Nursing care plans for pneumonia is an important tool for nurses, to make sure the nursing care plan is based on nursing diagnosis.
What is pneumonia?
Definition of Pneumonia:
Pneumonia is an acute inflammation of the lung parenchyma (alveolar spaces and interstitial tissue) caused by bacteria and viruses. After inflammation lung tissue becomes oedematous and its space fill with exudate, gas exchange cannot occur and non-oxygenated blood is entered into the vascular system cause hypoxia.
Types of pneumonia:
- Community-acquired pneumonia
- Hospital associated (nosocomial) pneumonia
Community-acquired pneumonia: The most common type of pneumonia. Patients with community-acquired pneumonia generally do not require hospitalization unless an underlying medical condition, such as chronic obstructive pulmonary disease (COPD), cardiac disease, or diabetes mellitus, or an immunocompromised state complicates the illness.
Hospital associated (nosocomial) pneumonia: Nosocomial pneumonia generally occurs by aspiration of oropharyngeal flora or stomach contents. in an individual whose immunity is altered. three routes of aspiration of infectious content.
Gastric acid aspiration (the most common route), causing toxic injury to the lung, obstructions (foreign body or fluids), and infections (rare).
Causes of pneumonia:
- Chemical irritants Organisms such as Escherichia coli,
- Haemophilus influenza,
- Staphylococcus aureus,
- Pneumocystis jiroveci,
- Streptococcus pneumoniae,
Sign and Symptoms pneumonia:
- Fever Cough Crackles,
- Pleural friction rub on auscultation
- Pleuritic pain
- Shortness of breath,
accessory muscle use Sputum production that’s rusty, green, or bloody with pneumococcal pneumonia and yellow-green with bronchopneumonia
Diagnostic laboratory tests for pneumonia:
- Chest X-ray examination: To confirm the presence of pneumonia.
- Sputum test: for Gram stain and culture and sensitivity testing (Sputum is obtained from the lower respiratory tract prior to initiating antibiotic therapy to identify the causative organism. It may be obtained by expectoration, aspiration, transtracheal aspiration, bronchoscopy or open lung biopsy.
- White blood cell count (WBC): Will be increased (over 12,000/mm3) in the presence of bacterial pneumonias.A normal or low WBC count (less than 4,000/mm3) may be seen in viral or mycoplasma pneumonias.
- Chemistry panel:To detect the presence of hypernatremia, hyperglycemia and/or dehydration.
- Blood culture and sensitivity: To determine the presence of bacteremia and help identify the causative organism. For best performance, blood cultures should be performed prior to administration of antibiotics.
- Urinary antigen testing:To detect Legionella pneumophila and Streptococcus pneumoniae.
- Serologic studies: for acute and convalescent antibody titers drawn to diagnose viral pneumonia. A relative increase in antibody titers suggests viral infection.
- Acid-fast stains and cultures for tuberculosis.
- Oximetry: May reveal decreased O2 saturation (92% or less).
- Arterial blood gas (ABG) values: May vary, depending on the degree of pulmonary involvement or other coexisting diseases.
hypoxemia (PaO2 less than 80 mm Hg) hypocarbia (PaCO2 less than 32-35 mm Hg), with resultant respiratory alkalosis (pH greater than 7.45) in the absence of underlying lung disease. However, with increasing respiratory distress, respiratory acidosis may occur.
8 Nursing diagnosis for pneumonia
- Ineffective Airway Clearance
- Impaired Gas Exchange
- Iisk for Infection
- Activity Intolerance
- Acute Pain
- Risk for imbalanced nutrition: less than body requirements
- Risk for Deficient Fluid Volume
- Deficient Knowledge regarding condition, treatment, self-care, and discharge needs
Nursing care plans for pneumonia
Ineffective airway clearance
May Be Related To
- tracheal bronchial inflammation, oedema formation
- chronic obstructive pulmonary disease Exudate in alveoli
- Increased sputum production in response to respiratory infection
- Are energy and increase fatigue aspiration level
- Changes in respiratory rate
- Diminished/adventitious breath sounds, Dyspnea, cyanosis, Ineffective cough
- Infiltrate seen on chest x-ray film
- Respiratory Status: Airway Patency
- Identify and demonstrate behaviours to achieve airway clearance.
