen are unremarkable.

Chest radiography documents bilateral lower lobe infiltrates that are more pronounced on the right side. There are no pleural effusions.

Management questions. A validated prediction rule forecasts that this patient's risk of death from his CAP is <1% [ 3 ]. Therefore, he is a candidate for outpatient therapy.

What is the likely microbiological diagnosis? On the basis of the cough of 2 weeks' duration in the patient's 11-year-old child, the pneumonia could be due to M. pneumoniae or another atypical pathogen. However, this illness could represent pneumococcal pneumonia superimposed on a viral upper respiratory tract infection.

Clinical trial design questions. These are the hard questions and illustrate some of the many reasons for this workshop: Is the patient of sufficient reliability to participate in an outpatient clinical trial of antibacterials for mild CAP? Is it ethical or, from a practical standpoint, feasible to conduct a placebo-controlled trial? If an active comparator drug is used, how does one generate a valid and defensible margin of noninferiority?

What are valid, reproducible, and quantifiable clinical end points (outcomes)?

It would help greatly if the etiology of the pneumonia could be determined for the majority of the enrolled patients. What are the current diagnostic tools that can be applied and thereby “enrich” the patient population?

Multiple precautions are necessary to avoid bias in the interpretation of the results of clinical trials. For example, what are acceptable methods in the “blinding” of treatment arms?

How can investigators reliably and with reasonable sensitivity detect adverse drug effects?

The articles that follow address these questions and more. Participants in this workshop uniformly agreed that the interaction of US Food and Drug Administration regulations, industry sponsors, and Infectious Diseases Society of America academics represents an opportunity to modernize future clinical trials for CAP.

Supplement sponsorship. This article was published as part of a supplement entitled “Workshop on Issues in the Design and Conduct of Clinical Trials of Antibacterial Drugs for the Treatment of Community-Acquired Pneumonia,” sponsored by the US Food and Drug Administration and the Infectious Diseases Society of America.

Potential conflicts of interest. D.N.G. serves on the speakers' bureau of Abbott Laboratories, Bayer, GlaxoSmithKline, Lilly, Merck, Pfizer, Roche, Schering-Plough, and Wyeth; and has received consulting fees from Advanced Life Sciences and Pacific Beach Bioscience.

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Sample Nursing Case Study About Pneumonia

Pneumonia is quite a dangerous and common disease, especially in the cold season. People with weak immune systems are especially prone to it. There is a lot of sample nursing case study about pneumonia, but scientists still have a field for the research in order to develop the most reasonable methods of preventing, diagnosing and treating this disease.

The Relevance of the Topic

The acute form of pneumonia is observed in 10-14 people out of 1,000.

In the age group over 50 years, 17 out of 1,000 people are susceptible to this disease. The urgency of the problem of the incidence of acute pneumonia persists even despite the progressive achievements if medicine due to the high percentage of sequelas and lethality (up to 9%) from this disease. This makes a case study on pneumonia an important topic to research. Among the most common death causes, this disease is on the 4th place after heart and vascular diseases, malignant neoplasms, injuries, and poisonings. It can develop in weakened patients, joining the course of heart failure, cancer, impaired cerebral circulation, and complicates the outcome of the latter. In this situation, case study pneumonia is even more complicated.

In patients with AIDS, this illness is the main direct cause of death since an organism has no forces to fight with it.

Causes and Mechanism of Illness

A bacterial infection is the main reason of this disease. This is why streptococcus pneumonia case study should pay a great attention precisely to the appearance of this infection and the organism’s reaction to it.Also, this disease can develop due to the influence of non-infectious factors such as chest injuries, ionizing radiation, toxic substances, and allergic agents. In this situation the research of a disease if more complicated since a doctor should take all these factors into account.

The risk group for the development of the illness includes patients with congestive heart failure, chronic bronchitis, chronic nasopharyngeal infection, congenital malformations of the lungs, severe immunodeficient conditions, weakened and emaciated patients, and elderly and senile people.Smoking and alcohol abusers are especially vulnerable to the development of complicated forms of illness. Nicotine and alcohol vapors damage the bronchial mucosa and depress the protective factors of the bronchopulmonary system, creating a favorable environment for the introduction and reproduction of infection.

Sequelae of Pneumonia

This illness is complicated if it is accompanied by the development of inflammatory and reactive processes. The course and outcome of the disease depend on the presence of sequelae in many ways. Its sequelae can be pulmonary and extra pulmonary.

Pneumococcal pneumonia case study shows that pulmonary sequelae may include obstructive syndrome, abscess, gangrene of the lung, acute respiratory failure, parapneumonic exudative pleurisy. Acute cardiopulmonary insufficiency, endocarditis, myocarditis, meningitis and meningoencephalitis, glomerulonephritis, infectious-toxic shock, anemia, psychosis, etc., often develop among extrapulmonary sequelae.

Diagnostics of Pneumonia

When diagnosing this illness, several problems are solved simultaneously: differential diagnosis of inflammation with other pulmonary processes, elucidation of the etiology and severity of pneumonia. It should be suspected on the basis of symptomatic signs: rapid development of fever and intoxication and coughing.

This explains the necessity of a case study on pneumonia for nurses. As it was said, this illness is rather typical for elder people, and as a rule, precisely nurses spend a lot of time with them. If a nurse is able to suspect this illness only on the basis of visible symptoms and tell a doctor about it, then the healing can be more successful.As a rule, the diagnosis is confirmed after lung radiography. Radiographs are usually done at the onset of the disease and after 3-4 weeks to exclude of other pathology.

The Healing of Pneumonia

Patients with this illness, as a rule, are hospitalized in the general therapeutic department or pulmonologist department.

