NUR 111 (Nursing Care of Clients with Life –

Threatening Conditions, Acutely Ill/Multi-organ

Problems, High Acuity and Emergency
STUDENT ACTIVITY SHEET Situation)
BS NURSING / FOURTH YEAR
Session # 3

Materials: MS notebook, paper, pen, index card,

LESSON TITLE: Pneumonia and bond paper (short & long size)
LEARNING TARGETS: References:
At the end of the lesson, the student nurses will be to: Smeltzer S.C., & Bare B.G. (2010) Brunner and
1. Define pneumonia and differentiate its classification; Suddarth’s Textbook of Medical- Surgical Nursing.
2. Trace the pathophysiology of the disease condition; Lippincott William & Wilkins
3. Discuss its causes, manifestation and identify
preventive measures; Sommer S., Johnson J. (2013) RN Adult Medical
4. Formulate nursing diagnosis for pneumonia; and, Surgical Nursing. Assessment Technology
5. Develop nursing care plans for pneumonia. Institute, LLC.
https://www.nurseslab.com

LESSON PREVIEW/REVIEW (10 minutes)

Instruction: Enumerate the causes of direct injury to the lungs.
1. _________________________
2. _________________________
3. _________________________
4. _________________________
MAIN LESSON (60 minutes)

Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria,
mycobacteria, fungi, and viruses.

Pneumonitis is a more general term that describes the inflammatory process in the lung tissue that may predispose and
place the patient at risk for microbial invasion.

Classification:
Pneumonia is classified into four: community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP),
pneumonia in the immunocompromised host, and aspiration pneumonia.

Community-Acquired Pneumonia
 CAP occurs either in the community setting or within the first 48 hours after hospitalization.
 The causative agents for CAP that needs hospitalization
include streptococcus pneumoniae, H. influenza, Legionella, and Pseudomonas aeruginosa.
 Only in 50% of the cases does the specific etiologic agent become identified.
 Pneumonia is the most common cause of CAP in people younger than 60 years of age.
 Viruses are the most common cause of pneumonia in infants and children.

Hospital-Acquired Pneumonia
 HAP is also called nosocomial pneumonia and is defined as the onset of pneumonia symptoms more than 48
hours after admission in patients with no evidence of infection at the time of admission.
 HAP is the most lethal nosocomial infection and the leading cause of death in patients with such infections.

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  Common microorganisms that are responsible for HAP include Enterobacter species, Escherichia
coli, influenza, Klebsiella species, Proteus, Serratia marcescens, S. aureus, and S. pneumonia.
 The usual presentation of HAP is a new pulmonary infiltrate on chest x-ray combined with evidence of infection.

Pneumonia in the Immunocompromised Host

 Pneumonia in immunocompromised hosts includes Pneumocystis pneumonia, fungal pneumonias and
Mycobacterium tuberculosis.
 Patients who are immunocompromised commonly develop pneumonia from organisms of low virulence.
 Pneumonia in immunocompromised hosts may be caused by the organisms also observe in HAP and CAP.

Aspiration Pneumonia
 Aspiration pneumonia refers to the pulmonary consequences resulting from entry of endogenous or exogenous
substances into the lower airway.
 The most common form of aspiration pneumonia is a bacterial infection from aspiration of bacteria that normally
reside in the upper airways.
 Aspiration pneumonia may occur in the community or hospital setting.
 Common pathogens are S. pneumonia, H.influenza, and S. aureus.

Pathophysiology
 Having an idea about the disease process helps the patient understand the treatment regimen and its importance,
increasing patient compliance.
 Pneumonia arises from normal flora present in patients whose resistance has been altered or from aspiration of
flora present in the oropharynx.
 An inflammatory reaction may occur in the alveoli, producing exudates that interfere with the diffusion of oxygen
and carbon dioxide.
 White blood cells also migrate into the alveoli and fill the normally air-filled spaces.
 Due to secretions and mucosal edema, there are areas of the lung that are not adequately ventilated and cause
partial occlusion of the alveoli or bronchi.
 Hypoventilation may follow, causing ventilation-perfusion mismatch.
 Venous blood entering the pulmonary circulation passes through the under ventilated areas and travels to the left
side of the heart deoxygenated.
 The mixing of oxygenated and poorly oxygenated blood can result to arterial hypoxemia.

