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INTRODUCTION

Pneumonia is an inflammation or infection of the lungs most commonly


caused by a bacteria or virus. Pneumonia can also be caused by inhaling
vomit or other foreign substances. It also refers to the consolidation or
solidification of the air sacs with the inflammatory exudates. The pulmonary
alveoli, bronchioles and the smaller bronchi are with inflammatory cells. In all
cases, the lungs' air sacs fill with pus , mucous, and other liquids and
cannot function properly. This means oxygen cannot reach the blood and the
cells of the body.
Most pneumonia is caused by bacterial infections. The most common
infectious cause of pneumonia in the United States is the bacteria
Streptococcus pneumoniae. Other bacteria, as well as certain viruses, may
also cause pneumonia. Since these infections may not cause all of the classic
pneumonia symptoms, they are often called "atypical
pneumonias."Aspiration (or inhalation) pneumonia is a swelling and
irritation of the lungs caused by breathing in vomit, fumes from such
chemicals as bug sprays, pool cleaners, gasoline, or other substances. This
kind of pneumonia cannot be spread to other people.
10 facts about pneumonia in children
The International Union Against Tuberculosis and Lung Disease
68, boulevard Saint-Michel, 75006 Paris, France union@iuatld.org
http://www.iuatld.org tel: (+33) 1 44.32.03.60 fax: (+33) 1
43.29.90.87
Pneumonia kills more people than any other condition affecting the lungs;
it is a prime cause of death in young children.
10 to 12 million deaths occur annually in children under 5 years of age;
over 90% are in the developing world.
More than 3 million (28% of all deaths) are attributable to acute
respiratory
infections (ARI).
The largest part of these ARI deaths are due to severe and very severe
pneumonia,
the majority of which are curable with cheap, effective antibiotics.
It is small children less than one year of age - living in the poorest
communities
who most often suffer and die from this condition.
In developing countries pneumonia is 5 times more common, and the
death rate is
10 to 50 times higher, than in developed countries.
Pneumonia is often a result of other infections such as measles and
pertussis.

The frequency of pneumonia in children could be reduced by 10-20%


through immunization with these vaccines. Many developing countries have
very low immunization rates due to funding and delivery problems.
Important reductions could be achieved through immunization with the
new vaccines against the two most common causes of bacterial pneumonia
in children but they are too expensive for most developing countries.
The ways and means are available to reduce this enormous problem and
yet it remains stubbornly unresolved. This is primarily because those
affected are the most vulnerable with the least access to the advantages
provided by modern health care.
The ability to reach these vulnerable individuals is a challenge rarely solved.
The International Union Against Tuberculosis and Lung Disease (IUATLD)
has achieved success in addressing similar challenges in the management of
tuberculosis.

Nice To Know:
Pneumonia can also be defined by how much
of the lung is involved.
In
lobar Pneumonia:
pneumonia, one section (lobe) of
Facts
about
a lung is affected.
Pneumonia is a serious illness that
affects
one out
of every (or
100 people each
In
bronchial
pneumonia
bronchopneumonia), patches throughout
both lungs are affected.

year.

Pneumonia can be caused by bacteria or


viruses, or by inhalation of vomit or
certain chemicals.

There are about 30 different causes of pneumonia. However, they all fall into
one of these categories:

Infective pneumonia: Inflammation and infection of the lungs and


bronchial tubes that occurs when a bacteria (bacterial pneumonia) or
virus (viral pneumonia) gets into the lungs and starts to reproduce.
Aspiration pneumonia: An inflammation of the lungs and bronchial
tubes caused by inhaling vomit, mucous, or other bodily fluids.
Aspiration pneumonia can also be caused by inhaling certain
chemicals.

