PNEUMONIA

PRESENTED BY:
MR. CHISHALA FRANK

4 TH YEAR STUDENT: BSc. NRS

STUDENT LECTURER
UNZA- SCHOOL OF MEDICINE
DEPARTMENT OF NURSING SCINCES
 INTRODUCTION

Pneumonia is one of the commonest conditions of

the lower respiratory system.

Affects most oftenlly those who are

immunocompromised.

In Zambia, pneumonia remains one of the leading

causes of morbidity and mortality.

Premature babies, HIV positive children and adults

more affected.
 OBJETICVES

General Objective:
At the end of the lecture/discussion, the students
should be able to gain knowledge and an
understanding on the management of pneumonia.
 OBJECTIVES CONT

Specific Objectives: At the end of the lecture/discussion,

students should be able to:
1. Define pneumonia.
2. Classify pneumonia
3. Describe the pathophysiology of bronchopneumonia.
4. State the signs and symptoms of bronchopneumonia.
5. Outline the laboratory investigations done to rule out
bronchopneumonia
6. Explain the complications of bronchopneumonia
7. Describe the management of bronchopneumonia.
 DEFINITION OF PNEUMONIA

Pneumonia is an acute inflammation of the lung

parenchyma caused by microbial agents (Dirksen,
2004).
It is the inflammation of the lung tissue leading to
consolidation of the alveoli and infiltration of the
interstitial tissue with inflammatory cells.
Pneumonia is an infection of the lungs
characterized primarily by inflammation of the
alveoli in the lungs that are filled with fluid.
 CLASSIFICATION OF PNEUMONIA

Pneumonia can be classified in several ways, most

commonly by where it was acquired, the area of lung
affected, duration of infection and by the cause.

1.1 Area where it is acquired:

Hospital acquired pneumonia- also called
nosocomial pneumonia.
Acquired during or after hospitalization for an illness
or procedure with onset at least 72 hours after
admission.
 CLASSIFICATION CONT

Common causes include: Methilin Resistant

Staphylococcus Aureus, Pseudomonas and
Enterobacter. All are normal flora of pharynx

Risk factors in hospital include:

Mechanical ventilation, Prolonged malnutrition,
Underlying condition and diseases that lower
immune system and exposure to so many
communicable diseases from other patients
 CLASSIFICATION CONT

Community acquired pneumonia (CAP)- the most

common infectious pneumonia in a person who has
not recently been hospitalized.

The most common causes of CAP is

Streptococcus pneumoniae (normal flora for
pharynx)
 CLASSIFICATION CONT

1.2 Area of lung affected:

Bronchopneumonia- acute or chronic inflammation
of the walls of the bronchioles.
Characterized by multiple foci (small points of
isolated, acute consolidation, affecting one or
more pulmonary lobules.
In bacterial pneumonia, invasion of the lung
parenchyma (lung tissue) by bacteria produces an
inflammatory immune response.
 CLASSIFICATION CONT

Lobar pneumonia- an infection that only involves a

single lobe, or section, of a lung.
Lobar pneumonia is often due to Streptococcus
pneumoniae mostly.
Klebsiella pneumoniae (M. genitalium) found in the
normal flora of the mouth is also possible
Interstitial pneumonia- involves the areas in
between the alveoli.
Mostly caused by viruses or by atypical bacteria
such as mycoplasma species, langionella species,
chlamydia spp and viruses.
 CLASSIFICATION CONT

1.3. By duration
Acute pneumonia: an inflammation of the lung
parenchyma in which signs and symptoms appear
abruptly and severe within 24 to 48 hours of being
exposed to the causative agent and usually
disappear in less than three weeks.
Chronic pneumonia: an inflammation of the lungs
that persists for a period of time, without a sudden
onset and lasts more than three weeks
 CLASSIFICATION CONT

