I.

DEFINITION

Pneumonia is an inflammation of the lungs caused by an infection. It is also called Pneumonitis or

Bronchopneumonia. Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for older
adults and those with chronic illnesses, it can also strike young, healthy people as well.  It is a common illness that
affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality
in the country.
There are many kinds of pneumonia that range in seriousness from mild to life-threatening. In infectious
pneumonia, bacteria, viruses, fungi or other organisms attack your lungs, leading to inflammation that makes it hard to
breathe. Pneumonia can affect one or both lungs. In the young and healthy, early treatment with antibiotics can cure
bacterial pneumonia. The drugs used to fight pneumonia are determined by the germ causing the pneumonia and the
judgment of the doctor. It’s best to do everything we can to prevent pneumonia, but if one do get sick, recognizing and
treating the disease early offers the best chance for a full recovery.
A case with a diagnosis of Pneumonia may catch one’s attention, though the disease is just like an ordinary
cough and fever, it can lead to death especially when no intervention or care is done. Since the case is a toddler, an
appropriate care has to be done to make the patient’s recovery faster. Treating patients with pneumonia is necessary to
prevent its spread to others and make them as another victim of this illness.
Bronchopneumonia is a type of pneumonia that is characterized by an inflammation of the lung generally
associated with, and following a bout with bronchitis. This is really a specific type of pneumonia that is localized in the
bronchioles and surrounding alveoli. This article provides a general overview of this condition, including symptoms and
treatment options for those who have been diagnosed with bronchopneumonia. The most common pneumonia-causing
bacterium in adults is Streptococcus pneumoniae (pneumococcus)

II. ETIOLOGY

Bronchopneumonia is common in hospitalized patients. It may occur as a complication of some disease.

Eg. In children - Diphtheria , Measles , Whooping Cough .
      In adults -  Influenza,  typhoid  & paratyphoid fever etc.

- It is often seen in two extremes of life (in infants & old age).
- Most bronchopneumonia cases are caused by organisms aspirated from the mouth.

Causative Organisms:   
1)  Staphylococci
2) Streptococci
3) Pneumococci 
4) Haemophilus influenzaea
5)  Pseudomonas aeruginosa
6) Coliform bacteria .

III. CLINICAL MANIFESTATIONS

People with infectious pneumonia often have a cough producing

greenish or yellow sputum, or phlegm and a high fever that may be
accompanied by shaking chills. Shortness of breath is also common, as
is pleuritic chest pain, a sharp or stabbing pain, either experienced
during deep breaths or coughs or worsened by them. People with
pneumonia may cough up blood, experience headaches, or develop
sweaty and clammy skin. Other possible symptoms are loss of appetite,
fatigue, blueness of the skin, nausea, vomiting, mood swings, and joint
pains or muscle aches. Less common forms of pneumonia can cause
other symptoms; for instance, pneumonia caused by Legionella may
cause abdominal pain and diarrhea, while pneumonia caused by
tuberculosis or Pneumocystis may cause only weight loss and night sweats. In elderly people, manifestations of
pneumonia are seldom typical. They may develop a new or worsening confusion (delirium) or may experience
unsteadiness, leading to falls. Infants with pneumonia may have many of the symptoms above, but in many cases they
are simply sleepy or have a decreased appetite. [9]
Pneumonia fills the lung's alveoli with fluid, keeping oxygen from reaching the bloodstream. The alveolus on the
left is normal, while the alveolus on the right is full of fluid from pneumonia.
Symptoms of pneumonia need immediate medical evaluation. Physical examination by a health care provider may reveal
fever or sometimes low body temperature, an increased respiratory rate, low blood pressure, a high heart rate, or a low
oxygen saturation, which is the amount of oxygen in the blood as indicated by either pulse oximetry or blood gas
analysis. People who are struggling to breathe, who are confused, or who have cyanosis (blue-tinged skin) require
immediate attention.
Findings from physical examination of the lungs may be normal, but often show decreased expansion of the chest on
the affected side, bronchial breathing on auscultation with a stethoscope (harsher sounds from the larger airways
transmitted through the inflamed and consolidated lung), and rales (or crackles) heard over the affected area during
inspiration. Percussion may be dulled over the affected lung, but increased rather than decreased vocal resonance
(which distinguishes it from a pleural effusion). While these signs are relevant, they are insufficient to diagnose or rule
out a pneumonia; moreover, in studies it has been shown that two doctors can arrive at different findings on the same
patient.

IV. ANATOMY & PHYSIOLOGY

The lungs constitute the largest organ in the

respiratory system. They play an important role in
respiration, or the process of providing the body with
oxygen and releasing carbon dioxide. The lungs expand
and contract up to 20 times per minute taking in and
disposing of those gases.
Air that is breathed in is filled with oxygen and goes to
the trachea, which branches off into one of two bronchi.
Each bronchus enters a lung. There are two lungs, one on
each side of the breastbone and protected by the ribs.
Each lung is made up of lobes, or sections. There are three
lobes in the right lung and two lobes in the left one. The
lungs are cone shaped and made of elastic, spongy tissue.
Within the lungs, the bronchi branch out into minute
pathways that go through the lung tissue. The pathways
are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and
provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body.
The alveoli also take in carbon dioxide, which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of
those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has
a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other
during breathing.

