Ns. Siswoyo, M.Kep.

Departemen KMB-Kritis PSIK UNEJ

 Respiratory epithelium

 Connective tissue fibers, and cartilage: support and

maintain open air way

 Alveolar cells (type I and type II)

Type I
Type I
pneumocyte
pneumocyte

Alveolar
space

Capillary
lumen

Type II
pneumocyte
Endothelium
• Gas exchange

• Protection against infection by alveolar macrophages

• Surfactant secretion: allow expansion of alveoli with

air
1- Dyspnea: subjective sensation of uncomfortable

breathing, feeling “short of breath”

 Ranges from mild discomfort after exertion to extreme

difficulty breathing at rest.

 Usually caused by diffuse and extensive rather than focal

pulmonary disease.
Causes of Dyspnea :
◦ Airway obstruction
 Greater force needed to provide adequate
ventilation
 Wheezing sound due to air being forced through
airways narrowed due to constriction or fluid
accumulation

◦ Decreased compliance of lung tissue

 Signs of dyspnea:

 Flaring nostrils

 Use of accessory muscles in breathing

 Retraction (pulling back) of intercostal spaces

2- Cough
 Attempt to clear the lower respiratory passages by

forceful expulsion of air

 Most common when fluid accumulates in lower

airways
Causes of Cough:
 Inflammation of lung tissue
 Increased secretion in response to mucosal irritation
 Inhalation of irritants
 Intrinsic source of mucosal disruption – such as tumor invasion of
bronchial wall

 Excessive blood hydrostatic pressure in pulmonary

capillaries
◦ Pulmonary edema – excess fluid passes into airways
 When cough can raise fluid into pharynx, the cough is
described as a productive cough, and the fluid is sputum.
◦ Production of bloody sputum is called hemoptysis

 Not threatening, but can indicate a serious pulmonary

disease
 Tuberculosis, lung abscess, cancer, pulmonary
infarction.
 If sputum is purulent------- infection of lung or airway is
indicated.
 Cough that does not produce sputum is called a dry, or
nonproductive cough.
 Acute cough is one that resolves in 2-3 weeks from onset
of illness or treatment of underlying condition.
 Acute cough caused by upper respiratory tract (URT) infections,
allergic rhinitis, acute bronchitis, pneumonia, congestive heart
failure, pulmonary embolus, or aspiration.
 A chronic cough is one that persists for more than 3
weeks.
 In nonsmokers, almost always due to postnasal
drainage syndrome, asthma, or gastroesophageal
reflux disease
 In smokers, chronic bronchitis is the most common
cause, although lung cancer should be considered.
3- Cyanosis
 When blood contains a large amount of unoxygenated
hemoglobin, it has a dark red-blue color which gives skin a
characteristic bluish appearance.
 Most cases arise as a result of peripheral vasoconstriction – result
is reduced blood flow, which allows hemoglobin to give up more
of its oxygen to tissues- peripheral cyanosis.
 Best seen in nail beds
 Due to cold environment, anxiety, etc.
 Central cyanosis can be due to :
◦ Abnormalities of the respiratory membrane
◦ Mismatch between air flow and blood flow
◦ Expressed as a ratio of change in ventilation (V) to perfusion (Q) :
V/Q ratio

 Pulmonary thromboembolus ---- reduced blood flow

 Airway obstruction ---- reduced ventilation
 In persons with dark skin can be seen in the whites of the
eyes and mucous membranes.
 Lack of cyanosis does not mean oxygenation is normal!!
 In adults not evident until severe hypoxemia is present
 Clinically observable when reduced hemoglobin
levels reach 5 g/ dl.
 Severe anemia and carbon monoxide poisoning give
inadequate oxygenation of tissues without cyanosis
 Individuals with polycythemia may have cyanosis
when oxygenation is adequate.
4- Pain
 Originates in pleurae, airways or chest wall
 Inflammation of the parietal pleura causes sharp or
stabbing pain when pleura stretches during inspiration
◦ Usually localized to an area of the chest wall, where a pleural
friction rub can be heard
◦ Laughing or coughing makes pain worse
◦ Common with pulmonary infarction due to embolism
 Inflammation of trachea or bronchi produce a central chest
pain that is pronounced after coughing
◦ Must be differentiated from cardiac pain

 High blood pressure in the pulmonary circulation can

cause pain during exercise that often mistaken for cardiac
pain (angina pectoris).
5- Clubbing
 The selective bulbous enlargement of the end of a digit
(finger or toe).
 Usually painless
 Commonly associated with diseases
that cause decreased oxygenation
◦ Lung cancer
◦ Cystic fibrosis
◦ Lung abscess
◦ Congenital heart disease
Pneumonia
Definition
 Pathology:
◦ Alveolar
 Bronchopneumonia (Streptococcus pneumoniae, Haemophilus
influenza, Staphylococcus aureus)
 Lobar (Streptococcus pneumoniae)

