5 Nursing diagnosis of pneumonia and care plans

Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue).

As a result of the inflammation, the lung tissue becomes edematous and the air spaces fill with exudate (consolidation), gas exchange cannot occur, and non-oxygenated blood is diverted into the vascular system, resulting in hypoxemia.

Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung.

Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). A third type is pneumonia in immunocompromised individuals.

Community acquired pneumonias

The most common. People with community-acquired pneumonia usually do not need to be hospitalized unless an underlying condition such as chronic obstructive pulmonary disease (COPD), heart disease or diabetes mellitus, or a weakened immune system complicates the disease.

Hospital associated Nosocomial pneumonias

usually occur after aspiration of oral pharyngeal flora or gastric contents in persons whose resistance is altered or whose cough mechanism is impaired 

Bacteria enter the lower respiratory tract via three routes

(1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs,

(2) obstruction (foreign bodies or fluids), and 

(3) infections (rare). 

Gram-negative pneumonia is associated with a high mortality rate, even with appropriate antibiotic therapy. Aspiration pneumonia is a nonbacterial (anaerobic) cause of hospital-associated pneumonia that results from aspiration of gastric contents. Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections.

Pneumonia in the immunocompromised individual 

Immunosuppression and neutropenia are predisposing factors for the development of nosocomial pneumonia caused by common and uncommon pathogens. Severely immunosuppressed patients are affected not only by bacteria but also by viruses (cytomegalovirus) and fungi (Candida, Aspergillus, Pneumocystis jirovecii). Most commonly, P. jirovecii occurs in individuals with human immunodeficiency virus infection or in individuals who are therapeutically immunosuppressed after organ transplantation.

HEALTH CARE SETTING

Primary care, with acute or intensive care hospitalization due to complications.

Assessment of pneumonia

Outcomes are influenced by the age of the patient, the extent of the disease process, the underlying disease, and the pathogen involved. In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia.

General signs and symptoms of pneumonia

• Cough
• increased sputum 
• fever
• pleuritic chest pain 
• Dyspnea
• chills
• headache, and myalgia
• Older adults may be confused or disoriented and have a low-grade fever but few other signs and symptoms.

General physical assessment findings of pneumonia

• Restlessness
• Anxiety,
• Decreased skin turgor and dry mucous membranes as a result of dehydration, 
• presence of nasal bleeding and exhalation grunting.
• Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas, 
• Tachypnea (more than 20 breaths/min), 
• Tachycardia (resting heart rate [HR] more than 100 bpm), 
• decreased breath sounds, 
• high-pitched and inspiratory crackles (rales) that are amplified by coughing or heard only after coughing, 
• deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding).

Diagnostic test for pneumonia

Chest x-ray examination: To confirm presence of pneumonia (i.e., infiltrate appearing on the film).

Sputum for Gram stain and culture and sensitivity tests:

Sputum is obtained from the lower respiratory tract before starting antibiotic therapy to identify the causative organisms. It can be obtained by coughing, aspiration, transtracheal aspiration, bronchoscopy or open lung biopsy.

White blood cell (WBC) count: 

Is elevated in bacterial pneumonias (greater than 12,000/mm3). Normal or low leukocyte counts (less than 4000/mm3) may occur in viral or mycoplasma pneumonia.

Chemistry panel: 

To detect presence of hypernatremia, hyperglycemia, and/or dehydration.

Blood culture and sensitivity: To determine the presence of bacteremia and identify the causative organism. For best yield, blood cultures should be obtained before antibiotics are administered.

Urinary antigen test: To detect Legionella pneumophila and Streptococcus pneumoniae.

Oximetry: May reveal decreased O2 saturation (92% or less).

Arterial blood gas (ABG) values:  May vary depending on extent of pulmonary involvement or other coexisting conditions. Findings may show hypoxemia (PaO2 less than 80 mm Hg) and hypocarbia (PaCO2 less than 32-35 mm Hg) with resultant respiratory alkalosis (pH greater than 7.45) in the absence of underlying pulmonary disease. However, with increasing respiratory distress, respiratory acidosis may occur.

Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. A relative increase in antibody titers indicates viral infection.

Acid-fast stains and cultures: To rule out tuberculosis.

Nursing Diagnosis of pneumonia

• Risk for Infection (nosocomial pneumonia)
• Impaired Gas Exchange
• Ineffective clearance of the airway
• Deficient fluid volume

Risk for Infection (nosocomial pneumonia)

associated with inadequate primary defenses (e.g., decreased ciliary activity), invasive procedures (e.g., intubation), and/or chronic disease Desired outcome: patient is free of infection as evidenced by normothermia, a leukocyte count of 12,000/mm3 or less, and clear to whitish sputum.

Nursing care plan risk for infection

Nursing intervention	Rationale
Identify candidates for surgical intervention who are at increased risk for nosocomial pneumonia.	This assessment helps ensure that surgical patients remain infection-free, as nosocomial pneumonia has a high morbidity and mortality rate. Factors that increase the risk of nosocomial pneumonia in surgical patients include: older adults (older than 70 years), obesity, COPD, other chronic lung diseases (e.g., asthma), history of smoking, abnormal pulmonary function tests (especially decreased forced expiratory flow rate), intubation, and upper abdominal/thoracic surgery.
Thorough hand hygiene before and after patient contact (even if gloves are worn).	This measure helps prevent the spread of infection by removing pathogens from the hands. Hand hygiene includes the use of a waterless alcohol-based antiseptic when hands are not visibly soiled or the use of soap and water when hands are dirty or contaminated with proteinaceous material.
Preoperative education, explanation, and demonstration of pulmonary activities used postoperatively to prevent respiratory infections.	Pulmonary activities that help prevent infection/pneumonia include deep breathing, coughing, turning in bed, splinting wounds before breathing exercises, walking, maintaining adequate oral fluid intake, and using a hyperinflation device.
Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately.	These interventions help ensure that the patient has the appropriate knowledge and is able to perform these activities. Learning to apply information through a return demonstration is more helpful than verbal instruction alone. A knowledgeable patient is more likely to comply with therapy.
Advise individuals who smoke to stop smoking, especially during the preoperative and postoperative periods. Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed.	Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia.
Administer analgesics 1/2 hour prior to deep breathing exercises. Support (splint) the surgical wound with hands, pillows, or a folded blanket placed firmly over the incision site.	These measures help control pain that would otherwise interfere with lung expansion.
Identify patients at increased risk for aspiration.	Individuals with depressed level of consciousness, advanced age, dysphagia, or a nasogastric (NG) or enteral tube are at increased risk for aspiration, which predisposes them to pneumonia.
Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. If the patient is enteral fed, recommend continuous rather than bolus feeding. Stop feeding when the patient is lying flat	Aspiration is one of the two leading causes of nosocomial pneumonia. Aspiration precautions include maintaining a 30-degree elevation of the HOB, turning the patient onto his or her side rather than back, and using continuous rather than bolus feeding when the patient is enteral.
Recognize the risk factors for infection in patients with tracheostomy and take the following actions:	Risk factors include the presence of underlying pulmonary disease or other serious illness, increased colonization of the oropharynx or trachea by aerobic gram-negative bacteria, increased bacterial access to the lower airway, and cross-contamination from manipulation of the tracheostomy tube.
Wear gloves on both hands when handling the cannula or when handling ventilation tubing.	Loss of skin integrity or space around the tube would allow pathogens to enter via the wound or tube.
Suction as needed and not routinely.	Frequent suctioning increases risk of trauma and cross-contamination.
Always wear gloves on both hands for suctioning. Use a sterile catheter for each suctioning procedure. Consider using a closed suction system; replace closed suction system according to agency guidelines. Always change the suction system between patients. Use only sterile fluids and dispense with sterile technique. Change ventilation tubing according to agency guidelines. Fill fluid containers immediately before use (not well in advance).	These practices further reduce the risk of contamination.
Avoid instillation of saline during suctioning. Increase heat and humidity if patient has persistent secretions.	Saline instillation can cause bacteria to shift to the lower lung areas, increasing the risk of inflammation and invasion of sterile tissues. It may also stimulate coughing.

