Anda di halaman 1dari 19



2. Physiology
Breathing is an event Definition breath of air from the outside containing oxygen into
the body and blowing air that contains CO2 as the rest of the oxidation out of the
This air sucking is called inspiration and exhaling is called expiration. Lung breathing
Represents the exchange of oxygen and carbon dioxide that occurs in the lungs.
Breathing through the lungs or respiratory external oxygen is taken by mouth and
nose when breathing where oxygen entering through the trachea to the alveoli
associated with blood in the capillaries pulmonary, alveoli separate oxygen from the
blood, O2 penetrate the membrane, drawn by the red blood cells were taken to heart
And from the heart is pumped throughout the body.
For respiration:
A. Taking O2 which is then carried by the blood throughout the body (cells) to burn.
B. Eject CO2 that occurs as a residue from combustion, then carried by blood to the
lungs for disposal (because it is no longer useful by the body).
C. Warm and moisturize the air.
Breathing normally Adults: 16-18 x / mnt Children approx: 24 x / min Babies approx:
30 x / min
Respiratory organs
D. Upper respiratory tract
The nose is the first air channel, has 2 holes, separated by the nasal septum (oil septum)
in which there are feathers that are useful for filtering air, dust, and dirt into the
Faring Is the place of intersection between janaln breath and street food. It is under the
base of the teng korak, behind the ronga of the nose and the front mouth of the neck
bone deer.
Pharynx divided into three parts:
E. The upper part is the same height as the koana called the nesofaring
F. The middle section of the same height denan istmus fausium called orofaring.
G. The lower part of the partition, called the langiofaring.
H. Larynx It is a short channel that connects the pharynx and trachea, and acts as a
sound formation.
I. Lower respiratory tract organs
Trachea is a continuation of the larynx formed by 16 s / d 20 rings consisting of horse-
shaped bones shaped like a horse's hooves. The trakhea length is 9-11 cm and the
back consists of connective tissue lined with smooth muscle.
Bronchial and alveoli The distal end of the trachea divides into the right and left
primary bronchi located within the chest cavity.
The function of the bronchial branching to provide a channel for air between the
trachea and the alveoli. Alveoli amounts to 300-500 million in the lungs, its function
is as the only place of gas exchange between the external environment and blood
A. The lungs are a body tool consisting mostly of bubbles (bubble of air-alveoli). These
alveolar bubbles are composed of epithelial and endothelial cells. The number of
lung bubbles is approximately 700,000,000 pieces (left and right lung).
Lung capacity:
Total Capacity: The amount of air that can fill the lungs in deep insulation.
Vital capacity: The amount of air that can be expelled after maximum expiration.
The thoracic cavity consists of the right and left pleural space and the middle part
called the mediastinum. The thorax has an important role in breathing, because of
the elliptical shape of the ribs and the angle of attachment of the spine. Changes in
the size of the thorax is what allows the process of inspiration and expiration.
Parts of the lungs:
Pleura is the outermost part of the lung surrounded by a smooth, slippery or pleural
Mediastinum is the part of the wall that divides the thoracic cavity into 2 parts
The lobe is the lung part divided into the left lobe consisting of the lower and middle
lobes and the upper and lower lobes
Bronchial and bronchioles have several bronchial divisions within each lobe. Brokiolus
is a branch of the bronchi
Pulmonary alveoli is formed by about 300 million alveoli arranged in closter between
15-20 alveoli
Pulmonary Respiratory Physiology is an elastic structure wrapped in a thoracic cage,
which is a strong air chamber with a pressure-resistant wall.
The effect of this movement is to alternately increase and decrease the chest capacity.
Inspiration is when the capacity in the chest rises, air enters through the trachea.
The expiration is when the chest wall and the diaphragm return to their original size

3. Definitions
Pneumonia is an inflammation of the lung parenchyma caused by microorganisms-bacteria,
viruses, fungi, parasites (Djojodibroto, 2009). According to Corwin (2011) pneumonia is
an acute infection of lung tissue by microorganisms.
Clinically pneumonia is defined as a lung inflammation caused by microorganisms (bacteria,
viruses, fungi, parasites). Pneumonia caused by Mycobacterium tuberculosis is not
included. While pulmonary inflammation caused by nonmicroorganisms (chemicals,
radiation, aspiration of toxic substances, drugs and others) is called pneumonitis (PDDI,
Based on where the occurrence of pneumonia is divided into:
CAP (community-acquired pneumonia), acquired pneumonia in the community.
HAP (hospital-acqiured pneumonia / nosocomial pneumonia), acquired pneumonia at
the hospital.

