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BRONCHOPNEUMONIA

In this guide are pneumonia nursing care plans and nursing diagnosis, nursing
interventions and nursing assessment for pneumonia. Nursing interventions for
pneumonia and care plan goals for patients with pneumonia include measures to assist
in effective coughing, maintain a patent airway, decreasing viscosity and
tenaciousness of secretions, and assist in suctioning.

Pneumonia is an inflammation of the lung parenchyma, associated with alveolar


edema and congestion that impair gas exchange. Pneumonia is caused by a bacterial or
viral infection that is spread by droplets or by contact and is the sixth leading cause of
death in the United States.

The prognosis is typically good for people who have normal lungs and adequate host
defenses before the onset of pneumonia. Pneumonia is a particular concern in high-
risk patients: persons who are very young or very old, people who smoke, bedridden,
malnourished, hospitalized, immunocompromised, or exposed to MRSA.

Types of Pneumonia

There are two types of pneumonia: community-acquired pneumonia (CAP), or


hospital-acquired pneumonia (HAP) or also known as nosocomial pneumonia.

Pneumonia may also be classified depending on its location and radiologic


appearance. Bronchopneumonia (bronchial pneumonia) involves the
terminal bronchioles and alveoli. Interstitial (reticular) pneumonia involves
inflammatory response within lung tissue surrounding the air spaces or vascular
structures rather than the area passages themselves. Alveolar (or acinar)
pneumonia involves fluid accumulation in the lung’s distal air spaces. Necrotizing
pneumonia causes the death of a portion of lung tissue surrounded by a viable tissue.

Pneumonia is also classified based on its microbiologic etiology – they can be viral,
bacterial, fungal, protozoan, mycobacterial, mycoplasmal, or rickettsial in origin.
Aspiration pneumonia, another type of pneumonia, results from vomiting
and aspiration of gastric or oropharyngeal contents into the trachea and lungs.

Signs and Symptoms

The main symptoms of pneumonia are coughing, sputum production, pleuritic chest
pain, shaking chills, rapid shallow breathing, fever, and shortness of breath. If left
untreated, pneumonia could complicate to hypoxemia, respiratory failure, pleural
effusion, empyema, lung abscess, and bacteremia.

Nursing care plan (NCP) and care management for patients with pneumonia start with
an assessment of the patient’ medical history, performing respiratory assessment every
four (4) hours, physical examination, and ABG measurements. Supportive
interventions include oxygen therapy, suctioning, coughing, deep breathing, adequate
hydration, and mechanical ventilation. Other nursing interventions are detailed on the
nursing diagnoses in the subsequent sections.

Ineffective Airway Clearance is a common NANDA nursing diagnosis for


pneumonia nursing care plans. This diagnosis is related to excessive secretions and
ineffective cough or nonproductive coughing. Inflammation and increased secretions
in pneumonia make it difficult to maintain a patent airway.

Nursing Diagnosis

 Ineffective Airway Clearance. Inability to clear secretions or obstructions


from the respiratory tract to maintain a clear airway.

Related Factors

The following are the common related factors for the nursing diagnosis Ineffective
Airway Clearance related to pneumonia:

 Tracheal bronchial inflammation, edema formation, increased sputum


production
 Pleuritic pain
 Decreased energy, fatigue
 Aspiration

Defining Characteristics

Here are the common assessment cues that could serve as defining characteristics or
“as evidenced by” for ineffective airway clearance secondary to pneumonia.

 Changes in rate, depth of respirations


 Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
 Use of accessory muscles
 Dyspnea, tachypnea
 Cough, effective or ineffective; with/without sputum production
 Cyanosis
 Decreased breath sounds over affected lung areas
 Ineffective cough
 Purulent sputum
 Hypoxemia
 Infiltrates seen on chest x-ray film

Desired Outcomes

Below are the common expected outcomes for ineffective airway clearance secondary
to pneumonia:

 Patient will identify/demonstrate behaviors to achieve airway clearance.


