Nursing Care Plans OF Pneumonia

1. Ineffective Airway Clearance

Nursing Diagnosis

Ineffective Airway Clearance

May be related to

Tracheal bronchial inflammation, edema formation, increased sputum production

Pleuritic pain

Decreased energy, fatigue

Possibly evidenced by

Changes in rate, depth of respirations

Abnormal breath sounds, use of accessory muscles

Dyspnea, cyanosis

Cough, effective or ineffective; with/without sputum production

Desired Outcomes

Identify/demonstrate behaviors to achieve airway clearance.

Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis.

Nursing Interventions

Rationale

Assess the rate and depth of respirations

Tachypnea, shallow respirations, and

and chest movement.

asymmetric chest movement are frequently

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present because of discomfort of moving
chest wall and/or fluid in lung.
Decreased airflow occurs in areas with

Auscultate lung fields, noting areas of

decreased or absent airflow and
adventitious breath sounds: crackles,
wheezes.

consolidated fluid. Bronchial breath sounds

can also occur in these consolidated areas.
Crackles, rhonchi, and wheezes are heard
on inspiration and/or expiration in response
to fluid accumulation, thick secretions, and
airway spams and obstruction.
Doing so would lower the diaphragm and

Elevate head of bed, change position

promote chest expansion, aeration of lung

frequently.

segments, mobilization and expectoration

of secretions.
Deep breathing exercises facilitates

Teach and assist patient with proper deepbreathing exercises. Demonstrate proper
splinting of chest and effective coughing
while in upright position. Encourage him to
do so often.

maximum expansion of the lungs and

smaller airways. Coughing is a reflex and a
natural self-cleaning mechanism that
assists the cilia to maintain patent airways.
Splinting reduces chest discomfort and an
upright position favors deeper and more
forceful cough effort.

Suction as indicated: frequent coughing,

adventitious breath sounds, desaturation
related to airway secretions.

Stimulates cough or mechanically clears

airway in patient who is unable to do so
because of ineffective cough or decreased
level of consciousness.

Force fluids to at least 3000 mL/day (unless

Fluids, especially warm liquids, aid in

contraindicated, as in heart failure). Offer

mobilization and expectoration of

warm, rather than cold, fluids.

secretions.

Assist and monitor effects of nebulizer

Nebulizers and other respiratory therapy

treatment and other respiratory

facilitates liquefaction and expectoration of

physiotherapy: incentive spirometer, IPPB,

secretions. Postural drainage may not be

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Nursing Interventions

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as effective in interstitial pneumonias or

percussion, postural drainage. Perform

those causing alveolar exudate or

treatments between meals and limit fluids

destruction. Coordination of treatments and

when appropriate.

oral intake reduces likelihood of vomiting

with coughing, expectorations.
Aids in reduction of bronchospasm and

Administer medications as indicated:

mucolytics, expectorants, bronchodilators,
analgesics.

mobilization of secretions. Analgesics are

given to improve cough effort by reducing
discomfort, but should be used cautiously
because they can decrease cough effort
and depress respirations.
Room humidification has been found to

Provide supplemental fluids: IV.

provide minimal benefit and is thought to

increase the risk of transmitting infection.
Followers progress and effects of the

Monitor serial chest x-rays, ABGs, pulse

disease process, therapeutic regimen, and

oximetry readings.

may facilitate necessary alterations in

therapy.

Assist with bronchoscopy and/or

thoracentesis, if indicated.
Urge all bedridden and postoperative
patients to perform deep breathing and
coughing exercises frequently.

2. Impaired Gas Exchange

Nursing Diagnosis

Impaired Gas Exchange

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Occasionally needed to remove mucous

plugs, drain purulent secretions, and/or
prevent atelectasis.
To promote full aeration and drainage of
secretions.