Impaired Gas Exchange due to pneumonic condition

Associated with altered oxygenation and alveolar-capillary membrane changes resulting from the inflammatory process and exudate in the lungs.

Desired Outcome:

Discharge from the hospital is expected if the patient has at least five of the following indicators: temperature 37.7°C or less, heart rate 100 beats/minute or less, heart rate 24 breaths/minute or less, systolic blood pressure (SBP) 90 mm Hg or more, oxygen saturation greater than 92%, and ability to maintain oral intake.

Nursing care plan for impaired gas exchange

Nursing intervention	Rational
Watch for signs and symptoms of respiratory distress and report them promptly.	Signs and symptoms of respiratory distress include agitation, anxiety, mental status changes, shortness of breath, tachypnea, and use of accessory respiratory muscles. Respiratory distress requires immediate medical intervention.
Auscultate breath sounds at least every 2 to 4 hours or as the patient’s condition dictates. Report significant findings.	Decreased or random breath sounds (e.g., crackles, wheezes) may indicate possible respiratory failure, which would further exacerbate hypoxia and require immediate intervention.
Monitor and document vital signs (VS) every 2 to 4 hours or as the patient’s condition requires. Report significant findings.	Increasing temperature and other changes in VS (e.g., increased HR and RR) may indicate a worsening inflammatory response in the lungs. This could cause further hypoxia, contributing to adult respiratory distress syndrome and the need for mechanical ventilation.
Administer antibiotics within 6 hours of hospital admission and ongoing as prescribed.	Early administration of antibiotics reduces the inflammatory response in the lungs, promotes healing, and reduces the risk of death. Typical antibiotic therapy for community-acquired pneumonia includes administration of B-lactams (high-dose amoxicillin or amoxicillin-clavulanate) and cephalosporins (ceftriaxone, cefotaxime, and cefpodoxime) along with macrolides (azithromycin, clarithromycin, and erythromycin). Cephalosporins alone do not provide protection against atypical bacteria unless a macrolide is also used. Fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin, and gemifloxacin) can be used alone because of their broad spectrum of activity. However, they are not routinely the first-line agents because of the risk of increasing resistance. Correct identification of the organism and determination of susceptibility to specific antibiotics are critical for appropriate therapy.
Monitor oximetry values; report O2 saturation of 92% or less.	An O2 saturation of 92% or less is indicative of a significant oxygenation problem and may indicate the need for O2 therapy.
Administer oxygen as prescribed.	Oxygen is administered when O2 saturation or ABG results show hypoxemia. Initially, oxygen is administered at low concentrations, and oxygen saturation is closely monitored. If O2 saturation does not increase to an acceptable level (greater than 92%), FiO2 is increased in small increments while simultaneously checking O2 saturation or obtaining ABG values. A significant increase in oxygen demand to maintain O2 saturation greater than 92% should be reported immediately.
Monitor ABG results.	Acute hypoxemia (PaO2 below 80 mm Hg) often indicates the need for oxygen therapy. Hypocarbia (PaCO2 less than 35 mm Hg) with resulting respiratory alkalosis (pH greater than 7.45) is consistent with pneumonia in the absence of underlying lung disease. However, when pneumonia leads to acute respiratory distress, respiratory acidosis is the result.
Position the patient to be comfortable (usually in the half-Fowler position).	This position provides comfort, promotes descent of the diaphragm, maximizes inspiration, and decreases work of breathing. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. In patients with unilateral pneumonia, positioning on the unaffected side (i.e., “good side down”) promotes ventilation to perfusion adaptation.
Facilitate coordination within the care team to allow rest periods between care activities. Allow 90 minutes for undisturbed rest.	Rest lowers the oxygen demand of a patient whose reserves are likely to be limited.

Ineffective clearance of the airway

Associated with the presence of tracheobronchial secretions that occur with infection Desired outcomes: The patient demonstrates an effective cough. After the intervention, the patient’s airway is free of incidental breath sounds.

