Pneumonia introduction

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Pneumonia is an inflammation and consolidation of the lungs; that is the definition of the disease. It is a very common respiratory problem. Millions of people each year get pneumonia, and many of them need to be hospitalized. The majority of cases of pneumonia are caused by an infection from bacteria or viruses, but there are other microorganisms that can cause pneumonia such as fungi and parasites. Pneumonia is also classified by how and where it was contracted, e.g., community-acquired versus hospital-acquired.

For most people, pneumonia is a relatively serious condition, but if the infection is quickly detected and the proper treatments are done the patient will recover completely. But for some people - the very young, the very old, people who have chronic diseases or a compromised immune system - pneumonia can be dangerous. The treatment of pneumonia provides most people with an excellent chance of recovery, but it is worth knowing that many years ago pneumonia was known as “the captain of the men of death,” it is still a significant cause of illness, and in vulnerable patients it can be a potentially dangerous disease.

After completing this module the learner will be able to:
1. Identify the correct definition of pneumonia.

2. Identify the causes of pneumonia.

3. Identify the signs and symptoms of pneumonia.

4. Identify risk factors for developing pneumonia.

5. Identify how pneumonia is treated.
Precise statistics are not available, but every year approximately 4 million Americans develop pneumonia and many of them need to be hospitalized. Pneumonia is more common in men than women, and men are more likely to die from the disease, as well. The incidence of pneumonia increases with advancing age: the older someone is the more likely she/he is to develop pneumonia and to die from pneumonia. The mortality rate from pneumonia in people 80 years or older has been reported to be > 37%.

The risk of developing pneumonia is strongly associated with someone’s state of health. For example, certain diseases, chronic medical conditions, and lifestyle issues are factors that increase the likelihood that a person will get pneumonia.

Table I: Risk Factors for Pneumonia

  • Age: The very young and the elderly are very susceptible to pneumonia.

  • Aspiration: Aspiration is defined as “the movement of a foreign substance into the lungs.” When we speak of aspiration and pneumonia we are referring to gastric contents that have entered the lungs and caused an infection. People who are likely to aspirate are those who: 1) have had a stroke; 2) had a seizure; 3) had a syncopal episode (a.k.a., fainting) or; 4) have a nasogatric tube or an endotracheal tube in place. Someone who has had a stroke has had permanent damage to the gag reflex. Someone who has had a seizure or a syncopal episode has had a temporary disruption of the gag reflex. And for someone with a nasogastric or endotracheal tube the gag reflex is mechanically blocked.

  • Chronic diseases: Chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) increase the risk of developing pneumonia. Cancers, diabetes, liver disease, and renal disease increase the risk, as well.

  • Immunocompromised patients: People who have a compromised immune system cannot fight off infections and are at risk for pneumonia. People who have AIDS, people who have certain cancers, people who are receiving chemotherapy, people who are malnourished, and people who have had an organ transplant are likely to have a compromised immune system.

  • Intravascular devices: Patients who have in-dwelling intravascular devices such as a percutaneous in-dwelling central catheter (commonly called a PICC line) can develop pneumonia because the PICC line allows microorganisms access to the bloodstream.

  • Life style factors: Chronic alcohol or drug abuse and cigarette smoking increase the risk of developing pneumonia.

Learning Break: The gag reflex is a protective mechanism that prevents something from entering the throat except during voluntary swallowing. If certain parts of the oral cavity such as roof of the mouth or the back of the tongue are touched, there is a reflex action that causes gagging and expels foreign objects. The gag reflex protects the lungs from fluids or solids being aspirated.
Pneumonia is an inflammatory process that is caused by an infection with a microorganism. As mentioned in the introduction, most cases of pneumonia are caused by bacteria or viruses, and many of those microorganisms are found everywhere. Some of the microorganisms that typically cause pneumonia are listed in Table II. A microorganism that can cause an infection is called a pathogen.
Table II: Microorganisms Causing Pneumonia

  • Streptococcus

  • Haemophilus influenzae

  • Rhinoviruses

  • Coronaviruses

  • Influenza viruses

All of these are very common. They are found on the skin, in the nasal passages, in the throat and other parts of the body, and they are also in the environment. So, if these microorganisms are a natural and normal part of the body and they are commonly found in the environment, why do they cause pneumonia?