 Patient will display/maintain patent airway with breath sounds clearing;
absence of dyspnea, cyanosis, as evidenced by keeping a patent airway and
effectively clearing secretions.

Nursing Interventions and Rationale

In this section are the ineffective airway clearance nursing interventions and actions
for pneumonia together with its rationales or scientific explanations. The following
nursing assessment for pneumonia and nursing interventions are measures to promote
airway patency, increase fluid intake, and teaching and encouraging effective cough
and deep-breathing techniques.

Nursing Interventions Rationale

Assessment

Tachypnea, shallow respirations and


asymmetric chest movement are frequently
present because of discomfort of moving chest
Assess the rate, rhythm, and depth of
wall and/or fluid in lung due to a compensatory
respiration, chest movement, and use of
response to airway obstruction. Altered
accessory muscles.
breathing pattern may occur together with use
of accessory muscles to increase chest
excursion to facilitate effective breathing.

Coughing is the most effective way to remove


Assess cough effectiveness and productivity secretions. Pneumonia may cause thick and
tenacious secretions to patients.

Decreased airflow occurs in areas with


consolidated fluid. Bronchial breath sounds can
Auscultate lung fields, noting areas of also occur in these consolidated areas.
decreased or absent airflow and adventitious Crackles, rhonchi, and wheezes are heard
breath sounds: crackles, wheezes. on inspirationand/or expiration in response to
fluid accumulation, thick secretions, and
airway spasms and obstruction.

Changes in sputum characteristics may indicate


Observe the sputum color, viscosity, and odor. infection. Sputum that is discolored, tenacious,
Report changes. or has an odor may increase airway resistance
and may warrant further intervention.

Airway clearance is hindered with inadequate


Assess the patient’s hydration status.
hydration and thickening of secretions.

Therapeutic Interventions

Elevate head of bed, change position Doing so would lower the diaphragm and
frequently. promote chest expansion, aeration of lung
segments, mobilization and expectoration of
Nursing Interventions Rationale

secretions.

 Deep breathing exercises facilitates


maximum expansion of the lungs and
smaller airways, and improves the
productivity of cough.
 Coughing is a reflex and a natural
Teach and assist patient with proper deep-
breathing exercises. Demonstrate proper self-cleaning mechanism that assists
splinting of chest and effective coughing while the cilia to maintain patent airways. It
in upright position. Encourage him to do so
often. is the most helpful way to remove
most secretions.
 Splinting reduces chest discomfort
and an upright position favors deeper
and more forceful cough effort
making it more effective.

Stimulates cough or mechanically clears airway


in patient who is unable to do so because of
Suction as indicated: frequent coughing,
ineffective cough or decreased level of
adventitious breath sounds, desaturation related
consciousness. Note: Suctioning can cause
to airway secretions.
increased hypoxemia; hyper oxygenate before,
during, and after suctioning.
Fluids, especially warm liquids, aid in
Maintain adequate hydration by forcing fluids mobilization and expectoration of secretions.
to at least 3000 mL/day unless contraindicated Fluids help maintain hydration and increases
(e.g., heart failure). Offer warm, rather than ciliary action to remove secretions and reduces
cold, fluids. the viscosity of secretions. Thinner secretions
are easier to cough out.
 Nebulizers humidify the airway to
Assist and monitor effects of nebulizer
treatment and other respiratory physiotherapy: thin secretions and facilitates
incentive spirometer, IPPB, percussion, liquefaction and expectoration of
postural drainage.
secretions.
Perform treatments between meals and limit
 Postural drainage may not be as
fluids when appropriate.
effective in interstitial pneumonias or
those causing alveolar exudate or
Nursing Interventions Rationale

destruction.
 Incentive spirometry serves to
improve deep breathing and helps
prevent atelectasis.
 Chest percussion helps loosen and
mobilize secretions in smaller
airways that cannot be removed by
coughing or suctioning.
 Coordination of treatments and oral
intake reduces likelihood of vomiting
with coughing, expectorations.

