HISTORY. The patient may have a history of a recent upper respiratory infection, influenza, or a viral syndrome. Elicit a history of a chronic pulmonary disease, such as asthma, bronchitis, or tuberculosis; prolonged immobility; sickle cell anemia; neurological disorders that cause paralysis of the diaphragm; surgery of the thorax or abdomen; smoking; alcoholism; IV drug therapy or abuse; and malnutrition. Establish any history of exposure to noxious gases, aspiration, or immunosuppressive therapy. Ask about the major symptoms of pneumonia: cough, fever, sputum production, chest pain, and shortness of breath. Ask the patient to describe the type of cough and the nature of the sputum production. Determine the location of any pain, especially chest pain. Ask about sore throat or chills, vomiting, diarrhea, or anorexia.

PHYSICAL EXAMINATION. Observe the patient's general appearance and respiratory pattern to determine level of fatigue, presence of cyanosis, and presence of dyspnea or tachypnea. Examine the patient's extremities, torso, and face for rash. Assess vital signs for rapid, weak, thready pulse; fever; and blood pressure changes such as hypotension and orthostasis (postural hypotension). Palpate the chest to determine any areas of consolidation or tactile fremitus. Percuss the chest to detect dullness over the area of consolidation. When you auscultate the patient's breathing, listen for rales, crackles, ronchi, and wheezes; "E" to "A" changes; and whispered pectoriloquy.

PSYCHOSOCIAL. The patient with pneumonia may be anxious, fatigued, and in pain from the constant coughing. Assess the patient's ability to cope with a sudden, debilitating illness. The patient may be anxious because of difficulty breathing and be distressed over purulent sputum.

Diagnostic Highlights


Normal Result

Abnormality with Condition


Sputum cultures and sensitivities

Chest x-ray

Negative cultures and sensitivities (other than normal bacterial flora)

Clear lung fields

Presence of infecting organisms

Areas of increased density; can be a lung segment, lobe, one lung, or both lungs

Cultures identify organism; sensitivity testing identifies how resistant or sensitive the bacteria are to antibiotics

Findings reflect areas of infection and consolidation

Other Tests: Arterial blood gases, complete blood count, blood cultures, bronchoscopy

742 Pneumonia

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