◦ Interstitial (Influenza virus, Mycoplasma pneumoniae)

 Pathogenesis
◦ Inhalation of air droplets
◦ Aspiration of infected secretions or objects
◦ Hematogenous spread
◦ Inhalation

◦ Aspiration of oropharingeal secretion

◦ Hematogenic spread

◦ Direct spread (thorax wall, mediastinum)

 Airways mechanical barrier damage
 Specific and/or nonspecific immune defense
mechanisms injury
 Bronchial obstruction
 Micro aspiration of upper respiratory truck
secretion.
 Lung edema
 Viral infections.
 History, physical examination

 Chest X-Ray

 Sputum examination (gram stained)

 Sputum , blood cultures

 Serological tests

 Peripheral blood analysis

Symptoms
fever rapidly fever of 38.3 – 40° C , shaking chills,
cough, sputum (expectoration),
pleuritic pain.
Others: (dispnea, fatigue, sweating, loss of appetite...)

Physical signs:
increased vibration thoracic
impaired percussion (matity),
end inspiratory rales (crepitations) and
bronchial breathing (tuber soufle)
Others (cyanosis, tachipnea, tachicardia...)
Radiology:

lobar opacities,
interstitial images,
bronchopneumonic (patchy) opacities,
Others (absea, pneumatocele, pleurisy...)
 Gold standart test for pneumonia

 For differencial diagnosis

 For grading pneumonia severity

 For examining complications

 Lobar consolidation

 Bronchopneumonia

 Interstitial pneumonia
Classification with ethiology

•Bacterial
•Viral
•Fungal
•Parazites
 Community acquired pneumonia
 Hospital acquired pneumonia (Nosocomial)
 Immunosuppresed (immunocompromised)
patients pneumonia
 Pneumonia acquired outside
hospital frequently in healthy
persons
Typical pneumonia Atypical pneumonia
acute subacute,
fever,chills subfebril fever
productive cough non productive cough
pleural pain nonrespiratory symptoms
physical signs ( + ) physical signs ( - )
lobar consolidation non-lobar infiltration

Agents
S. pneumoniae M.pneumonia
H. Influenzae C.pneumoniae
Gr(-)aerop bacillus L. Pneumophila
Aneorobes Virus
 Fibrinosuppurative consolidation – whole lobe
 Rare due to antibiotic treatment.
 ~95% - Strep pneumoniae
 The course runs in four stages:
◦ Congestion.
◦ Red Hepatization.
◦ Gray Hepatizaiton.
◦ Resolution.
 CONGESTION 1-2 days
 RED HEPATIZATION 2-4 days
 GREY HEPATIZATION 4-8 days
 RESOLUTION 8-9 days
 Heavy red lungs
 Severe vascular congestion
 Intra alveolar exudate with few
neutrophils
 Watery sputum
 Bacteria +++
 Firm airless , liver-like lung
 Fibrinopurulent pleuritis
 Intra alveolar exudate : organisms ++
cells:
* erythrocytes
* neutrophils
* fibrin
* rusty sputum
 Dry grey brown cut surface
 ↑ intra alveolar fibrin & macrophages
 Disintegrating neutrophils & ↓ RBC’s

4- Resolution :
 Enzymatic digestion of exudate 
resorption, phagocytosis , sometimes
with residual adhesion
Lobar pneumonia
 Lobar pneumonia:
whole lobe(s) involved

Fixed specimen, grey

hepatization

Lobar pneumonia
 Suppurative inflammation of lung tissue caused by
Staph, Strep, Pneumo & H. influenza
 Patchy consolidation – not limited to lobes.
 Usually bilateral
 Lower lobes common, but can occur anywhere
 Complications:
◦ Abscess
◦ Empyema
◦ Dissemination
Bronchopneumonia
Interstitial pneumonia
1- Pleural effusion
2- Non resolution and organization of
exudate  fibrosis
3- Abscess formation
4- Bacteremic dissemination  meningitis ,
arthritis , infective endocarditis
5- Empyema : accumulation of pus in pleural
cavity which is followed by adhesions
6- Atelectasis
Empyema
 Focal suppuration with necrosis of lung tissue
 Organisms commonly cultured:
◦ Staphylococci
◦ Streptococci
◦ Gram-negative
◦ Anaerobes
◦ Frequent mixed infections
 Mechanism:
◦ Aspiration
◦ Post pneumonic
◦ Septic embolism
◦ Neoplasms
 Productive Cough, fever.
 Clubbing
 Complications: Systemic spread, septicemia.
 Caused by Mycobacterium tuberculosis.
 Transmitted through inhalation of infected droplets
 Primary
◦ Single granuloma within parenchyma and hilar lymph nodes
(Ghon complex).
 Infection does not progress (most common).
 Progressive primary pneumonia
 Miliary dissemination (blood stream).
Ghon complex
 Secondary
◦ Infection (mostly through reactivation) in a previously sensitized
individual.
◦ Pathology

