Pneumonia: Nursing Study Guide

Pneumonia is a high-yield respiratory topic for nursing exams. This guide reviews what pneumonia is, how it's classified, how to recognize and grade severity, and the priority nursing actions, complications, and patient teaching every nurse should know.

What Is Pneumonia?

• An inflammatory condition of the lungs in which the alveoli fill with fluid or pus.
• Caused by bacteria, viruses, or fungi infecting lung tissue.
• Fluid-filled alveoli impair gas exchange, leading to hypoxemia and respiratory symptoms.

Classification by Setting

• Community-Acquired Pneumonia (CAP): Acquired outside healthcare settings. Common organisms: S. pneumoniae, H. influenzae, M. pneumoniae.
• Hospital-Acquired Pneumonia (HAP): Acquired ≥48 hours after hospital admission. Common organisms: P. aeruginosa, MRSA, E. coli, Klebsiella.
• Ventilator-Associated Pneumonia (VAP): Acquired ≥48 hours after intubation. Often multidrug-resistant organisms similar to HAP.
• Aspiration Pneumonia: Caused by inhaling food or fluid into the lungs. Organisms: K. pneumoniae, S. pneumoniae, anaerobes.
• Opportunistic Pneumonia: Occurs in immunocompromised patients. Organisms: P. jirovecii, fungi, CMV.

Risk Factors

• Age under 2 or over 65 years.
• Chronic disease: COPD, asthma, diabetes, heart disease.
• Smoking and excessive alcohol use (impair lung defenses).
• Immunocompromised states: HIV, chemotherapy, steroids.
• Recent viral infection (cold or flu).
• Aspiration risk: stroke, seizure, weakened gag reflex.
• Hospitalization, ventilator use, or recent surgery.

Clinical Presentation

Symptoms

• Fever with chills and shaking.
• Productive cough with yellow, green, or rust-colored sputum.
• Shortness of breath and rapid breathing.
• Pleuritic chest pain — sharp, worsens with breathing.
• Fatigue, malaise, loss of appetite.

Signs on Examination

• Tachypnea and tachycardia.
• Crackles/rales on auscultation.
• Bronchial breath sounds over consolidated areas.
• Egophony and increased tactile fremitus suggest consolidation.
• Dullness on percussion over affected areas.
• Cyanosis of lips and nails in severe cases.
• Confusion, especially in older adults.

Viral vs. Bacterial

• Viral: low-grade fever, non-productive (dry) cough.
• Bacterial: high fever, productive cough, elevated WBC.

CURB-65 Severity Score

Each criterion = 1 point:

• C — Confusion (new mental status changes)
• U — Uremia (BUN >19 mg/dL or >7 mmol/L)
• R — Respiratory rate ≥30/min
• B — Blood pressure (SBP <90 or DBP ≤60 mmHg)
• 65 — Age ≥65 years

Interpretation:

• 0–1: Low severity → outpatient treatment.
• 2: Moderate severity → consider hospital admission.
• ≥3: Severe pneumonia → urgent hospital admission.
• Higher scores correlate with increased mortality.

Diagnostic Tests

• Chest X-ray — gold standard; shows infiltrates or consolidation.
• Sputum culture — identifies organism for targeted antibiotic therapy.
• CBC with differential — elevated WBC in bacterial infection.
• Pulse oximetry — SpO₂ <92% indicates severity.
• Blood cultures — identify bacteremia.

Complications — "SLAP HER" Mnemonic

• S — Sepsis: infection spreads through bloodstream.
• L — Lung abscess: pus-filled cavity forms within lung tissue.
• A — ARDS: severe inflammation causing widespread pulmonary fluid.
• P — Pleural effusion: fluid accumulates around the lungs.
• H — Hypotension: from septic shock.
• E — Empyema: pus in the pleural space; requires drainage.
• R — Respiratory failure: lungs cannot provide adequate oxygenation.

Treatment

Medications

• Antibiotics for bacterial pneumonia, based on cultures.
• Antivirals for viral pneumonia (e.g., influenza).
• Antipyretics for fever.
• Analgesics for pleuritic chest pain.

