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I. Pathophysiology
a. Inflammation of the lung parenchyma associated with
alveolar edema and congestion that impairs gas exchange
b. Common pathogens
i. Viruses
1. Common causative organisms include respiratory
syncytial virus (RSV) and influenza
2. Accounts for approximately half of all cases of
community-acquired pneumonia (CAP)
ii. Bacteria
1. Divided into typical and atypical types
2. Gram-positive Streptococcus pneumoniae,
Haemophilus, and Staphylococcus most common
bacterial causes
iii. Fungus
1. Most common causes Histoplasma capsulatum and
Coccidioides immitis
2. Pneumocystis carinii and cytomegalovirus (CMV)
often occur in immunocompromised persons
iv. Other
1. Agents include Mycoplasma, Mycobacterium tuberculosis,
Coxiella burnetii, Chlamydia, and Legionella
II. Classification
a. Site and causative agent
i. Lobar, single lobe; broncho, smaller lung areas in several
lobes; interstitial, tissues surrounding the alveoli and
ii. Bacteria, viruses, and fungi
b. Distribution
i. CAP commonly caused by S. pneumoniae, Chlamydia
pneumoniae, Haemophilus influenzae, RSV, occasionally
atypical pathogens
ii. Nosocomial develops at least 48 hours after admission to
an institution or care center; hospital-acquired pneumonia
(HAP) and/or ventilator-associated pneumonia (VAP) is
often caused by Pseudomonas aeruginosa, Klebsiella
pneumoniae, Staphylococcus aureus, and both methicillinsensitive
and methicillin-resistant S. aureus (MRSA)

III. Etiology
a. Primary pneumonia is caused by the client’s inhalation or
aspiration of a pathogen (microaspiration).
b. Secondary pneumonia ensues from lung damage caused by
the spread of an infectious agent—bacterial, viral, or
fungal—from another site in the body or from various
chemical irritants (including gastric reflux and aspiration,
smoke inhalation) or radiation therapy.
c. Risk factors: comorbidities, such as heart or lung disease,
compromised immune system, diabetes mellitus, liver
or renal failure, malnutrition, smoking, over age 70,
previous antibiotic therapy, abdominal or thoracic surgical
procedures, endotracheal intubation with mechanical
IV. Statistics (American Lung Association, 2007c; National
Center for Health Statistics [NCHS], 2007; National Heart,
Lung and Blood Institute [NHLBI], 2008a)
a. Morbidity: An estimated 6 million cases are reported
annually; hospital discharges attributed to pneumonia in
2005 were 651,000 males (44.9 per 10,000) and 717,000
females (47.7 per 10,000).
b. Mortality: Approximately 58,000 deaths per year; eighth
leading cause of death in the United States (pneumonia
and influenza combined, with pneumonia the leading
cause); accounts for approximately 10% of all inpatient
c. Cost: Estimated annual cost is $8.4 billion for CAP
(Lutfiyya, 2006); in excess of $1 billion per year for HAPs;
up to $20,000 to $29,000 per episode of VAP, with length
of stay increased by as much as 14 days (Niederman, 2001;
Schleder, 2004).

Care Setting
Most clients are treated as outpatients in community settings;
however, persons at higher risk, such as those older
than 65 and persons with other chronic conditions such as
chronic obstructive pulmonary disease (COPD), diabetes,
cancer, and congestive heart failure, are treated in the hospital,
as are those already hospitalized for other reasons and
who have developed nosocomial pneumonia.

NURSING DIAGNOSIS: ineffective Airway Clearance

May be related to
Tracheal bronchial inflammation, edema formation, increased sputum production
Pleuritic pain
Decreased energy, fatigue
Possibly evidenced by
Changes in rate, depth of respirations
Abnormal breath sounds, use of accessory muscles
Dyspnea, cyanosis
Cough, effective or ineffective; with or without sputum production
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Airway Patency
Identify and demonstrate behaviors to achieve airway clearance.
Display patent airway with breath sounds clearing and absence of dyspnea and cyanosis.
Nursing Priorities
1. Maintain or improve respiratory function.
2. Prevent complications.
3. Support recuperative process.
4. Provide information about disease process, prognosis,
and treatment.
Discharge Goals
1. Ventilation and oxygenation adequate for individual needs.
2. Complications prevented or minimized.
3. Disease process, prognosis, and therapeutic regimen
4. Lifestyle changes identified and initiated to prevent
5. Plan in place to meet needs after discharge.

Airway Management
Assess rate and depth of respirations and chest movement.
Monitor for signs of respiratory failure; for example,
cyanosis and severe tachypnea.
Auscultate lung fields, noting areas of decreased or absent
airflow and adventitious breath sounds, such as crackles
and wheezes.
Elevate head of bed; change position frequently.
Assist client with frequent deep-breathing exercises.
Demonstrate and help client, as needed; learn to perform
activity, such as splinting chest and effective coughing
while in upright position.
Suction, as indicated; for example, oxygen desaturation
related to airway secretions.
Force fluids to at least 2,500 mL per day, unless contraindicated,
as in HF. Offer warm, rather than cold, fluids.
Assist with and monitor effects of nebulizer treatments and
other respiratory physiotherapy, such as incentive spirometer,
intermittent positive-pressure breathing (IPPB), percussion,
and postural drainage. Perform treatments between
meals and limit fluids when appropriate.
Administer medications, as indicated, for example mucolytics,
expectorants, bronchodilators, and analgesics.
Provide supplemental fluids such as IV, humidified oxygen,
and room humidification.
Monitor serial chest x-rays, ABGs, and pulse oximetry
readings. (Refer to ND: impaired Gas Exchange, following.)
Tachypnea, shallow respirations, and asymmetric chest movement
are frequently present because of discomfort of moving
chest wall or fluid in lung. When pneumonia is severe,
the client may require endotracheal intubation and
mechanical ventilation to keep airways clear.
Decreased airflow occurs in areas consolidated with fluid.
Bronchial breath sounds (normal over bronchus) can also
occur in consolidated areas. Crackles, rhonchi, and wheezes
are heard on inspiration and expiration in response to fluid
accumulation, thick secretions, and airway spasm or
Keeping the head elevated lowers diaphragm, promoting chest
expansion, aeration of lung segments, and mobilization
and expectoration of secretions to keep the airway clear.
Deep breathing facilitates maximum expansion of the lungs
and smaller airways. Coughing is a natural self-cleaning
mechanism, assisting the cilia to maintain patent airways.
Splinting reduces chest discomfort, and an upright position
favors deeper, more forceful cough effort. Note: Cough
associated with pneumonias may last days, weeks, or even
Stimulates cough or mechanically clears airway in client who
is unable to do so because of ineffective cough or
decreased level of consciousness.
Fluids, especially warm liquids, aid in mobilization and expectoration
of secretions.
Facilitates liquefaction and removal of secretions. Postural
drainage may not be effective in interstitial pneumonias or
those causing alveolar exudates or destruction. Coordination
of treatments, schedules, and oral intake reduces likelihood
of vomiting with coughing and expectorations.
Aids in reduction of bronchospasm and mobilization of secretions.
Analgesics are given to improve cough effort by
reducing discomfort, but should be used cautiously
because they can decrease cough effort and depress
Fluids are required to replace losses, including insensible, and
aid in mobilization of secretions. Note: Some studies
indicate that room humidification has been found to
provide minimal benefit and is thought to increase the risk
of transmitting infection.
Follows progress and effects of disease process and therapeutic
regimen, and facilitates necessary alterations in therapy.