May be related to

Alveolar-capillary membrane changes (inflammatory effects)

Altered oxygen-carrying capacity of blood/release at cellular level (fever, shifting

oxyhemoglobin curve)

Altered delivery of oxygen (hypoventilation)

Possibly evidenced by

Dyspnea, cyanosis

Tachycardia

Restlessness/changes in mentation

Hypoxia

Desired Outcomes

Demonstrate improved ventilation and oxygenation of tissues by ABGs within

patients acceptable range and absence of symptoms of respiratory distress.

Participate in actions to maximize oxygenation.

Nursing Interventions

Rationale
Manifestations of respiratory distress are

Assess respiratory rate, depth, and ease.

dependent on/and indicative of the degree

of lung involvement and underlying general
health status.
Cyanosis of nail beds may represent

Observe color of skin, mucous membranes,

vasoconstriction or the bodys response to

and nailbeds, noting presence of peripheral

fever/chills; however, cyanosis of earlobes,

cyanosis (nail beds) or central cyanosis

mucous membranes, and skin around the

(circumoral).

mouth (warm membranes) is indicative of

systemic hypoxemia.

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Nursing Interventions

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Restlessness, irritation, confusion, and

Assess mental status.

somnolence may reflect hypoxemia and

decreased cerebral oxygenation.
Tachycardia is usually present as a result of

Monitor heart rate and rhythm.

fever and/or dehydration but may represent

a response to hypoxemia.

Monitor body temperature, as indicated.

Assist with comfort measures to reduce
fever and chills: addition or removal of
bedcovers, comfortable room temperature,
tepid or cool water sponge bath.

High fever (common in bacterial pneumonia

and influenza) greatly increases metabolic
demands and oxygen consumption and
alters cellular oxygenation.

Maintain bedrest. Encourage use of

Prevents over exhaustion and reduces

relaxation techniques and diversional

oxygen demands to facilitate resolution of

activities.

infection.

Elevate head and encourage frequent

These measures promote maximum chest

position changes, deep breathing, and

expansion, mobilize secretions and improve

effective coughing.

ventilation.
Anxiety is a manifestation of psychological
concerns and physiological responses to

Assess anxiety level and encourage

verbalization of feelings and concerns.

hypoxia. Providing reassurance and

enhancing sense of security can reduce the
psychological component, thereby
decreasing oxygen demand and adverse
physiological responses.

Observe for deterioration in condition,

Shock and pulmonary edema are the most

noting hypotension, copious amounts of

common causes of death in pneumonia

bloody sputum, pallor, cyanosis, change in

and require immediate medical

LOC, severe dyspnea, and restlessness.

intervention.

Monitor ABGs, pulse oximetry.

Administer oxygen therapy by appropriate
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Follows progress of disease process and

facilitates alterations in pulmonary therapy.
The purpose of oxygen therapy is to

Nursing Interventions

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maintain PaO2 above 60 mmHg. Oxygen is
administered by the method that provides

means: nasal prongs, mask, Venturi mask.

appropriate delivery within the patients

tolerance. Note: Patients with underlying
chronic lung diseases should be given
oxygen cautiously.

3. Risk for Deficient Fluid Volume

Nursing Diagnosis

Risk for Deficient Fluid Volume

Risk factors may include

Excessive fluid loss (fever, profuse diaphoresis, mouth breathing/hyperventilation,

vomiting)

Decreased oral intake

Desired Outcomes

Demonstrate fluid balance evidenced by individually appropriate parameters, e.g.,

moist mucous membranes, good skin turgor, prompt capillary refill, stable vital signs.

Nursing Interventions

Rationale
Elevated temperature and prolonged fever

Assess vital sign changes: increasing

increases metabolic rate and fluid loss

temperature, prolonged fever, orthostatic

through evaporation. Orthostatic BP

hypotension, tachycardia.

changes and increasing tachycardia may

indicate systemic fluid deficit.

Assess skin turgor, moisture of mucous

Indirect indicators of adequacy of fluid

membranes.

volume, although oral mucous membranes

may be dry because of mouth breathing

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and supplemental oxygen.