- Display patent airway with breath sounds clearing and absence of dyspnea and cyanosis
- The patient will maintain a clear airway with normal breath normal respiratory rate and depth of respiration.
- The patient demonstrates an effective cough. Following the intervention, the
- patient’s airway is free of adventitious breath sounds.
Nursing intervention and rationale for ineffective airway clearance (nursing care plans for pneumonia)
Auscultate breath sounds q2-4h, and report changes in the patient’s ability to clear the lungs sounds.
|This assessment find the presence of adventitious breath sounds. Coarse crackles are a sign that the patient needs to cough.Thin crackles in the lung bases are likely to disappear with deep breathing. Wheezing is a sign of obstruction. airway obstruction, which requires prompt intervention to ensure effective gas exchange.|
|Inspect the amount, odour, color and consistency of sputum; document the results. ||As the patient’s condition worsens, sputum may become more copious and change in. Wheezing is a sign of obstruction.|
airway obstruction, which requires prompt intervention to ensure effective gas exchange. to ensure effective gas exchange.
|Inspect the amount, odor, color and consistency of sputum; document the results.||As the patient’s condition worsens, sputum may become more copious and change in color more copious and change color from clear/white to yellow and/or green, or green, or may show other green, or may show other discolouration characteristics of underlying bacterial infection (e.g., rust color; “gooseberry jelly”).|
|Ensure that the patient performs deep breathing with coughing exercises for at least|
at least q2h.
|These exercises help clear the airway of secretions. Controlled coughing (tensing the upper abdominal muscles while coughing 2 to 3 times) guarantees a more effective cough because it uses the diaphragmatic muscles|
diaphragmatic muscles, which increases the force of the effort.
|Help the patient into a position of comfort, usually the semi fowler’s position. ||This position provides comfort and facilitates the ease and efficacy of these exercises by promoting better|
and efficacy of these exercises by promoting better lung expansion (there is less pulmonary less lung compression by the abdominal organs) and gas exchange.
|Evaluate the need for hyperinflation therapy||The patient’s inability to take a deep breath is a sign of the need for this therapy. Deep inhalation with a hyperinflation device expands the alveoli and helps mobilize secretions into the airway, and coughing|
coughing further mobilizes and clears secretions.
|Report complications of hyperinflation therapy to healthcare personnel.||Complications include hyperventilation, gastric distention, headache hypotension, and signs and symptoms of pneumothorax|
|Teach the patient to splint the chest with a pillow, a folded blanket or crossed arms. arms crossed.||This action reduces pain when coughing, thus promoting a more effective cough. more effective coughing.|
|Assist patient with position changes q2h. If the patient is ambulatory Encourage ambulation according to patient tolerance||Movement and activity help mobilize secretions to facilitate airway clearance of the airway.|
|Suction as prescribed and indicated.||Suctioning maintains the airway by removing secretions.|
|Instruct patients who are unable to cough effectively to cascade||Cascade coughing removes secretions and improves ventilation by means of A succession of shorter, more forceful exhalations than with the usual coughing exercise. with the usual coughing exercise.|
|Deliver oxygen with humidity as prescribed.||This intervention provides oxygenation while decreasing convective moisture losses and helps mobilize secretions.|
and helps mobilize secretions
|When not contraindicated, encourage fluid intake.||Increased hydration decreases the viscosity of sputum, thereby facilitate elevation and expectoration|
|Suction, as indicated, e.g., oxygen desaturation related to airway secretions.|
to airway secretions.
|Stimulates cough or mechanically clears the airway in a client who is unable to do so due to an ineffective cough or decreased level of consciousness.|
Force fluid intake to a minimum of 2500 mL per day, unless contraindicated, as in HF. Offer warm, rather than cold, fluids.
|Fluids, especially warm fluids, help mobilization and expectoration of secretions.|
Impaired Gas Exchange
- Collection of mucus in airway inflammation of airways and alveoli fluid-filled alveoli.
- altered oxygen supply.
- Alveolar-capillary membrane changes.
- Ventilation-perfusion imbalance.