1.4. By cause of pneumonia:

Bacterial pneumonia: the kind of lung inflammation
caused by presence of bacteria in the lungs.
Streptococcus pneumoniae the most common
cause of bacterial pneumonia.
Viral pneumonia: pneumonias that do not typically
respond to antibiotic treatment.
commonly caused by adenoviruses, rhinovirus,
influenza virus (flu), respiratory syncytial virus (RSV),
and parainfluenza.
 CLASSIFICATION CONT

Fungal pneumonia: caused by Histoplasma

capsulatum; fungi commonly found in bird and bat
fecal material, Coccidioides; fungus that resides in
the soil, Aspergillus fungus; aerobic and are found in
almost all oxygen-rich environments and
Cryptococcus neoformans (an encapsulated
yeast)
Aspiration pneumonia- caused by aspirating foreign
objects which are usually oral or gastric contents,
either while eating, or after reflux or vomiting.
 CLASSIFICATION CONT

Inhalation pneumonia: inflammation of the lung

parenchyma caused by inhaled hot gasses or too
cold air.
Chemical pneumonia: caused by various irritant
substances such as chlorine or gasoline fumes.

Traumatic pneumonia: a noninfectious or

nonchemical pneumonia caused by trauma from a
sharp or blunt object striking the chest and cause
injury.
 BRONCHOPNEUMONIA

It is one of the anatomical classification of

pneumonia.
The inflammation occurs in bronchioles.
Can be caused by:
Bacteria
viruses
chemicals and aspirations
BRONCHOPNEUMONIA
 PATHOPHYSIOLOGY OF BRONCHOPNEUMONIA

Congestion in the first 24 hours:

Upon entry of a microorganism or any harmful
(irritant) particle into the bronchioles, they are
detected by the macrophages as foreign;
This causes the Neutrophils (polymorphonuclear
cells) and the complement system to release
cytokines such as histamine and bradykinin
Result into dilatation of the pulmonary vessels and
capillaries leading to vascular engorgement and
leakage of intravascular fluid into the lung alveoli.
 PATHOPHYSIOLOGY CONT

leading to intra-alveolar fluid, small numbers of

neutrophils in alveoli and often numerous bacteria.
Grossly, the lung is heavy and hyperemic (increased
blood flow to the lung tissue)
Red hepatization or consolidation:
Vascular congestion persists due to increased
histamine and kinin production leading to increased
extravasation of red cells into alveolar spaces
making the lung appear red, along with increased
numbers of neutrophils and fibrin.
 PATHOPHYSIOLOGY CONT

The filling of air spaces by the exudate leads to a gross

appearance of solidification, or consolidation, of the alveolar
parenchyma. This appearance has been likened to that of the
liver, hence the term "hepatization".
 PATHOPHYSIOLOGY CONT

Grey hepatization:
Red cells disintegrate due to immune system
functioning, with persistence of the neutrophils and
fibrin. The alveoli still appear consolidated, but
grossly the color is paler.
 PATHOPHYSIOLOGY CONT

Resolution :
Refers to complete recovery of the bronchioles
from inflammation:
The exudate is digested by enzymatic activity, and
cleared by macrophages or by cough mechanism.
PATHOGENESIS
SIGNS AND SYMPTOMS OF BRONCHOPNEUMONIA

Chills followed by fever: due to disturbance of the

hypothalamus in the way it controls temperature by
cytokines and prostaglandins and also increased
metabolic processes due to presence of an
infection

Chest pain on the side of the infected lung: due to

irritation of the pain nerve receptors in the lungs
and bronchioles by prostaglandins, histamines and
bradykinin produced during inflammation process
 SIGNS AND SYMPTOMS CONT

Cough: this may be dry at first, but eventually

produces phlegm (sputum). Caused by irritation of
the receptors in the airway and lungs resulting into
an automatic cough reflex.