The answer has three parts. 1) the microorganism causing the infection may be particularly strong and can overcome the normal immune defenses; 2) the host’s immune defenses are compromised or deficient, or: 3) a combination of the two. Some strains of the bacteria or viruses that cause pneumonia can be more virulent, and if someone is unlucky enough to be exposed to one of these, the risk of pneumonia is relatively high. But in many cases, the host’s immune defenses are not strong enough to eliminate these microorganisms, and pneumonia can develop. Many of the risk factors listed in Table I are risk factors because they negatively affect the immune system, so this will be discussed in more detail.

Pneumonia is a disease of the lungs, and like many organs of the body the respiratory system and the lungs have defense mechanisms that protect them from infections. The nasal hairs and the mucous membranes of the nasal cavity and the bronchial passages all work to trap bacteria and viruses, and they are so effective that the great majority of microorganism never reach the lungs. Coughing and the gag reflex also help expel these pathogens. If a microorganism does escape these initial defenses and reaches the lungs, cells called macrophages literally engulf or “swallow” them and the pathogens are destroyed.

However, if there is a particularly strong bacteria or virus or if the defense mechanisms are weak, the microorganism grows and multiplies and an infection begins. In pneumonia the infection happens in the alveoli, the tiny air sacs where oxygen leaves the lung and enters the bloodstream. The infection prompts the body to initiate an inflammation. The inflammation causes consolidation, and the inflammation and consolidation are the changes that cause the signs and symptoms of pneumonia.
Learning Break: Inflammation is a normal response of the body to injury or infection. Inflammation increases blood flow to the injured or infected area, it increases the production of mucous, and it stimulates the production of pus (Note: Pus is actually white blood cells and these fight infections). The increased blood flow, the excess mucous, and the production of pus help promote healing. But in an infection in the lungs, they also block air and oxygen from moving through the alveoli. Inflammation is one of the ways the body heals itself, but if the infection is very strong and can’t be quickly resolved, inflammation itself can cause harm.
Pneumonia causes inflammation in the alveoli, the inflammation causes consolidation with increased blood flow, excess mucous, and the production of pus, and the consolidation fills the alveoli. This prevents oxygen from reaching the bloodstream because the alveoli are essentially plugged, or consolidated.
Learning Break: Pneumonia prevents oxygen from being delivered to the bloodstream and reaching the organs and tissues. This is the most important effect that pneumonia has on the body.
Inflammation and consolidation prevent oxygen from reaching the blood stream, and these effects produce the two primary signs of pneumonia: a productive cough and dyspnea - difficulty breathing. Dyspnea may be present only when the patient exerts herself/himself but it may be present at rest. The other common signs and symptoms of pneumonia are listed in Table III
Table III: Signs and Symptoms of Pneumonia

  • Cough: The respiratory passages are inflamed and filled with excess mucous and pus, and the body’s natural response to these fluids that are blocking the passage of air is a cough. Some patients who have pneumonia will have a dry cough, but most patients will bring a lot of secretions and sputum when they cough; this is called a productive cough.

  • Chills

  • Diarrhea

  • Fatigue: The body expends energy trying to fight the infection so fatigue is a common symptom.

  • Fever: A high body temperature can help destroy microorganisms.

  • Headache

  • Increased respiratory rate: Pneumonia prevents oxygen from reaching the bloodstream, so someone who has pneumonia will breathe faster and deeper.

  • Muscle pain

  • Nausea

  • Tachycardia: The body needs oxygen so the heart beats faster and pumps more blood.

  • Sweating

  • Vomiting.

  • Weakness

Learning Break: Pneumonia decreases the amount of oxygen that is delivered to the body. The brain needs a high amount of oxygen to function, and some people cannot tolerate a drop in oxygen delivery. In those people, pneumonia can cause confusion and disorientation.

Someone who has pneumonia typically feels very ill. Most people have cough, fever,

headache, and some degree of dypsnea, and approximately 20% may have gastrointestinal signs and symptoms. Hospitalization may not be necessary, but that person will not be able to work and his/her level of activity will be significantly compromised: in simpler terms she/he will feel terrible and won’t be able to get out of bed. In most cases, the infection is localized to the lungs, it is treatable with antibiotics, and supportive care, and the patient recovers. Approximately 80% of cases of community-acquired pneumonia can be managed at home.