. 4. Etiology and Risk Factors

Pneumonia can be caused by various kinds of microorganisms, namely bacteria, viruses,
fungi and protozoa. From the CAP literature suffered by overseas community is caused
by Gram positive bacteria, while pneumonia in hospital is caused by Gram negative
bacteria, while aspiration pneumonia is caused by anaerobic bacteria (PDPI, 2010). In
general, bacteria that play a role in pneumonia are Streptococcus pneumoniae,
Staphylococcus aureus, H. Influenzae, Steptococcus Group B chlamydia and
mycoplasmic atypic germs.
Data of PDPI (2010), recent reports from several cities in Indonesia show that bacteria found
from sputum examination of CAP sufferers are Gram negative bacteria. Based on the last
5 years report from several lung centers in Indonesia (Medan, Jakarta, Surabaya, Malang,
and Makasar) by taking different materials and methods of microbiological examination,
the results of sputum examination are as follows:
O Klebsiella pneumoniae 45.18%
O Streptococcus pneumoniae 14.04%
O Streptococcus viridans 9.21%
O Staphylococcus aureus 9%
O Pseudomonas aeruginosa 8,56%
O Steptococcus hemolyticus 7.89%
O Enterobacter 5.26%
O Pseudomonas spp 0.9%
Some conditions such as malnutrition, young age, immunization completeness, occupancy
density, vitamin A deficiency, Zn deficiency, passive smoking exposure and
environmental factors (air pollution) are risk factors for pneumonia
5. Clinical Manifestations
Clinical symptoms and signs of pneumonia vary depending upon cause, age, immunological
status and severity of the disease. Clinical manifestations include shortness and cyanosis.
Symptoms and signs of pneumonia distinguished non-specific, pulmonary, pleural and
extrapulmonary symptoms.

1. Specific symptoms
A. Fever
B. Shivering
C. Sfalgia
D. Restless
E. Gastrointestinal disorders such as vomiting, bloating, diarrhea or abdominal pain

2. Pulmonary symptoms
A. Breath of the nostrils
B. Tachypnea, dyspnoea and apnea
C. Using intercostal and abdominal muscles
D. Cough
E. Wheezing

3. Pleural symptoms
Chest pain caused by Streptococcus pneumoniae and Staphylococcus aureus

4. Extrapulmonary symptoms
A. Skin or soft tissue abscess in case of pneumonia due to Staphylococus aureus
B. Otitis media, conjunctivitis, sinusitis can be found in cases of infection due to
Streptococcus pneumoniae or H. Influenza
6. Pathophysiology
Microorganisms enter the upper airway causing immune reactions and disturbed defense
mechanisms then form colonization of microorganisms resulting in inflammation. In
addition, bacterial toxins released directly damage the cells of the lower respiratory
system, including the production of alveolar II surfactants. Bacterial pneumonia results in
the most prominent immune and inflammatory response that travels clearly in
pneumococcal pneumonia (Corwin, 2011)
8. Management
In the case of treating patients with pneumonia need to be considered clinical circumstances.
If the clinical condition is good and no indication of treatment can be treated at home.
Also note the presence or absence of modification factors that are conditions that may
increase the risk of infection with specific pathogenic microorganisms eg S. pneumoniae
resistant penicillin. According to ATS (2012), which is included in the factor of
modification are:

A. Pneumococcus is resistant to penicillin

Age over 65 years
Wearing P lactam medications for the past three months
Immune disorders
Multiple comorbidities

B. Gram-negative enteric bacteria

Residents of the nursing home
Has a basic lung disease
Having multiple disease disorders
History of antibiotic treatment

C. Pseudomonas aeruginosa
Treatment of corticosteroids> 10 mg / day
Treatment of broad-spectrum antibiotics> 7 days in the last month

CAP management is divided into:

A. Outpatient
Supportive / symptomatic treatment
- Rest in bed
- Drink sufficiently to overcome dehydration
- When high heat needs to be compressed or take febrifuge
- If necessary can be given mukolitik and expektoran
Antiblotting should be given (as per the chart) for less than 8 hours

B. Inpatient sufferers in the normal room

Supportive / symptomatic treatment
- Provision of oxygen therapy
- Installation of infusion for rehydration and correction of calories and electrolytes
- Symptomatic drug administration include antipyretics, mucolytics Antibiotic treatment
should be given (according to the chart) less than 8 hours

C. Inpatient patient in Intensive Care Room

Supportive / symptomatic treatment
- Provision of oxygen therapy.
- Installation of infusion for rehydration and correction of calories and electrolytes
- Symptomatic drug administration include antipyretic, mukolitic.
Antibiotic treatment (according to chart.) Less than 8 hours.
If there is an indication the patient has a mechanical ventilator installed.

9. Investigations
A. Radiological Overview
Photo thorax (PA / Lateral) which is the main investigation to make the diagnosis

B. Laboratory Examination
On laboratory examination there is an increase in the number of leukocytes, usually more
than 10,000 / ul sometimes up to 30,000 / ul, and on the leucocyte count there is a shift to
the left and an increase in LED. For examination of etiologic diagnosis sputum
examination, blood culture and serology are required. Blood cultures can be positive in
20-25 percent of untreated people. Blood gas analysis showed hypoxemia and hikarbia, at
an advanced stage may occur respiratory acidosis (PDPI, 2010).
10. Complications
Pleural effusion
Lung abscess
Failed breathing
functional paralytic Ileus


A. Data focus assessment

1. Client identity.
Pneumonia can attack all ages depending on the germs that cause bacterial pneumonia can
occur at any age, atypical pneumonia often in children and young adults, and viral
pneumonia is common in infants and children.

2. The main complaint.

Complaints are preceded by respiratory tract infections, then sudden high heat accompanied
by a severe cough, chest pain and ngos breath.

3. Current medical history.

In clients of pneumonia often seen in waktuanamnese are clients complained suddenly high
heat (380C - 410C) with chills, sometimes vomiting, pleural pain and respiratory cough is
disturbed (takipnea), dry cough will produce sputum like rust and purulen

4. Past medical history.

Pneumonia is often followed by an upper respiratory tract infection, in PPOM disease,
tuberculosis, DM, post-influenza can underlie the onset of pneumonia.
5. Family disease history.
Are there any family members suffering from the same disease with a client or bronchial
asthma, tuberculosis, DM, or other ARD illnesses.

6. Physical examination.
A) General circumstances.
Client pneumonia conditions are generally weak, facial expressions withstand pain due to
stabbing chest pain.

B) Integumentary system.
On inspection of cyanisis and signs of skin turgor decline.

C) Respiratory system.
On the physical examination of the respiratory system will be found signs and symptoms as
Inspeksi : - Breathlessness and fatigue quickly.
- Early nonproductive cough becomes productive.
- Movements in the thorax on the diseased part are
left behind.
- Cyanosis occurs especially if the affected part of
the inflammation is quite large.
Vocal fremitus (vibration) will increase in intensity
Palpasi : on the sick side (more dense).
In the healthy part will sound the sonor and the sick
Perkusi : will sound dim (higher tone with shorter sound time).
Bronchial sound, a clear whisper, sometimes a
pleural friction.

Auskultasi :
D) Gastro intestinal system.
In Pneumonia clients found abdominal consolidation.
E) The celetal musculus system.
In Pneumonia clients frequent muscle weakness can occur
Disrupt the respiratory system.
B. Nursing diagnoses
1. Ineffective airway clearance associated with bronchial tracheal inflammation,
edema formation, increased sputum production.
2. The gas exchange disruption is related to the oxygen-carrying capacity
3. Disturbance of breath pattern associated with musculoskeletal gag
4. Activity intolerance is related to the imbalance between supply and oxygen
5. less nutrients than necessarily related to increased metabolic needs secondary to
fever and infection process.
6. Disturbance of fluid and eletrolite balance associated with excessive fluid loss,
decreased oral input.
A. Intervensi keperawatan

No Diagnosis Goal Intervensi Rasional

1. Ineffective airway After nursing care 1. Assess the frequency 1. Tachypnoea, shallow
clearance is associated done 2x24 hours / depth of breathing breathing and
with bronchial tracheal Effective airway with and chest movement. symmetrical chest
inflammation, edema the criteria: movements often occur
formation, increased due to discomfort.
- Effective cough
sputum production . 2. Auscultation of the 2. decreased blood flow
lung area, note the occurs in the area of
- Normal breath
area of decline 1 times consolidation with
- The sound of a there is airflow and fluid.
clean breath the breath sound .

