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, one section

 (lobe) of a lung is affected.
 In bronchial pneumonia (or
bronchopneumonia), patches throughout
both lungs are affected.

Facts about Pneumonia:

 Pneumonia is a serious illness that

affects one out of every 100 people
each 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

sub-divides 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 aren’t
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 ACTUAL UNITS REFERENCE CLINICAL
FINDINGS VALUES IMPLICATIONS /
SIGNIFICANCE
WBC Count 19.8 10.9/L 4-10 HIGH
May be increased with
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
RBC Count 4.52 10.12/L 4.2-6.3 NORMAL
Decreased with anemia;
increased when too
many made and with
fluid loss due to
diarrhea, dehydration,
burns
Hemoglobin 116 9/L 120-180 LOW
measures the amount of
oxygen-carrying protein
in the blood.
Hematocrit 0.35 2/L 0.37-0.54 LOW
measures the
percentage of red blood
cells in a given volume
of whole blood.

Platelet Count 727 10 g/L 150-450 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 Wiskott-
Aldrich, Bernard-
Soulier), with Systemic
lupus erythematosus,
pernicious anemia,
hypersplenism (spleen
takes too many out of
circulation), leukemia,
and chemotherapy
MCV 77 f1 80-100 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
MCH 25.6 Pg 27-33 LOW
Mirrors MCV results
MCHC 332 g/L 320-360 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 LOW
Lymphocyte (P) may indicate
lymphocytosis;increased
in convalescent phase
after bacterial/viral
infection
- Monocyte 7.2 % 3-9 NORMAL
(p)
- 70.2 % 20-65 HIGH
Granulocyte (P) 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/µL gives 120
basophils, which is
normal. However, 2%
basophils in a WBC of
75,000/µL gives 1500
basophils/µL, which is
grossly abnormal and
establishes the
diagnosis of chronic
myelogenous leukemia
over that of leukemoid
reaction with fairly good
accuracy.
RDW 14.00 % 13-16 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
MPV 5.90 % 7.1-9.5 LOW
Vary with platelet
production; younger
platelets are larger than
older ones

PDW 10.20 % 10-18 NORMAL

measure the conformity
of platelet in the
specimen. Serves as a
validity check &
monitors false result.
- Lymphocyte 4.40 10.9/L 1.2-3.2 HIGH
(a)
- Monocyte (a) 1.40 10.9/L 0.2-0.8 LOW
- Granulocyte 14.20 10.9/L 1.2-6.8 HIGH
(a)
 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 ACTUAL SIGNS RATIONALE
AND SYMPTOMS AND SYMPTOMS

 Dyspnea  Present  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.

 All abnormal
 Chest discomfort  Present formation/accumulation/
reaction in our body
causes inflammatory
response, which
stimulates the nerve
fibers and produces
sensation of pain.

 Absent  Mucus production is

increased, and the leaky
 Cough productive of
capillaries may tinge the
purulent
mucus with blood. Mucus
 or blood-tinged plugs actually further
sputum
decrease the efficiency of
gas exchange in the lung.
The alveoli fill further 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
 Tachypnea increasing the respiratory
 rate.

 As well as the Cardiac rate,

 Tachycardia
to increase the circulating
blood in the body.

 When air passes the fluid

Adventitious Sound Breadth
 airways, causing collapsed
alveoli to pop open as the
* crackles (or rales)
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
* wheezes (or rhonchi)
produces a high pitch,
musical, squealing sound
called wheezes.

 Refers to a high-pitched
harsh sound heard during
 inspiration, caused by
* stridor  obstruction of the upper
airway.

 Because of inadequate
diffusion of oxygen, gas
In advanced cases you may exchange in the lungs, the
see:  blood carries insufficient
amount to oxygen to
 Cyanosis 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,
 Confusion characterized when the
lower ribs goes in when
the child breaths in too.


 Chest indrawing
 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. INTRODUCTION

II. BACKGROUND

III. PATIENT’S DATA AND HISTORY

IV. COURSE IN THE WARD

V. ANATOMY AND PHYSIOLOGY

VI. PATHOPHYSIOLOGY

VII. CLINICAL MANIFESTATION

VIII. PROGNOSIS

IX. CLINICAL LABORATORY RESULTS

X. DIAGNOSTIC TEST

XI. NURSING MANAGEMENT

XII. DRUG STUDY

XIII. NURSING CARE PLAN

XIV. DISCHARGE PLAN

PATHOPHYSIOLOGY
The invading microorganism causes symptoms, in part, by provoking an
The invading microorganism causes symptoms, in part, by provoking an
overly exuberant immune response in the lungs. The small blood vessels
overly exuberant immune response in the lungs. The small blood vessels
in the lungs (capillaries) become leaky, and protein-rich fluid seeps
in the lungs (capillaries) become leaky, and protein-rich fluid seeps
into the alveoli. This results in a less functional area for oxygen-
into the alveoli.
carbon dioxide 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.
This results in a less functional area for oxygen-carbon dioxide
Mucus production
exchange. is increased,
The patient and the leaky
becomes relatively oxygencapillaries may tinge the
deprived, while
mucus with blood. Mucus plugs actually further decrease the efficiency
retaining potentially damaging carbon dioxide. The patient breathes
of gas exchange in the lung. The alveoli fill further with fluid and
faster and faster, in an effort to bring in more oxygen and blow off
debris from the large number of white blood cells being produced to
more carbon dioxide.
fight the infection.

Consolidation, a feature of bacterial pneumonias, occurs when the

alveoli, which are normally hollow air spaces within the lung, instead
The alveoli
become solid, fill
due further with fluid
to quantities and debris
of fluid from the large number of
and debris.
white blood cells being produced to fight 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.

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.

Consolidation, a feature Viral pneumonias, and

of bacterial pneumonias,
occurs when the alveoli,
which are normally hollow
air spaces within the
lung, instead become
solid, due to quantities
of fluid and debris.
mycoplasma pneumonias, do
not result in
consolidation. These
types of pneumonia
primarily infect the
walls of the alveoli and
the parenchyma 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 x-

ray. 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 x-rays, 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