- abnormal skin color (e.g., pale, dusky)
- Disorientation and confusion,
- Maintained temperature 37.7° C or less,
- HR 100 bpm or less,
- RR 24 breaths/ min or less,
- systolic blood pressure (SBP) 90 mm Hg or more,
- oxygen saturation more than 92%,
- ability to maintain oral intake.
Nursing intervention and rationale for Impaired Gas Exchange (nursing care plans for pneumonia)
|Monitor for symptoms of respiratory distress.||Signs and symptoms of respiratory distress include restlessness, anxiety, mental status changes, shortness of breath, tachypnea, and use of accessory breathing muscles. Respiratory distress requires prompt medical intervention.|
|Monitor oximetry readings; report O2 saturation of 92% or less.||An O2 saturation of 92% or lower is a sign of a significant oxygenation problem and may indicate the need for O2 therapy.|
|Administer oxygen as prescribed.||Oxygen is administered when O2 saturation or blood gas results show hypoxemia. Significant increases in oxygen requirements to maintain O2 saturations above 92% should be reported promptly.|
|Monitor ABG results.||Acute hypoxemia (PaO2 less than 80 mm Hg) usually indicates the need for oxygen therapy. Hypocarbia (PaCO2 less than 35 mm Hg), with resultant respiratory alkalosis (pH greater than 7.45) in the absence of underlying lung disease, is compatible with pneumonia. However, if pneumonia progresses to acute respiratory distress, acidosis will result.|
|Place the patient in a comfortable position (usually in the semi fowlers position).||This position provides comfort, promotes diaphragmatic descent, maximizes inhalations, and reduces work of breathing. Gravity and hydrostatic pressure when the patient is semi fowlers position promote perfusion and ventilation-perfusion matching. |
|Observe the color of the skin, mucous membranes and nail bed, noting the presence of peripheral cyanosis||Cyanosis of the nail beds may represent vasoconstriction or the body’s response to fever or chills; however, cyanosis of the earlobes, mucous membranes, and skin of mouth is indicative of systemic hypoxemia.|
Risk for Infection
- Inadequate primary defences.(decreased ciliary action, stasis of body fluids)
- Inadequate secondary defenses—[presence of existing infection], immunosuppression; chronic disease, malnutrition
- The patient is free of infection evidence by normal body temperature negative sputum report
- WBC count 12,000/mm3 or less, and sputum clear in color.
- Patient demonstrate hygiene measures like hand washing.
- Elevated WBC
- Positive sputum culture report
- Cough with purulent sputum
Nursing intervention and rationale for Risk for Infection(nursing care plans for pneumonia)
|Advise individuals who smoke to quit, especially during the preoperative and postoperative periods. Refer to a community smoking cessation program, as needed, or provide nicotine replacement therapy.||Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor that increases the likelihood of developing pneumonia.|
|Administer analgesics 12 hours before deep breathing exercises. Support (splint) the surgical wound with hands, pillows or a folded blanket placed firmly over the incision site.||These interventions help control pain that would otherwise interfere with lung expansion.|
|Identify patients at increased risk for aspiration.||Individuals with depressed LOC, advanced age, dysphagia, or a nasogastric or enteral tube in place are at risk for aspiration, which predisposes them to pneumonia.|
|Keep the head of the bed (HOB) at an elevation of 30 to 45 degrees and place the patient in a lateral position. When the patient is receiving enteral feedings, recommend continuous feeding rather than bolus feeding. Maintain feeding when the patient is lying down.||Aspiration is one of the leading causes of nosocomial pneumonia. Aspiration precautions include keeping the operating table at 30 degrees elevation, turning the patient to the side rather than to the back, and using continuous rather than bolus feedings when the patient is receiving enteral feedings.|
|Recognize the risk factors for infection in patients with tracheostomy and intervene as follows: – Recognize the risk factors for infection in patients with tracheostomy and intervene as follows|
intervene as follows:
|Risk factors include the presence of underlying lung disease or other serious illness, increased colonization of the oropharynx or trachea by aerobic gram-negative bacteria, increased access of bacteria to the lower respiratory tract, and cross-contamination caused by manipulation of the tracheostomy cannula.|
|Wear gloves on both hands when handling the cannula or when handling the mechanical ventilation tube.||Loss of the integrity of the skin or space around the tube would allow pathogens to enter through the wound or tube.|
|Limit visits as indicated. I Take isolation precautions that are appropriate for each case during client contact.||Reduce the likelihood of exposure to other infectious pathogens. Depending on the type of infection, response to antibiotics, general health of the client, and development of complications, isolation techniques may be instituted to prevent spread and protect the client from other infectious processes.|
|Provide tissues and garbage bags for sputum disposal.||Careful disposal of contaminated tissue reduces the transmission of microorganisms.|
- An imbalance between oxygen supply and demand
- General weakness
Possibly characterised by
- Report of weakness, fatigue, exertional dyspnea
- Abnormal heart rate response to activity
- Activity Tolerance
- Report and demonstrate a measurable increase in tolerance to activity with the absence of dyspnea and excessive fatigue, with vital signs within the client’s acceptable range.