Bacterial pneumonia can attack anyone. The most common cause of


bacterial pneumonia in adults is a bacteria called Streptococcus
pneumoniae or Pneumococcus. Pneumococcal pneumonia occurs only in
the lobar form.
An increasing number of viruses are being identified as the cause of
respiratory infection. Half of all pneumonias are believed to be of viral origin.
Most viral pneumonias are patchy and the body usually fights them off
without help from medications or other treatments.
Pneumococcus can affect more than the lungs. The bacteria can also cause
serious infections of the covering of the brain (meningitis), the
bloodstream, and other parts of the body.
Nice To Know:
The viruses and bacteria that cause
pneumonia are contagious and are usually
found in fluid from the mouth or nose of an
infected person. Pneumonia can spread by
coughs and sneezes, by sharing drinking
glasses and eating utensils with an infected
person, and contact with used tissues or
handkerchiefs.
Handwashing is important when around a

person with pneumonia, since the bacteria and


viruses can also be spread to your hands and
then to your mouth.
Inhaling vomit, irritating fumes, or other substances can result in aspiration
pneumonia. Agents such as petroleum solvents, dry cleaning fluid, lighter
fluid, kerosene, gasoline, and liquid polishes and waxes are the most likely
causes. Pulmonary edema, or fluids in the lung from injury, can develop
rapidly. With repeated exposure, the lungs may lose elasticity and small
airways may become obstructed. This can lead to increased reactive airway
disease and chronic lung disease in adults.

Nice To Know:
Although most cases of pneumonia are caused
by a viral or bacterial infection, the disease
can also be caused anything that obstructs the
bronchial tubes. Tumors, peanuts, hard
candies, or small toys in the bronchial tubes
can trap bacteria, viruses, or fungi, resulting in
pneumonia.

The incubation period last from 1-3 days with sudden onset of shaking chills,
rapidly raising fever and stabbing chest pain aggravated by coughing and
respiration.It can be transmitted through (a)Droplet infection from the
mouth and nose of an infected person via the nasopharynx intimate contact
with carrier and (b)Indirect contact by contaminated objects is possible,

systemic infection inhalation of caustic or toxic chemicals, and aspiration of


food, fluids or vomitus.

Anatomy &
Physiology of the
Respiratory
System
The respiratory system is situated in
the thorax, and is responsible for
gaseous exchange between the
circulatory system and the outside
world. Air is taken in via the upper

airways (the nasal cavity, pharynx and larynx) through the lower airways
(trachea, primary bronchi and bronchial tree) and into the small bronchioles
and alveoli within the lung tissue.
The lungs are divided into lobes; The left lung is composed of the upper
lobe, the lower lobe and the lingula (a small remnant next to the apex of
the heart), the right lung is composed of the upper, the middle and the
lower lobes.
Mechanics of Breathing
To take a breath in, the external intercostal muscles contract, moving the
ribcage up and out. The diaphragm moves down at the same time, creating
negative pressure within the thorax. The lungs are held to the thoracic wall
by the pleural membranes, and so expand outwards as well. This creates
negative pressure within the lungs, and so air rushes in through the upper
and lower airways.
Expiration is mainly due to the natural elasticity of the lungs, which tend to
collapse if they are not held against the thoracic wall. This is the mechanism
behind lung collapse if there is air in the pleural
space (pneumothorax).
Physiology of Gas Exchange

Each branch of the bronchial tree eventually subdivides to form very narrow terminal bronchioles,
which terminate in the alveoli. There are many
millions of alveloi in each lung, and these are the areas responsible for
gaseous exchange, presenting a massive surface area for exchange to occur
over.
Each alveolus is very closely associated with a network of capillaries
containing deoxygenated blood from the pulmonary artery. The capillary and
alveolar walls are very thin, allowing rapid exchange of gases by passive
diffusion along concentration gradients.
CO2 moves into the alveolus as the concentration is much lower in the
alveolus than in the blood, and O2 moves out of the alveolus as the
continuous flow of blood through the capillaries prevents saturation of the
blood with O2 and allows maximal transfer across the membrane.
How do the lungs normally work?