For the period of fever and intoxication, bed rest, copious warm drink, high-calorie, vitamin-rich meals are prescribed. In severe manifestations of respiratory failure, patients are prescribed inhalation of oxygen. The main thing in the healing is antibacterial therapy. It is necessary to prescribe antibiotics as early as possible, without waiting for the definition of the pathogen. Selection of an antibiotic is performed only by a doctor. The choice of the method of administration of an antibiotic is determined by the severity of the course of the illness.

The course of healing can last from 7-10 to 14 days; it is possible to change the antibiotic.Detoxification therapy, immunostimulation, antipyretic, expectorant and mucolytic substances, antihistamines are recommended. Healing is carried out until the patient’s complete recovery, which is determined by the normalization of the state and well-being, physical, radiologic and laboratory indicators. With frequently repeated cases of disease of the same localization, the question of surgical intervention is solved.

Possible Prognosis

The prognosis is determined by a number of factors: virulence of the pathogen, age of the patient, background diseases, immune reactivity, and adequacy of healing.

Complicated forms of illness, a resistance of pathogens to antibiotic therapy are unfavorable with respect to the prognosis. This illness is especially dangerous if talk about children under 1 year. With timely and adequate medical measures, it ends in recovery.

Prevention of Pneumonia

Measures to prevent the development of this illness are to temper the body, maintain immunity, eliminate the hypothermia, stop smoking and use alcohol. It is advisable to perform respiratory and therapeutic gymnastics, massage if to talk about weakened recumbent patients.

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Case Study: A Systematic Approach to Early Recognition and Treatment of Sepsis

Submitted by Madeleine Augier RN BSN

Tags: assessment Case Study emergency department guidelines mortality prevention risk factors sepsis standard of care treatment

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Sepsis is a serious medical condition that affects 30 million people annually, with a mortality rate of approximately 16 percent worldwide (Reinhart, 2017). The severity of this disease process is not well known to the public or health care workers. Often, health care providers find sepsis difficult to diagnose with certainty. Deaths related to sepsis can be prevented with accurate assessments and timely treatment. Sepsis must be considered an immediate life-threatening condition and needs to be treated as a true emergency.

Relevance and Significance

Sepsis is defined as “the life-threatening organ dysfunction resulting from a dysregulated host response to infection” (Kleinpell, Schorr, & Balk, 2016, p. 459). Jones (2017) study of managing sepsis affirms that the presence of sepsis requires a suspected source of infection plus two or more of the following: hyperthermia (>38.1 degrees Celsius) or hypothermia (<36 degrees Celsius), tachycardia (>91 beats per minute), leukocytosis or leukopenia, altered mental status, tachypnea (>21 breaths per minute), or no urine output for 12 hours. If the infection persists, acute organ dysfunction or failure occurs from widespread inflammation, eventually leading to septic shock (Palleschi, Sirianni, O’Connor, Dunn, & Hasenau, 2013).  Palleschi et al.  (2013) states that during septic shock, “the cardiovascular system fails, resulting in hypotension, depriving vitals organs of an adequate supply of oxygenated blood” (p. 23). Ultimately the body can go into multiple organ dysfunction syndrome (MODS), leading to death if there is inaccurate assessment and inadequate treatment.

The purpose of this case study is to make the nurse practitioner aware of the severity sepsis, and how to accurately diagnose and treat using evidence-based data. Sepsis can affect everyone, despite his or her age or comorbidity.  Center for Medicare and Medicaid Services (CMS) has diagnosed this problem as a priority and uses sepsis management in determining payment to providers (Tedesco, Whiteman, Heuston, Swanson-Biearman, & Stephens, 2017). This medical diagnosis is unpredictable and presents a challenge to nurse practitioners worldwide. Early recognition and treatment of sepsis by the nurse practitioner is critical to decrease morbidity and mortality.

After completing this case study, the reader should be able to:

• Identify the risk factors of sepsis
• Identify the signs and symptoms of sepsis
• Identify the treatment course of sepsis

Case Presentation

A 65-year-old Asian female presented to the emergency department accompanied by her husband with a chief complaint of altered mental status. Upon assessment, the patient was lethargic, and alert and oriented to person only. The patient’s heart rate was 136, blood pressure 104/50, oral temperature 99 degrees Fahrenheit, oxygen saturation 97% on 4 liters nasal cannula, and respirations 26 per minute. The patient’s blood glucose was obtained with a result 454.

Further orders, such as labs and imaging were made by the provider to rule out potential diagnoses. A rectal temperature was obtained revealing a fever of 103.7 degrees Fahrenheit. The patient remained restless on the stretcher. After one hour in the emergency department, her heart rate spiked to 203 beats per minute, respirations became more rapid and shallow, and she became more lethargic. The patient’s altered mental status, increasing heart rate and respirations caused the providers to act rapidly.

Medical History

The patient’s husband reports that she is a type one diabetic, he denies any other medical conditions. In addition, the patient’s husband states that she has not been exposed to any sick individuals in the past few weeks. The husband reports a family history of diabetes, other wise no significant familial history. No history of smoking, drinking, or illicit drug use was to be noted.

Physical Assessment Findings

The patient appeared lethargic and confused with a Glasgow Coma Scale of 12. She appeared tachypnic, with shallow respirations, and a rate of 28 breaths per minute. Upon auscultation, breath sounds were coarse. Her abdomen was soft and non-tender, no nausea or vomiting noted. The patient appeared diaphoretic, and her legs were mottled.

