I.

Definition

Community-acquired pneumonia (CAP) is defined as pneumonia acquired outside of hospital or

healthcare facilities. Clinical diagnosis is based on a group of signs and symptoms related to lower
respiratory tract infection with presence of fever >100ºF (>38ºC), cough, expectoration, chest pain,
dyspnea, and signs of invasion of the alveolar space. However, older patients in particular are often
afebrile and may present with confusion and worsening of underlying diseases.

II. Overview of the system involved

Respiratory system

A bacteria or virus enters the body through an airway. Once the infection gets into the lungs,
inflammation causes air sacs, called alveoli, to fill up with fluid or pus. This can lead to trouble breathing,
coughing, and coughing up yellow or brown mucus.

Breathing may feel more difficult or shallow. You may experience chest pain when you take a deeper
breath.

The buildup of fluid in and around the lungs leads to more complications. Fluid that collects in one area
is called an abscess. If the abscess doesn’t go away with antibiotic treatment, it may need to be surgically
removed. Fluid that forms between the covering of the lungs and inner lining of the chest wall is called a
pleural effusion. An infected pleural effusion will need to be drained. A chest tube is usually used to do
this.

If the infection and fluid buildup get severe enough, it can stop the lungs from doing their job.

III. Causes and Risk factor

There are many causes of CAP, including bacteria, viruses, mycoplasmas, fungal agents and protozoa.
Typical bacterial pathogens that cause CAP include Streptococcus pneumoniae, Haemophilus influenzae,
and Moraxella catarrhalis. CAP may also result from aspiration of food, fluids or vomitus it from
inhalation of toxic or caustic chemicals, smoke, dusts or gases. CAP may complicate immobility and
chronic illnesses. It often follows influenza.

Major risk factors for CAP include (1) advanced age, (2) a history of smoking, (3) upper respiratory
infection, (4) tracheal infection, (5) prolonged immobility, (6) immunosuppressive therapy, (7) a
nonfunctional immune system, (8) malnutrition, (9) dehydartion, and (10) chronic disease states, such as
diabetes, heart disease, chronic disease states, renal disease, and cancer. Additional risk factors are
exposure to air pollutions: altered consciousness (from alcoholism, drug overdose, general anesthesia, or
a seizure disorder): inhalation of noxious substances: aspiration of food, liquid, or foreign or gastric
material: and residence in institutional settings, where transmission of disease is more likely.

IV. Complications

Major complications of CAP include:

* Sepsis, when microorganisms enter the bloodstream and the immune system responds. Sepsis often
occurs with bacterial pneumonia, with streptococcus pneumoniae the most-common cause. Patients
with sepsis require intensive care, with blood-pressure monitoring and support against hypotension.
Sepsis can cause liver, kidney and heart damage.
* Respiratory failure: CAP patients often have dyspnea, which may require support. Non-invasive
machines (such as bilevel positive airway pressure), a tracheal tube or a ventilator may be used.

* Pleural effusion and empyema: Microorganisms from the lung may trigger fluid collection in the pleural
cavity. If the microorganisms are in the fluid, the collection is an empyema. If pleural fluid is present, it
should be collected with a needle and examined. Depending on the results, complete drainage of the
fluid with a chest tube may be necessary. If the fluid is not drained, bacteria may continue to proliferate
because antibiotics do not penetrate the pleural cavity well.

* Abscess: A pocket of fluid and bacteria may be seen on an X-ray as a cavity in the lung. Abscesses,
typical of aspiration pneumonia, usually contain a mixture of anaerobic bacteria. Although antibiotics
can usually cure abscesses, sometimes they require drainage by a surgeon or radiologist.

V. Pathophysiology of the disease

The CAP is an inflammatory pulmonary response to the offending organism or agent. The defense
mechanisms of the lungs lose effectiveness and allow organisms to penetrate the sterile lower
respiratory tract, where inflammation develops. Disruption of the mechanical defenses of cough and
ciliary motility leads to colonization of the lungs and subsequent infection. Inflamed and fluid - filled
alveolar sacs cannot exchange oxygen and carbon dioxide effectively. Alveolar exudate tends to
consolidate, so it is increasingly difficult to expectorate. Bacterial pneumonia may be associated with
significant ventilation - perfusion mismatch as the infection grows.

VI. Management

Medical Management

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.

Nursing Assessment

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.