The chest contains two lungs, one lung on the right side of the chest, the
other on the left side of the chest. Each lung is made up of sections called
lobes. The lung is soft and protected by the ribcage. The purposes of the
lungs are to bring oxygen (abbreviated O2), into the body and to remove
carbon dioxide (abbreviated CO2). Oxygen is a gas that provides us energy
while carbon dioxide is a waste product or "exhaust" of the body.
How do the lungs protect themselves?
The lungs have several ways of protecting themselves from irritants. First,
the nose acts as a filter when breathing in, preventing large particles of
pollutants from entering the lungs. If an irritant does enter the lung, it will
get stuck in a thin layer of mucus (also called sputum or phlegm) that lines
the inside of the breathing tubes. An average of 3 ounces of mucus are
secreted onto the lining of these breathing tubes every day. This mucus is
"swept up" toward the mouth by little hairs called cilia that line the breathing
tubes. Cilia move mucus from the lungs upward toward the throat to the
epiglottis. The epiglottis is the gate, which opens allowing the mucus to be
swallowed. This occurs without us even thinking about it. Spitting up sputum
is not "normal" and does not occur unless the individual has chronic
bronchitis or there is an infection, such as a chest cold, pneumonia or an
exacerbation of chronic obstructive pulmonary disease (COPD).
Another protective mechanism for the lungs is the cough. A cough, while a
common event, is also not a normal event and is the result of irritation to the
bronchial tubes. A cough can expel mucus from the lungs faster than cilia.
The last of the common methods used by the lungs to protect themselves
can also create problems. The airways in the lungs are surrounded by bands
of muscle. When the lungs are irritated, these muscle bands can tighten,
making the breathing tube narrower as the lungs try to keep the irritant out.
The rapid tightening of these muscles is called bronchospasm. Some lungs
are very sensitive to irritants. Bronchospams may cause serious problems for
people with COPD and they are often a
major problem for those with asthma,
because it is more difficult to breathe
through narrowed airways.
How does air get into the body?
To deliver oxygen to the body, air is
breathed in through the nose, mouth or
both. The nose is the preferred route
since it is a better filter than the mouth.
The nose decreases the amount of
irritants delivered to the lung, whilst also

heating and adding moisture (humidity) into the air we breathe. When large
amounts of air are needed, the nose is not the most efficient way of getting
air into the lungs and therefore mouth breathing may be used. Mouth
breathing is commonly needed when exercising.
After entering the nose or mouth, air travels down the trachea or "windpipe".
The trachea is the tube lying closest to the neck. Behind the trachea is the
esophagus or "food tube". When we inhale air moves down the trachea and
when we eat food moves down the esophagus. The path air and food take is
controlled by the epiglottis, a gate that prevents food from entering the
trachea. Occasionally, food or liquid may enter the trachea resulting in
choking and coughing spasms.
The trachea divides into one left and one right breathing tube, and these are
termed bronchi. The left bronchus leads to the left lung and the right
bronchus leads to the right lung. These breathing tubes continue to divide
into smaller and smaller tubes called bronchioles. The bronchioles end in tiny
air sacs called alveoli. Alveoli, which means "bunch of grapes" in Italian, look
like clusters of grapes attached to tiny breathing tubes. There are over 300
million alveoli in normal lungs. If the alveoli were opened and laid out flat,
they would cover the area of a doubles tennis court. Not all alveoli are in use
at one time, so that the lung has many to spare in the event of damage from
disease, infection or surgery.
Which muscles help in the breathing process?
Many different muscles are used in breathing. The largest and most efficient
muscle is the diaphragm. The diaphragm is a large muscle that lies under the
lungs and separates them from the organs below, such as the stomach,
intestines, liver, etc. As the diaphragm moves down or flattens, the ribs flare
outward, the lungs expand and air is drawn in. This process is called
inhalation or inspiration. As the diaphragm relaxes, air leaves the lungs and
they spring back to their original position. This is called exhalation or
expiration. The lungs, like balloons, require energy to blow up but no energy
is needed to get air out.