However, pneumonia can be a serious and even fatal disease. The risk factors listed in Table I that increase the chances of developing pneumonia also make pneumonia more dangerous once it develops. In addition, some of the chronic diseases can be made worse by pneumonia: a person with COPD is chronically oxygen deprived and cannot tolerate a decrease in oxygen supply. So, there are special populations that are more likely to be seriously affected by pneumonia.
Table IV: Diseases and Life Style Issues and Pneumonia

  • Alcoholics: People who chronically abuse alcohol are often malnourished, and they often have compromised immune systems. They are more likely to smoke cigarettes, and they are more likely to have chronic diseases such as COPD, diabetes, and liver disease that will make case of pneumonia more serious.

  • Cigarette smokers: Cigarette smoking injures the lungs and because of that the lung tissue is more easily affected by an infection. Cigarette smoking also damages the local defense mechanisms in the lung, so an infection is more likely to develop and to remain.

  • COPD and heart disease: The issue of COPD and pneumonia was previously discussed. Patients who have cardiovascular disease are less able to tolerate pneumonia because the lack of oxygen demands extra work from the heart and the vascular system. Also, COPD, like cigarette smoking, injures the lungs and affects the local defense mechanisms in the lungs.

  • Diabetics: Diabetics are four times more likely to develop pneumonia than people who do not have diabetes and they are two to three times more likely to die from pneumonia.

  • Elderly: As we age, our immune systems become less effective. Elderly people are also more likely to have chronic diseases.

  • HIV/AIDS: A person with HIV/AIDS often has a very compromised immune system. These people are also more likely to develop complications from pneumonia.

  • Infants: Children who are three months old or younger do not have a fully developed immune system. They cannot protect themselves very well from infections once an infection has started, and they are also more likely to get an infection than an older child or an adult.

These special populations need close monitoring and may need hospitalization if pneumonia develops. The treatment for these patients would be the same as for a patient managed at home: antibiotics, fluids, rest, and supportive care. Some patients may need supplemental oxygen and in very severe cases, the patient will need intubation and mechanical ventilation and admission to intensive care.

The biggest risk in a severe case of pneumonia or if a patient who has pneumonia is an alcoholic, diabetic, elderly, etc. is sepsis. Sepsis is defined as an infection that has entered the bloodstream and caused a massive, widespread inflammation. Sepsis is a very serious condition: the mortality rate of severe sepsis is almost 30%. Patients who have pneumonia and have sepsis are usually cyanotic, they have a very high fever, and they are hypotensive and tachycardic.
Pneumonia can be classified by the microorganism that is causing the inflammation: bacterial and viral are the most common types, and fungi and protozoa are relatively unusual.

Pneumonia can also be classified by where it was acquired. The classification of pneumonia in this way recognizes three different types of the disease: 1) community-acquired; 2: hospital-acquired, and; 3) ventilator-acquired.

Community-Acquired Pneumonia
Community-acquired pneumonia is the most common form of pneumonia. This form of pneumonia can affect anyone, although some people are obviously more at risk. Approximately 80% of all people with community-acquired pneumonia have a bacterial pneumonia. Community-acquired pneumonia can affect anyone, but it is more likely to occur in people who have the risk factors listed in Table I.

Hospital-Acquired Pneumonia
Hospital-acquired pneumonia is similar to community-acquired pneumonia in many ways. The patients have a fever, chills, fatigue, and most cases are caused by bacteria. But hospital-acquired pneumonia is usually more severe for several reasons. The microorganisms that cause the bacteria are usually stronger than the ones that cause community-acquired pneumonia, and hospitalized patients are more likely to be elderly, they are more likely to be at risk for aspiration, and they are more likely to have risk factors that can increase the seriousness of the disease.
Ventilator-Acquired Pneumonia
Ventilator-acquired pneumonia is simple a hospital-acquired pneumonia that has occurred to a patient who is being mechanically ventilated. The primary difference between these two forms of the diseases is that the mortality rate is much higher for ventilator-acquired pneumonia.
Someone who has pneumonia typically experiences chills, headache, fever, fatigue, and sweating. But the common cold and influenza (the flu) are two common respiratory illnesses, and they share many of the same signs and symptoms. How is it possible to know if this clinical picture is caused by a case of the flu or represents pneumonia?