V. PATHOPHYSIOLOGY

Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid.
Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body cells can’t work properly.
Because of this and spreading infection through the body pneumonia can cause death. Pneumonia affects your lungs in
two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects
patches throughout both lungs.
 Bacteria are the most common cause of pneumonia. Of these,
Streptococcus pneumoniae is the most common. Other pathogens include
anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae,
Chlamydia pneumoniae, C. psittaci, C. trachomatis, Moraxella (Branhamella)
catarrhalis, Legionella pneumophila, Klebsiella pneumoniae, and other gram-
negative bacilli. Major pulmonary pathogens in infants and children are
viruses: respiratory syncytial virus, parainfluenza virus, and influenza A and B
viruses. Among other agents are higher bacteria including Nocardia and
Actinomyces sp; mycobacteria, including Mycobacterium tuberculosis and
atypical strains; fungi, including Histoplasma capsulatum, Coccidioides
immitis, Blastomyces dermatitidis, Cryptococcus neoformans, Aspergillus
fumigatus, and Pneumocystis carinii; and rickettsiae, primarily Coxiella
burnetii (Q fever).
The usual mechanisms of spread are inhaling droplets small enough to
reach the alveoli and aspirating secretions from the upper airways. Other
means include hematogenous or lymphatic dissemination and direct spread
from contiguous infections. Predisposing factors include upper respiratory viral infections, alcoholism,
institutionalization, cigarette smoking, heart failure, chronic obstructive airway disease, age extremes, debility,
immunocompromise (as in diabetes mellitus and chronic renal failure), compromised consciousness, dysphagia, and
exposure to transmissible agents.
Typical symptoms include cough, fever, and sputum production, usually developing over days and sometimes
accompanied by pleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles with
bronchial breath sounds. This syndrome is commonly caused by bacteria, such as S. pneumoniae and H. influenzae.

VI. DIAGNOSIS

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
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. [9]
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:
Fever > 37.8 °C (100.0 °F)
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. 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 (and vice versa), especially in the elderly, due to its similar symptoms and signs.
Other diseases to be taken into consideration include bronchiectasis, lung cancer and pulmonary emboli.

Appearance on X ray

AP CXR showing left lower lobe

AP CXR showing right
pneumonia associated with a small
Normal AP CXR Normal lateral CXR lower lobe pneumonia
left sided pleural effusion

Right upper lobe pneumonia as

A lateral CXR showing right AP CXR showing pneumonia marked by the circle.
lower lobe pneumonia of the lingula of the left lung

VII. MEDICAL MANAGEMENT

Antibiotics improve outcomes in those with bacterial pneumonia. Initially antibiotic choice depends on the
characteristics of the person affected such as age, underlying health, and location the infection was acquired.
In the UK empiric treatment is usually with amoxicillin, erythromycin, or azithromycin for community-acquired
pneumonia. In North America, where the "atypical" forms of community-acquired pneumonia are becoming more
common, macrolides (such as azithromycin), and doxycycline have displaced amoxicillin as first-line outpatient
treatment for community-acquired pneumonia. The use of fluoroquinolones in uncomplicated cases is discouraged due
to concerns of side effects and resistance.
The duration of treatment has traditionally been seven to ten days, but there is increasing evidence that short
courses (three to five days) are equivalent. Antibiotics recommended for hospital-acquired pneumonia include third- and
fourth-generation cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, and vancomycin. These antibiotics
are often given intravenously and may be used in combination.

VIII. NURSING MANAGEMENT

INDEPENDENT

 positioning of the patient with head on mid line, with slight flexion
rationale: to provide patent, unobstructed airway , maximum lung excursion
 auscultating patient’s chest
rationale:  to monitor for the presence of abnormal breath sounds
 provide chest and back clapping with vibration
rationale:  chest physiotheraphy facilitates the loosening of secretions
 considering that the patient is an infant, and has developed a strong stranger anxiety
as manifested by “white coat syndrome” ,  it is a nursing action to play with the patient.
rationale:  to establish rapport, and gain the patients trust

DEPENDENT

 administer due medications as ordered by the physician, bronchodilators, anti pyretics and anti biotics
rationale:  bronchodilators decrease airway resistance, secondary to bronchoconstriction,
anti pyretics alleviate fever, antibiotics fight infection
 placing patient on TPN  prn
rationale:  to compensate for fluid and nutritional losses during vomiting

COLLABORATIVE

 assist respiratory therapist in performing nebulization of the patient

rationale:  nebulization is a favourable route of administering bronchodilators
and aid in expectorating secretions, hence patient’s breathing
 WESLEYAN UNIVERSITY – PHILIPPINES
Mabini Extension, Cabanatuan City
College of Nursing

CASE STUDY:
Bronchopneumonia

Submitted by:
Norberto S. Batisan, Jr.
BSN IV – 1
WU-P SN ‘11
Submitted to:
Ma’am Danna Ventosa, R. N.
Clinical Instructor