Laboratory and Diagnostic Testing and Results

During the initial assessment, a complete blood count (CBC), basic metabolic panel (BMP), and lactic acid level were ordered for blood work. A STAT electrocardiogram (EKG), urinalysis, and a chest X-ray were ordered to differentiate possible diagnoses. The CBC revealed leukocytosis with a white blood cell count of 23,000 and an increased lactic acid level of 4.3. The anion gap and potassium level remained within a normal limit, ruling out the possibility of diabetic ketoacidosis (DKA). The patient’s EKG showed supraventricular tachycardia (SVT). The chest X-ray revealed infiltrates to the right lung. The urinalysis was free from leukocytes or nitrites. Blood cultures were ordered to confirm their hypothesized diagnosis, septicemia.

Pharmacology

The provider initiated intravenous (IV) fluid treatment with Lactated Ringers at a bolus of 30 mL/kg. Because the patient’s heart rate was elevated, 6 mg of adenosine was ordered to combat the SVT. Additionally, broad-spectrum IV antibiotics were initiated. One gram of vancomycin and 3.375 grams of piperacillin-tazobactam were the preferred antibiotics of choice.

Final Diagnosis

Upon arrival, the providers were ruling out DKA and sepsis, given the patient’s history.

The patient’s elevated white blood cell counts, temperature, lactic acid level, heart/respiratory rate, and altered mental status were all clinical indicators of sepsis. The chest X-ray revealed a right lung infiltrate, persuading the providers to diagnose the patient with sepsis secondary to pneumonia.

Patient Management

After sepsis was ruled as the patient’s diagnosis, rapid antibiotic administration and IV fluid treatment became priority after the patient’s heart rate was controlled. A cooling blanket and a temperature sensing urinary catheter was placed to continuously monitor and control the patient’s fever. Later, the patient was transferred to a critical care unit for further treatment. Shortly after being transferred, the patient went into respiratory failure and was placed on a ventilator. After two days in the ICU, the patient remained in septic shock, and died from multisystem organ failure.

When the patient initially presented to the emergency department, accurate and rapid diagnosis of sepsis was critical in order to stabilize the patient and prevent mortality. A challenge was presented to the provider regarding a rapid diagnosis due to the patient’s history and her presenting signs and symptoms. Increased awareness and interprofessional education regarding sepsis and its’ treatment is vital to decrease mortality. Health care providers need to be competent in recognizing and accurately treating sepsis in a rapid manner.

Research shows that outcomes in sepsis are improved with timely recognition and early resuscitation (Javed et al., 2017). It is important for the provider to identify certain risk factors and symptoms to easily diagnose sepsis. A research study by Henriksen et al. (2015) proved that age, and comorbidities including psychotic disorders, immunosuppression, diabetes, and alcohol abuse served as top risk factors for sepsis.

Once the diagnosis of sepsis is determined, rapid treatment must be initiated. The golden standard of treatment consists of a bundle of care that includes blood cultures, broad-spectrum antibiotic agents, and lactate measurement completed within 3 hours as described by Henriksen et al. (2015). A study by Seymour et al. (2017) showed that the more rapid administration of the bundle of care is correlated with a decreased mortality rate. In addition, The Survival of Sepsis Campaign formed a guideline to sepsis treatment; Rhodes et al. (2016) suggests giving a 30 mL/kg of IV crystalloid fluid for hypoperfusion. If hypotension persists (mean arterial pressure <65), vasopressors, preferably norepinephrine, should be initiated (Rhodes et al., 2016). Prompt recognition of sepsis and implementation of the bundle of care can help reduce avoidable deaths.

To increase awareness, interprofessional education regarding sepsis and its’ common signs and symptoms needs to be established. Evidence-based protocols should be utilized in hospital care settings that provide nurse practitioners with a guideline to follow to ensure rapid and accurate treatment is given. Increased awareness and education helps providers and other healthcare workers to properly identify and accurately treat sepsis.

The public and health care providers must become more aware and educated on the severity of sepsis. It is crucial to be able to recognize signs and symptoms of sepsis to prevent further complications such as septic shock and multi-organ failure. Increased awareness, interprofessional education, accurate assessment, and rapid treatment can help reduce incidence and mortality. Sepsis management must focus upon early goal-directed therapy (antibiotic administration, fluid resuscitation, blood cultures, lactate level) and individualized management pertaining to the patient’s history and assessment (Head & Coopersmith, 2016). Misdiagnosis and delay in emergency treatment can result in missed opportunities to save lives.

• Head, L. W., & Coopersmith, C. M. (2016). Evolution of sepsis management:from early goal-directed therapy personalized care. Advances in Surgery, 50 (1), 221-234. doi:10.1016/j.yasu.2016.04.002
• Henriksen, D. P., Pottegard, A., Laursen, C. B., Jensen, T. G., Hallas, J., Pedersen, C., & Lassen, A. T. (2015). Risk factors for hospitalization due to community-acquired sepsis-a population-based case-control study. PLOS ONE, 10 (4), 1-12. doi:10.1371/journal.pone.0124838
• Javed, A., Guirgis, F. W., Sterling, S. A., Puskarich, M. A., Bowman, J., Robinson, T., & Jones, A. E. (2017). Clinical predictors of early death from sepsis. Journal of Critical Care, 42 , 30-34. doi:10.1016/j.jcrc.2017.06.024
• Jones, J. (2017). Managing sepsis effectively with national early warning scores and screening tools. British Journal of Community Nursing, 22 (6), 278-281. doi:10.12968/bjcn.2017.22.6.278
• Kleinpell, R. M., Schorr, C. A., & Balk, R. A. (2016). The new sepsis definitions: Implications for critical care. American Journal of Critical Care, 25 (5), 457-464. doi:10.4037/ajcc2016574
• Palleschi, M. T., Sirianni, S., O'Connor, N., Dunn, D., & Hasenau, S. M. (2013). An interprofessioal process to improve early identification and treatment for sepsis. Journal for Healthcare quality, 36 (4), 23-31. doi:10.1111/jhq.12006
• Reinhart, K., Daniels, R., Kissoon, N., Machado, F. R., Schachter, R. D., & Finfer, S. (2017). Recognizing sepsis as a global health priority-A WHO resolution. The New England Journal of Medicine, 377 (5), 414-417. doi:10.1056/NEJMp1707170
• Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Anotnelli, M., Ferrer, R.,...Beale, R. (2017). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Medicine, 43 (3), 304-377. doi:10.1007/s00134-017-4683-6
• Seymour, C. W., Gesten, F., Prescott, H. C., Friedrich, M. E., Iwashyna, T. J., Phillips, G. S.,...Levy, M. M. (2017). Time to treatment and mortality during mandated emergency care for sepsis. The New England Journal of Medicine, 376 (23), 2235-2244. doi:10.1056/NEJMoal1703058
• Tedesco, E. R., Whiteman, K., Heuston, M., Swanson-Biearman, B., & Stephens, K. (2017). Interprofessional collaboration to improve sepsis care and survival within a tertiary care emergency department. Journal of Emergency Nursing, 43 (6), 532-538. doi:10.1016/j.jen.2017.04.014