Epidemiology
 Pneumonia has affected a lot of people, especially those who have a weak immune system. Learning statistics on
pneumonia could give you an idea about how many has fallen victim to this respiratory disease.
 Pneumonia and influenza account for nearly 60,000 deaths annually.
 Pneumonia also ranks as the eighth leading cause of death in the United States.
 It is estimated that more than 915, 000 episodes of CAP occur in adults 65 years old and above in the United
States.
 HAP accounts for 15% of hospital-acquired infections and is the leading cause of death in patients with such
infections.
 The estimated incidence of HAP 4 to 7 episodes per 1000 hospitalizations.

Causes
Each type of pneumonia is caused by different and several factors.

Community-Acquired Pneumonia
 Streptococcus pneumoniae. This is the leading cause of CAP in people younger than 60 years of age without
comorbidity and in those 60 years and older with comorbidity.
 Haemophilus influenzae. This causes a type of CAP that frequently affects elderly people and those with
comorbid illnesses.
 Mycoplasma pneumoniae.

Hospital-Acquired Pneumonia

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  Staphylococcus aureus. Staphylococcus pneumonia occurs through inhalation of the organism.
 Impaired host defenses. When the defenses of the body are down, several pathogens may invade the body.
 Comorbid conditions. There are several conditions that lower the immune system, causing bacteria to pool in the
lungs and eventually result in pneumonia.
 Supine positioning. When the patient stays in a prolonged supine position, fluid in the lungs pools down and stays
stagnant, making it a breeding place for bacteria.
 Prolonged hospitalization. The risk for hospital infections or nosocomial infections increases the longer the patient
stays in the hospital.

Clinical Manifestations
Pneumonia varies in its signs and symptoms depending on its type but it is not impossible to diagnose a specific
pneumonia through its clinical manifestations.
 Rapidly rising fever. Since there is inflammation of the lung parenchyma, fever develops as part of the signs of an
infection.
 Pleuritic chest pain. Deep breathing and coughing aggravate the pain in the chest.
 Rapid and bounding pulse. A rapid heartbeat occurs because the body compensates for the low concentration of
oxygen in the body.
 Tachypnea. There is fast breathing because the body tries to compensate for the low oxygen concentration in the
body.
 Purulent sputum. The sputum becomes purulent because of the infection in the lung parenchyma which produced
sputum-filled with pus.

Prevention
It is better to prevent the occurrence of pneumonia instead of treating the disease itself. Here are several ways that can
help prevent pneumonia.
 Pneumococcal vaccine. This vaccine can prevent pneumonia in healthy patients with an efficiency of 65% to 85%.
 Staff education. To help prevent HAP, the CDC (2004) encouraged staff education and involvement in infection
prevention.
 Infection and microbiologic surveillance. It is important to carefully observe the infection so that there could be an
appropriate application of prevention techniques.
 Modifying host risk for infection. The infection should never be allowed to descend on any host, so the risk must
be decreased before it can affect one.

Complications
Pneumonia has several complications if left untreated or the interventions are inappropriate. These are the following
complications that may develop in patients with pneumonia.
 Shock and respiratory failure. These complications are encountered chiefly in patients who have received no
specific treatment and inadequate or delayed treatment.
 Pleural effusion. In pleural effusion, the fluid is sent to the laboratory for analysis, and there are three stages:
uncomplicated, complicated, and thoracic empyema.

Assessment and Diagnostic Findings

Assessment and diagnosis of pneumonia must be accurate since there are a lot of respiratory problems that have similar
manifestations. The following are assessments and diagnostic tests that could determine pneumonia.
 History taking. The diagnosis of pneumonia is made through history taking, particularly a recent respiratory tract
infection.
 Physical examination. Mainly, the number of breaths per minute and breath sounds is assessed during physical
examination.
 Chest x-ray. Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple abscesses/infiltrates,
empyema (staphylococcus); scattered or localized infiltration (bacterial); or diffuse/extensive nodular infiltrates
(more often viral). In mycoplasmal pneumonia, chest x-ray may be clear.
 Fiberoptic bronchoscopy. May be both diagnostic (qualitative cultures) and therapeutic (re-expansion of lung
segment).
 ABGs/pulse oximetry. Abnormalities may be present, depending on extent of lung involvement and underlying
lung disease.
 Gram stain/cultures. Sputum collection; needle aspiration of empyema, pleural, and transtracheal or
transthoracic fluids; lung biopsies and blood cultures may be done to recover causative organism. More than one
type of organism may be present; common bacteria include Diplococcus pneumoniae, Staphylococcus aureus, a-

