ASKEP PNEUMONIA IN ENGLISH

CHAPTER 1
INTRODUCTION
1.1.

Background
Acute respiratory infections namely pneumonia cause up to 5 million deaths annually among
children less than 5 years old in developing nations. Of the estimated total of 12.9 million deaths
globally in 1990 in children under 5 years of age, over 3.6 million were attributed to acute
respiratory infections mostly due to pneumonia. This represents 28% of all deaths in young
children and places pneumonia as the largest single cause of childhood mortality. In Malaysia the
prevalence of ARI in children below the age of 5 years is estimated to be 28% - 39.3%. Low
birth weight, malnutrition, nasopharyngeal colonization, poor environmental factors and tobacco
smoke are risk factors for developing pneumonia. Two local studies conducted in hospitalized
children with acute lower respiratory tract infections identified the following factors as risks for
developing pneumonia.

1.2.

Problem Question
How about the nursing process of pneumonia case?

1.3. Objectives
a. Explain about nursing process of pneumonia case.
b. Explain about nursing care in pneumonia occurrence.

CHAPTER 2
STUDY LITERATURE

2.1.

Clinical definition
There is no single definition for pneumonia. It is a clinical illness defined in terms of
symptoms and signs, and its course. WHO defines pneumonia in terms of febrile illness with
tachypnea for which there is no apparent cause.
There are two clinical definitions of pneumonia:

1. Bronchopneumonia which is a febrile illness with cough, respiratory distress with evidence of
localized or generalized patchy infiltrates on chest x-ray
2. Lobar pneumonia which is similar to bronchopneumonia except that the physical findings and
radiographs indicate lobar consolidation.

2.2.2.

Physiology
A pressure gradient is required to generate flow. In spontaneous respiration inspiratory
flow is achieved by creating a sub-atmospheric pressure in the alveoli (of the order of -5cmH2O
during quiet breathing) by increasing the volume of the thoracic cavity under the action of the
inspiratory muscles. During expiration the intra-alveolar pressure becomes slightly higher than
atmospheric pressure and gas flow to the mouth results.

2.3.

Etiology
A specific etiological agent cannot be identified in 40% to 60% of cases. Viral pneumonia
cannot be distinguished from bacterial pneumonia based on a combination of clinical findings.
The majority of lower respiratory tract infections that present for medical attention in young
children are viral in origin such as respiratory syncytial virus, influenza, adenovirus and
influenza virus. Indicator of pathogens causing pneumonia
Age

Bacterial Pathogens

Group B streptococcus, Escherichia coli, Klebsiella species, Enterobacteriaceae

1- 3 months

Chlamydia trachomatis

Preschool

Streptococcus pneumoniae, Haemophilus influenzae type b,

Staphylococcal aureus,
Less common: group A streptococcus, Moraxella catarrhalis, Pseudomonas aeruginosa
School

Mycoplasma pneumoniae, Chlamydia pneumonia

2.5.

Signs And Symptoms

Hypotension;

Cough;

Tachycardia;

Hypoxia;

Pyrexia;

Rash;

Oliguria;

Pallor;

Dizziness;

Erratic blood glucose levels;

Confusion;

Sweats;

Peripheral vasodilation;

Rigors;

Hypothermia;

Dyspnea;

Ischemia;

Vomiting;

Tachypnea;

Diarrhea.

Metabolic acidosis;

2.6.

Clinical Features
The clinical diagnosis of pneumonia has traditionally been made using auscultatory
findings such as bronchial breath sounds and crepitations in children with cough. However, the
sensitivity of auscultation has been shown to be poor and varies between 33 %- 60% with an
average of 50 % in children. Tachypnea is the best single predictor in children of all ages.
Measurement of Tachypnea is better compared with observations of retractions or auscultatory
findings. It is nonetheless important to measure respiratory rate accuratel. Respiratory rate should
be counted by inspection for 60 seconds. However in the young infants, pneumonia may present
with irregular breathing and hypopnea.

2.7.

Diagnostic Assessment
Children with bacterial pneumonia cannot be reliably distinguished from those with viral
disease on the basis of any single parameter; clinical, laboratory or chest radiograph findings.

2.7.1 Chest Radiograph

Chest radiograph is indicated when clinical criteria suggests pneumonia. It will not identify
the etiological agent. However the chest radiograph is not always necessary if facilities are not
available or the pneumonia is mild.
2.7.2 Complete White Blood Cell And Differential Count
This test may be helpful as an increased white blood count with predominance of
polymorphonuclear cells may suggest bacterial cause. However, leucopenia can either suggest a
viral cause or severe overwhelming infection.
2.7.3 Blood Culture
Blood culture remains the non-invasive gold standard for determining the precise etiology of
pneumonia. However the sensitivity of this test is very low. Positive blood cultures are found
only in 10% to 30% of patients with pneumonia. Even in 44% of patients with radiographic
findings consistent with pneumonia, only 2.7% were positive for pathogenic bacteria. Blood
culture should be performed in severe pneumonia or when there is poor response to the first line
antibiotics.
2.7.4 Culture From Respiratory Secretions
It should be noted that bacteria isolates from throat swabs and upper respiratory tract
secretions are not representative of pathogens present in the lower respiratory tract. Samples
from the nasopharynx and throat have no predictive values. This investigation should not be
routinely done.
2.7.5 Other Tests
Bronchoalveolar lavage is usually necessary for the diagnosis of Pneumocystis carini
infections primarily in immunosuppressed children. It is only to be done when facilities and
expertise are available. If there is significant pleural effusion diagnostic, pleural tap will be
helpful.
Mycoplasma pneumoniae, Chlamydia, Legio nella and Moxarella catarrhalis are difficult
organisms to culture, and thus serological studies should be performed in children with suspected
atypical pneumonia. An acute phase serum titre of more than 1:160 or paired samples taken 2-4