Helps mobilize secretions and reduces


Encourage ambulation.
atelectasis.
 Mucolytics increase or liquefy
respiratory secretions.
 Expectorants increase productive
cough to clear the airways. They
Administer medications as indicated: liquefy lower respiratory tract
secretions by reducing its viscosity.
 mucolytics  Bronchodilators are medications
 expectorants used to facilitate respiration by
 bronchodilators dilating the airways.
 analgesics  Analgesics are given to improve
cough effort by reducing discomfort,
but should be used cautiously
because they can decrease cough
effort and depress respirations.

Increasing the humidity will decrease the


Use humidified oxygen or humidifier at
viscosity of secretions. Clean the humidifier
bedside.
before use to avoid bacterial growth.
Monitor serial chest x-rays, ABGs, pulse Follows progress and effects and extent of
Nursing Interventions Rationale

oximetry readings. pneumonia. Therapeutic regimen, and may


facilitate necessary alterations in therapy.
Oxygen saturation should be maintain at 90%
or greater. Imbalances in PaCO2 and PaO2
may indicate respiratory fatigue.
Bronchoscopy is occasionally needed to
remove mucous plugs, drain purulent
secretions, obtain lavage samples for culture
Assist with bronchoscopy and/or thoracentesis, and sensitivity.
if indicated. Thoracentesis is done to drain associated
pleural effusions and prevent atelectasis.

These measures are needed to correct


Anticipate the need for supplemental oxygen or hypoxemia. Intubation is needed for deep
intubation if patient’s condition deteriorates. suctioning efforts and provide a source for
augmenting oxygenation.
Urge all bedridden and postoperative patients
To promote full aeration and drainage of
to perform deep breathing and coughing
secretions.
exercises frequently.

This nursing diagnosis for pneumonia nursing care plans is usually written
as Impaired Gas Exchange related to retained secretions and inflammatory
pulmonary.

Nursing Diagnosis

 Impaired Gas Exchange: excess or deficit in oxygenation and/or carbon


dioxide elimination at the alveolar-capillary membrane.

Related Factors

The following are the common related factors for impaired gas exchange related to
pneumonia:

 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)
 Collection of mucus in airways
 Inflammation of airways and alveoli
 Fluid-filled alveoli

Defining Characteristics

The common assessment cues that could serve as defining characteristics or part of
your “as evidenced by” in your diagnostic statement.

 Dyspnea, Tachypnea
 Pale, dusky, skin color
 Cyanosis
 Tachycardia
 Restlessness, irritability, changes in mentation
 Hypoxemia
 Hypotension
 Disorientation

Desired Outcomes

Common expected outcomes for the nursing diagnosis impaired gas


exchange secondary to pneumonia:

 Patient will demonstrate improved ventilation and oxygenation of tissues by


ABGs within patient’s acceptable range and absence of symptoms of
respiratory distress.
 Patient will maintain optimal gas exchange.
 Patient will participate in actions to maximize oxygenation.

Nursing Interventions and Rationales


Here are the nursing interventions and rationales to address the nursing diagnosis
impaired gas exchange secondary to pneumonia. They are mostly measures to
maintain oxygen saturations above 90%.

Nursing Interventions Rationale

Assessment

Manifestations of respiratory distress are


dependent on/and indicative of the degree of
lung involvement and underlying general
health status as patients will adapt their
breathing patterns to facilitate effective gas
Assess respirations: note quality, rate, rhythm, exchange.
depth, use of accessory muscles, ease, and
position assumed for easy breathing. Rapid, shallow breathing patterns and
hypoventilation directly affects gas exchange.
Hypoxia is associated with signs of increased
breathing effort. Tripod positioning is an
evidence of significant dyspnea.

As oxygenation and perfusion become


impaired, peripheral tissues become cyanotic.
Observe color of skin, mucous membranes, Cyanosis of nail beds may represent
and nail beds, noting presence of peripheral vasoconstriction or the body’s response to
cyanosis (nail beds) or central cyanosis fever/chills; however, cyanosis of earlobes,
(circumoral). mucous membranes, and skin around
the mouth(“warm membranes”) is indicative of
systemic hypoxemia.