Oxygen Therapy

• Supplemental O₂ to maintain SpO₂ >92%.
• Severe hypoxemia may require non-invasive ventilation.
• Intubation and mechanical ventilation for respiratory failure.

Supportive Care

• IV fluids for hydration.
• Chest physiotherapy to mobilize secretions.
• Incentive spirometry to promote lung expansion.
• Turn, cough, and deep breathe every 2 hours.
• Oral fluids ~3 L/day to thin secretions (unless contraindicated).

VAP Prevention Bundle

• Elevate head of bed 30–45°.
• Daily sedation vacations.
• Peptic ulcer prophylaxis.
• DVT prophylaxis.
• Oral care with chlorhexidine.

Nursing Assessment

• Monitor vital signs: temperature, HR, RR.
• Continuous SpO₂ monitoring; titrate oxygen as ordered.
• Auscultate for crackles, rhonchi, or diminished breath sounds.
• Assess respiratory effort: accessory muscle use, retractions.
• Monitor sputum color, amount, consistency.
• Assess level of consciousness — confusion may signal hypoxemia.
• Watch for signs of sepsis (hypotension, tachycardia).
• Monitor intake and output.

Nursing Interventions

• Administer oxygen to maintain SpO₂ >92%.
• Position patient in High-Fowler's to ease breathing.
• Encourage deep breathing and coughing every 2 hours.
• Assist with incentive spirometry to prevent atelectasis.
• Administer antibiotics and medications on time.
• Monitor for medication side effects.
• Encourage oral fluids (unless contraindicated).
• Provide chest physiotherapy as ordered.
• Suction if patient cannot clear secretions.
• Monitor for complications (respiratory failure, sepsis).
• Provide rest periods between activities.
• Maintain fall precautions, especially in the elderly.

Important: Do NOT suppress the cough — coughing clears infected secretions.

Patient Teaching

• Complete the full antibiotic course, even if feeling better.
• Perform deep breathing exercises every hour while awake.
• Use the incentive spirometer as taught.
• Cough effectively to clear secretions.
• Drink 2–3 L of fluid daily (unless fluid-restricted).
• Rest when tired; increase activity gradually.
• Ambulate as tolerated to mobilize secretions.

Signs to Report

• Worsening shortness of breath or chest pain.
• Fever that returns or persists.
• Change in sputum color or amount.
• Confusion or dizziness.

Prevention

• Annual influenza vaccine.
• Pneumococcal vaccines as indicated.
• Good hand hygiene.
• Avoid smoking and secondhand smoke.
• Avoid exposure to sick individuals.

Common NCLEX Traps

• Priority action for hypoxemia: start oxygen before notifying the provider.
• A silent chest signals worsening respiratory status, not improvement.
• Do NOT suppress cough — it helps clear secretions.
• Elderly patients may present with confusion or falls, without fever or cough.
• Bacterial = high fever + productive cough; Viral = low fever + dry cough.
• Chest X-ray is the gold standard for diagnosis — not sputum culture.
• CURB-65 ≥3 requires urgent hospital admission.
• Aspiration pneumonia is more common with dysphagia or stroke.
• VAP prevention: HOB elevation + oral care.
• Aminoglycosides can cause nephrotoxicity and ototoxicity.

Key Takeaways

• Pneumonia fills alveoli with fluid/pus → hypoxemia; maintain SpO₂ >92% as the priority intervention.
• Classify by setting: CAP, HAP, VAP, aspiration, opportunistic — each with typical organisms.
• CURB-65 (Confusion, Uremia, RR ≥30, low BP, Age ≥65) guides admission; ≥3 = severe.
• Chest X-ray confirms diagnosis; sputum culture identifies the organism.
• Core nursing care: High-Fowler's, oxygen, hydration, incentive spirometry, deep breathing/coughing, and complete antibiotic course.
• Watch for SLAP HER complications — sepsis, lung abscess, ARDS, pleural effusion, hypotension, empyema, respiratory failure.