Distinguishing between a cold and the flu or a cold and pneumonia is relatively simple. The common cold does not cause a fever, most people do not have a cough, and the signs and symptoms are much less severe.

Determining if someone has the flu or pneumonia is more difficult. Both influenza and pneumonia can cause a high fever, and the signs and symptoms of influenza are basically the same. However, pneumonia will cause a productive cough, but influenza will not. Also, the signs and symptoms of pneumonia are typically more severe than a case of influenza. It is not always possible to decide if someone has influenza or pneumonia by examining the patient and taking vital signs. Some times the only way to be sure is by obtaining a chest x-ray (CXR).
The microorganisms that cause pneumonia are everywhere, and the risk factors that increase someone’s chances of developing pneumonia are very common. Most young, healthy people do not develop pneumonia. But there are many people who can be in danger of developing pneumonia, and preventing pneumonia in this population is obviously much better than treating it. Fortunately, there are steps that can be taken to prevent pneumonia.

The first step is to get vaccinated. The pneumonia vaccine, the pneumococcal polysaccharide vaccine (PPSV), can be effective protection against pneumonia. The vaccine is a simple injection with minimal side effects. It should be given to people ages 2 to 64 that have risk factors such as cancer, cigarette smoking, diabetes, heart disease, HIV/AIDS, or an organ transplant. The influenza vaccine should also be given to vulnerable people. This will prevent someone from developing the flu. Influenza itself may predispose someone to pneumonia, and the influenza virus itself can cause pneumonia, as well.

The second step is to avoid situations in which contracting pneumonia may be likely. If someone has a lot of risk factors for developing pneumonia they should try and avoid day care centers, hospitals, and crowded public places where close contact with other people can’t be avoided: an example would be a subway or a bus.

The third step is to practice good hygiene, and for pneumonia good hygiene means handwashing. Handwashing is the most important infection control technique. Pneumonia and other illnesses such as the flu can transmitted by infected droplets that are coughed out or exhaled from someone who has pneumonia. These droplets settle on surfaces such as computer keyboards, doorknobs, and telephone receivers. Hand-to-mouth contact can then transmit the infect droplets to anyone who has touched the surface

How dangerous is pneumonia? The simplest and most accurate answer is: it depends.

Young, healthy people who do not have risk factors can stay at home and with the proper care they will recover in two weeks or so. Antibiotics and supportive care will be given, the patient’s own immune system will be mobilized and help fight the infection, and the patient will recover.

Elderly people or people who will have difficulty fighting the infection may take a month or more to recover, and some may need to be hospitalized. The mortality rate for people who are treated as out-patients is less than 1%; for people who are hospitalized the mortality rate is approximately 10%.
Learning Break: The mortality rates for pneumonia reflect the rates for all people who have pneumonia, and that fact can make those figures misleading. Example: The mortality rate for people who have pneumonia but stay home is less than 1% but for people who are age 75 or older is much higher. For people who are age 25 or younger the mortality rate is much lower than less than 1%.
There are two basic goals for treating someone who has pneumonia: 1) treat the infection, and; 2) treat the signs and symptoms. Treating the infection will destroy the microorganism that is causing the pneumonia. Treating the signs and symptoms will make the patient more comfortable, it will prevent complications, and it will allow the patient’s natural defense mechanisms to operate.
Treating the Infection
Antibiotics are used to treat pneumonia that is caused by bacteria. Antibiotics can be given orally or IV. Oral antibiotics take a little longer to act than IV, and the blood levels of oral antibiotics take a little longer to reach their peak than IV, so people who are hospitalized will usually receive IV antibiotics.

The choice of antibiotics will depend on what microorganism is responsible for the pneumonia. Many times that the physician will not know this or it would be impractical to find out. In those cases, antibiotics will be used that are effective against the bacteria that is the likely cause; this is called empirical therapy.

Antibiotics will not be effective if the pneumonia is caused by a virus; antibiotics are only effective against bacteria. However, if the physician suspects that a pneumonia is caused by the influenza virus, anti-viral drugs such as Amantadine or Tamiflu® may be prescribed.
Treating the Signs and Symptoms
Treating the signs and symptoms of pneumonia is commonly called symptomatic-supportive-care. Symptomatic-supportive care consists of: 1) rest; 2) nutrition; 3) fluids; 4) oxygen; 5) anti-pyretics, and; 6) over-the-counter medications.