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ORIGINAL RESEARCH article

The existence of adrenal insufficiency in patients with covid-19 pneumonia.

• Department of Medicine, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand

Introduction: Infection with SARS-CoV-2 virus may result in long COVID, a syndrome characterized by symptoms such as dyspnea, cardiac abnormalities, cognitive impairment, and fatigue. One potential explanation for these symptoms is hypocortisolism.

Objective: To evaluate the prevalence of hypocortisolism in patients with a history of COVID-19 pneumonia.

Methods: Cross-sectional study of patients who were aged ≥18 years and had a 3-month history of radiography-confirmed COVID-19 pneumonia. Exclusion criteria included current or previous treatment with glucocorticoids and use of an oral contraceptive. Adrenal function was evaluated using a low dose (1ug) corticotropin stimulation test (CST). Serum cortisol levels were measured at 0, 30, and 60 minutes, and baseline plasma ACTH was also measured.

Results: Of the 41 patients enrolled, the median age was 62 years, 17 (42%) were female, and all 41 (100%) had severe pneumonia at baseline. Eleven patients (27%) had hypocortisolism, as evidenced by peak cortisol of less than 402.81 nmol/l after low dose (1 µg) CST. Of these 11 patients, 10 (91%) had secondary hypocortisolism (median ACTH 6.27 pmol/L, range 4.98–9.95 pmol/L) and one had primary hypocortisolism (mean ACTH 32.78 pmol/L). Six of the 11 patients with hypocortisolism (54.5%) reported symptoms of persistent fatigue and 5 (45.5%) required regular glucocorticoid replacement.

Conclusions: Our results suggest that hypocortisolism, predominantly caused by pituitary disruption, may emerge after SARS-CoV-2 infection and should be considered in patients with a history of COVID-19 pneumonia with or without clinical hypocortisolism.

We evaluated the low dose corticotropin stimulation test in patients with history of COVID-19 pneumonia. Our study suggested that participants with history of COVID-19 pneumonia may have adrenal insufficiency predominantly by pituitary disruption. Physicians should be aware of the hypocortisolism in these patients who present with clinical symptoms such as shock, nausea, vomiting, and fatigue.

Introduction

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China, on December 31, 2019. Since then, the disease has evolved into a global pandemic, fueled by the emergence of multiple SARS-CoV-2 variants. To date, more than 600 million confirmed cases of COVID-19 have been reported worldwide ( 1 ). The disease is primarily known for its respiratory symptoms, which range from mild cough to severe acute respiratory distress syndrome (ARDS). However, COVID-19 has also been linked to a variety of multisystemic manifestations, including cardiovascular complications, neurological sequelae, and endocrine dysfunction. In addition, many individuals with COVID-19 experience persistent symptoms, known as “long COVID,” which includes fatigue, headache, dyspnea, and brain fog lasting more than 12 weeks after the initial onset of the illness. Long COVID can involve several organ systems, including the cardiovascular, neurological, gastrointestinal, and endocrine systems ( 2 , 3 ).

Among the endocrine disorders potentially associated with COVID-19, adrenal insufficiency has gained increasing attention. Adrenal insufficiency can occur in various clinical contexts, including primary adrenal failure (Addison’s disease) and secondary adrenal insufficiency due to hypothalamic-pituitary disorders. The possible link between COVID-19 and adrenal insufficiency is multifaceted. First, the direct cytopathic effects of SARS-CoV-2 on the adrenal glands are a consideration, given the presence of angiotensin-converting enzyme 2 (ACE2) receptors ( 4 ), which are the cellular entry points for SARS-CoV-2, in adrenal cortical cells. Second, the systemic inflammatory response triggered by COVID-19, characterized by a cytokine storm and immune dysregulation, may lead to adrenal gland dysfunction through various pathways, including direct tissue damage, disruption of the hypothalamic-pituitary-adrenal (HPA) axis feedback mechanisms, and impairment of adrenal steroidogenesis ( 5 ).

During the severe acute respiratory syndrome (SARS) pandemic in 2002–2004, Leow et al. ( 6 ) evaluated the function of the hypothalamic–pituitary axis in 61 patients with SARS infection and found evidence of hypocortisolism in 40% of the cohort. The proposed mechanisms included reversible hypophysitis or direct hypothalamic damage caused by the virus. However, data on the prevalence and causes of adrenal insufficiency following SARS-CoV-2 infection are currently limited. Consequently, this study aims to evaluate the prevalence of adrenal insufficiency in adult patients who were discharged from the hospital after being diagnosed with COVID-19 pneumonia and had a 3-month history of COVID-19.

Materials and methods

Study design.