Restlessness, irritation, confusion, and


somnolence may reflect hypoxemia and
Assess mental status, restlessness, and changes decreased cerebral oxygenation and may
in level of consciousness. require further intervention. Check pulse
oximetry results with any mental status
changes in older adults.

Assess anxiety level and encourage Anxiety is a manifestation of psychological


Nursing Interventions Rationale

verbalization of feelings and concerns. concerns and physiological responses to


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

Tachycardia is usually present as a result of


fever and/or dehydration but may represent a
response to hypoxemia. Initial hypoxia and
Monitor heart rate and rhythm and blood
hypercapnia increases BP and HR. As hypoxia
pressure.
becomes more severe, BP may drop while HR
tends to continue to be rapid with
dysrhythmias.

Monitor body temperature, as indicated. Assist


High fever (common in bacterial pneumonia
with comfort measures to reduce fever and
and influenza) greatly increases metabolic
chills: addition or removal of bedcovers,
demands and oxygen consumption and alters
comfortable room temperature, tepid or cool
cellular oxygenation.
water sponge bath.

Observe for deterioration in condition,


Shock and pulmonary edema are the most
noting hypotension, copious amounts of bloody
common causes of death in pneumonia and
sputum, pallor, cyanosis, change in LOC,
require immediate medical intervention.
severe dyspnea, and restlessness.

Follows progress of disease process and


facilitates alterations in pulmonary therapy.
Monitor ABGs, pulse oximetry.
Pulse oximetry detects changes in oxygenation.
O2 sats should be at 90% or greater.

Therapeutic Interventions

Prevents over exhaustion and reduces oxygen


Maintain bedrest by planning activity and rest
demands to facilitate resolution of infection.
periods to minimize energy use. Encourage use
Relaxation techniques helps conserve energy
of relaxation techniques and diversional
that can be used for effective breathing and
activities.
coughing efforts.

Elevate head and encourage frequent position These measures promote maximum chest
Nursing Interventions Rationale

changes, deep breathing, and effective expansion, mobilize secretions and improve
coughing. ventilation.

The purpose of oxygen therapy is to maintain


PaO2 above 60 mmHg. Oxygen is administered
Administer oxygen therapy by appropriate by the method that provides appropriate
means: nasal prongs, mask, Venturi mask. delivery within the patient’s tolerance. Note:
Patients with underlying chronic lung diseases
should be given oxygen cautiously.

3. Ineffective Breathing Pattern


In this case, the nursing diagnosis Ineffective Breathing Pattern is related to
compensatory tachypnea due to an inability to meet metabolic demands. It is
experienced by many clients with pneumonia. Changes in breathing pattern occur
because affected alveoli cannot effectively exchange oxygen and carbon dioxide, as a
result of chest pain, and increased body temperature.

Nursing Diagnosis

 Ineffective Breathing Pattern: Inspiration and/or expiration that does not


provide adequate ventilation.

Related Factors

Common related factors for ineffective breathing pattern:

 Alteration of patient’s O2/CO2 ratio


 Anxiety
 Hypoxia
 Decreased lung expansion
 Inflammatory process
 Pain
Defining Characteristics

The common assessment cues that could serve as defining characteristics or part of
your “as evidenced by” in your diagnostic statement.

 Changes in rate, depth of respirations


 Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
 Use of accessory muscles
 Dyspnea, tachypnea
 Cough, effective or ineffective; with/without sputum production
 Cyanosis
 Decreased breath sounds over affected lung areas
 Ineffective cough
 Purulent sputum
 Hypoxemia
 Infiltrates seen on chest x-ray film
 Reduced vital capacity

Desired Outcomes

Common goals and outcomes for ineffective breathing pattern:

 Patient maintains an effective breathing pattern, as evidenced by relaxed


breathing at normal rate and depth and absence of dyspnea.
 Patient’s respiratory rate remains within established limits.

Nursing Interventions and Rationales

The following are nursing actions to address ineffective breathing pattern. These
interventions include: positioning the client to facilitate effective breathing (raising
head of bed to 45 degrees), teaching how to splint chest wall with a pillow, and use of
incentive spirometry.