Night sweats: due to increased temperature

resulting from increased endotoxins in circulation
which disturb control of temperature by
hypothalamus.
 SIGNS AND SYMPTOMS CONT

Nausea and vomiting: due to stimulation of the

vomiting center and the chemoreceptor trigger
zone both located in the medulla oblongata by
endotoxins and cytokines
Respond by increasing series of contractions of the
smooth muscles lining the digestive tract.
Muscle aches: due to irritation of the tissue pain
receptors by endotoxins that diffuse into the
muscles from circulation
 SIGNS AND SYMPTOMS CONT

Rapid breathing and heartbeat: as a compensatory

mechanism by the stimulated respiratory center for
reduced oxygen concentration in circulation and
also hypercarpnia resulting from impaired lung
gaseous exchange related to exudate
accumulation in the alveoli
 SIGNS AND SYMPTOMS CONT

Difficulties in breathing: this is due to hypoxemia

and hypercarpnia resulting from exudate
accumulation in the lungs leading to impaired lung
gaseous exchange
Weight loss: this is due to increased tissue
breakdown resulting from nutrition imbalance
related to increased nutrition demand by immune
cells and lung tissues during infection and healing
process
 MANAGEMENT OF BRONCHOPNEUMONIA

INVESTIGATIONS
Physical examinations
Inspection:
It is the head to toe examination of the client
through observation.
Observe color of hair to see if brown, spaced and
thin to confirm nutrition imbalance,
The conjunctiva and mucus membrane to check
for cyanosis
 MANAGEMENT CONT

Rate of chest movement and pattern to rule out

pulmonary congestion and flail chest

Pallor in the palms of hands and clubbing of fingers

to rule out reduced hemoglobin levels

Observe the whole body in general for edema for

differential diagnosis of cardiac failure
 MANAGEMENT CONT

Palpation:
They are 4 types: light, deep, bimanual and
ballottement.

In bronchopneumonia , light palpation is used to

check for chest movement rate and pattern and
high heart rate through pulse rate and also feel for
edema (for differential diagnosis).
 MANAGEMENT CONT

Percussion
They are of three types, direct, indirect and fist :
Direct percussion involves tapping the organ with
the plexor finger of the dominant hand to elicit
sounds and pain.
Indirect percussion involves tapping the lung with
the plexor finger of the dominant hand on the
pleximeter finger in contact with the body to elicit
sounds and pain.
The normal lung sound is resonance. However, in
bronchopneumonia, dull sound is produced due to
fluid accumulation in the alveoli, flatness if severe
 MANAGEMENT CONT

Arterial blood gas analysis

Arterial blood gas analysis provides information on
Oxygenation of blood through gas exchange in the
lungs, Carbon dioxide (CO2) elimination through
respiration and Acid-base balance or imbalance in
extra-cellular fluid (ECF)
In bronchopneumonia, results show decreased PH,
increased carbon dioxide and less oxygen partial
pressure in arterial blood.
 MANAGEMENT CONT

Complete blood count (CBC): Gives important

information about the kinds and numbers of cells in
the blood, a high WBC count (leukocytosis) may
signify an infectious bronchopneumonia.
In bronchopneumonia, there are raised neutrophils
in blood > 1800cells/mm3 which are responsible for
fighting infection in the lungs.
Blood culture: Cultures are done to determine the
specific organism causing the pneumonia, but they
usually cannot distinguish between harmless and
dangerous organisms.
 MANAGEMENT CONT

Thoracentesis:
Fluid in the pleura is withdrawn using a long thin
needle inserted between the ribs. The fluid is then
sent to the lab for multiple tests to detect the
present microorganisms.

Complications of this procedure are rare, but can

include collapsed lung, bleeding, and introduction
of infection.
 MANAGEMENT CONT

Polymerase Chain Reaction (PCR):

In some difficult cases, PCR may be performed. The
test makes multiple copies of the genetic material
(RNA) of a virus or bacteria to make it detectable in
blood.

