🦠 Pneumonia
An infection of the alveoli themselves. Why it floods gas exchange, how it sounds, and the four things that actually change the outcome.
🧬 What it is & how it gets there
Pneumonia is an infection of the alveoli — the gas-exchange sacs themselves, not the airways. They fill with pus and fluid, so the surface where oxygen crosses into blood is flooded.
That single fact explains every sign: the crackles, the hypoxia, the consolidation on X-ray.
🦠 How organisms reach the alveoli
🏥 The classification that changes the antibiotic
| Type | Acquired | Usual organisms |
|---|---|---|
| CAP — community acquired | Outside hospital, or <48 h after admission | Strep pneumoniae most common; Mycoplasma in young adults |
| HAP — hospital acquired | ≥48 h after admission | Pseudomonas, MRSA, gram negatives — more resistant |
| VAP — ventilator associated | ≥48 h after intubation | Same resistant organisms |
| Aspiration | After a swallow failure | Anaerobes; often right lower lobe |
Why the right lower lobe? The right mainstem bronchus is wider, shorter and more vertical than the left, so anything aspirated tends to fall into it. That anatomical detail is asked directly.
🤵 Who is at risk
- Age — over 65 or under 2
- Impaired swallow — stroke, sedation, dementia, tube feeding
- Immobility — post-op, bed rest; the lung bases do not expand
- Smoking — paralyzes the cilia that clear organisms
- Chronic disease — COPD, heart failure, diabetes
- Immunosuppression — steroids, chemotherapy, HIV
👀 How it shows up
The classic adult picture: fever with chills, a productive cough with rust-colored or purulent sputum, pleuritic chest pain that is worse on inspiration, dyspnea and tachypnoea.
🩺 What you hear and find
| Assessment | Finding over the affected lobe |
|---|---|
| Auscultation | Crackles (rales); bronchial breath sounds where they should be vesicular |
| Percussion | Dull — fluid where air should be |
| Fremitus | Increased — solid tissue conducts sound better |
| Egophony | Spoken “E” sounds like “A” |
| Oximetry | Falling SpO&sub2;, especially on exertion |
🚨 The presentation that is missed
In an older adult, pneumonia often presents as confusion and a fall — with no fever and no cough at all. The immune response is blunted, so the classic signs never appear.
New confusion in an elderly patient is a reason to look for infection, not to assume dementia.
👶 In children
Watch for grunting, nasal flaring, retractions and head bobbing. Tachypnoea is the most sensitive single sign. Infants may simply feed poorly and be irritable.
🧪 How it is confirmed
| Test | What it shows |
|---|---|
| Chest X-ray | The confirming test. Infiltrates or consolidation in the affected lobe |
| Sputum culture | Identifies the organism and its sensitivities |
| CBC | WBC raised with a left shift. A LOW WBC in sepsis is worse, not better |
| Blood cultures | Detects spread to the bloodstream |
| ABG | Hypoxemia; respiratory alkalosis early, acidosis when tiring |
| Procalcitonin / lactate | Bacterial infection and tissue perfusion |
⚠️ The sequencing rule
Obtain sputum and blood cultures BEFORE the first antibiotic dose.
Once antibiotics are in, the culture may not grow the organism — and then nobody knows what is being treated. But never delay antibiotics beyond an hour in a septic patient to chase a specimen.
🧠 Collecting a good sputum sample
- Early morning, before eating — secretions have pooled overnight
- Rinse the mouth with water, not mouthwash
- Cough deeply from the lungs — saliva is not a specimen
- Send to the laboratory promptly
🩺 What you do
The nursing care is oxygenation, secretion clearance, hydration and antibiotics on time. Everything else supports those four.
💧 The interventions that actually change the outcome
| Intervention | Why it works |
|---|---|
| Semi-Fowler’s or high Fowler’s | Drops the diaphragm, expands the bases |
| Incentive spirometer | Prevents atelectasis; 10 breaths per hour while awake |
| Fluids 2–3 L/day | Thins secretions so they can be coughed up |
| Ambulate early | Mobilizes secretions better than any drug |
| Oxygen, titrated | Target SpO&sub2; usually ≥92% (88–92% in COPD) |
| Antibiotics on schedule | Blood levels must stay above the killing concentration |
Position the patient with the GOOD lung DOWN. Gravity sends more blood to the dependent lung, so putting the healthy one down matches blood flow with the lung that can actually oxygenate it.
"Good lung down" — one of the highest-yield positioning rules in respiratory nursing.
🚨 Preventing aspiration pneumonia
- Swallow screen before anything by mouth after a stroke
- Head of bed at least 30–45° for tube feeds, and for 30–60 min after
- Check tube placement and residuals per policy
- Oral care every 4 hours — it measurably reduces ventilator-associated pneumonia
Aspiration is the most preventable pneumonia in the hospital. Sitting the patient up is the intervention.
⚠️ What goes wrong, and prevention
| Complication | Recognize by |
|---|---|
| Sepsis / septic shock | Fever or hypothermia, hypotension, rising lactate, confusion |
| Pleural effusion / empyema | Worsening dyspnea, dullness, decreased breath sounds |
| ARDS | Refractory hypoxemia — oxygen does not fix it |
| Respiratory failure | Rising CO&sub2;, tiring, falling level of consciousness |
| Atelectasis | Diminished sounds, low-grade fever after surgery |
A patient whose oxygen saturation will not come up despite increasing oxygen is developing ARDS or shunting. Escalate - do not simply keep turning the oxygen up.
💉 Prevention — the teaching that prevents readmission
Vaccines
- Pneumococcal — age 65+, and younger with chronic disease
- Influenza — annually
- COVID-19 per current guidance
Daily habits
- Stop smoking — cilia recover
- Hand hygiene
- Move; deep breathe hourly when unwell
⭐ Discharge teaching
- Finish the entire antibiotic course, even once feeling well
- Fatigue can last weeks — this is expected, not failure
- Return for worsening breathlessness, chest pain, confusion, or fever that returns
- Keep using the incentive spirometer at home
🎯 NCLEX traps
- Cultures before antibiotics — but never delay treatment in sepsis
- Good lung down for unilateral pneumonia
- Confusion in an elder = look for infection
- A low WBC with infection signals an overwhelmed immune system
- Fluids are a treatment here — they thin secretions