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.
-Lymphocy 22.6 % 30-60 LOW
te (P)
may indicate
lymphocytosis;increas
 ed 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 1.40 10.9/L 0.2-0.8 LOW
(a)
 - 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 ACTUAL SIGNS RATIONALE
SIGNS AND AND SYMPTOMS
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
➢ Chest discomfort faster to
compensate.
• Present

 All abnormal
➢ Cough productive formation/accu
of purulent mulation/
➢ or blood-tinged reaction in our
sputum body causes
inflammatory
 response,
which
• Absent
stimulates the
nerve fibers
and produces
➢ Tachypnea sensation of
pain.
➢ Tachycardia

 Mucus
production is
increased, and
Adventitious Sound the leaky
Breadth capillaries may
* crackles (or rales) tinge the
mucus with
blood. Mucus
plugs actually
further
decrease the
efficiency of
gas exchange
•
in the lung.
The alveoli fill
further with
fluid and
debris from
* wheezes (or the large
•
rhonchi) number of
white blood
cells being
produced to
fight the
infection.
  Because of the
deprived
circulating
oxygen, the
body
compensate
• by increasing
the respiratory
* stridor
rate.

 As well as the
Cardiac rate,
to increase the
circulating
blood in the
In advanced cases you
body.
may see:
 Cyanosis

•
 When air
passes the
fluid airways,
causing
 Confusion
collapsed
alveoli to pop
open as the
 Chest indrawing 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.

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

•
 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.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 overly exuberant immune response in the lungs. The
small blood vessels in the lungs (capillaries) become leaky, and
protein-rich fluid seeps into the alveoli. This results in a
less functional area for oxygen-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.
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 with fluid and debris from the large number of
white blood cells being produced to fight the infection.
Consolidation, a feature 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.
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.
 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
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NURSING MANAGEMENT