Nursing Interventions Rationales


Assessment

The average rate of respiration for adults is 10 to


20 breaths per minute. It is important to take
Assess and record respiratory rate and depth
action when there is an alteration in the pattern of
at least every 4 hours.
breathing to detect early signs of respiratory
compromise.

Assess ABG levels, according to facility


This monitors oxygenation and ventilation status.
policy.

Unusual breathing patterns may imply an


underlying disease process or dysfunction.
Cheyne-Stokes respiration signifies bilateral
dysfunction in the deep cerebral or diencephalon
Observe for breathing patterns.
related with brain injury or metabolic
abnormalities. Apneusis and ataxic breathing are
related with failure of the respiratory centers in
the pons and medulla.

Auscultate breath sounds at least every four This is to detect decreased or adventitious breath
(4) hours. sounds.

Work of breathing increases greatly as lung


Assess for use of accessory muscle.
compliance decreases.

Paradoxical movement of the abdomen (an


Monitor for diaphragmatic muscle fatigue or inward versus outward movement during
weakness (paradoxical motion). inspiration) is indicative of respiratory muscle
fatigue and weakness.

These signs signify an increase in respiratory


Observe for retractions or flaring of nostrils.
effort.

Therapeutic Interventions

Place patient with proper body alignment for A sitting position permits maximum lung
maximum breathing pattern. excursion and chest expansion.

Encourage sustained deep breaths by: These techniques promotes deep inspiration,
which increases oxygenation and prevents
atelectasis. Controlled breathing methods may
 Using demonstration: highlighting also aid slow respirations in patients who are
slow inhalation, end tachypneic. Prolonged expiration prevents air
holding
trapping.
inspiration for a few seconds, and
passive exhalation
 Utilizing incentive spirometer
 Requiring the patient to yawn

Encourage diaphragmatic breathing for This method relaxes muscles and increases the
patients with chronic disease. patient’s oxygen level.
Maintain a clear airway by
encouraging patient to mobilize own This facilitates adequate clearance of secretions.
secretions with successful coughing.
Suction secretions, as necessary. This is to clear blockage in airway.
This will reduce the patient’s anxiety, thereby
Stay with the patient during acute episodes of
respiratory distress. reducing oxygen demand.
Ambulate patient as tolerated with doctor’s Ambulation can further break up and move
order three times daily. secretions that block the airways.
Extra activity can worsen shortness of breath.
Encourage frequent rest periods and teach
Ensure the patient rests between strenuous
patient to pace activity.
activities.
Encourage small frequent meals. This prevents crowding of the diaphragm.
This conserves energy and avoids overexertion
Help patient with ADLs, as necessary.
and fatigue.
Avail a fan in the room. Moving air can decrease feelings of air hunger.
Educate patient or significant other proper
These allow sufficient mobilization of secretions.
breathing, coughing, and splinting methods.
Teach patient about:

 pursed-lip breathing
 abdominal breathing
 performing relaxation techniques
 performing relaxation techniques
These measures allow patient to participate in
 taking prescribed medications maintaining health status and improve
(ensuring accuracy of dose and ventilation.
frequency and monitoring adverse
effects)
 scheduling activities to avoid
fatigue and provide for rest periods
Risk for Infection
The NANDA nursing diagnosis Risk for Infection is chosen to prevent the spread of
infection.

Nursing Diagnosis

 Risk for [Spread] of Infection: at increased risk for being invaded by


pathogenic organisms.

Risk Factors

The following are the common risk factors:

 Inadequate primary defenses (decreased ciliary action, stasis of respiratory


secretions)
 Inadequate secondary defenses (presence of existing infection,
immunosuppression), chronic disease, malnutrition

Desired Outcomes

Goals and expected outcomes for Risk for Infection secondary to pneumonia.

 Achieve timely resolution of current infection without complications.