weeks apart showing four fold rise is a good indicator of Mycoplasma pneumoniae infection. 17
This test should be considered for children aged five years or older with pneumonia.
2.8. Management
2.8.1. Assessment of oxygenation
The best objective measurement of hypoxia is by pulse oximetry which avoids the need
for arterial blood gases. It is a good indicator of the severity of pneumonia
2.8.2. Criteria for hospitalization
Community acquired pneumonia can be treated at home. It is crucial to identify indicators of
severity in children who may need admission as failure to do so may result in death. The
following indicators can be used as a guide for admission.
1.
2.
3.
4.
5.
6.
7.

Children aged <3 months whatever the severity of pneumonia.

Fever (>38.50 C), refusal to feed and vomiting
Rapid breathing with or without cyanosis
Systemic manifestation
Failure of previous antibiotic therapy
Recurrent pneumonia
Severe underlying disorders (i.e. immunodeficiency, chronic lung disease)

2.8.3. Antibiotic therapy

When treating pneumonia clinical, laboratory and radiographic findings should be
considered. The age of the child, local epidemiology of respiratory pathogens and sensitivity of
these pathogens to particular microbial agents and the emergence of antimicrobial resistance also
determine the choice of antibiotic therapy. The severity of the pneumonia and drug costs have
also a great impact on the selection of therapy.
The majority of childhood infections are caused by viruses and do not require any
antibiotic. However, it is also very important to remember that we should be vigilant to choose
appropriate antibiotics especially in the initial treatment to reduce further mortality and
morbidity.

Susceptibility (%) pattern of Streptococcus pneumonia

Antibiotic

Susceptible

Intermediate

Resistance

Azithromycin

98.1

1.9

Cefuroxime

99.6

0.4

Chloramphenicol

95.1

1.5

3.4

Chlindamycin

9.2

0.4

0.4

Cotrimoxazole

86.4

3.9

9.7

Erythromycin

98.4

0.4

1.1

Penicillin

93.0

Tetracycline

78.2

7.0
0.8

21.0

Predominant bacterial pathogens of children and the recommended antimicrobial agents to be

used.
Pathogens

Antimicrobial agent

Beta- lactam susceptible

Streptococcus pneumonia

Penicillin, Cephalosporins

Haemophilus influenzae type b

Ampicillin,Chloramphenicol,

Cephalosporins
Staphylococcus aureus

Cloxacillin

Group A Sreptococcus

Penicillin,Cephalosporin

Mycoplasma pneumoniae

Macrolides such as erythromycin and

Azithromycin
Chlamydia pneumoniae

Macrolides such as erythromycin and

Azithromycin
Bordetella pertussis

Macrolides such as erythromycin and

Azithromycin
Commonly used antibiotics and their dosages
Intravenous Antibiotics

Dosages

Amoxycillin-Clavulanate Acid

10-25mg/kg/dose 8 hrly

Ampicillin -sulbactam

10-25 mg/kg/dose 8 hrly

Ampicillin

100mg/kg/day 6 hrly

C. Penicillin

25,000-50,000U/kg/dose 6 hourly

Cefuroxime

10-25 mg/kg/dose 8 hrly

Cefotaxime

25-50mg/kg/dose 8 hrly

Cloxacillin

25-50mg/kg/dose 6hrly

Co-trimoxazole (trimethoprim )

4 mg/kg/dose 12 hrly

Erythromycin

7.5mg kg/dose 6 hrly

Oral Antibiotis

Dosages

Azithromycin

10-15 mg/kg/day daily dose

Augmentin

114 mg 12 hourly (less than 2 years)

228 mg 12 hourly (> 2 years)

Cefuroxime

125 mg 12 hourly (less than 2 years)

250 mg 12 hourly (> 2 years)

2.9.

Cotrimoxazole

4 mg/kg/dose 12 hourly

Cloxacillin

50mg/kg /dose 6 hourly

Erythromycin Estolate

7.5 mg/kg/dose 12 hour ly

Penicillin V

7.5 - 15 mg/kg/dose 6 hourly

Nursing Diagnosis
a.

Ineffective Airway Clearance

b. Impaired Gas Exchange

c.

Imbalanced Nutrition: Less Than Body Requirements

d. Acute Pain
e.