This was a cross-sectional study that enrolled consecutive patients with a history of COVID-19 pneumonia of 3 months duration at Chulabhorn Hospital, Chulabhorn Royal Academy, Thailand. The study was approved by the Human Research Ethics Committee Chulabhorn Research (Project code 140/2564) and was conducted in accordance with the Declaration of Helsinki and its amendments. All participants provided written informed consent prior to inclusion. The study was registered at the Thai Clinical Trials Registry (TCTR20220606002).

Participants

Participants were recruited from a COVID-19 cohort ward and acute respiratory unit clinic at Chulabhorn Hospital between March 1, 2022 and April 20, 2022. Eligible patients had a 3-month history of COVID-19 pneumonia and were aged ≥18 years. A diagnosis of COVID-19 was confirmed by real-time reverse-transcriptase polymerase chain reaction of SARS-CoV-2 RNA in nasopharyngeal swab specimens. The severity of COVID-19 was defined as critical, severe, and non-severe according to the World Health Organization (WHO) criteria ( 7 ). Critical COVID-19 was defined by as acute respiratory distress syndrome, sepsis shock, sepsis, or the need for life-sustaining therapies such as mechanical ventilation or vasopressor therapy. Severe COVID-19 was defined as one or more of (a) oxygen saturation <90% on room air, (b) signs of pneumonia, or (c) signs of severe respiratory distress. Non-severe COVID-19 was defined as the absence of any criteria for severe or critical COVID-19. Pneumonia was confirmed by imaging with either a chest radiograph or computed tomography (CT) of the chest. Among the exclusion criteria were comorbidity with pituitary disease or adrenal disease; unstable clinical condition; chronic kidney disease (creatinine >1.5 mg/dL); severe hepatitis (alanine aminotransferase >1.5× upper limit of normal); pregnancy or plans to become pregnant; and concurrent use of oral contraceptive pills, steroids (oral, inhaled, topical, or intra-articular), and other medications known to affect cortisol-binding globulin (including oral estrogens). Suitable subjects identified from a review of case notes were contacted in person or via the telephone.

Image analysis

COVID-19 pneumonia was confirmed by chest radiography or CT scan. CT scans were performed on the first and second day after COVID-19 diagnosis. The severity of pneumonia on CT was scored according to the COVID-19 Reporting And Data System (CO-RADS) classification using lobar-based assessment. In brief, each of the five lung lobes was subjectively scored from 0 to 5 (0, no involvement; 1, <5% involvement; 2, 6–25% involvement; 3, 26–50% involvement; 4, 51–75% involvement; 5, ≥76% involvement). The total score was the sum of the individual lobar scores and ranged from a minimum of 0 to a maximum of 25. Total scores of <7, 8–17, and 18–25 were classified as mild, moderate, and severe pneumonia, respectively ( 8 ).

Study protocol

Blood samples were collected at baseline for measurement of plasma ACTH and serum cortisol, free thyroxine (FT4), thyroid-stimulating hormone (TSH), anti-thyroglobulin (anti-Tg), and anti-thyroid peroxidase (anti-TPO). Corticotropin stimulation test (CST) were performed as described below. Participants with hypocortisolism were evaluated for potential causes other than SARS-CoV-2 infection by magnetic resonance imaging (MRI) of the pituitary gland or an adrenal CT protocol as appropriate.

Corticotropin stimulation test

Low-dose (1 µg) CST were performed between 8 am and 10 am . An intravenous catheter was inserted into an antecubital vein and 0.4 mL (1 µg) of a synthetic ACTH 1–24 solution (Synacthen ® , Novartis, Chippenham, UK) in 0.9% sodium chloride was administered through the catheter, followed by flushing with 15 mL of 0.9% sodium chloride. Blood samples were collected immediately before Synacthen injection to determine baseline ACTH and cortisol, and at 30 min and 60 min after Synacthen injection to determine the cortisol response to stimulation. A diagnosis of hypocortisolism was defined as a peak cortisol level of <402.81 nmol/L based on the new criteria for the Roche Elecsys Cortisol Generation II assay (Roche Diagnostic, Mannheim, Germany) ( 9 , 10 ). Primary hypocortisolism was defined as a baseline plasma ACTH level >2× the upper limit of the reference range ( 11 ).

Laboratory investigations

Serum cortisol and plasma ACTH were measured using automated electrochemiluminescence immunoassays (Roche Elecsys Cortisol Generation II assay and Roche Elecsys ACTH assay; Roche Diagnostic, Mannheim, Germany). For plasma ACTH measurement, blood was collected in EDTA tubes and immediately transferred to the laboratory. FT4, TSH, anti-Tg, and anti-TPO were also measured using automated electrochemiluminescence immunoassays on the Roche Elecsys system. Reference ranges were 2.86–13.86 pmol/L for plasma ACTH, 11.97–21.88 pmol/L for FT4, and 0.27–4.2 mIU/L for TSH.

Statistical analysis

The sample size calculation was based on an infinite population proportion formula ( 12 ) and previous analysis of the prevalence of hypocortisolism in SARS-CoV-2 patients ( 6 ). Data analysis was conducted using STATA/SE version 16.1 (StataCorp LP, College Station, TX, USA). Continuous data are presented as mean ± standard deviation (SD) or the median with interquartile range (IQR) as appropriate. Normally distributed continuous data were compared using a Student’s t-test for two groups or by one-way analysis of variance for three or more groups. Non-normally distributed continuous data were compared using the Mann–Whitney U test for two groups or the Kruskal–Wallis test with Dunn’s post hoc test for three or more groups. Categorical data were compared using a Chi-squared test. An analysis of weight change was conducted using analysis of covariance (ANCOVA) to compare participants with hypocortisolism to those without hypocortisolism at both baseline and the three-month follow-up. The relationship between two continuous variables was determined using Pearson’s correlation. The α level for statistical significance was set at 0.05.