Urine Tests:
Urine antigen tests for Legionella pneumophila
(Legionnaires' disease) and Streptococcus
pneumoniae may be performed in patients with
severe Community Acquired Pneumonia
 MANAGEMENT CONT

Bronchoscopy:
A bronchoscopy is done in the following way:
The patient is given a local anesthetic,
supplementary oxygen, and sedatives.
The physician inserts a fiber optic tube into the
lower respiratory tract through the nose or mouth.
The tube acts like a telescope to view the windpipe
and major airways and look for pus, abnormal
mucus, or other problems.
 MANAGEMENT CONT

Bronchoalveolar lavage (BAL):

involves injecting high amounts of saline through the
bronchoscope into the lung and then immediately
sucking the fluid out. The fluid is then analyzed in the
laboratory.

Complications can occur of procedure include:

Allergic reactions to the sedatives or anesthetics,
Asthma attacks in susceptible patients, Bleeding
and Fever
 MANAGEMENT CONT

Chest x-ray:
X-ray is a form of electromagnetic radiation (like
light). They are of higher energy and can penetrate
the body to form an image on film. Structures that
are dense (such as bone) will appear white, air will
be black.

In bronchopneumonia the picture will appear white

due to lung consolidation and high density
 MANAGEMENT CONT

Computed tomography:
CT scan of the chest can help detect the presence
of tissue damage, abscesses, and tumors. This
procedure typically uses a needle inserted
between the ribs to draw fluid out of the lung for
analysis.
Other names include: Lung aspiration, Lung
puncture, Thoracic puncture, Transthoracic needle
aspiration, Percutaneous needle aspiration and
Needle aspiration
 MANAGEMENT CONT

Lung Biopsy:
In very severe cases of pneumonia or when the
diagnosis is unclear, a lung biopsy may be required.
A lung biopsy involves taking some tissue from the
lungs and examining it under a microscope.
 MANAGEMENT CONT

MEDICAL MANAGEMENT
Treatment for pneumonia depends on the
underlying cause.

The medical treatment for Bronchopneumonia may

include antiviral medications, antibiotics, cough
suppressants, bronchodilator medications for
wheezing, and nonsteroidal anti-inflammatory
medications for pain and fever as follows:
 MANAGEMENT CONT

Antiviral drugs for viral bronchopneumonia:

Oseltamivir and Zanamivir (1 inhalation once daily
for 7 days). Prevents viral replication by inhibiting
enzyme neuraminidase found in influenza and
parainfluenza viruses

Side effects include: diarrhea, sinusitis, nausea,

cough, dizziness and headache). These are
recommended drugs for influenza type A or B
infections.
 MANAGEMENT CONT

Patients with bronchopneumonia caused by

varicella-zoster and herpes simplex viruses treated
with intravenous acyclovir (10 mg/kg for 7 days).

Converted to acyclovir triphosphate, becomes part

of DNA and prevents DNA synthesis and viral
replication

Side effects include nausea and vomiting

 MANAGEMENT CONT

No antiviral drugs have been proven effective in

adults with Respiratory Syncytial Virus, parainfluenza
virus, adenovirus, coronavirus, or hantavirus.

Treatment is largely supportive, with patients

receiving oxygen and ventilator therapy as
needed.
 MANAGEMENT CONT

Antibiotics for bacterial bronchopneumonia:

Ampicillin
Dosage: 200-400 mg ampicillin/kg/day every 6
hours; maximum: 8 g ampicillin/day. Given IM or IV
Inhibits cell wall synthesis
Side effects: include pain at site of injection, mild
nausea and vomiting and headache.
Nursing implication: Avoid giving those who react to
any penicillin or any history of allergies
 MANAGEMENT CONT
Penicillin G
Dosage: 1.2 million units/day in as a single dose
given every 4 hours, (given up to 1to 2 weeks).
Contraindicated in someone with hypersensitivity
reaction to penicillin
Side effects: include lethargy (weakness), fever,
dizziness, rash, pain at injection site.
Nursing implication: Being conscious about drug
interaction with erythromycin. Ask if they react to
penicillin and those with history of seizures to
prevent hypersensitivity reactions and axcerserbate
the seizures.
 MANAGEMENT CONT