The other muscles used in breathing are located between the ribs and
certain muscles extending from the neck to the upper ribs. The diaphragm,
muscles between the ribs and one of the muscles in the neck called the
scalene muscle are involved in almost every breath we take. If we need more
help expanding our lungs, we "recruit" other muscles in the neck and
shoulders. In some conditions, such as emphysema, the diaphragm is pushed
down so that it no longer works properly. This means that the other muscles
must work extra hard because they arent as efficient as the diaphragm.
When this happens, patients may experience breathlessness or shortness of
breath.

CLINICAL LABORATORY TEST


Date taken: 10-JUL-2009

HEMATOLOGY
PARAMETERS
WBC Count

ACTUAL
FINDINGS
19.8

UNITS
10.9/L

REFERENCE
VALUES
4-10

CLINICAL
IMPLICATIONS /
SIGNIFICANCE
HIGH
May be increased with

RBC Count

4.52

10.12/L

4.2-6.3

Hemoglobin

116

9/L

120-180

Hematocrit

0.35

2/L

0.37-0.54

Platelet Count

727

10 g/L

150-450

infections,
inflammation, cancer,
leukemia;
decreased
with some medications
(such
as
methotrexate), some
autoimmune
conditions,
some
severe
infections,
bone
marrow failure, and
congenital
marrow
aplasia
(marrow
doesn't
develop
normally
NORMAL
Decreased
with
anemia;
increased
when too many made
and with fluid loss due
to
diarrhea,
dehydration, burns
LOW
measures the amount
of
oxygen-carrying
protein in the blood.
LOW
measures the
percentage of red
blood cells in a given
volume of whole
blood.
HIGH
Decreased
or
increased
with
conditions that affect
platelet
production;
decreased
when
greater numbers used,
as
with
bleeding;
decreased with some
inherited
disorders
(such
as
WiskottAldrich,
BernardSoulier), with Systemic
lupus erythematosus,
pernicious
anemia,
hypersplenism (spleen
takes too many out of

MCV

77

f1

80-100

MCH

25.6

Pg

27-33

MCHC

332

g/L

320-360

circulation), leukemia,
and chemotherapy
Normal
a measurement of
the average size of
your RBCs. The MCV is
elevated when RBCs
are larger than normal
(macrocytic),
for
example in anemia
caused by vitamin B12
deficiency. When the
MCV
is
decreased,
RBCs are smaller than
normal (microcytic) as
is
seen
in
iron
deficiency anemia or
thalassemias
LOW
Mirrors MCV results
NORMAL
Mean corpuscular
hemoglobin
concentration (MCHC)
is a calculation of the
average concentration
of hemoglobin inside a
red cell. Decreased
MCHC
values
(hypochromia)
are
seen
in
conditions
where the hemoglobin
is abnormally diluted
inside the red cells,
such
as
in
iron
deficiency anemia and
in
thalassemia.
Increased
MCHC
values (hyperchromia)
are seen in conditions
where the hemoglobin
is
abnormally
concentrated
inside
the red cells, such as
in burn patients and
hereditary
spherocytosis,
a
relatively
rare
congenital disorder.

22.6

30-60

-Lymphocyte
(P)

Monocyte (p)
Granulocyte
(P)

7.2

3-9

70.2

20-65

RDW

14.00

13-16

LOW
may
indicate
lymphocytosis;increas
ed in convalescent
phase
after
bacterial/viral infection
NORMAL
HIGH
include
neutrophils
(bands
and
segs),
eosinophils,
and
basophils.
In
evaluating numerical
aberrations of these
cells (and of any other
leukocytes),
one
should first determine
the absolute count by
multiplying the per
cent value by the total
WBC
count.
For
instance, 2% basophils
in a WBC of 6,000/L
gives 120 basophils,
which
is
normal.
However,
2%
basophils in a WBC of
75,000/L gives 1500
basophils/L, which is
grossly abnormal and
establishes
the
diagnosis of chronic
myelogenous leukemia
over that of leukemoid
reaction with fairly
good accuracy.
NORMAL
The
red
cell
distribution width is
a
numerical
expression
which
correlates with the
degree of anisocytosis
(variation in volume of
the population of red
cells).
Some
investigators feel that
it
is
useful
in
differentiating