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

Nursing Interventions and Rationales

The following measures are to prevent the spread of infection. These are the nursing
interventions for pneumonia nursing care plans with Risk for Infection nursing
diagnosis:

Nursing Interventions Rationale


Nursing Interventions Rationale

Assessment

During this period of time, potentially fatal


Monitor vital signs closely, especially during
complications (hypotension, shock) may
initiation of therapy.
develop.

Although patient may find expectoration


Instruct patient concerning the disposition of offensive and attempt to limit or avoid it, it is
secretions: raising and expectorating versus essential that sputum be disposed of in a safe
swallowing; and reporting changes in color, manner. Changes in characteristics of sputum
amount, odor of secretions. reflect resolution of pneumonia or development
of secondary infection.

Immunizations with pneumococcal vaccine and


Assess patient’s immunization status. seasonal influenza are used to reduce the risk
for developing pneumonia.

Therapeutic Interventions

Demonstrate and encourage good hand Effective means of reducing spread or


washing technique. acquisition of infection.

Change position frequently and provide good


Promotes expectoration, clearing of infection.
pulmonary toilet.

Reduces likelihood of exposure to other


Limit visitors as indicated.
infectious pathogens.

Dependent on type of infection, response


to antibiotics, patient’s general health, and
development of complications, isolation
Institute isolation precautions as individually
techniques may be desired to prevent spread
appropriate. Keep patient away from other
from other infectious processes. Nosocomial
patients who are at high risk for developing
pneumonia is at high risk of development for
pneumonia.
immunocompromised patients, provide careful
room assignments when patients are in
semiprivate rooms.

Encourage adequate rest balanced with


Facilitates healing process and enhances
moderate activity. Promote adequate nutritional
Nursing Interventions Rationale

intake. natural resistance.

Signs of improvement in condition should


Monitor effectiveness of antimicrobial therapy.
occur within 24–48 hr. Note any changes.

Investigate sudden change in condition, such as


Delayed recovery or increase in severity of
increasing chest pain, extra heart sounds,
symptoms suggests resistance to antibiotics or
altered sensorium, recurring fever, changes in
secondary infection.
sputum characteristics.

Fiberoptic bronchoscopy (FOB) may be done


Prepare and assist with diagnostic studies as in patients who do not respond rapidly (within
indicated. 1–3 days) to antimicrobial therapy to clarify
diagnosis and therapy needs.

To prevent relapse of pneumonia, the patient


Administer prescribed antimicrobial agents as
needs to complete the course of antibiotics as
ordered.
prescribed.

Acute Pain
Increased sputum production in pneumonia comes with frequent coughing. Persistent
coughing can be painful therefore the need for Acute Pain nursing diagnosis.

Nursing Diagnosis

 Acute Pain: Unpleasant sensory and emotional experience arising from


actual or potential tissue damage or described in terms of such damage;
sudden or slow onset of any intensity from mild to severe with anticipated
or predictable end and a duration of <6 months.

Related Factors

Common related factors for acute pain nursing diagnosis:


 Inflammation of lung parenchyma
 Cellular reactions to circulating toxins
 Persistent coughing

Defining Characteristics

The common assessment cues that could serve as defining characteristics or part of
your “as evidenced by” in your diagnostic statement.

 Reports of discomfort: pleuritic chest pain, headache, muscle/joint pain


 Guarding of affected area
 Self-focused
 Moaning, restlessness
 Facial mask, distraction behaviors
 Irritability
 Tachycardia
 Increased BP
 Tachypnea

Desired Outcomes

Goals and expected outcomes for acute pain nursing diagnosis:

 Patient will verbalize relief/control of pain at level less than 3 to 4 using a


rating scale of 0 to 10.
 Patient will demonstrate relaxed manner, resting/sleeping and engaging in
activity appropriately.
 Patient will verbalize understanding of nonpharmacological interventions
for pain relief.