Nursing intervention and rationale for Activity Intolerance(nursing care plans for pneumonia)
|Assess the client’s response to the activity, like dyspnea, increased weakness and fatigue, and changes in vital signs during and after activities.||Establish the client’s capabilities and needs and facilitate the choice of interventions.|
|Provide a quiet environment and limit visits during the acute phase, as indicated. Encourage the use of stress management and distraction activities, as appropriate.||Reduce stress and overstimulation by promoting rest.|
|Explain the importance of rest in the treatment plan and the need to balance activities with rest.||Bed and chair rest is continued during the acute phase to decrease metabolic demands, Subsequent activity restrictions are determined based on the client’s individual response to activity and resolution of respiratory failure.|
|To assist the client in assuming a comfortable position for rest and sleep.||Client may be comfortable with the head of the bed elevated, sleeping in a chair, or leaning forward on an over-bed table with pillow support.|
|Assist with self-care activities as necessary. during a recovery phase.||Minimizes exhaustion and helps balance oxygen supply and demand.|
Injuring agents e.g.,
- Biological—inflammation of lung parenchyma, cellular reactions to circulating toxins;
- Physical—persistent coughing
- Pleuritic chest pain,
- Joint pain
- Guarded behaviour
- Expressive behaviour—restlessness
- Pain Level
Verbalize relief of pain. Demonstrate relaxed manner, resting, sleeping, and engaging in activity appropriately.
- Patient exhibit increased comfort Sachin age best line level for HR BP and respiration and relaxed muscle tone or body posture.
Nursing intervention and rationale for Acute Pain(nursing care plans for pneumonia)
|Determine the characteristics of the pain, such as sharp, constant and stabbing. Investigate changes in character, location and intensity of pain. Monitor vital signs.||Chest pain, which is usually present to some degree with pneumonia, may also herald the onset of complications of pneumonia, such as pericarditis and endocarditis.|
|Monitor vital signs||Changes in heart rate or blood pressure (BP) may indicate that the client is experiencing pain, especially when other reasons for changes in vital signs have been ruled out.|
|Provide comfort measures, such as back massage, change of position, and quiet music or conversation. Encourage the use of relaxation and breathing exercises.||Non-analgesic measures administered with a gentle touch can decrease discomfort and enhance the therapeutic effects of analgesics. Client participation in pain control measures promotes independence and increases the sense of well-being.|
|Instruct and assist the client in chest positioning techniques during coughing episodes. ||Helps control chest discomfort and increases the effectiveness of coughing effort|
|Administer analgesics and antitussives, as indicated.||These medications may be used to suppress nonproductive or paroxysmal cough or reduce excess mucus, thereby improving|
improve overall comfort and rest.