Nursing Intervention	Rationale
Auscultation of breath sounds every 2 to 4 hours (or depending on the patient’s condition) and reporting of changes in the patient’s ability to secrete lung secretions.	This examination detects the presence of random breath sounds (e.g., crackles, wheezes). Coarse crackling sounds are a sign that the patient is coughing. Fine crackles at the base of the lungs are likely to disappear with deep breathing. Wheezing is a sign of airway obstruction that requires immediate intervention to ensure effective gas exchange.
Examine sputum for volume, odor, color, and consistency; document findings.	As the patient’s condition worsens, sputum may become more abundant and change color from clear/white to yellow and/or green, or it may exhibit other discolorations characteristic of an underlying bacterial infection (e.g., rust-colored; “currant jelly”).
Ensure that the patient performs deep breathing with coughing exercises at least every 2 hours.	These exercises help clear the airway of secretions. Controlled coughing (tensing the upper abdominal muscles while coughing 2 to 3 times) makes for a more effective cough because it uses the diaphragm muscles, which increases the penetrating power of the effort.
Help the patient get into a comfortable position, usually the half-Fowler position.	This position provides comfort and facilitates the ease and effectiveness of these exercises by promoting better lung expansion (less compression of the lungs by the abdominal organs) and better gas exchange.
Assess the need for hyperinflation therapy.	The patient’s inability to take deep breaths is an indication of the need for this therapy. Deep inhalation with a hyperinflation device dilates the alveoli and helps move secretions into the airway, and coughing further mobilizes and clears secretions. The focus of this therapy is on inhalation to maximally expand the lungs. The patient inhales slowly and deeply at 2 times the normal tidal volume and holds the breath for at least 5 seconds at the end of inspiration. To maintain adequate alveolar inflation, 10 such breaths/hour are recommended.
Reporting complications of hyperinflation therapy to the health care provider.	Complications include hyperventilation, gastric hyperinflation, headache, hypotension, and signs and symptoms of pneumothorax (shortness of breath, stabbing chest pain, decreased breath sounds on one side, dyspnea, cough).
Teach the patient to splint the chest with a pillow, folded blanket, or folded arms.	This intervention decreases pain during coughing, thereby promoting a more effective cough.
Instruct patients who are unable to cough effectively in a cascade cough.	A cascade cough removes secretions and improves ventilation through a sequence of shorter and more forceful exhalations than is the case with the usual coughing exercise.
Administer oxygen with hydration as prescribed.	This intervention provides oxygenation while reducing convective moisture loss and helping to mobilize secretions.
Assist the patient with position changes every 2 hours. If the patient is ambulatory, walking should be encouraged within the patient’s tolerance.	Exercise and activity help mobilize secretions to facilitate airway clearance.
Suction as prescribed and indicated.	Suctioning keeps the airway clear by removing secretions.
Unless contraindicated, promote fluid intake (2.5 L/day or more).	Increased fluid intake decreases viscosity of sputum, making it easier to lift and cough up.

Deficient fluid volume

associated with increased fluid loss in the presence of tachypnea, fever, or diaphoresis Desired outcome: at least 24 hours before hospital discharge, the patient is normovolemic, i.e., has a urine output of 30 mL/h or greater, stable weight, heart rate less than 100 bpm, blood pressure greater than 90 mm Hg, fluid intake equal to fluid excretion, moist mucous membranes, and normal skin turgor.

Nursing Intervention	Rationale
Assess intake and output (I&O). Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr.	This assessment monitors the trend in fluid volume. An indicator of inadequate fluid volume is a urine output of less than 30 ml/hr for 2 consecutive hours. Consider imperceptible losses if the patient is diaphoretic and tachypneic.
Weigh patient daily at same time of day and on same scale; record weight. Report weight changes of 1-1.5 kg/day.	These measures ensure consistency and accuracy of weight measurements. Weight changes of 1-1.5 kg/day may occur with fluid excess or deficit.
Promote fluid intake (at least 2.5 L/day in unrestricted patients). Maintain intravenous (IV) fluid therapy as prescribed.	These interventions contribute to adequate fluid intake.
Promote oral hygiene, including lip and tongue care.	Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit.
Provide moisture for oxygen therapy.	Moisture helps minimize convective moisture loss during oxygen therapy.