Med-Surg · Respiratory
Pneumonia & Respiratory Failure
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current drug references.
1. Overview and Pathophysiology
Pneumonia is infection of the lung parenchyma causing alveolar inflammation and consolidation. Gas exchange suffers as alveoli fill with exudate. Categories that change empiric treatment and isolation:
- Community-acquired (CAP) vs hospital-acquired (HAP) / ventilator-associated (VAP)
- Viral, bacterial, fungal, or aspiration
- Lobar vs bronchopneumonia patterns
means the lungs can’t maintain adequate gas exchange:
| Type | Problem | Classic ABG pattern |
|---|---|---|
| Type 1 (hypoxemic) | Low PaO₂ (often < 60 mmHg) with normal/low PaCO₂ | Pneumonia, PE, pulmonary edema, ARDS |
| Type 2 (hypercapnic) | High PaCO₂ (often > 50) with acidosis | COPD exacerbation, drug overdose, neuromuscular weakness |
is acute diffuse inflammatory lung injury with severe hypoxemia (often PaO₂/FiO₂ ≤ 300), bilateral opacities, and noncardiogenic edema. Nursing care centers on lung-protective ventilation, prone positioning when ordered, and meticulous infection control.
2. Causes and Risk Factors
- Age extremes, smoking, COPD/asthma, heart failure, immunosuppression, aspiration risk (stroke, seizure, intoxication), immobility, recent surgery, viral URI
- HAP/VAP: endotracheal tube, poor oral care, supine positioning, contaminated equipment
- Aspiration pneumonia: right lower lobe often involved
3. Signs and Symptoms
- Fever, chills, productive cough (rust-colored in pneumococcal; foul in anaerobic aspiration)
- Dyspnea, tachypnea, pleuritic chest pain, crackles or bronchial breath sounds, dullness to percussion
- Older adults: confusion or falls may be the main clue; fever may be absent
- Severe: cyanosis, hypotension (sepsis), use of accessory muscles, SpO₂ drop
- Respiratory failure: progressive hypoxemia, rising CO₂, altered mentation, fatigue of respiratory muscles
4. Diagnostics and Labs
Lab reference ranges vary by laboratory. Always use your facility’s ranges.
| Test | Typical reference / target | Nursing relevance |
|---|---|---|
| Chest X-ray / CT | — | Infiltrates/consolidation |
| WBC | ~5,000–10,000/mm³ | Leukocytosis common; may be low in sepsis/elderly |
| Sputum Gram stain/culture | — | Obtain before antibiotics when possible without delaying critical care |
| Blood cultures | — | Especially if septic or hospitalized |
| ABG | See respiratory outline | Guides O₂/ventilation decisions |
| Procalcitonin / CRP | Lab-dependent | Sometimes used to support bacterial infection decisions |
| Influenza/COVID/other viral panels | — | Guides isolation and antivirals |
| Lactate | Often < 2 mmol/L | Sepsis severity |
5. Priority Nursing Assessments
- ABCs, SpO₂, work of breathing, lung sounds, sputum
- Mental status and early sepsis signs (qSOFA/facility screen)
- Aspiration risk; swallow safety
- Hydration, nutrition, fever curve, response to antibiotics
- Ventilator/NIPPV settings and patient–ventilator synchrony if applicable
- Isolation needs (droplet for influenza; airborne for TB if suspected)
6. Priority Nursing Interventions
- High Fowler’s; encourage cough and deep breathe; incentive spirometry
- O₂ to target SpO₂; escalate to high-flow, NIPPV, or intubation as ordered
- Cultures before antibiotics when feasible; then give antibiotics promptly (especially sepsis)
- Fluids as ordered; antipyretics; early mobility; oral care (VAP bundle)
- Aspiration precautions: HOB elevated, thickened liquids if ordered, supervise feeding
- Chest physiotherapy / suctioning as needed; cluster care to reduce O₂ demand
- For ARDS: lung-protective strategies per protocol, prone positioning team care, careful fluid balance
7. Medications
| Class / examples | How it helps | Key nursing considerations |
|---|---|---|