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 hemolytic streptococcus, Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures may not
identify all offending organisms. Blood cultures may show transient bacteremia.
 CBC. Leukocytosis usually present, although a low white blood cell (WBC) count may be present in viral infection,
immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia. Erythrocyte sedimentation
rate (ESR) is elevated.
 Serologic studies, e.g., viral or Legionella titers, cold agglutinins. Assist in differential diagnosis of specific
organism.
 Pulmonary function studies. Volumes may be decreased (congestion and alveolar collapse); airway pressure
may be increased and compliance decreased. Shunting is present (hypoxemia).
 Electrolytes. Sodium and chloride levels may be low.
 Bilirubin. May be increased.
 Percutaneous aspiration/open biopsy of lung tissues. May reveal typical intranuclear and cytoplasmic
inclusions (CMV), characteristic giant cells (rubeola).

Medical Management
The management of pneumonia centers is a step-by-step process that zeroes on the treatment of the infection through
identification of the causative agent.
1. Blood culture. Blood culture is performed for identification of the causal pathogen and prompt administration
of antibiotics in patients in whom CAP is strongly suspected.
2. Administration of macrolides. Macrolides are recommended for people with drug-resistant S. pneumoniae.
3. Hydration is an important part of the regimen because fever and tachypnea may result in insensible fluid losses.
4. Administration of antipyretics. Antipyretics are used to treat fever and headache.
5. Administration of antitussives. Antitussives are used for treatment of the associated cough.
6. Bed rest. Complete rest is prescribed until signs of infection are diminished.
7. Oxygen administration. Oxygen can be given if hypoxemia develops.
8. Pulse oximetry. Pulse oximetry is used to determine the need for oxygen and to evaluate the effectiveness of the
therapy.
9. Aggressive respiratory measures. Other measures include administration of high concentrations of oxygen,
endotracheal intubation, and mechanical ventilation.

Nursing Assessment
Nursing assessment is critical in detecting pneumonia. Here are some tips for your nursing assessment for pneumonia.
 Assess respiratory symptoms. Symptoms of fever, chills, or night sweats in a patient should be reported
immediately to the nurse as these can be signs of bacterial pneumonia.
 Assess clinical manifestations. Respiratory assessment should further identify clinical manifestations such as
pleuritic pain, bradycardia, tachypnea, and fatigue, use of accessory muscles for breathing, coughing, and
purulent sputum.
 Physical assessment. Assess the changes in temperature and pulse; amount, odor, and color of secretions;
frequency and severity of cough; degree of tachypnea or shortness of breath; and changes in the chest x-ray
findings.
 Assessment in elderly patients. Assess elderly patients for altered mental status, dehydration, unusual behavior,
excessive fatigue, and concomitant heart failure.

Diagnosis
Through the data collected during assessment, the following nursing diagnoses are made:
1. Ineffective airway clearance related to copious tracheobronchial secretions.
2. Activity intolerance related to impaired respiratory function.
3. Risk for deficient fluid volume related to fever and a rapid respiratory rate.

Nursing Care Planning & Goals

Planning is essential to establish the interventions that are appropriate for the patient’s condition.
1. Improve airway patency.
2. Rest to conserve energy.
3. Maintenance of proper fluid volume.
4. Maintenance of adequate nutrition.
5. Understanding of treatment protocol and preventive measures.
6. Absence of complications.

Nursing Priorities:

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 1. Maintain/improve respiratory function.
2. Prevent complications.
3. Support recuperative process.
4. Provide information about disease process, prognosis, and treatment.