thalassemia from iron


deficiency anemia, but
its use in this regard is
far
from
universal
acceptance. The RDW
may also be useful in
monitoring the results
of hematinic therapy
for iron-deficiency or
megaloblastic
anemias.
As
the
patient's
new,
normally-sized
cells
are
produced,
the
RDW
initially
increases, but then
decreases
as
the
normal cell population
gains the majority
LOW
Vary
with
platelet
production;
younger
platelets are larger
than older ones

MPV

5.90

7.1-9.5

PDW

10.20

10-18

- Lymphocyte
(a)
- Monocyte
(a)
Granulocyte
(a)

4.40

10.9/L

1.2-3.2

NORMAL
measure
the
conformity of platelet
in
the
specimen.
Serves as a validity
check & monitors false
result.
HIGH

1.40

10.9/L

0.2-0.8

LOW

14.20

10.9/L

1.2-6.8

HIGH

CHEST X-RAY
Date taken : July 10, 2009
Examination: Chest AP
FINDINGS:
Bilateral Bronchopneumonia
Paratracheal Adenopathy

CLINICAL MANIFESTATION
SUBJECTIVE SYMPTOMS

OBJECTIVE SYMPTOMS

ACTUAL MANIFESTATION
THEORETICAL
SIGNS AND
SYMPTOMS

Dyspnea

Chest discomfort

ACTUAL
SIGNS AND
SYMPTOMS
Present

of purulent
or blood-tinged
sputum

The fluid created by


the inflammatory
response inside the
alveoli/lobes
interferes with
oxygen-carbon
dioxide exchange. As
an effort to bring
more oxygen patient
breathes faster to
compensate.

Present

Absent

Cough productive

RATIONALE

All abnormal
formation/accumulati
on/ reaction in our
body causes
inflammatory
response, which
stimulates the nerve
fibers and produces
sensation of pain.
Mucus production is
increased, and the
leaky capillaries may
tinge the mucus with
blood. Mucus plugs
actually further
decrease the
efficiency of gas
exchange in the lung.
The alveoli fill further

Tachypnea

with fluid and debris


from the large
number of white
blood cells being
produced to fight the
infection.
Because of the
deprived circulating
oxygen, the body
compensate by
increasing the
respiratory rate.

Tachycardia

Adventitious Sound
Breadth

As well as the Cardiac


rate, to increase the
circulating blood in
the body.

* crackles (or rales)

* wheezes (or
rhonchi)

When air passes the


fluid airways, causing
collapsed alveoli to
pop open as the
airway pressure
equalize. They can
also occur when
membranes lining the
chest cavity and the
lungs became
inflamed
A bronchi with thick a
mucosa or have an
edema, just like a
small flute, with its
narrow like pipe way,
it produces a high

pitch, musical,
squealing sound
called wheezes.

* stridor

In advanced cases you


may see:

Refers to a highpitched harsh sound


heard during
inspiration, caused by
obstruction of the
upper airway.

Cyanosis

Confusion

Chest indrawing

Because of
inadequate diffusion
of oxygen, gas
exchange in the
lungs, the blood
carries insufficient
amount to oxygen to
oxygenate the tissues,
organs of the body.
Organs like the brains
which when deprived
with oxygen will cause
in decrease nervous
function thus cause
confusion.
Another major sign of
severe pneumonia,
characterized when
the lower ribs goes in
when the child
breaths in too.

PATIENT DATA
Name: Patient X
Address: Ragay, Camarines Sur
Age: 2 years old
Date of Birth: April 13, 2007
Place of Birth: Ragay, Camarines Sur
Nationality: Filipino
Religion: Evangelical
Hospital Admission:
Date: July 10, 2009
Time: 4:00 P.M.