Medical records of 2719 patients seen at our hospital between March 1, 2022 and April 20, 2022 were reviewed. A total of 2463 patients were excluded (182 patients <18 years of age, 2 patients were deceased, and 2279 patients had no documentation of pneumonia by radiography). The remaining 256 participants were contacted in person or by telephone and 215 declined to participate. Finally, a total of 41 patients were enrolled in the study ( Figure 1 ).

Figure 1 Study participation.

The study cohort comprised 41 patients, with a mean (SD) age of 57.1 (13.7) years. Among them, 17 (41%) were female. All of the patients had severe COVID-19 pneumonia at baseline based on the WHO criteria ( 6 ). Thirty-seven patients underwent chest CT; based on the CO-RADS system of pneumonia classification ( 7 ), 36 of the 37 patients (87.8%) had mild pneumonia and 1 patient (2.4%) had moderate pneumonia. None of the patients developed acute respiratory failure. Most patients were obese (29/41; 70.7%) and the mean body mass index (BMI) of the full cohort was 28.85 kg/m 2 . Fifteen patients (36.7%) received dexamethasone treatment for COVID-19. Of the fifteen COVID-19 patients who received glucocorticoid treatment, fourteen were administered dexamethasone at a dosage of 6 milligrams per day for a duration of 10 days. One patient received dexamethasone at a dosage of 18 milligrams per day for 5 days, followed by 6 milligrams per day for an additional 5 days. Other baseline characteristics of the study participants are shown in Table 1 .

Table 1 Baseline characteristics of the 41 study participants.

Eleven (27%) of the 41 participants showed evidence of hypocortisolism in the CST ( Figure 2 ). The mean baseline cortisol level was 198.92 ± 83.87 nmol/L, and 3 patients had baseline cortisol levels <137.95 nmol/L. Of the 11 patients with hypocortisolism, 10 (90.9%) were diagnosed with central hypocortisolism based on low-to-normal ACTH levels (median ACTH 6.27 pmol/L, IQR 4.98–9.95). The remaining patient had a plasma ACTH level of 32.78 pmol/L and was diagnosed with primary hypocortisolism. Six of the 11 patients (54.50%) reported persistent fatigue after resolution of the acute infection. Participants with hypocortisolism had nonsignificantly greater reduction in body weight compared to those without hypocortisolism (-2.00 kg, 95% CI -4.42 to 0.42 vs. 0.21 kg, 95% CI -0.37 to 0.78, p = 0.079). Only 5 of the 11 patients received corticosteroid therapy for the treatment of COVID-19 ( Table 2 ). Six of the 10 patients with secondary hypocortisolism underwent MRI of the pituitary and no abnormal lesions were found. Four patients did not perform MRI imaging due to personal reason. The patient with primary hypocortisolism underwent an adrenal CT protocol and had normal bilateral adrenal glands.

Figure 2 Corticotropin stimulation test results in patients with (n = 11) or without (n = 30) hypocortisolism.

Table 2 Clinical characteristics and laboratory values of patients with hypocortisolism (n=11).

In addition to the varied cut-off levels for hypocortisolism, we implemented a more stringent cut-off value of 345 nmol/L for the low-dose synacthen test to ensure robustness in our analysis. Despite this stricter criterion, three patients (7%) still exhibited hypocortisolism. Detailed characteristics and laboratory test results for patients numbered 2, 3, and 5 are provided in Table 2 .

Two of the 41 patients (5%) had abnormal thyroid function tests; one had iatrogenic thyrotoxicosis, and positive autoimmune thyroid antibodies. She was being treated with levothyroxine suppressive therapy for papillary thyroid cancer, and the second had subclinical hypothyroidism (thyroid-stimulating hormone 5.4 µIU/mL). Five patients (12%) were positive for anti-thyroid peroxidase or anti-thyroglobulin antibodies with normal thyroid function test. Further clinicopathological details of the study participants is provided in Supplementary Table 1

There is no statistical significance, but a trend towards more fatigue symptoms in participants with adrenal insufficiency compared to those without hypocortisolism. The odds ratio for fatigue was 3.19 (95% CI, 0.70 to 14.56), with a p-value of 0.135 in participants with hypocortisolism ( Table 3 ). Furthermore, none of the participants reported symptoms of brain fog, headache, memory problems, or muscle pain. We also performed logistic regression analysis to determine the risk factors associated with hypocortisolism in the subsets of patients with (n = 11) or without (n = 30) hypocortisolism. Increased BMI (adjusted P = 0.019) was the only significant risk factor for hypocortisolism. Age, sex, treatment modality, glucocorticoid usage, history of COVID-19 vaccination, and disease severity were not associated with hypocortisolism ( Table 3 ).

Table 3 Evaluation of risk factors for hypocortisolism by logistic regression.

The results of our study suggest that hypocortisolism is a common complication in patients with COVID-19 pneumonia, with most cases in our cohort (10 of 11 patients) manifesting as central hypocortisolism. Additionally, a significant proportion of these patients in (55%) reported clinical symptoms of long COVID, including fatigue, insomnia, and dyspnea.

The underlying mechanism of hypocortisolism in COVID-19 patients is likely to involve the ACE2 receptor, the major functional receptor for infection by both SARS-CoV and SARS-CoV-2. Indeed, ACE2 has been detected in many human tissues, including endocrine glands such as the adrenal and pituitary glands ( 13 – 16 ). ACE2 receptors mediate viral entry in concert with S glycoprotein priming by the host cell transmembrane serine protease 2 ( 13 , 14 ).