Amoxicillin
Dosing range: 250-500 mg every 8 hours or 500-875
mg twice daily; maximum dose: 2-3 g/day
Side effects: diarrhea and abdominal crumps,
nausea, vomiting, headache and vaginal
candidiasis
Nursing implication: Ask if they have history of
allergies to penicillin and cephalosporins to avoid
reactions and axcerserbation of allergies
 MANAGEMENT CONT

Cough suppressants:
Codeine: 6mg QID, orally
An opioid( inhibits ascending pathways) and based
cough depressant

Side effect: nausea, vomiting, dizziness, supine

hypotension
 MANAGEMENT CONT

pain relief medication:

Paracetamol: 500mg TDS (8 hourly)

Brufein: Dosage: 400 mg per dose, (TDS) and 1200 mg

per day is considered the maximum amount

Ibuprofen (INN) is a nonsteroidal anti-inflammatory

drug (NSAID) used for pain relief, fever reduction.
 MANAGEMENT CONT

Bronchodilators (beta adrenergic agonists)

Albuterol Inhaler
Proventil Inhaler
Ventolin Inhaler

Nonsteroidal anti- inflammatory drugs

Aspirin: Dosage: 325 to 650 mg orally or rectally
every 4 hours as needed, not to exceed 4 g/day.
Brufein: Dosage: 400 mg per dose, (TDS)
 NURSING CARE FOR PATIENT WITH
BRONCHOPNEUMONIA
Environment:
Provide a quiet, clean, warm but well ventilated
environment. Ensure that a bed is well made and
always dry
Psychological care:
Explain the causes of symptoms and signs and the
response of such to medication to the patient to
alley anxiety. Explain the purposes of all drugs and
equipment being used for treatment. Explain and
orient the patient to the hospital environment.
 NURSING CARE CONT

Rest:
Ensure patient rest to allow for the energy available
in the body to be used by immune system to fight
infection and also for tissue regeneration during
healing by providing a quiet environment and
diversional therapy such as music.
Observation
Measure temperature every four hours to check for
temperature range and deviation from normal and
to ascertain the effectiveness of medication being
used for temperature regulation
 NURSING CARE CONT

Check the pulse rate, blood pressure, respiratory

rate every four hour to check for the progress of
treatment and response of signs and symptoms to
treatment being given
 NURSING CARE CONT

Exercise:
Ensure that the patient is able to move around and
do some random of motion exercises while lying in
bed frequently to promote blood circulation and
foster healing process

Show the patient the breathing in and out exercise

to ensure sufficient intake of oxygen in lung to foster
gaseous exchange and prevent or counteract
hypercarpnia, hypoxemia and hypoxia.
 NURSING CARE CONT

Nutrition
Teach the patient and family present on how to
maintain adequate food intake by ensuring that a
patient takes enough variety of protein giving
foods, energy giving foods, less fatty foods as they
reduce appetite, enough water orally daily and
fruits and vegetables for minerals and vitamins to
foster maximum immune functioning and tissue
repair during healing process if patient is able to eat
on their own.
 NURSING CARE CONT

Administer intravenous fluids according to

prescription so that to maintain normal body fluids
and excretion of blood toxins through urine for the
purpose of maintaining normal body functioning

Encourage patient to be taking small but frequent

meals to avoid vomiting as when a large meal is
taken it cases distension and irritation of the
stomach muscles which axcerserbate nausea and
vomiting
 NURSING CARE CONT

Hygiene
Teach the patient on the importance of hand
washing whenever they come from passing human
excreta, whenever they want to eat food and also
washing fruits before eating to avoid other infection
and.
Ensure that a patient is bathed, (either assisted bath
or bed bath) in the morning and evening to prevent
skin infections, bed sores and promote blood
circulation and exercise
 NURSING CARE CONT

Ensure that oral care is by those who are able to do

it on their own after being instructed and on all
unconscious patients to avoid oral infections and
promote appetite
 I.E.C

Educate the patient on the effect of smoking on

pneumonia and encourage him/her to reduce or if
possible stop smoking to avoid axcerserbation of
cough which may complicate into hemoptysis.