| Antibiotics (per CAP/HAP guidelines) | Treat bacterial pathogen | Allergy history; renal dosing; C. diff risk; finish course |
| Antivirals (oseltamivir) | Influenza when indicated | Start early for best effect |
| Bronchodilators | If concurrent reactive airways | Same monitoring as COPD/asthma |
| Corticosteroids | Selected severe CAP/COPD overlap / ARDS protocols | Hyperglycemia, infection masking |
| Vasopressors | Septic shock | ICU monitoring |
| Mucolytics / expectorants | Symptom support | Hydration still primary for secretions |
| VTE prophylaxis | Immobile/hospitalized clients | SCDs + pharmacologic per order |
8. Patient Education
- Take full antibiotic course; report fever return or worse dyspnea
- Hand hygiene, vaccines (pneumococcal, influenza, COVID-19)
- Smoking cessation; incentive spirometry after surgery
- Aspiration risk teaching for caregivers
- When to seek emergency care: severe SOB, chest pain, confusion, blue lips
9. Complications
- Sepsis / septic shock
- Pleural effusion, empyema, lung abscess
- Respiratory failure / ARDS
- Delirium in older adults
- Superinfection or C. difficile after antibiotics
10. Memory Aids
- “Culture, then abx—but don’t delay sepsis care”
- “Confusion can be pneumonia in older adults”
- Type 1 = O₂ problem; Type 2 = CO₂ problem
- VAP bundle: elevate HOB, oral care, sedation vacation, DVT/PUD prophylaxis (per facility)
11. NCLEX-Style Practice Questions
1. Orders include sputum culture and IV antibiotics for suspected pneumonia. What is the best sequence?
A. Antibiotics first, culture later today
B. Obtain sputum (and blood cultures if ordered), then start antibiotics promptly
C. Wait 24 hours for culture results before any antibiotic
D. Give antibiotics only if fever > 39°C
Answer: B. Cultures guide therapy, but antibiotics should start soon after cultures—especially if the client is unstable—without waiting for final results.
2. An 82-year-old is more confused than baseline with RR 28 and SpO₂ 90%. Priority action?
A. Request a psychiatry consult first
B. Assess respiratory status and apply oxygen per protocol
C. Encourage ambulation in the hall
D. Give a hypnotic for sleep
Answer: B. New confusion in older adults may signal hypoxia/infection; support oxygenation and complete a focused assessment.
3. Which ABG best fits acute hypercapnic respiratory failure?
A. pH 7.50, PaCO₂ 28, HCO₃⁻ 22
B. pH 7.28, PaCO₂ 58, HCO₃⁻ 24
C. pH 7.40, PaCO₂ 40, HCO₃⁻ 24
D. pH 7.48, PaCO₂ 42, HCO₃⁻ 30
Answer: B. Low pH with high PaCO₂ and near-normal HCO₃⁻ = acute respiratory acidosis.
4. Best position for a dyspneic client with unilateral pneumonia (good lung down vs up)?
A. Always lie flat
B. Follow facility guidance; often “good lung down” to improve matching of ventilation/perfusion for the better lung, unless otherwise ordered
C. Trendelenburg always
D. Prone only for mild cases
Answer: B. Positioning can optimize V/Q; know the exception (e.g., some abscess/hemorrhage cases keep bad lung down). Follow order/protocol.
5. A ventilated client is due for oral care. Why is this a priority?
A. It replaces the need for suctioning
B. Reduces VAP risk by limiting oropharyngeal bacterial load
C. Prevents all pneumothoraces
D. Raises PaCO₂ therapeutically
Answer: B. Regular antiseptic oral care is a core VAP prevention measure.
References
Centers for Disease Control and Prevention. (n.d.). Pneumonia. Retrieved October 15, 2026, from https://www.cdc.gov/pneumonia/
MedlinePlus. (n.d.). Pneumonia. National Library of Medicine. Retrieved October 15, 2026, from https://medlineplus.gov/pneumonia.html
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page
Diamond, M., Peniston, H. L., Sanghavi, D., & Mahapatra, S. (2024). Acute respiratory distress syndrome. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK436002/
Shebl, E., & Mirabile, V. S. (2023). Respiratory failure. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526127/