Many studies have reported cases of pituitary disruption after SARS-CoV-2 infection, including central hypocortisolism, central diabetes insipidus, hypothalamic hypogonadism, lymphocytic hypophysitis, and pituitary apoplexy. Primary hypocortisolism has also been reported in COVID-19 patients. Details of previously reported cases of pituitary dysfunction and primary hypocortisolism occurring more than 2 weeks after SARS-CoV-2 infection are shown in Table 4 ( 17 – 23 , 25 , 27 , 28 ). The findings from those studies are consistent with our own results and support the conclusion that pituitary and adrenal function may be affected by SARS-CoV-2 infection.

Table 4 Literature cases of hypothalamic–pituitary dysfunction and primary adrenal insufficiency occurring more than 2 weeks after SARS-CoV-2 infection.

In the present study, high BMI patients was significantly associated with an increased risk of hypocortisolism. This could be explained by high ACE2 expression in adipose tissue resulting in an increased viral burden, thereby increasing virus-associated damage to the endocrine glands ( 16 ). Other potential mechanisms are an increased proinflammatory phenotype associated with metabolic dysfunction and dysregulation of the renin–angiotensin pathway ( 29 ). Obesity is also an important risk factor for increased severity of COVID-19.

In our study, most of the patients with hypocortisolism exhibited non-critical COVID-19 disease severity. During the 6-month follow-up period, one patient received a daily dose of prednisolone at 5 mg, while the remaining patients received corticosteroids as needed, primarily during illness episodes.

Our study results differ from those of Clarke et al. ( 30 ) who previously found no evidence of hypocortisolism in patients with COVID-19 ( 30 ). However, the two studies differed in that we performed the CST using a low dose (1 µg) of CST whereas Clarke et al. used the standard CST (250 µg ACTH), which may have failed to detect patients with mild or early onset hypocortisolism ( 31 ). The results of our study are similar to those of Urhan et al. ( 32 ) except that the frequency of patients with hypocortisolism was higher in our study (27% vs 16.2%). This may be due to differences between the two studies in the severity and duration of COVID-19, especially because all of our study participants had severe COVID-19 pneumonia. Another difference between the two studies was that we evaluated adrenal function within 3 months of SARS-CoV-2 infection compared with the study of patients at 3–7 months post-infection by Urhan et al. ( 32 ).

A strength of our study lies in the utilization of a low cut-off value for serum cortisol (402.8 nmol/L) to define hypocortisolism, a measure that likely contributed to a decreased false-positive rate. Traditionally, the practical cut-off values for diagnosing adrenal insufficiency following standard and low-dose CST has been set at 500 nmol/L and has been widely accepted for an extended period ( 11 , 33 , 34 ). In our study, we adopted a similar approach by evaluating adrenal function using a low-dose CST, a strategy aimed at mitigating false-negative results. However, recent investigations, such as those conducted by Javorsky BR et al. utilizing the Elecsys ® Cortisol II assay, have identified a lower cut-off value of 402.8 nmol/L for diagnosing hypocortisolism following a standard dose CST ( 9 ). Furthermore, we conducted imaging studies to explore other potential etiologies of adrenal insufficiency in the majority of the 11 study participants diagnosed with hypocortisolism.

However, it is important to acknowledge certain limitations in our study. A significant limitation is the absence of a widely accepted standard cut-off value for the low-dose CST specifically for the Roche Elecsys Cortisol Generation II assay. Although we used a lower cut-off value than previously established, the cut-off value for low-dose CST should ideally be lower than that for standard CST. Accurate diagnosis of hypocortisolism relies heavily on precise cortisol cut-off values, which are inherently assay and protocol-dependent. In our study, we set the peak cortisol level cut-off at 30 or 60 minutes of the low-dose CST at 402.8 nmol/L, based on recommendations from Javorsky BR et al. and Mongioi et al. ( 9 , 10 ). However, it is worth noting that this approach may potentially lead to an overestimation of hypocortisolism diagnoses.

To address this concern, we explored alternative cut-off values suggested by Karaca Z et al. ( 35 ), which utilized different assays but employed low-dose CST. This study measured serum cortisol levels by radioimmunoassay (RIA) method and established a cut-off value of 345 nmol/L. Reassessment of our data using this cut-off revealed that three out of 41 participants (7%) remained diagnosed with hypercortisolism. Notably, all three of these participants did not receive corticosteroid treatment during COVID-19 management. As a result, eight participants exhibited cortisol levels falling within a grey zone for the diagnosis of hypocortisolism.

Due to the absence of a defined standard cut-off value for the low-dose CST by the Elecsys ® Cortisol II assay, it is conceivable that some of these participants may indeed suffer from hypocortisolism. This result underscores the urgency of determining the appropriate cut-off value for the low-dose CST using the Elecsys ® Cortisol II assay. A higher cut-off value provides more sensitivity but lower specificity, and vice versa. Therefore, further studies are urgently needed to establish an optimal cut-off value that balances sensitivity and specificity for accurate diagnosis of hypocortisolism. In addition, the sample size was small, and the study was conducted at a single center, both of which might impede the generalizability of our findings. Four participants with secondary adrenal insufficiency did not undergo MRI of the pituitary gland, which could have identified potential pituitary abnormalities. This limitation was due to the participants’ decision to decline the procedure when invited. Another limitation involves the potential for selection bias because participants may have been more inclined to join the study based on their concern about their post-COVID condition or the presence of symptoms resembling adrenal insufficiency. We made efforts to minimize this bias through formal consecutive invitations to all eligible patients, but it may still exist. Furthermore, there was no assessment of baseline pituitary (ACTH)-adrenal (cortisol) function in participants before their COVID-19 diagnosis or hospitalization. Determining whether participants had impaired function is challenging, especially during the critical phase of severe COVID-19 at presentation, which may lead to false-negative test outcomes. However, we addressed this limitation by excluding patients with a history of pituitary or adrenal disease and those concurrently using medications known to affect pituitary-adrenal function. Additionally, all study participants had severe COVID-19 pneumonia, and the results may not accurately represent patients with milder forms of the disease or critically ill patients.