Nursing Interventions and Rationales

The following measures are to address acute pain related to persistent coughing. These
nursing interventions and actions are for pain relief to facilitate effective mobilization
of secretions through coughing and deep breathing exercises.
Nursing Interventions Rationale

Assessment

Assess pain characteristics: sharp, constant, Chest pain, usually present to some degree with
stabbing. Investigate changes in character, pneumonia, may also herald the onset of
location, or intensity of pain. Assess reports of complications of pneumonia, such as
pain with breathing or coughing. pericarditis and endocarditis.

Changes in heart rate or BP may indicate that


patient is experiencing pain, especially when
Monitor vital signs.
other reasons for changes in vital signs have
been ruled out.

Therapeutic Interventions

Non-analgesic measures administered with a


gentle touch can lessen discomfort and
Provide comfort measures: back rubs, position
augment therapeutic effects of analgesics.
changes, quite music, massage. Encourage use
Patient involvement in pain control measures
of relaxation and/or breathing exercises.
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 the effectiveness of cough effort.

These medications may be used to suppress


non-productive cough or reduce excess mucus,
Administer antitussives as indicated. Do not thereby enhancing general comfort.
suppress a productive cough; moderate
amounts of analgesics are used to relieve
Coughing is necessary to mobilize secretions
pleuritic pain.
and suppressing cough will cause retained
secretions and delay resolution of pneumonia.
Nursing Interventions Rationale

Administer analgesics as prescribed. Encourage Medications allow for pain relief and the ability
patient to take analgesics before discomfort to deep breathe and cough. Analgesics help
becomes severe. prevent peak periods of pain.

6. Activity Intolerance
The nursing diagnosis Activity Intolerance is related to decreased oxygen levels for
metabolic demands. For these pneumonia nursing care plans, energy reserves are also
depleted due to insufficient intake of food during periods of dyspnea.

Nursing Diagnosis

 Activity Intolerance: Insufficient physiologic or physiological energy to


endure or complete required or desired activity.

Related Factors

Common related factors for activity intolerance secondary to pneumonia:

 Imbalance between oxygen supply and demand


 General weakness
 Exhaustion associated with interruption in usual sleep pattern because of
discomfort, excessive coughing, and dyspnea

Defining Characteristics

The common assessment cues that could serve as defining characteristics or part of
your “as evidenced by” in your diagnostic statement.

 Verbal reports of weakness, fatigue, exhaustion


 Exertional dyspnea, tachypnea
 Tachycardia in response to activity
 Development/worsening of pallor/cyanosis

Desired Outcomes

Common goals and expected outcomes:

 Report/demonstrate a measurable increase in tolerance to activity with


absence of dyspnea and excessive fatigue, and vital signs within patient’s
acceptable range.

Nursing Interventions and Rationales

Nursing interventions for activity intolerance in this pneumonia nursing care plan
should include assessment of the client’s baseline activity level and response to
activity and noting how well the client tolerates activity. Next is to schedule activities
after treatment or medications and providing emotional support and a quiet
environment to reduce anxiety and promote rest.

Nursing Interventions Rationale

Assessment

Determine patient’s response to activity. Note


reports of dyspnea, increased weakness and Establishes patient’s capabilities and needs and
fatigue, changes in vital signs during and after facilitates choice of interventions.
activities.

Therapeutic Interventions

Provide a quiet environment and limit visitors


during acute phase as indicated. Encourage use Reduces stress and excess stimulation,
of stress management and diversional activities promoting rest
as appropriate.

Bedrest is maintained during acute phase to


Explain importance of rest in treatment plan
decrease metabolic demands, thus conserving
Nursing Interventions Rationale

and necessity for balancing activities with rest. energy for healing. Activity restrictions
thereafter are determined by individual patient
response to activity and resolution of
respiratory insufficiency.

Effective coughing may exhaust an already


Pace activity for patients with reduced activity. compromised patient. Fatigue may be a
contributing factor to ineffective coughing.

Patient may be comfortable with head of bed


Assist patient to assume comfortable position
elevated, sleeping in a chair, or leaning forward
for rest and sleep.
on overbed table with pillow support.

Assist with self-care activities as necessary.


Minimizes exhaustion and helps balance
Provide for progressive increase in activities
oxygen supply and demand.
during recovery phase. and demand.