Investigate reports of nausea and vomiting.

Presence of these symptoms reduces oral

intake.

Monitor intake and output (I&O), noting

color, character of urine. Calculate fluid

Provides information about adequacy of

balance. Be aware of insensible losses.

fluid volume and replacement needs.

Weigh as indicated.
Force fluids to at least 3000 mL/day or as
individually appropriate.
Administer medications as indicated:
antipyretics, antiemetics.
Provide supplemental IV fluids as
necessary.

Meets basic fluid needs, reducing risk of

dehydration and to mobilize secretions and
promote expectoration.
To reduce fluid losses.
In presence of reduced intake and/or
excessive loss, use of parenteral route may
correct deficiency.

4. Risk for Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis

Risk for Imbalanced Nutrition Less Than Body Requirements

Risk factors may include

Increased metabolic needs secondary to fever and infectious process

Anorexia associated with bacterial toxins, the odor and taste of sputum, and certain
aerosol treatments

Abdominal distension/gas associated with swallowing air during dyspneic episodes

Desired Outcomes

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Demonstrate increased appetite.

Maintain/regain desired body weight.

Nursing Interventions
Identify factors that are contributing to
nausea or vomiting: copious sputum,
aerosol treatments, severe dyspnea, pain.

Rationale
Choice of interventions depends on the
underlying cause of the problem.

Provide covered container for sputum and

remove at frequent intervals. Assist and

Eliminates noxious sights, tastes, smells

encourage oral hygiene after emesis, after

from the patient environment and can

aerosol and postural drainage treatments,

reduce nausea.

and before meals.

Schedule respiratory treatments at least 1

Reduces effects of nausea associated with

hr before meals.

these treatments.

Maintain adequate nutrition to offset

hypermetabolic state secondary to
infection. Ask the dietary department to

To replenish lost nutrients.

provide a high-calorie, high-protein diet

consisting of soft, easy-to-eat foods.
Consider limiting use of milk products

Milk products may increase sputum

production.
To prevent aspiration. Note: Dont give

Elevate the patients head and neck, and

large volumes at one time; this could cause

check for tubes position during NG tube

vomiting. Keep the patients head elevated

feedings.

for at least 30 minutes after feeding. Check

for residual formula regular intervals.
Bowel sounds may be diminished if the
infectious process is severe. Abdominal

Auscultate for bowel sounds. Observe for

distension may occur as a result of air

abdominal distension.

swallowing or reflect the influence of

bacterial toxins on the gastrointestinal (GI)
tract.

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Nursing Interventions
Provide small, frequent meals, including
dry foods (toast, crackers) and/or foods
that are appealing to patient.

Rationale
These measures may enhance intake even
though appetite may be slow to return.
Presence of chronic conditions (COPD or

Evaluate general nutritional state, obtain

baseline weight.

alcoholism) or financial limitations can

contribute to malnutrition, lowered
resistance to infection, and/or delayed
response to therapy.

5. Acute Pain
Nursing Diagnosis

Acute Pain

May be related to

Inflammation of lung parenchyma

Cellular reactions to circulating toxins

Persistent coughing

Possibly evidenced by

Reports of pleuritic chest pain, headache, muscle/joint pain

Guarding of affected area

Distraction behaviors, restlessness

Desired Outcomes

Verbalize relief/control of pain.

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Demonstrate relaxed manner, resting/sleeping and engaging in activity appropriately.

Nursing Interventions
Assess pain characteristics: sharp,
constant, stabbing. Investigate changes in
character, location, or intensity of pain.

Rationale
Chest pain, usually present to some degree
with pneumonia, may also herald the onset
of complications of pneumonia, such as
pericarditis and endocarditis.
Changes in heart rate or BP may indicate

Monitor vital signs.

that patient is experiencing pain, especially

when other reasons for changes in vital
signs have been ruled out.
Non-analgesic measures administered with

Provide comfort measures: back rubs,

a gentle touch can lessen discomfort and

position changes, quite music, massage.

augment therapeutic effects of analgesics.