3. Let the cough 3. Cough is a natural

technique work. airway clearance
mechanism for
coughing or cleansing
the airway mechanical
4. Sucking as indicated. sounds on factors that
are unable to perform
due to effective cough
or decreased level of
(khususnya yang
5. Give sed fluidsikitnya. hangat) memobilisasi
dan mengeluarkan
4. a tool to decrease
bronchial spasm by
6. Collaboration with secretarial
doctor for mobilization, analgesic
administration of drug is given to improve
as indicated: cough by decreasing
mukolitik, ex. discomfort but must be
used carefully, as it can
decrease cough effort /
depress breathing.
2. Gas exchange disorders After nursing care 1. Assess the frequency / 1. Manifestation of
associated with oxygen- done 2x24 hour gas depth and ease of respiratory distress
carrying blood disorders, exchange disruption breathing. depends on the
oxygen delivery resolved by criteria: indication of degree of
disorders lung involvement and
- Normal breath
general health status.
2. nail cyanosis
2. Observe skin color, demonstrates
mucous membranes vasoconstriction of the
and nails. Note the body's response to
presence of peripheral fever / chills but
cyanosis (nail) or cyanosis in the
central cyanosis.Kaji earlobes, mucous
status mental. membranes and skin
around the mouth
suggests systemic
hypoxemia .
3. restless easily aroused,
confused and
3. Elevate head and somnolent can show
thrust frequently hipoksia atau
change position, deep penurunan oksigen
breath and effective serebral.
cough 4. This action increased
maximum inspiration,
increased secret
expenditures to
improve ineffective
4. 4. Collaboration: Give ventilation
oxygen therapy 5. Keep the PaO2 above
properly eg with nasal 60 mmHg. O2 is given
plong master, master by a method that
venturi. delivers precise
delivery in the
tolerance of pe .
3. Respiratory disorders After nursing care 1. Monitor vital signs tightly 1. during the beginning of
associated with done 2x24 hours of especially during the this period, potential for
musculoskeletal breath disorder does beginning of fatal may occur.
disorders not occur with the therapy.Show good 2. Effectively means
criteria: handwashing decreased spread /
techniquesLimit visitors alteration of infection.
time of repair as indicated 3. reduce transmission to
of the pattern 2. Cut balance to adequate other pathogenic infections.
of breath / balance with moderate 4. . ease the healing process
quick activity. Increase adequate and increase natural
recovery nutrition pressure.
without input.Collaboration: 5. Drugs are used to kill most
transmission Provide antimicrobial as microbial pulmonia.
of the disease indicated by sputum /
to others blood cultures such as
penicillin, erythromycin,
tetracycline, amlicin,
sepalosporin, amantadine.
4. Activity intolerance is After nursing care 1. Evaluate the patient's 1. is the ability, the needs of
related to the imbalance 2x24 hours Activity response to the the patient and facilitate
between supply and intolerance is activity. the choice of interan.
oxygen demand resolved by: 2. Provide a quiet 2. reduce stress and
environment and limit excessive stimulation,
visitors during the improve rest.
acute phase as
3. Explain the need for a 3. patient may be
break in the treatment comfortable with high
plan and the need for a head, sleep in a chair.
balance of activity and 4. minimize fatigue and help
rest. balance the supply and
4. Help the patient oxygen demand.
choose a comfortable
position for rest or
5. Help the necessary
self-care activities.
5. Less nutrients than needs After nursing care 1. Determine the 1. hours of nutrients less
are associated with done 2x24 hours of characteristics of than wholeness usually
increased metabolic nutrition less than nutritional hours less present in how many
needs secondary to fever kenutuhan can be than wholeness, eg, degrees of pneumonia,
