pneumonia nursing care plan

Pneumonia is a respiratory condition characterized by lung parenchymal inflammation caused by viral, bacterial, or fungal invasion. In some cases, the inflammation is accompanied by alveolar edema, lung consolidation, and respiratory congestion. The symptoms of the disease contribute to an impairment in the gas exchange of the patient, poor oxygen delivery to the tissues, and a host of other complications.

There are several types of pneumonia that the nurse must be familiar with such as community-acquired pneumonia (CAP) and nosocomial or hospital-acquired pneumonia (HAP). These two classifications are made to determine the origin of the infection and not the microorganism that caused the infection.

Another classification is aspiration pneumonia, where the inflammation is caused by regurgitation or inhalation of substances from the gastrointestinal tract into the lungs. These classifications would provide the nurse with a good source of information on the etiology of the infection, how the patient acquired it and the interventions that can help address the nursing problem.

Physical assessment of the patient reveals the presence of areas of lung consolidation, presence of coughing with sputum production, shortness of breath and fever. Patients are also observed to manifest with rapid shallow respirations, chills, pleuritic chest pains and use of accessory muscles in respirations. Complicated cases may present with presence of effusion, abscesses in the lungs, widespread bacterial infections (or superimposed infections in patients who are severely immunocompromised).

Nurses caring for patients with pneumonia should assess patients thoroughly to be able to identify both actual and potential health problems. Assessment data that the nurse needs to identify includes ABG levels, vital signs (with emphasis on the respiratory rate, rhythm and patterns), characteristics of the sputum, oxygen saturation levels and activity tolerance. The nurse can also focus on the assistive respiratory devices and how these can affect patient prognosis and response to interventions.

Patients with pneumonia can suffer from both actual and potential health problems. Prioritization of these problems is, therefore, a must for the nurse to undertake, especially since several of these problems can bring about serious complications if they are not addressed as soon as they were diagnosed.

The following diagnoses are usually made when caring for patients with pneumonia:

  1. Impaired gas exchange
  2. Ineffective airway clearance
  3. Ineffective breathing pattern
  4. Knowledge deficit/Deficient knowledge
  5. Activity intolerance
  6. Risk for infection
  7. Risk for nutritional imbalance: less than body requirements

The nurse must remember, however, that the nursing diagnoses that can be made among patients suffering from pneumonia are not limited to the ones identified above. Other diagnoses can also be made, depending on available assessment data and patient verbalization, and laboratory findings. Goals of care must also focus not only on addressing the present or at-risk problem, but also help in ensuring that the patient is able to maintain an optimum level of functioning.

Pneumonia Nursing Care Plan

Below are examples of two (2) most common health problems seen among patients with pneumonia.

Ineffective Airway Clearance

Ineffective airway clearance related to presence of inflammation along the bronchial walls secondary to diagnosis of pneumonia as evidenced by increased in respiratory effort, expiratory wheezing, deep shallow respirations, flaring of the nostrils and pain upon respirations.

Ineffective airway clearance related to presence of thick, tenacious sputum along the airways as evidenced by dyspnea, tachypnea, unproductive cough and crackles heard upon auscultation.

NOTE: .**Other symptoms can be added in to the defining characteristics if seen manifested by the patient).

Desired Outcomes:

After the nursing interventions, the patient is expected to:

  • Present with a patent airway
  • Manifest clear breath sounds upon auscultation
  • Verbalize ease in respiration
  • Be able to expectorate sputum effectively
Nursing Action Rationale
Assess and document vital signs, paying close attention to the respiratory rate, depth and rhythm.

 

Identifying characteristics in respiratory patterns can help the nurse assess for presence of abnormalities, improvement or worsening of the patient’s condition. It can also be used as a baseline and evaluation data to determine the response of the patient to therapy later on.

 

Note and document patient’s use of accessory muscles in respirations, flaring of the nostrils and characteristics of sputum.

 

Use of accessory muscles may indicate difficulty in respiration and the need of the patient to have enhanced air intake and to help facilitate gas exchange.
Assess coughing and sputum production, noting the consistency and other characteristics of the expectorate.

 

Patients with productive coughing can eliminate sputum easier than patients who do not have the capacity to cough productively. The characteristics of the sputum will also give the nurse an idea of the possible etiology of pneumonia.

 

Encourage increased fluid intake Increasing the fluid intake helps to liquefy secretions, making it easier for patients to expectorate it.
Instruct patients about the proper deep breathing and coughing techniques such as splinting, coughing from the lungs and deep breathing. Proper techniques for deep breathing, coughing and splinting help the patient to have maximal lung expansion, improve the overall productivity of the coughing efforts and reduce chest discomfort.