Discourage patient from taking alcohol or abuse of

alcohol as it lowers the immune system and result
into axcerserbation of signs and symptoms of
pneumonia.
 I.E.C. CONT

Educate the patient to avoid use of over the

counter non steroid anti- inflammatory drugs
without advice from any health care provider as
they may cause gastrointestinal problems and heart
problems and lower the rate of recovery.
Educate the patient and present family members
on importance of nutrition during an illness so as to
empower them with knowledge for them to be able
to encourage the patient to eat as frequent as
possible.
 I.E.C. CONT

Educate the patient to avoid being exposed to the

dusty and toxic containing environment to avoid
axcerserbation of signs and symptoms of
pneumonia
 I.E.C. CONT

Educate the patient on the importance of

compliance to medication and the effect of
noncompliance in order to encourage patient take
prescribed medication and ensure quick recovery

Educate the patient on the importance of exercise

and encourage them to be exercising by mobilizing
and continue doing some random of motion
exercises while in bed to ensure quick recovery
 COMPLICATIONS

Abscess: an abscess in the lung is a thick-walled,

pus-filled cavity that forms when infection has
destroyed lung tissue.
Respiratory Failure. Respiratory failure is one of the
top causes of death in patients with more severe
pneumonia due to consolidation of the all lungs.

Bacteremia: bacteria in blood are the most

common complication of pneumococcus infection
 COMPLICATIONS CONT

Pleural Effusions : The filling of fluid in between the

pleural.
Empyema: formation of abscess outside the lining
of the lung
Collapse of the Lung: In some cases, air or fluid may
fill up the area between the pleural membranes,
causing the lungs to collapse
Pneumothorax: occurs when air leaks from inside
the lung to the space between the lung and the
chest wall.
 NURSING CARE PLAN

DISCUSS USING THE FOLLOWING PROBLEMS:

1. CHEST PAIN
2. DYSPNEA
3. INEFFECTIVE AIRWAY CLEARANCE
4. FEVER
5. NUTRITION IMBALANCE LESS THAN BODY
REQUIREMENTS
6. RISK OF DEHYDRATION
 SUMMARY

Pneumonia is the inflammation of the lung tissue

leading to consolidation of the alveoli and
infiltration of the interstitial tissue with inflammatory
cells.
Pneumonia can be classified by where it was
acquired (hospital versus community), by the area
of lung affected (bronchopneumonia, lobar
pneumonia and interstitial pneumonia) or by the
cause such as viral pneumonia, bacteria
pneumonia, aspiration pneumonia and inhalation
pneumonia
 SUMMARY CONT

Bronchopneumonia is the acute inflammation of

the walls of the bronchioles
characterized by multiple foci (small points of
isolated, acute consolidation, affecting one or
more pulmonary lobules
Laboratory investigations done to rule out
pneumonia include: CT scan of the chest, Chest x-
ray- X-ray, arterial blood gas analysis, complete
blood count, polymerase Chain Reaction,
bronchoscopy, bronchoalveolar lavage and Lung
Biopsy.
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2. Gordon C. Alimuddin Z. (2003), Manson Tropical

Diseases, 21st edition, UK

3. Gray Z. e tal. (1998), The Merik manual of medical

information, 3rd edition, Philadelphia, USA

4. Kathryn L. (1998), Pathophysiology: the biologic basis

for disease in adults and children, 3rd edition,
Philadelphia, USA