Risk for imbalanced nutrition: less than body requirements
Nursing intervention and rationale for Risk for imbalanced nutrition: less than body requirements (nursing care plans for pneumonia)
|Provide a lidded container for sputum and replace it at frequent intervals. Assist and encourage oral hygiene after emesis, and before meals.||Removes noxious images, tastes and odours from the client’s environment and may reduce nausea.|
|Schedule breathing treatments at least one hour before meals. Auscultate bowel sounds. Observe and palpate for abdominal distention.||Reduce the effects of nausea associated with these treatments. Bowel sounds may be diminished or absent if the infectious process is severe. Abdominal distention may be caused by ingestion of air or reflect the influence of bacterial toxins in the gastrointestinal (GI) tract.|
|Provide small, frequent meals, including dry foods, such as toast or crackers, and foods that are appealing to the client. Assess overall nutritional status.||These measures may improve intake even if appetite is slow to return. Lifestyle, financial and socio-economic conditions prior to the current illness may contribute to malnutrition. patient may have a hypermetabolic state and reduced resistance to infection, which can exacerbate malnutrition and delay response to treatment.|
|Periodically weigh and graph the results.||Monitor the efficacy of nutritional therapy.|
|Assist in the treatment of the underlying disease.||May promote healing and strengthen the immune system, improve appetite and enhance|
improve appetite and increase general well-being.
|Consult dietician and nutrition team.||Develop a dietary plan individualised to the client’s specific needs and challenges.|
and challenges of the client.
Risk for Deficient Fluid Volume
- an increased insensible loss occurring with tachypnea, fever, or
- At least 24 hr before hospital discharge, the patient is normovolemic as evidenced by urine output 30 mL/hr or more.
- stable weight,
- HR less than 100 bpm,
- SBP greater than 90 mm Hg,
- fluid intake approximating fluid output,
- moist mucous membranes,
- normal skin turgor.
Nursing intervention and rationale for Risk for Deficient Fluid Volume (nursing care plans for pneumonia)
|Assess intake and voiding (I&O). Watch for urine output 30 ml/h and report it.||This assessment monitors the fluid volume trend. An indicator of poor fluid volume is urine output less than 30 mL/h for 2 consecutive hours.|
|Weigh the patient daily at the same time of day and on the same scale; record the weight. Report weight changes of 1-1.5 kg/day.||Weight changes of 1-1.5 kg/day may occur with excess or deficit fluid volume.|
|fluid intake at least 2.5 L/day in unrestricted patients. Maintain intravenous (IV) fluid therapy as prescribed.|
These actions help ensure adequate hydration.
|Promote oral hygiene, including lip and tongue care. Oral hygiene moistens dry tissues and mucous membranes in patients with fluid volume deficits.||Provide humidity for oxygen therapy. Moisture helps minimize convective moisture losses during oxygen therapy.|
Deficient Knowledge regarding condition, treatment, self-care, and discharge needs
- Lack of exposure.
- Information misinterpretation.
- Lack of recall.
- Reports the problem.
- Inaccurate follow-through of instructions.
- Knowledge: Pneumonia Management.
- Verbalize understanding of the condition, disease process, and prognosis.
- Verbalize understanding of therapeutic regimen.
- Initiate necessary lifestyle changes.
- Participate in the treatment program.
Nursing intervention and rationale for Deficient Knowledge regarding condition,treatment, self-care, and discharge needs (nursing care plans for pneumonia)
|Determine patients’ understanding of the complication of pneumonia and its treatment.||This information is an important starting point for education.|
|Teach those present deep breathing exercises and effective coughing techniques.||These techniques facilitate the clearance of sections and prevent atelectasis.|
|Discuss with the patient or caregiver the need to complete the full course of antibiotics as prescribed and adequate rest for recovery.||A full course of antibiotics is necessary to prevent substitution due to the development of resistant organisms. A prolonged period of convalescence may be necessary for elderly patients.|
|Provide information on the need to do the following.|
1. Maintain natural resistance to infection through proper nutrition, rest and exercise.
2. Avoid contact with persons with upper respiratory infections.
3. Open a chest X-ray examination 2 weeks after completion of therapy.
4. Re-vaccinate the elderly and chronically ill against influenza.
|These are preventive measures to reduce disease recurrence and promote a healthy immune system.|
|Provide smoking cessation and counseling as indicated.||One of the national patient safety goals is to provide smoking cessation counseling to patients while they are hospitalized.|
Disclaimer : this post is only for education purposes only and is not intended as medical advice and any treatment. while we strive for 100% accuracy but error may occur, and medication or protocols can change over time.