 

Encourage the patient to assume semi-Fowler’s or high Fowler’s position and ambulate if not contraindicated. Positioning the patient in Fowler’s position also helps in postural drainage, enabling forceful expirations and enhanced coughing while ambulation helps to mobilize secretions.
Anticipate an order for oxygen therapy, especially among patients with moderate to severe congestion. Oxygen therapy, especially the use of humidified oxygen, helps loosen secretions and helps to reduce the risk of hypoxemia among patients.
Administer medications as prescribed such as: expectorants, mucolytics, bronchodilators and others. These medications have their own unique functions in helping a patient with ineffective airway clearance. Expectorants help patients to mobilize secretions and enable them to eliminate it from the airway through coughing. Mucolytics act to liquefy secretions, while bronchodilators help increase airway clearance by widening bronchial passages.
For severe patients: Anticipate an order for intubation and hooking the patient to a ventilator. Intubation and mechanical ventilation is usually needed for patients with severely impaired breathing and gas exchange. This would help oxygen tissue perfusion.

Risk for Infection

Risk for infection related to inadequate primary defenses secondary to stasis of respiratory secretions

Risk for infection related to inadequate primary defenses secondary to reduced ciliary action along the bronchial passages

Risk for infection related to immunosuppression secondary to effects of therapy (medications)

Note: “evidenced by” is not usually applicable for a risk diagnosis since the presence of signs and symptoms already makes the nursing problem an actual diagnosis.

Desired Outcomes

After the nursing interventions, the patient is expected to:

  • Have reduced risk for developing infection
  • Verbalize knowledge on ways of how to reduce the risk of infection
Nursing Action Rationale
Assess and document vital signs, noting for changes in temperature, respiratory effort and complaints of pain.

 

Vital signs monitoring provide the nurse with immediate information about the general status of the patient. Increases in temperature may indicate the presence of infection.
Stress the importance of proper handwashing techniques to the patient and his significant others.

 

Hand washing is one of the easiest and most effective ways to reduce the risk of contamination and transferring infections. Teaching the patient the principles of handwashing and demonstrating it to them will be helpful in promoting its practice.
Ensure that the patient is turned at least once every 2 hours. If the patient is ambulatory, encourage the patient to walk about in his room several times each day.

 

Frequent turning and/or ambulation is helpful in mobilizing secretions and preventing it from pooling to the lower lung fields.

 

Encourage increased fluid intake Increasing the fluid intake helps to liquefy secretions, making it easier for patients to expectorate it.
Ensure that the patient’s activities are alternated with ample periods of rest. Enhanced resting helps the patient to build and maintain his natural defenses and resistance to infections. It also helps to promote faster healing.
Practice proper isolation precautions. Ensuring that the patient is kept away from others with communicable infections, limiting visitors, enforcing aseptic technique and other precautions help protect the patient from opportunistic infections, especially in an inpatient setting. If possible, place the patient in a private or semi-private room.
Teach deep breathing, coughing and expectoration of sputum. Pooled secretions in the lung field can be a good culture medium for bacteria and other microorganisms which may cause infection.
Administer medications as prescribed such as: expectorants, mucolytics, bronchodilators and others. These medications have their own unique functions in helping a patient with ineffective airway clearance. Expectorants help patients to mobilize secretions and enable them to eliminate it from the airway through coughing. Mucolytics act to liquefy secretions, while bronchodilators help increase airway clearance by widening bronchial passages.
Ensure that the patient understands and adheres to the antibiotic therapies. Most cases of complicated infections and drug-resistant strains of infections are caused by patients who are not able to adhere to the prescribed length of therapy and proper dosage.

References

  1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis.
  2. Carpenito, L. (2016). Handbook of Nursing Diagnosis (15th ed.).
  3. Herdman, T., & Kamitsuru, S. (2018). NANDA International, Inc. nursing diagnoses (11th ed.).
  4. Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-
  5. Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). St. Louis: Elsevier.
  6. McCance, K.L. & Huether, S.E. (2017). Understanding Pathophysiology: The Biologic Basis for Disease in Adults and Children (6th ed.). St. Louis: Elsevier/Mosby.
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1 COMMENT

  1. This is a great platform for nurses to learn. I’m a nurse who joined hematology department in february 2012, after 7 years of primary health care. I currently need a lot to learn to be competent enough. I would love to join the group in sharing information.

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