Encourage use of relaxation and/or

Patient involvement in pain control

breathing exercises.

measures promotes independence and

enhances sense of well-being.
Mouth breathing and oxygen therapy can

Offer frequent oral hygiene.

irritate and dry out mucous membranes,

potentiating general discomfort.

Instruct and assist patient in chest splinting

Aids in control of chest discomfort while

techniques during coughing episodes.

enhancing effectiveness of cough effort.

These medications may be used to

Administer analgesics and antitussives as

suppress non productive cough or reduce

indicated.

excess mucus, thereby enhancing general

comfort.

6. Activity Intolerance

Nursing Diagnosis

Activity intolerance

May be related to

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Imbalance between oxygen supply and demand

General weakness

Exhaustion associated with interruption in usual sleep pattern because of discomfort,

excessive coughing, and dyspnea

Possibly evidenced by

Verbal reports of weakness, fatigue, exhaustion

Exertional dyspnea, tachypnea

Tachycardia in response to activity

Development/worsening of pallor/cyanosis

Desired Outcomes

Report/demonstrate a measurable increase in tolerance to activity with absence of

dyspnea and excessive fatigue, and vital signs within patients acceptable range.

Nursing Interventions

Rationale

Determine patients response to activity.

Note reports of dyspnea, increased

Establishes patients capabilities and needs

weakness and fatigue, changes in vital

and facilitates choice of interventions.

signs during and after activities.

Provide a quiet environment and limit
visitors during acute phase as indicated.

Reduces stress and excess stimulation,

Encourage use of stress management and

promoting rest

diversional activities as appropriate.

Explain importance of rest in treatment plan

Bedrest is maintained during acute phase

and necessity for balancing activities with

to decrease metabolic demands, thus

rest.

conserving energy for healing. Activity

restrictions thereafter are determined by
individual patient response to activity and

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resolution of respiratory insufficiency.
Patient may be comfortable with head of

Assist patient to assume comfortable

bed elevated, sleeping in a chair, or leaning

position for rest and sleep.

forward on overbed table with pillow

support.

Assist with self-care activities as

necessary. Provide for progressive

Minimizes exhaustion and helps balance

increase in activities during recovery

oxygen supply and demand.

phase. and demand.

7. Risk for Infection

Nursing Diagnosis

Risk for [Spread] of Infection

Risk factors may include

Inadequate primary defenses (decreased ciliary action, stasis of respiratory

secretions)

Inadequate secondary defenses (presence of existing infection,

immunosuppression), chronic disease, malnutrition

Desired Outcomes

Achieve timely resolution of current infection without complications.

Identify interventions to prevent/reduce risk/spread of/secondary infection.

Nursing Interventions

Rationale

Monitor vital signs closely, especially during

During this period of time, potentially fatal

initiation of therapy.

complications (hypotension, shock) may

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develop.
Although patient may find expectoration

Instruct patient concerning the disposition

offensive and attempt to limit or avoid it, it is

of secretions: raising and expectorating

essential that sputum be disposed of in a

versus swallowing; and reporting changes

safe manner. Changes in characteristics of

in color, amount, odor of secretions.

sputum reflect resolution of pneumonia or

development of secondary infection.

Demonstrate and encourage good hand

Effective means of reducing spread or

washing technique.

acquisition of infection.

Change position frequently and provide

Promotes expectoration, clearing of

good pulmonary toilet.

infection.

Limit visitors as indicated.

Reduces likelihood of exposure to other

infectious pathogens.
Dependent on type of infection, response to

Institute isolation precautions as

individually appropriate.

antibiotics, patients general health, and

development of complications, isolation
techniques may be desired to prevent
spread from other infectious processes.