Admission Diagnosis : Severe Pneumonia, cerebral Palsy

Brief History
Patient X was rushed to hospital last July 10, 2009 at 4:00 in the afternoon. Prior to
admission hospitalized he was confined first in a hospital in Ragay, Camarines sur for 4 days.
After being discharged, the patient stayed at home for almost two weeks. His parents
decided to bring him to Bicol Medical Center because of his high fever (39 C), Halak
(crackles) difficulty of breathing, cyanosis when crying and convulsion, and were
consequently admitted.
The cyanosis exhibited by the patient started when he was only 3 months old and
until now the manifestation still occurs whenever he cries. The patient had a history of blood
infection. According to his mother 3 days after his birth, he became yellowish and was
confined that early in the hospital. After being discharged, there were several recurrences of
jaundice. The diagnosis is Sepsis Neonatorum. At seven days old, the patient was operated
in the abdomen and was confined for one week at the ICU. Since then, the patient has been
undergoing monthly check-up at Tagkawayan Their preferred pediatrician there had treated
him for six consecutive months. Unfortunately, according to his parent, his condition did not
improve at all. His Halak had never been treated successfully.

TABLE OF CONTENTS
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
XIII.
XIV.

INTRODUCTION
BACKGROUND
PATIENTS DATA AND HISTORY
COURSE IN THE WARD
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
CLINICAL MANIFESTATION
PROGNOSIS
CLINICAL LABORATORY RESULTS
DIAGNOSTIC TEST
NURSING MANAGEMENT
DRUG STUDY
NURSING CARE PLAN
DISCHARGE PLAN

PATHOPHYSIOLOGY
The
invading microorganism causes symptoms, in part, by provoking an
The invading m icroorganism causes sym ptom s, in part, by provoking an
overly exuberant immune response in the lungs. The small blood vessels in
overly exuberant im m une response in the lungs. The sm allblood vessels in
the lungs (capillaries) become leaky, and protein-rich fluid seeps into the
the lungs (capillaries) becom e leaky, and protein-rich fl
uid seeps into the
alveoli. This results in a less functional area for oxygen-carbon dioxide
alveoli.
exchange. The patient becomes relatively oxygen deprived, while retaining
potentially damaging carbon dioxide. The patient breathes faster and faster,
in an effort to bring in more oxygen and blow off more carbon dioxide.
Mucus
is increased,
and
the
leaky capillaries
may
tinge the mucus
This rproduction
esults in a less
functionalar
ea f
or oxygencarbon dioxi
de exchange.
with
blood.
Mucus
plugs
actually
further
decrease
the
efficiency
gas
The patient becom es relatively oxygen deprived, w hile retaining potof
ent
ially
exchange in the lung. The alveoli fill further with fluid and debris from the
dam aging carbon dioxide. The patient breathes faster and faster, in an eff
ort
large number of white blood cells being produced to fight the infection.
to bring in m ore oxygen and blow offm ore carbon dioxide.

Consolidation, a feature of bacterial pneumonias, occurs when the alveoli,


which are normally hollow air spaces within the lung, instead become solid,
The
veolifi
llfurt
w itand
h fl
uidebris.
d and debris from the large num ber of w hite
due
toal
quantities
ofher
fluid
blood cells being produced to fi
g ht the infection.

Viral pneumonias, and mycoplasma pneumonias, do not result in


consolidation. These types of pneumonia primarily infect the walls of the
alveoli and the parenchyma of the lung.
M ucus production is increased, and the leaky capillaries m ay tinge the m ucus
w ith blood. M ucus plugs actually further decrease the ef f
ciency of gas
i
exchange in the lung.

Consolidation, a feature of
bacterialpneum onias,
occurs w hen the alveoli,
w hich are norm ally hollow
air spaces w ithin the lung,
instead becom e solid, due
to quantities of fl
u id and
debris.

