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 childrenThe International Union Against Tuberculosis and Lung Disease68, 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 respiratoryinfections (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 communitieswho most often suffer and die from this condition.

● In developing countries pneumonia is 5 times more common, and the death rate is10 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.

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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 FINDINGS

UNITS REFERENCE VALUES

CLINICAL IMPLICATIONS / SIGNIFICANCE

WBC Count 19.8 10.9/L 4-10 HIGHMay 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 NORMALDecreased with anemia; increased when too many made and with fluid loss due

to diarrhea, dehydration, burns

Hemoglobin 116 9/L 120-180 LOWmeasures the amount of oxygen-carrying protein in the blood.

Hematocrit 0.35 2/L 0.37-0.54 LOWmeasures the percentage of red blood cells in a given volume of whole blood.

Platelet Count 727 10 g/L 150-450 HIGHDecreased 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 LOWMirrors 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.

-Lymphocyte (P)

22.6 % 30-60 LOWmay indicate lymphocytosis;increased in convalescent phase after bacterial/viral infection

- Monocyte (p)

7.2 % 3-9 NORMAL

- Granulocyte (P)

70.2 % 20-65 HIGHinclude 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 NORMALThe 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 LOWVary with platelet production; younger platelets are larger than older ones

PDW 10.20 % 10-18 NORMALmeasure the conformity of platelet in the specimen. Serves as a validity check & monitors false result.

- Lymphocyte (a)

4.40 10.9/L 1.2-3.2 HIGH

- Monocyte (a)

1.40 10.9/L 0.2-0.8 LOW

- Granulocyte (a)

14.20 10.9/L 1.2-6.8 HIGH

CHEST X-RAY

Date taken : July 10, 2009Examination: Chest AP

FINDINGS:

Bilateral BronchopneumoniaParatracheal Adenopathy

CLINICAL MANIFESTATION

SUBJECTIVE SYMPTOMS OBJECTIVE SYMPTOMS

ACTUAL MANIFESTATIONTHEORETICAL

SIGNS AND SYMPTOMS

ACTUAL SIGNS AND SYMPTOMS

RATIONALE

Dyspnea

Chest discomfort

Cough productive of purulent

or blood-tinged sputum

Tachypnea

Present

Present

Absent

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 formation/accumulation/ reaction in our body causes inflammatory response, which stimulates the nerve fibers and produces sensation of pain.

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

Tachycardia

Adventitious Sound Breadth

* crackles (or rales)

* wheezes (or rhonchi)

* stridor

infection.

Because of the deprived circulating oxygen, the body compensate by increasing the respiratory rate.

As well as the Cardiac rate, to increase the circulating blood in the body.

When air passes the fluid airways, causing collapsed alveoli to pop open as the 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.

In advanced cases you may see:

Cyanosis

Confusion

Chest indrawing

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.

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

Viral pneumonias, and mycoplasma pneumonias, do not result in consolidation. These types of pneumonia primarily infect the walls of the

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

Consolidation, a feature of bacterial pneumonias, occurs when the alveoli, which are normally hollow air spaces within the lung, instead become

Viral pneumonias, and mycoplasma pneumonias, do not result in consolidation. These types of pneumonia primarily infect the walls of the

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