Encourage adequate rest balanced with

moderate activity. Promote adequate
nutritional intake.

Facilitates healing process and enhances

natural resistance.

Monitor effectiveness of antimicrobial

Signs of improvement in condition should

therapy.

occur within 2448 hr. Note any changes.

Investigate sudden change in condition,

such as increasing chest pain, extra heart
sounds, altered sensorium, recurring fever,
changes in sputum characteristics.

Delayed recovery or increase in severity of

symptoms suggests resistance to
antibiotics or secondary infection.

Prepare and assist with diagnostic studies

Fiberoptic bronchoscopy (FOB) may be

as indicated.

done in patients who do not respond

rapidly (within 13 days) to antimicrobial
therapy to clarify diagnosis and therapy

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needs.

8. Deficient Knowledge
Nursing Diagnosis

Deficient Knowledge regarding condition, treatment, self-care, and discharge needs

May be related to

Lack of exposure

Misinterpretation of information

Altered recall

Possibly evidenced by

Requests for information; statement of misconception

Failure to improve/recurrence

Desired Outcomes

Verbalize understanding of condition, disease process, and prognosis.

Verbalize understanding of therapeutic regimen.

Initiate necessary lifestyle changes.

Participate in treatment program.

Nursing Interventions

Rationale

Review normal lung function, pathology of

Promotes understanding of current

condition.

situation and importance of cooperating

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with treatment regimen.
Information can enhance coping and help
reduce anxiety and excessive concern.

Discuss debilitating aspects of disease,

Respiratory symptoms may be slow to

length of convalescence, and recovery

resolve, and fatigue and weakness can

expectations. Identify self-care and

persist for an extended period. These

homemaker needs.

factors may be associated with depression

and the need for various forms of support
and assistance.

Provide information in written and verbal

form.

Fatigue and depression can affect ability to

assimilate information and follow
therapeutic regimen.

Reinforce importance of continuing

During initial 68 wk after discharge,

effective coughing and deep-breathing

patient is at greatest risk for recurrence of

exercises.

pneumonia.
Early discontinuation of antibiotics may

Emphasize necessity for continuing

result in failure to completely resolve

antibiotic therapy for prescribed period.

infectious process and may cause

recurrence or rebound pneumonia.
Smoking destroys tracheobronchial ciliary

Review importance of cessation of

smoking.

action, irritates bronchial mucosa, and

inhibits alveolar macrophages,
compromising bodys natural defense
against infection.

Outline steps to enhance general health

and well-being: balanced rest and activity,
well-rounded diet, avoidance of crowds
during cold/flu season and persons with

Increases natural defense, limits exposure

to pathogens.

URIs.
Stress importance of continuing medical

May prevent recurrence of pneumonia

follow-up and obtaining vaccinations as

and/or related complications.

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Nursing Interventions

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appropriate.
Identify signs and symptoms requiring
notification of health care provider:
increasing dyspnea, chest pain, prolonged

Prompt evaluation and timely intervention

fatigue, weight loss, fever, chills,

may prevent complications.

persistence of productive cough, changes

in mentation.
This may results in upper airway
Instruct patient to avoid using antibiotics
indiscriminately during minor viral
infections.

colonization with antibiotic resistant

bacteria. If the patient then develops
pneumonia, the organisms producing the
pneumonia may require treatment with
more toxic antibiotics.

Encourage pneumovax and annual flu

shots for high-risk patients.

To help prevent occurrence of the disease.

Other Possible Nursing Care Plans

Impaired dentitionmay be related to dietary habits, poor oral hygiene, chronic

vomiting, possibly evidenced by erosion of tooth enamel, multiple caries, abraded
teeth.

Impaired oral mucous membranemay be related to malnutrition or vitamin

deficiency, poor oral hygiene, chronic vomiting, possibly evidenced by sore, inflamed
buccal mucosa, swollen salivary glands, ulcerations, and reports of sore mouth
and/or throat.

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