 Cavitary fibrocaseous lesions

 Bronchopneumonia

 Miliary TB
Fibrocaseous
Granuloma
Miliary TB
 Infections that affect immunosuppressed patients
 Associated disorders:
◦ AIDS
◦ Iatrogenic
 Cancer patients
 Transplant recipients
 Progressive fibrosing disorder of unknown cause
 Adults 30 to 50 years old
 Respiratory and heart failure (cor pulmonale) ~ 5 y
 GROUP 1 GROUP 2 GROUP 3
OUTPATIENT- HOSPITAL INTENSIVE
CLINIC CARE

Mild pneumonia, Moderate Severe

pneumonia pneumonia
 CAP Therapy: Group I

No antibiotic usage Penicillin,

No comorbidity Macrolide,

With comorbidities
Pneumococci resistant to penicillin
Gram (–) agents Floroquinolone,
Usage of antibiotic last three months ß laktame +
Usage of corticosteroid Macrolide
 CAP Therapy: Group II

First choise Alternatif

• S.pneumoniae ________________________________________
• H.influenzae
Penicillin G ± makrolide Levofloksasin
• M.pneumoniae
• C.pneumoniae Aminopenicillin ± makrolide Moksifloksasin
• Mix infection)
Aminopenicillin / β-laktamase
• Enteric Gram
negatives ! inhibitor ± macrolide
• Virus Non- antipseudomonal cefalosporin II-III
± macrolide
 CAP Therapy: Group III

No risk of P. aeruginosa
 Non pseudomonal cefalosporin III+ macrolide
or
 Non pseudomonal cefalosporin III +
(moksifloksasin or levofloksasin)

With risk of P. aeruginosa

 Anti-pseudomonal cefalosporin (sefepim-seftazidim)
or
 Ureidopenicillin/beta-laktamase inhibitor (piperasilin..
or
 Karbapenem + siprofloksasin
 Duration of the therapy

After fever drop 1 week

- Pneumococcic pneumonia 7-10 days

- Legionella pneumonia 14-21 days
- Mycoplasma ve C. pneumoniae 10-14 days

Severe pneumonia 2-3 weeks

 Age >65 y.
 Presence of coexisting dis. : DM, COPD,
CRF, CCF, aspiration, altered mental
status, post splenectomy, alcohol.
 Physical : BP <90/60, temp. >38.3,
Extrapulm. Infection
 Lab findings : Leucocytes<4,000/
>30,000, PaO2<60 / PaCO2 >50, mech.
Vent., Creatinine>1.2, Multilobar,
spread, Sepsis.
Nursing Management:
1. Administer medications as prescribed (antibiotics,
antipyretics)
2. Improving gas exchange.
a. Observe for cyanosis, dyspnea, hypoxia, and
confusion.
b. Checking ABG’s.
c. Administer oxygen.
d. Place patient in an upright position.

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3. Improving airway patency.
a. Encourage pt. to cough.
b. Suctioning.
c. Encourage increased fluid intake.
d. Humidify air or oxygen therapy.
e. Chest physiotherapy.
f. Changing pt. position frequently.

79
4. Relieving pleuritic pain.
a. Place patient in semi – Fowler position.
b. Administer analgesics as prescribed.
(avoid opioids in patient's with a history of COPD)
c. Avoid suppressing a productive cough.
5. Monitoring for complications.
6. Patient education.
a. Advise smoking cessation, and excessive alcohol
intake, and heavy exercises.
b. Advise the patient to keep up natural resistance with
good nutrition, adequate rest.
c. Encourage breathing exercises.

Gerontologic Considerations:
Sedatives, opioids, and cough suppressants should be used cautiously
in elderly pt.s, because their tendency to suppress cough and gag
reflexes and respiratory drive. Also , provide frequent oral care for
Pneumonia prevention.