Hyperthermia

f.

Anxiety

g. Ineffective Coping
h. Risk For Deficient Fluid Volume
i.

Risk For Infection

CHAPTER 3
DISCUSSION
CASE STUDY
3.1.

Nursing Assessment
Mrs. Inem is a 39-year-old secretary who was admitted to the hospital with an elevated
temperature, fatigue, rapid, labored respirations; and mild dehydration. The nursing history
reveals that she has had a bad cold for several weeks that just wouldnt go away. She has been
dieting for several months and skipping meals. She mentions that in addition to her fulltime job
as a secretary she is attending college classes two evenings a week. She has smoked one package
of cigarettes per day since she was 18 years old. Chest x-ray confirms pneumonia.

3.2.

Physical Examination
Height

: 167.6 cm (56)

Weight

: 54.4 kg (120 lb)

Temperature

: 39.4C (103F)

Pulse

: 68 BPM

Respirations

: 24/minute

Blood pressure

: 118/70 mm Hg

Skin pale; cheeks flushed; chills; use of accessory muscles; inspiratory crackles with diminished
breath sounds right base; expectorating thick, yellow sputum.
3.3.

Diagnostic Data
Chest x-ray

: right lobar infiltration

HCO3

: 20 mEq/L

WBC

: 14,000

PaO2

: 80 mm Hg

pH

: 7.49

O2 sat

: 88%

PaCO2

: 33 mm Hg

3.4.

Nursing diagnosis
Ineffective Airway Clearance related to thick sputum, secondary to pneumonia (as evidenced by
rapid respirations, diminished and adventitious breath sounds, thick yellow sputum)

3.5.

Desired Outcome
Respiratory Status

3.6.

: Airway Patency as evidenced by not compromised

Respiratory rate
Moves sputum out of airway
No adventitious breath Sounds
Nursing Interventions
Nursing Interventions
Assist Ms. Singh to a sitting position with head

Rationale
Lying flat causes the abdominal organs to shift

slightly flexed, shoulders relaxed, and knees

toward the chest, crowding the lungs and

flexed.
Encourage her to take several deep breaths.

making it more difficult to breathe.

Deep breathing promotes oxygenation before

Encourage her to take a deep breath, hold for 2

controlled coughing.
Controlled coughing is accomplished by

seconds, and cough two or three times in

closure of the glottis and the explosive

succession.

expulsion of air from the lungs by the work of

Encourage use of incentive spirometry, as

abdominal and chest muscles.

Breathing exercises help maximize ventilation.

appropriate.
Promote systemic fluid hydration, as

Adequate fluid intake enhances liquefaction of

appropriate. Encourage her to take several deep pulmonary secretions and facilitates
breaths.

expectoration of mucus.

Monitor rate, rhythm, depth, and effort of

Provides a basis for evaluating adequacy of

respirations.
Note chest movement, watching for symmetry,

ventilation.
Presence of nasal flaring and use of accessory

use of accessory muscles, and supraclavicular

muscles of respirations may occur in response

and intercostal muscle retractions.

to ineffective ventilation.

Auscultate breath sounds, noting areas of

As fluid and mucus accumulate, abnormal

decreased or absent ventilation and presence of

breath sounds can be heard including crackles

adventitious sounds.

and diminished breath sounds owing to fluid-

Auscultate lung sounds after treatments to note

filled air spaces and diminished lung volume.

Assists in evaluating prescribed treatments and

results.
Monitor clients ability to cough effectively.

client outcomes.
Respiratory tract infections alter the amount
and character of secretions. An ineffective
cough compromises airway clearance and

Monitor clients respiratory secretions.

prevents mucus from being expelled.

People with pneumonia commonly produce

Institute respiratory therapy treatments (e.g.,

rust-colored, purulent sputum.

A variety of respiratory therapy treatments may

nebulizer) as needed.

be used to open constricted airways and liquefy

Monitor for increased restlessness, anxiety, and

secretions.
These clinical manifestations would be early

air hunger.
Note changes in SpO2, tidal volume, and

indicators of hypoxia.
Evaluates the status of oxygenation, entilation,

changes in arterial blood gas values, as

and acidbase balance.

appropriate.

CHAPTER 4
CONCLUSIONS AND RECOMMENDATIONS
4.1.

Conclusions
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 minimize 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.
4.2.

Recommendations
As a professional nurse, we must understand about pneumonia and that nursing process, so
we should provide the best intervention.

REFERENCES
Acute Respiratory infections in children: Case management in small hospitals in developing countries. A
manual for doctors and other senior health workers. WHO/ARI/90.5 website: www.who.int
Bellamy, R. 2006. Pneumocystis pneumonia in people with HIV. Clinical Evidence; 15: 982985.
Clinical Practice Guidelines on Pneumonia and Respiratory Tract Infections in Children WHO/ARI/90.5
website: www.who.int

Laterre, P.F. et al (2005) Severe community-acquired pneumonia as a cause of severe sepsis: data from
the PROWESS study. Critical Care Medicine; 35: 5,952961.