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Pneumonia 1: recognising risk, Signs and symptoms

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This is a two-part unit on pneumonia. The first part explores the common signs and symptoms of pneumonia, and also explains how nurses can identify those with a high risk of acquiring the infection. In addition, part 1 outlines the signs and symptoms of sepsis and the criteria for a diagnosis of systemic inflammatory response syndrome (SIRS).

 

Learning objectives

1. List the common signs and symptoms of pneumonia.

2. Identify patients who are at high risk of acquiring pneumonia.

AUTHOR

David Watson, BA Nursing, PGD Critical Care, SPQ Critical Care, Dip Nursing, is charge nurse, hospital emergency care team, Monklands Hospital, Airdrie.

 

ABSTRACT

Watson, D. (2008) Pneumonia 1: recognising risk, signs and symptoms. Nursing Times; 104: 4, 28–29.

Nationwide, the number of acute admissions to hospital is ever increasing (Unscheduled Care Collaborative, 2005). Within this patient group, respiratory disease is found to be a major cause of acute admission, with a proportion of these patients having pneumonia. Due to the nature of the disease, cases tend to peak in the middle of winter, placing added stress on an already resource-stretched NHS.

The incidence of pneumonia is frequently underestimated in clinical practice. However, it can very quickly compromise patients’ health and result in admission to critical care areas or even death. Not all cases of pneumonia require hospital admission but they should be monitored closely, with both ends of the age spectrum being the most vulnerable.

For those patients who do need hospital admission, they will on average stay for longer than one week. Of those patients, approximately 10% will require admission to a critical care or intensive care department. If the infection is left untreated, it carries a mortality rate of over 30%.

Causes
There are several causes of pneumonia developing in patients. Pneumonia is defined as inflammation in the bronchioles and the alveoli. The alveoli become filled up with secretions and mucus, limiting gas exchange and, depending on the severity, resulting in hypoxia. Depending on the literature, pneumonia may be classified under two broad terms. These are: the site/area of the lung affected (such as lobar or bronchial); and the other is based on the causative organism (Macfarlane et al, 2000).

There are many organisms that can cause pneumonia – these are viral, bacterial or fungal in nature. Pneumonias of a fungal nature tend to affect those patients who are immuno-compromised. In clinical practice this will be patients who are neutropenic and have succumbed to fungal infection.

Viral pneumonia results in the development of inflammation, which spreads to the alveoli, whereas bacterial pneumonia results in the breakdown of the alveolar/capillary membrane. Bacterial pneumonia is the cumulative effect of invasion by pathogens – this may be an acutely isolated event or as the end point of another chronic disease process.

Community-acquired and hospital-acquired pneumonia
Community-acquired pneumonia and hospital-acquired pneumonia are alternative terms used to categorise the infection. Pneumonia is classified as community-acquired if signs and symptoms are present on admission or within the first 48 hours. Annually, one person per 1,000 of the population is admitted with community-acquired pneumonia, which carries a mortality rate of 10% (Royal College of Surgeons, 2004).

From these categories, there are organisms that are more likely to cause the infection. The most common cause of community-acquired pneumonia is Streptococcus pneumoniae (Royal College of Surgeons, 2004), with other possible causative agents being chlamydia or Mycoplasma pneumoniae.

Hospital-acquired pneumonia is the classification given to pneumonias that develop after 48 hours in hospital or within 10 days of discharge from hospital. These are common post-operatively and have a 25–50% mortality rate. These are more
likely to be attributed to Gram-negative organisms or staphylococci, which have the potential to be serious (Royal College of Surgeons, 2004).

Risk factors
There are a variety of patients who are at risk of developing a chest infection. Patients with pre-existing disease such as renal impairment or diabetes are at risk from infection. For these patients, it is advisable that they receive flu vaccinations offered on at least a yearly basis. Those patients with known asthma or COPD should also be advised to be cautious.

Those patients who are immuno-compromised (HIV-positive patients, transplant patients and the very young) are also at risk and should be nursed carefully to minimise exposure to infection (Bellamy, 2006). Patients with a history of alcohol and substance misuse or who have poor nutritional or physical health are at risk of aspiration pneumonia, which may occur during periods of unconsciousness, as are patients who have a seizure. Aspiration pneumonias can be troublesome and require aggressive treatment.

Patients who are intubated (have a tracheal tube placed in their trachea) are at risk of pneumonia if infection control measures are not strictly adhered to. The normal process of breathing helps prevent the entry of bacteria. The nasal passages help filter out the larger particles, with smaller particles, with smaller particles eliminated by coughing and sneezing. For those very small particles that manage to enter the lungs, they are usually trapped in the mucous layers. Due to the nature of ventilation via an endotracheal tube, this safety mechanism is bypassed and bacteria may enter the alveoli (Woodrow and Roe, 2003; Zack et al, 2002).

Presentation
As with all clinical conditions, the presentation may vary from patient to patient, and be influenced by pre-existing disease processes, age and general health. It is important not to assume that only the very young and very old die from pneumonia. It can also be life-threatening in other age groups. The various signs and symptoms are summarised in box 1.

The severity of pneumonia can be classified using the CURB-65 score, which will be discussed in part 2 of this
unit. However, the presence of other existing diseases should also be taken into consideration.

When caring for patients with pneumonia or any other type of infection, practitioners should always be vigilant for the development of sepsis/systemic inflammatory response syndrome (SIRS), with the underlying source likely, but not always, the chest. For those patients who go on to develop severe sepsis, the mortality rate is drastically increased (Laterre et al, 2005). The signs of sepsis are:

  • Hypotension;
  • Tachycardia;
  • Pyrexia;
  • Oliguria;
  • Dizziness;
  • Confusion;
  • Peripheral vasodilation;
  • Hypothermia;
  • Ischaemia;
  • Tachypnoea;
  • Metabolic acidosis;
  • Cough;
  • Hypoxia;
  • Rash;
  • Pallor;
  • Erratic blood glucose levels;
  • Sweats;
  • Rigors;
  • Dyspnoea;
  • Vomiting;
  • Diarrhoea.

Patients must have at least two criteria from Box 2 to be labelled as having SIRS.

Conclusion
Pneumonia is a potentially serious and sometimes life-threatening condition. It carries a significant mortality rate, especially in vulnerable or at-risk patients. Those who are at risk should be offered preventive treatment if appropriate, such as vaccination. Healthcare professionals caring for at-risk groups in hospital should ensure that patients are nursed carefully to minimise exposure to infection.

It is vital that nurses are aware of the signs and symptoms of pneumonia, to facilitate early diagnosis and interventions. They should also know the signs and symptoms of sepsis, and understand the criteria for SIRS.

Part 2 of this unit, which discusses nursing management of pneumonia, will be published in next week’s issue.

Box 1: Signs an symptoms of neumonia
Hypoxia
Confusion Tachycardia Hypotension
Hypo-resonance Cyanosis
Pyrexia
Chest pain
Nausea
Malaise
Myalgias
Dyspnoea
Wheeze
Pleural rub
Cough
Tachypnoea Bradycardia Sweating
Flushed
Vomiting
Source: Ramrakha and Moore (1999)
Portfolio Pages can be filed in your professional portfolio as evidence of your learning and professional development. They contain learning activities that correspond to the learning objectives in this unit, presented in a convenient format for
you to print out or work through on screen.

 

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