and infection processes resolved by: stroke, constant can also arise due to
stabbed. pneumonia such as
Weight gain
2. Monitor vital signs. pericarditis and
3. Give comfortable endocarditis.
- ideal weight weight
back massage, change 2. Changes in FC of the
-shows improved position, quiet music / heart / TD Pc bringing
taste function of talk. menu pain, especially
swallowing 4. Raise and assist the when other reasons for
patient in the signs of vital signs
technique of pressing change have been seen.
the chest during the 3. non analgesic action
cough episode. given with a gentle
5. Collaboration: Give touch can eliminate
analgesics and discomfort and magnify
antitusions as the effect of analgesic
indicated. degree.
4. a tool for controlling
chest discomfort while
increasing the
effectiveness of cough
5. drugs can be used to
suppress non
productive cough or
lower excessive
mucosa increased
general resting comfort.
Less nutrients than the After nursing care 1. Identify factors that 1. the choice of
body's needs are done 2x24 hours cause nausea / intervention depends on
associated with increased Nutrition less than vomiting, eg: sputum, the cause of the
metabolic needs body needs can be a lot of pain. problem.
secondary to fever and overcome by: 2. Schedule or breathe at 2. decreased manual
inflammatory processes least 1 hour before effects associated with
- Patients show
meals this disease
increased appetite
3. Give small portions 3. This action may
of food and often increase input even
- Patients maintain
include dry food though the appetite may
increased BB
(toast) food that is be slow to return.
interesting by the 4. the existence of chronic
patient. conditions limited
4. Evaluate general space can cause
nutritional status, malnutrition, low
measure baseline resistance to
weight. inflammation / slow
response to therapy.
6. Disruption of fluid and After the treatment of 1. Assess vital alteration 1. Assess vital alteration
electrolyte balance nursing care 2x24 changes eg increase in changes eg increase in
associated with excessive hours Disruption of temperature of temperature of
fluid loss, decreased oral fluid and eletrolite elongated fever, elongated fever,
input. balance with criteria: tachycardia. tachycardia.
Patient shows fluid 2. Assess skin turgor, 2. Assess skin turgor,
balance evidenced by moisture of mucous moisture of mucous
appropriate membranes (lips, membranes (lips,
individual parameters tongue) tongue)
eg moist mucous 3. Write down reports of 3. Write down reports of
membranes, good nausea / vomiting. nausea / vomiting.
skin turgor, stable 4. Monitor input and 4. Monitor input and
vital signs. output record color, output record color,
character urine. character urine.
Calculate fluid Calculate fluid balance.
balance. Measure the Measure the weight as
weight as indicated. indicated.
5. Emphasize the liquid 5. Emphasize the liquid
slightly 2400 mL / day slightly 2400 mL / day
or according to or according to
individual conditions individual conditions
6. Collaboration: Give 6. Collaboration: Give
medicine indications medicine indications
such as antipyretic, such as antipyretic,
antimitic. antimitic.
7. Give additional IV 7. Give additional IV
fluids as needed. fluids as needed.

Doenges, Marilynn, E. dkk. Rencana Asuhan Keperawatan, Edisi 3, 2010. Jakarta:

Penerbit Buku Kedokteran EGC
Guyton & Hall (2011), Buku Ajar Fisiologi Kedokteran Edisi 9, Penerbit Buku
Kedoketran EGC, Jakarta
Asih, Retno. dkk. 2010. Continuing Education Ilmu Kesehatan Anak XXXVI Kapita
Selekta Ilmu Kesehatan Anak Kuliah Pneumonia.
Corwin, J. Buku Saku Patofisiologi, Ed.3. 2010. Jakarta: Penerbit Buku Kedokteran EGC
Djojodibroto, D. Respirologi (Respiratory Medicine). 2010. Jakarta : Penerbit Buku
Kedokteran EGC
Doenges, Marilynn, E. dkk. Rencana Asuhan Keperawatan, Edisi 3, 2010. Jakarta: Penerbit
Buku Kedokteran EGC
PPDI. 2010. Pneumonia Komuniti Pedoman Diagnosis dan Penatalaksanaan