Rest is often overlooked as a therapy, and patients and health care professionals may not appreciate how helpful rest can be. But the more active we are, the more oxygen our bodies need, and pneumonia is decreasing the amount of oxygen that is delivered to the body. The body works hard to fight and infection and the need for oxygen is high, so any unneeded activity will not be helpful. Rest allows oxygen to be delivered to the tissues and organs, oxygen is essential for healing, and oxygen helps the immune system control and eliminate the infection.

Nutrition is another aspect of symptomatic-supportive care that may be overlooked. But fighting an infection takes energy, and good nutrition is also essential for proper functioning of the immune system.

Adequate fluid intake is very important for someone who has pneumonia. Fever is causes sweating and loss of fluids. Diarrhea and vomiting are less common than fever, but they do occur and are another source of fluid loss. Maintaining normal fluid levels allows for the immune system to function and it helps the patient feel comfortable. Good hydration also helps loosen secretions, so the patient is better able to cough them up. If you are caring for a patient who has pneumonia, make sure that person stays well hydrated and keep an accurate record of his/her intake and output.

Anti-pyretics are medications that are used to lower fever. Acetaminophen and ibuprofen are very effective for temperature control. Either one can be used, but acetaminophen is preferred because it has fewer potential side effects than ibuprofen and it is better tolerated for most patients than ibuprofen. It is very important to stay within the dosing guidelines for acetaminophen; excess doses can cause liver damage.
Learning Break: Fever is often the most dramatic sign of pneumonia or any infection. But fever itself is not dangerous, and a fever is the body’s natural response to infection. A fever is uncomfortable for the patient, but it’s possible that a fever may help fight the microorganisms that are causing the pneumonia, and there is no evidence that lowering a fever helps patients recover more quickly from an illness. So, fever control is helpful, but antibiotics are far more important.
People who have pneumonia and are managed at home will seldom need oxygen, but supplemental oxygen is often prescribed for hospitalized patients who have pneumonia. Oxygen delivery is decreased by pneumonia, and some patients cannot tolerate this. There are many ways oxygen can be delivered; one of the most common and one that is relatively comfortable is the nasal cannula. It should always be remembered that oxygen is, essentially, a drug. Oxygen can only be given if it is ordered by a physician, and the amount of oxygen the patient receives should never be decreased or increased unless a physician has given specific directions for this.

There are literally 100s of over-the-counter cold and cough products. They can contain acetaminophen, an antihistamine, a cough suppressant, or a decongestant, and there are many combinations of these four ingredients that are available.

The over-the-counter cold and cough medications can relieve some symptoms of pneumonia. However, the symptom relief is usually brief and these products will not decrease the length of time someone is sick; they are not a cure. The cough and cold medications can also easily be overused. Because they are available without a prescription, many people have the impression that they are harmless. But if excess doses are taken, these ingredients - the acetaminophen, the antihistamines, the decongestants, etc. - can cause serious harm, and they can have dangerous interactions with prescription medications, as well. So, if they are used correctly they might make someone feel a little bit better for a short period of time, but it is worth noting that the American Academy of Pediatrics has officially recommended against their use for children. Rest, good nutrition, and lots of fluids are safer and probably more effective for providing symptom relief.
Pneumonia is caused by an infection, and the infection is typically from common microorganisms that are found everywhere. Is pneumonia contagious? Does someone who has pneumonia need to be placed in isolation? If you are caring for someone who has pneumonia, do you need to wear a face mask or a respirator?

The answer to the first question is yes; pneumonia is contagious. However, unless the pneumonia is caused by one of several specific microorganisms, pneumonia is not spread through the air. Pneumonia can be contracted by hand-to-mouth contact of infected droplets that are in the environment, but transmission of pneumonia through the air is not the norm. So, isolation is not needed. Unless a physician or an infection control specialist has ordered otherwise, face masks or respirators are not needed when caring for a patient who has pneumonia.

Standard precautions, however are always needed and especially when you are caring for a patient who has an infection. Standard precautions are the basic infection control techniques that are mandatory when providing patient care. This module will not discuss standard precautions in detail, but the critical points to remember about standard precautions are:

  • Handwashing is the most effective way of preventing the infections from spreading patient to patient. Handwashing should always be done before and after performing patient care, even if wearing gloves. Handwashing should also be done if there has been contact with any body fluid or secretion. Handwashing can be done with soap and water or an alcohol-based hand sanitizer.