81
 VIRAL
( cytomegalo virus is the most
common)

 BACTERIAL
(streptococcal and staphylococcal
pneumonia)
PATHOPHYSIOLOGY
ALVEOLAR INFLAMMATION

AN EXUDATE INTERFERE WITH DIFFUSION OF O2 AND CO2

WBC, NEUTROPHIL MIGRATES TO ALVEOLI

FILLED THE AIR SPACE NORMALLY

PARTIAL OCCLUSION OF BRONCHI AND ALVEOLI

ALVEOLAR OXYGEN TENSION DECREASED

BROCHOSPASM

HYPOVENTILATION

HYPOXEMIA

LOBAR PNEUMONIA BRONCHOPNEUMONIA

 BOOK BASE PATIENT
 Runny nose MANIFESTATIONS
 Worsening cough
 Fever  Tachypnea
 Increased Respiratory  Poor feeding
rate  Nasal flaring
 Retraction  Wheezing
 Wheezing  Severe cough
 Cyanosis  Respiratory fatigue
 Decreases breath sounds  SOB
 Crackles
 Chest pain
 Abdominal pain
 Vomiting
◦ Ineffective breathing pattern.
◦ Ineffective airway clearance due to
secretion.
◦ Altered nutritional pattern less than
body requirement due to less food
intake.
◦ Hyperthermia related to infection.
◦ Disturbed sleeping pattern due to cough
and breathing difficulty.
 Improving airway patency.
 Promoting rest and conserving energy.
 Promoting fluid intake and maintaining nutrition
 Promoting family knowledge
 Monitoring and preventing potential
complications.
 Promoting home and community based care.
BOOK BASE
 Antibiotics
 e.g Ceftriaxone and other Cephalosporins.
 Ampicillin
 Supportive measures such IV fluids, antipyretic,
humidified O2, hydration

PATIENT TREATMENT
 Treated with injection cefuroxime IV, neb
Ventolin, pulmicort, atrovent and syrup adol.
 RESPIRATORY DISTRESS
HYPOTENSION
HEART FAILURE
CARDIAC DYSRRYTHMIAS
PERICARDITIS
MYOCARDITIS
PLEURAL EFFUSION
 ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
CUES/EVIDENCE: Ineffective airway Improve airway 1. Provide 1. Helps good air Relieved from
SUBJECTIVE: clearance related patency. fowlers entry. breathing
“Patient mother to copious position. 2. Retained difficulty.
complaints of tracheobronchial 2. Maintain a secretions
interfere with
difficulty in secretion. clear airway(
gas exchange.
breathing”. suction, CPT)
3. Loosen
OBJECTIVE: as indicated secretion
 Dyspnea 3. Administer improve
 SOB humidified ventilation.
 Respiratory O2. 4. Thins and
rate changes 4. Provide loosens
 Coughing adequate pulmonary
 Purulent hydration. secretion.
sputum 5. Implement Mobilize and
nursing loosen
secretions.
measures to
5. Provide toys,
reduce pain
watching TV,
and anxiety. etc.
6. Administer 6. Antibiotics
medications reduce
and infection;
nebulization nebulization
as order. helps soothing
and expulsion
of secretion
(e.g inj.
Cefuroxime,
neb ventolin
and pulmicort).
 ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
CUES/EVIDENCE: Hyperthermia Patient will relieve 1. Remove 1. Excessive Fever reduced.
SUBJECTIVE: related to infection from: excessive clothing may
“Patient’s mother (Bronchopneumoni  Fever clothing. increase
complaints baby a)  Tachypnea 2. Provide tipid temperature.
having  Chills sponge bath. 2. High
temperature”.  Fatigue 3. Encourage temperature
OBJECTIVE: increase fluid causes
 Fever intake. coagulation
 Tachypnea 4. Administer iv of cell protein
 Chills fluids. and cell die.
 Fatigue 5. Administer High
 Weakness antipyretic temperature
(e.g syrup leads to brain
adol, rofenac damage.
suppository as 3. To prevent
per order). dehydration
due to
tachypnea
and fever.
4. To maintain
electrolyte
imbalance.
5. To reduce
body
temperature.
 ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
CUES/EVIDENCE: Fluid Volume Proper 1. Encourage 1. Rapid Patient is
SUBJECTIVE: Deficit Related To maintenance of increase fluid repiratory hydrated.
“Mother told baby Fever and Rapid fluid volume and intake. rate leads to
is not taking orally Respiratory Rate adequate 2. Give insensible
well”. nutrition. nutritionally fluid loss
OBJECTIVE: enrich drinks during
 Dehydrated with more exhalation.
 Fatigue taste. Enrich 2. To avoid
 Drowsy with with dehydration.
 Rapid electrolyte 3. May helps to
respiratory (e.g. provide
rate Gatorade). fluids, calories
3. Administer IV and
fluids (e.g electrolytes.
dextrose in 4. To maintain
normal saline electrolytes
glucose) as per imbalance.
doctors order.
4. Provide rest
with calm and
quiet
environment.
 Encourage mother to continue full course of
antibiotics.
 Advise to increase activities gradually after fever
subsides.
 Encourage follow up chest x-ray.
 Increase steam inhalation.
 Keep away from allergic substances.
 Review principles of adequate nutrition and rest.
 Recommended influenza vaccine (pneumovac) to all
patients at risk.
 Refer patient for home care to facilitate adherence to
therapeutic regimen as indicated.
96