Nursing Interventions:
These nursing interventions, if implemented appropriately, would result in the achievement of the goals of the
management of pneumonia.
To improve airway patency:
 Removal of secretions. Secretions should be removed because retained secretions interfere with gas exchange
and may slow recovery.
 Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions.
 Humidification may loosen secretions and improve ventilation.
 Coughing exercises. An effective, directed cough can also improve airway patency.
 Chest physiotherapy. Chest physiotherapy is important because it loosens and mobilizes secretions.
To promote rest and conserve energy:
 Encourage avoidance of overexertion and possible exacerbation of symptoms.
 Semi-Fowler’s position. The patient should assume a comfortable position to promote rest and breathing and
should change positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion.
To promote fluid intake:
 Fluid intake. Increase in fluid intake to at least 2L per day to replace insensible fluid losses.
 To maintain nutrition:
 Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
 Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also help restore proper nutrition.
To promote patient’s knowledge:
 Instruct patient and family about the cause of pneumonia, management of symptoms, signs, and symptoms, and
the need for follow-up.
 Instruct patient about the factors that may have contributed to the development of the disease.

Evaluation
Expected patient outcomes include the following:
 Demonstrates improved airway patency.
 Rests and conserves energy by limiting activities and remaining in bed while symptomatic and then slowly
increasing activities.
 Maintains adequate hydration.
 Consumes adequate dietary intake.
 States explanation for management strategies.
 Complies with management strategies.
 Exhibits no complications.
 Complies with treatment protocol and prevention strategies.

CHECK FOR UNDERSTANDING (25 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:

Multiple Choice

1. The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax?
A. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures.
B. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere.
C. The injury allows air into the pleural space but prevents it from escaping from the pleural space.
D. A tension pneumothorax results from a puncture of the pleura during a central line placement.
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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2. The nurse is caring for a client with a right-sided chest tube secondary to a pneu- mothorax. Which interventions
should the nurse implement when caring for this client? Select all that apply.
A. Place the client in a low-Fowler's position.
B. Assess chest tube drainage system frequently.
C. Maintain strict bed rest for the client.
D. Secure a loop of drainage tubing to the sheet.
E. Observe the site for subcutaneous emphysema.
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

3. The initial characteristics symptoms of a simple pneumothorax is.

A. ARDS
B. Severe respiratory distress
C. Sudden chest pain
D. Tachypnea and chest discomfort
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

4. Clinical manifestation of related to pneumothorax includes the following except for:

A. Pleuritic pain
B. Respiratory distress
C. Acrocyanosis
D. Tachypnea
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

5. Which of the following should the nurse assess in patient with pneumothorax?
A. Tracheal alignment
B. Expansion of the chest
C. Breath sounds
D. All of the above
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

6. The pressure required in the pleural space to keep the lungs inflated is:
A. Positive
B. Negative
C. Atmospheric
D. All of the above
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

7. The following are types of pneumothorax except:

A. Trauma
B. Simple

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 C. Tension
D. Direct.
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

8. On auscultation, which of the following suggest a right pneumothorax/

A. Bilateral inspiratory and expiratory crackles.
B. Absence of breath sounds in the right thorax.
C. Inspiratory wheezes in the right thorax.
D. Bilateral pleural friction rub.
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
.

9. Nurse Lei is caring for a client with pneumothorax and who has had a chest tube inserted notes continues gentle
bubbling in the suction control chamber. Which action is appropriate?
A. Do nothing, because this is an expected finding.
B. Immediately clamp the chest tube and notify the physician.
C. Check for an air leak because the bubbling should be intermittent.
D. Increase the suction pressure so that the bubbling becomes vigorous.
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

10. An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of the
signs would indicate the presence of pneumothorax in this client?
A. A low respiratory rate
B. Diminished breath sounds
C. The presence of barrel chest
D. A sucking sound at the site of injury.
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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3. ANSWER: ________

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 RATIO:_______________________________________________________________________________________
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4. ANSWER: ________
RATIO:_______________________________________________________________________________________
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5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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6. ANSWER: ________
RATIO:_______________________________________________________________________________________
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7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________

RATIO:_______________________________________________________________________________________
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_____________________________________________________________________

LESSON WRAP-UP (25 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

Activity 1

AL Strategy: Number Heads Together

Instruction: You will be placed in teams of four. You will be given a designated number in each team. The teacher will
pose a question and you will be given time to discuss your answers as a team, after, the teacher will call out a number.
The student with that number stand. The student standing will be the team’s speaker. You will be given 3-4 minutes to
discuss your answer.

(For Related Learning Experience, please refer to your clinical instructor.)

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