Pneumonia: recognition, care and deterioration

Pneumonia is an infection of the lung tissue itself, so it is recognised by the consolidation it produces and the work of breathing it costs rather than by fever alone -- a cough that may or may not be productive, purulent sputum, pleuritic chest pain, breathlessness with a respiratory rate that has climbed, crackles or bronchial breathing with dullness to percussion over the affected area, and hypoxaemia -- while in the frail and in the older patient the same infection often arrives without fever and with little cough, showing instead as new confusion, a fall, weakness, loss of appetite or an underlying condition that has suddenly worsened, so a change in mental state is worked up as a possible chest infection rather than accepted as the patient's baseline; the diagnosis is that clinical picture together with an infiltrate on chest imaging, and how ill the patient is -- judged on the respiratory rate, the oxygen saturation, the blood pressure, the mental state and whether any organ is failing, not on the temperature -- is what sets the level of care and how closely the patient is watched; the nursing care is the breathing and the secretions, so the patient is given oxygen titrated to the target range, sat upright, encouraged to breathe deeply, to cough and to use an incentive spirometer, mobilised early rather than rested flat, kept hydrated so the secretions stay thin enough to clear, given analgesia for the pleuritic pain so that pain does not splint the chest and abolish the cough, and fed and allowed to rest between activities because breathing this hard costs more than it appears to; the cultures that are indicated are taken but the first antibiotic dose is not held waiting for them, every later dose is given on time, and the prescribed course is completed even though the patient feels well long before it ends; and throughout, the nurse watches for the infection outrunning the lung -- a respiratory rate and an oxygen requirement that keep climbing, new or deepening confusion, a falling blood pressure with a rising heart rate, a falling urine output, a chest that has gone quiet, or simply a patient who has not improved on treatment -- because pneumonia turns into respiratory failure, sepsis, a pleural effusion or an empyema in patients whose chart still records that the antibiotics are running.