Viralpneum onias, and


m ycoplasm a pneum onias,
do not result in
consolidation. These types
of pneum onia prim arily
infect the w alls of the
alveoliand the
parenchym a of the lung.

PROGNOSIS
The prognosis for pneumonia varies widely depending on the type of
infection. The recovery rate is nearly 100 percent, for example, in cases of
"walking pneumonia." By contrast, people with pneumonia caused by
Staphylococcus pneumoniae stand only a 60 percent to 70 percent chance of
survival. For the most common form of pneumonia, caused by Streptococcus
pneumoniae, the survival rate is about 95 percent.
In the United States, about one of every twenty people with pneumococcal
pneumonia die. In cases where the pneumonia progresses to blood poisoning
(bacteremia), just over 20% of sufferers die.
The death rate (or mortality) also depends on the underlying cause of the
pneumonia. Pneumonia caused by Mycoplasma, for instance, is associated
with little mortality. However, about half of the people who develop
methicillin-resistant Staphylococcus aureus (MRSA) pneumonia while on a
ventilator will die. In regions of the world without advanced health care

systems, pneumonia is even deadlier. Limited access to clinics and hospitals,


limited access to x-rays, limited antibiotic choices, and inability to treat
underlying conditions inevitably leads to higher rates of death from
pneumonia. For these reasons, the majority of deaths in children under five
due to pneumococcal disease occur in developing coutries.
Outlook for High-Risk Individuals
Hospitalized Patients. For patients who need hospitalization for pneumonia,
the death rate is 10 - 25%. If pneumonia develops in patients already
hospitalized for other conditions, death rates range from 50 - 70%, and are
higher in women than in men.
Older Adults. Community-acquired pneumonia is responsible for 350,000 620,000 hospitalizations in the elderly every year. Older adults have lower
survival rates than younger people. Even when older individuals recover from
CAP, they have higher-than-normal death rates over the next several years.
Elderly people who live in nursing homes or who are already sick are at
particular risk.
Very Young Children. Small children who develop pneumonia and survive are
at risk for developing lung problems in adulthood, including chronic
obstructive pulmonary disease (COPD). Research suggests that men with a
history of pneumonia and other respiratory illnesses in childhood are more
than twice as likely to die of COPD as those without a history of childhood
respiratory disease.
Pregnant Women. Pneumonia poses a special hazard for pregnant women,
possibly due to changes in a pregnant woman's immune system. This
complication can lead to premature labor and increases the risk of death
during pregnancy.
Patients With Impaired Immune Systems. Pneumonia is particularly serious in
people with impaired immune systems. This is especially true for AIDS
patients, in whom pneumonia causes about half of all deaths.
Patients With Serious Medical Conditions. Pneumonia is also very dangerous
in people with diabetes, cirrhosis, sickle cell disease, cancer, and in those
whose spleens have been removed.

DIAGNOSTIC PROCEDURES
Pneumonia can usually be diagnosed on the basis of a patient's symptoms. A
doctor will also listen to the patient's chest with a stethoscope. If the lungs
are infected, they produce an unusual sound when the patient breathes in
and out. Tapping on the patient's back is also a test for pneumonia. Normally,
the tapping produces a hollow sound because the lungs are filled with air. If
pneumonia is present, however, the lungs may contain fluid. In this case, the
sound is dull thump.
Some forms of bacterial pneumonia can be diagnosed by laboratory tests. A
sample of the patient's sputum is taken. The sample is then stained with
dyes and examined under a microscope. The organisms causing the disease
can often be seen and identified.
X rays can also be used to diagnose pneumonia. Dark spots on the patient's
lungs may indicate the presence of an infection. The appearance of the spots
may give a clue to the type of infection that has occurred.