Overall, the results of this study highlight the importance of monitoring for endocrine complications in patients with a history of SARS-CoV-2 infection. Further research will be needed to fully understand the underlying mechanisms of hypocortisolism following SARS-CoV-2 infection, and additional studies with larger sample sizes are needed to confirm the findings of this study and to better understand the prevalence and mechanisms of hypocortisolism in patients with COVID-19 pneumonia.

We conclude that patients with a history of COVID-19 pneumonia who present with clinical symptoms such as shock, nausea, vomiting, and fatigue should have hypocortisolism included in the differential diagnosis. These patients should also be followed over the long term to understand the persistence of adrenal insufficiency and its recovery rate. Finally, all patients who suffer from long COVID syndrome might benefit from an analysis of hypothalamic–pituitary axis function.

Data availability statement

The original contributions presented in the study are included in the article/ Supplementary Materials , further inquiries can be directed to the corresponding author/s.

Ethics statement

The studies involving humans were approved by Human Research Ethics Committee Chulabhorn Research Institute. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

TP: Conceptualization, Investigation, Methodology, Writing – original draft, Writing – review & editing. BD: Investigation, Writing – original draft. SS: Investigation, Writing – review & editing. PT: Investigation, Writing – review & editing. KT: Conceptualization, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by the Chulabhorn Royal Academy (grant number RAA 2565/032). The funding body played no role in the study design; data collection, analysis, or interpretation; manuscript writing; or the decision to submit the article for publication

Acknowledgments

The authors would like to thank the physicians, radiologists, laboratory staff, and nurses at Chulabhorn Hospital who contributed to the management of COVID-19 patients. We also thank Mullika Buttakosa for assistance conducting the study. We would like to acknowledge the assistance of ChatGPT, an AI language model developed by OpenAI, for providing valuable editing and language refinement services during the revision of this manuscript.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fendo.2024.1337652/full#supplementary-material

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Keywords: adrenal insufficiency, long COVID syndrome, COVID-19 pneumonia, hypocortisolism, low dose synacthen test

Citation: Porntharukchareon T, Dechates B, Sirisreetreerux S, Therawit P and Tawinprai K (2024) The existence of adrenal insufficiency in patients with COVID-19 pneumonia. Front. Endocrinol. 15:1337652. doi: 10.3389/fendo.2024.1337652

Received: 13 November 2023; Accepted: 12 June 2024; Published: 03 July 2024.

Reviewed by:

Copyright © 2024 Porntharukchareon, Dechates, Sirisreetreerux, Therawit and Tawinprai. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Thachanun Porntharukchareon, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Exercise and Attention-Deficit/Hyperactivity Disorder (ADHD): Emerging Research from Dr. Meghan Edmondson

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According to the National Institute for Mental Health, nearly 11 percent of children in the United States aged 5-17 have been diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD), a common neurodevelopmental disorder that results in difficulties with focused attention, impulsiveness and hyperactivity. Meghan Edmondson, Ph.D., RN, CCRN , assistant professor for Kent State University College of Nursing, studies the disorder which often persists through adolescence and into adulthood. Specifically, her research centers on improving daily life for those with ADHD, including exercise as an intervention, self-management of the disorder, and recognition of ADHD as a barrier to self-management of other chronic conditions.

Before delving into her current research exploring ADHD and the possible benefits of exercise, Edmondson developed expertise in using electronic health record data for the secondary purpose of research. In addition to her more than 13 years of experience as a critical care nurse, Edmondson’s background includes expertise with exercise science and management of large data sets. She was the lead author on the publication, “Challenges Frequently Encountered in the Secondary Use of Electronic Medical Record Data for Research,” for the journal Computers, Informatics, Nursing: CIN . For her doctoral studies, Edmondson completed dissertation research evaluating mortality and length of stay after critical care transport. Using electronic health record data from transport records, she performed a secondary data analysis to describe differences in mortality and length of stay for patients transferred to Surgical Intensive Care as opposed to other types of Intensive Care Units. She also identified factors predictive of higher mortality and longer length of stay. An article associated with her study findings, “Outcomes After Interhospital Critical Care Transfer,” is currently in press for Air Medical Journal.

Edmondson’s own personal journey with ADHD, background in exercise science and passion for helping others led to a shift in her research focus to better understand and improve ADHD symptoms, especially for emerging adults since difficulties stemming from ADHD have not been widely studied for this population. Her primary research goal is to generate clinically useful knowledge for people with ADHD and their healthcare providers, including the potential benefits of an exercise prescription. Her current study, “Effect of Low, Moderate, and High Intensity Exercise on Executive Function, Functional Impairment, and Symptom Severity in ADHD,” is designed to answer intensity-related research questions. Ultimately, Edmondson seeks to provide the right self-management tools to people with ADHD which allows them to both harness their strengths and minimize the impact of their weaknesses. In 2024, Edmondson received the competitive Kent State University Brain Health Research Institute (BHRI) Pilot Grant Program Gold Award to conduct this study with assistance by her mentorship team and lay the groundwork for future federal funding for this important area of research.

Edmondson earned her Ph.D. in Nursing from Case Western Reserve University and a Bachelor of Science in Nursing from the University of Texas Health Science Center. She also completed a Bachelor of Science in Exercise Science from the University of Houston. Edmondson currently serves as Fellow for the Healthy Communities Research Institute Grant Academy at Kent State University. Her affiliations include Children and Adults with ADHD (CHADD), as well as the Kent State University Brain Health Research Institute, Healthy Communities Research Institute and Neurodiversity Research Initiative.

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