  • All body fluids and secretions should be considered contaminated and must be handled and disposed of properly.

  • Personal protective equipment (PPE) should be worn if there is a risk, or there might be a risk of contact with body fluids. Personal protective equipment includes disposable gloves, gowns, foot covers, face masks, and hair covers: which of these to wear depends on the situation. All PPE is single-use and disposable.

  • Healthcare personnel, visitors, and other patients who have contact with someone who has pneumonia should practice cough etiquette. The mouth should be covered when coughing or sneezing, handwashing should be done after coughing or sneezing if the hands were used to cover the mouth, and disposable tissues should be readily available. If someone who is coughing must have contact with a patient who has pneumonia, that person should wear a disposable face mask.

Most patients who have pneumonia will recover. However, if someone who is particularly vulnerable has a severe case of pneumonia, a fatality is possible. If you are caring for a patient who has pneumonia, the warning signs listed below in Table V indicate that the patient is seriously ill. If any of these are present, a physician or a supervisor should be notified immediately.
Table V: Warning Signs

  • Very high fever

  • Pulse greater than 100 beats a minute.

  • Respiratory rate greater than 20 breaths a minute.

  • Hypotension: Systolic blood pressure less than 100 mm Hg

  • Cyanosis. The best places to look for cyanosis are the nail beds, the tips of the fingers and toes, and the patient’s face and lips.

  • Confusion or disorientation

Pneumonia is a very common respiratory illness. It is defined as an inflammation and consolidation of the lungs. As the pneumonia develops and progresses, the alveoli fill with fluid, mucous, and pus; this is the consolidation, and it interferes with oxygen moving through the lungs and into the bloodstream.

The great majority of pneumonias are caused by common microorganisms, bacteria and viruses that are found everywhere in the environment and on our bodies. Infections with these microorganisms are common, but if the bacteria are very virulent and/or the person is vulnerable, pneumonia can develop. Most pneumonias are caused by bacteria.

Anyone can get pneumonia, but some people are especially susceptible because of risk factors. These risk factors are: 1) the very young or very old; 2) aspiration; 3) chronic diseases; 4) compromised immune system; 5) an in-dwelling IV device, and; 6) life style factors. These risk factors increase someone’s chances of developing pneumonia, and they also increase the risk that someone will have a serious case of pneumonia and develop complications. There is a pneumonia vaccine available. This vaccine, the influenza vaccine, and good hygiene can help prevent someone from getting pneumonia.

Someone who has pneumonia will have chills, dyspnea, fever, a productive cough, and other signs and symptoms. The primary symptoms of pneumonia are a productive cough and dyspnea. Many of the signs and symptoms of pneumonia are also present in people who have influenza or a cold. Colds are usually much less severe, but at times a CXR is needed to distinguish a bad case of the flu from pneumonia. Most people who have pneumonia will recover, but pneumonia can be dangerous in vulnerable populations.

Pneumonia is treated with antibiotics and symptomatic-supportive care. Antibiotics will only be effective if the pneumonia is caused by bacteria; they will not be effective against viruses. Symptomatic-supportive care consists of rest, fluids, nutrition, supplemental oxygen, anti-pyretics, and over-the-counter cough and cold preparations. Most patients who have pneumonia do not need to be in isolation, and a face mask or a respirator is not needed. However, standard precautions and cough etiquette should always be used; these will protect other patients and the healthcare staff.

  • Pneumonia is an inflammation and consolidation of the lungs.

  • The consolidation prevents oxygen from moving through the lungs to the bloodstream.

  • A productive cough and dyspnea are the primary symptoms of pneumonia.

  • Pneumonias are usually caused by bacteria or viruses.

  • There are risk factors that increase someone’s chance of developing pneumonia.

  • The risk factors also increase the chances of pneumonia being serious and causing complications.

  • The most serious complication of pneumonia is sepsis.

  • Pneumonia is treated with antibiotics and symptomatic-supportive care.

  • Standard precautions and cough etiquette should always be used when caring for a patient who has pneumonia.

  • If the patient develops a high fever, confusion/disorientation, cyanosis, hypotension, a rapid respiratory rate, or tachycardia, a physician or a supervisor should be notified immediately.

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