If pneumonia is suspected on the basis of a patient's symptoms and findings


from physical examination, further investigations are needed to confirm the
diagnosis. Information from a chest X-ray and blood tests are helpful, and
sputum cultures in some cases. The chest X-ray is typically used for
diagnosis in hospitals and some clinics with X-ray facilities. However, in a
community setting (general practice), pneumonia is usually diagnosed based
on symptoms and physical examination alone. Diagnosing pneumonia can be
difficult in some people, especially those who have other illnesses.
Occasionally a chest CT scan or other tests may be needed to distinguish
pneumonia from other illnesses.

Investigations

Pneumonia as seen on chest x-ray. A: Normal chest xray. B: Abnormal chest x-ray with shadowing from
pneumonia in the right lung (white area, left side of
image).

An important test for pneumonia in unclear situations


is a chest x-ray. Chest x-rays can reveal areas of
opacity (seen as white) which represent
consolidation. Pneumonia is not always seen on xrays, either because the disease is only in its initial
stages, or because it involves a part of the lung not
easily seen by x-ray. In some cases, chest CT
(computed tomography) can reveal pneumonia that
is not seen on chest x-ray. X-rays can be misleading, because other
problems, like lung scarring and congestive heart failure, can mimic
pneumonia on x-ray. Chest x-rays are also used to evaluate for complications
of pneumonia If antibiotics fail to improve the patient's health, or if the
health care provider has concerns about the diagnosis, a culture of the
person's sputum may be requested. Sputum cultures generally take at least
two to three days, so they are mainly used to confirm that the infection is
sensitive to an antibiotic that has already been started. A blood sample may
similarly be cultured to look for bacteria in the blood. Any bacteria identified
are then tested to see which antibiotics will be most effective.
A complete blood count may show a high white blood cell count, indicating
the presence of an infection or inflammation. In some people with immune
system problems, the white blood cell count may appear deceptively normal.
Blood tests may be used to evaluate kidney function (important when
prescribing certain antibiotics) or to look for low blood sodium. Low blood
sodium in pneumonia is thought to be due to extra anti-diuretic hormone

produced when the lungs are diseased (SIADH). Specific blood serology tests
for other bacteria (Mycoplasma, Legionella and Chlamydophila) and a urine
test for Legionella antigen are available. Respiratory secretions can also be
tested for the presence of viruses such as influenza, respiratory syncytial
virus, and adenovirus. Liver function tests should be carried out to test for
damage caused by sepsis.

Combining findings
One study created a prediction rule that found the five following signs best
predicted infiltrates on the chest radiograph of 1134 patients presenting to
an emergency room:

Temperature > 100 degrees F (37.8 degrees C)


Pulse > 100 beats/min

Rales/crackles

Decreased breath sounds

Absence of asthma

The probability of an infiltrate in two separate validations was based on the


number of findings:

5 findings - 84% to 91% probability


4 findings - 58% to 85%

3 findings - 35% to 51%

2 findings - 14% to 24%

1 findings - 5% to 9%

0 findings - 2% to 3%

A subsequent study comparing four prediction rules to physician judgment


found that two rules, the one above and also were more accurate than
physician judgment because of the increased specificity of the prediction
rules.

Differential diagnosis
Several diseases and/or conditions can present with similar clinical features
to pneumonia and as such care must be taken in the proper diagnosis of the
disease. Chronic obstructive pulmonary disease (COPD) or asthma can
present with a polyphonic wheeze, similar to that of pneumonia. Pulmonary
edema can be mistaken for pneumonia due to its ability to show a third heart

sound and present with an abnormal ECG. Other diseases to be taken into
consideration include bronchiectasis, lung cancer and pulmonary emboli.

Clinical prediction rules


Clinical prediction rules have been developed to more objectively
prognosticate outcomes in pneumonia. These rules can be helpful in deciding
whether or not to hospitalize the person.

Pneumonia severity index (or PORT Score)


CURB-65 score, which takes into account the severity of symptoms, any
underlying diseases, and age

DISCHARGE PLAN

NURSING MANAGEMENT