Hyperthermia in pneumonia is caused by the inflammatory process and is related


to dehydration and infection.

Nursing Diagnosis

 Hyperthermia: Body temperature elevated above normal range.

Related Factors

 Dehydration
 Infection
 Increased metabolic rate

Defining Characteristics

 Body temperature above the normal range


 Hot, flushed skin
 Increased heart rate
 Increased respiratory rate

Desired Outcomes

 Patient maintains body temperature within normal range.


 Patient maintains BP and HR within normal limits.

Nursing Interventions and Rationales

For this pneumonia nursing care plan, interventions for hyperthermia includes
measures to maintain body temperature within normal range.

Nursing Interventions Rationales

Assessment

HR and BP increase as hyperthermia


Monitor the patient’s HR, BP, and especially progresses. Tympanic or rectal temperature
the tympanic or rectal temperature. gives a more accurate indication of core
temperature.

Extremes of age or weight increase the risk for


Determine the patient’s age and weight.
the inability to control body temperature.

Monitor fluid intake and urine output. If the Fluid resuscitation may be required to correct
patient is unconscious, central venous pressure dehydration. The patient who is significantly
or pulmonary artery pressure should be dehydrated is no longer able to sweat, which is
measured to monitor fluid status. necessary for evaporative cooling.

Review serum electrolytes, especially serum Sodium losses occur with profuse sweating and
sodium. accidental hyperthermia.

Therapeutic Interventions

Room temperature may be accustomed to near


Adjust and monitor environmental factors like
normal body temperature and blankets and
room temperature and bed linens as indicated. linens may be adjusted as indicated to regulate
temperature of the patient.

Exposing skin to room air decreases warmth


Eliminate excess clothing and covers.
and increases evaporative cooling.

Antipyretic medications lower body


Give antipyretic medications as prescribed. temperature by blocking the synthesis of
prostaglandins that act in the hypothalamus.

Hyperthermia increases the metabolic demand


Ready oxygen therapy for extreme cases.
for oxygen.

8. Risk for Deficient Fluid Volume


Risk for Deficient Fluid Volume may be related to the common risk factors
manifested by patients with pneumonia: fever, diaphoresis, and mouth breathing.

Nursing Diagnosis

 Risk for Deficient Fluid Volume: At risk for decreased intravascular,


interstitial, and intracellular fluid.

Risk Factors

The following are the common risk factors for the nursing diagnosis Risk for
Deficient Fluid Volume:

 Excessive fluid loss (fever, profuse diaphoresis, mouth


breathing/hyperventilation, vomiting)
 Decreased oral intake

Desired Outcomes

Common goals and expected outcomes:


 Patient demonstrates fluid balance evidenced by individually appropriate
parameters, e.g., moist mucous membranes, good skin turgor, prompt
capillary refill, stable vital signs.

Nursing Interventions and Rationale

Interventions and actions for the nursing diagnosis Risk for Deficient Fluid
Volume in this pneumonia nursing care plan are as follows:

Nursing Interventions Rationale

Assessment

Elevated temperature and prolonged fever


Assess vital sign changes: increasing increases metabolic rate and fluid loss through
temperature, prolonged fever, orthostatic evaporation. Orthostatic BP changes and
hypotension, tachycardia. increasing tachycardia may indicate systemic
fluid deficit.

Indirect indicators of adequacy of fluid volume,


Assess skin turgor, moisture of mucous although oral mucous membranes may be dry
membranes. because of mouth breathing and supplemental
oxygen.

Presence of these symptoms reduces oral


Investigate reports of nausea and vomiting.
intake.

Monitor intake and output (I&O), noting color,


Provides information about adequacy of fluid
character of urine. Calculate fluid balance. Be
volume and replacement needs.
aware of insensible losses. Weigh as indicated.

Therapeutic Interventions

Meets basic fluid needs, reducing risk of


Force fluids to at least 3000 mL/day or as
dehydration and to mobilize secretions and
individually appropriate.
promote expectoration.
Nursing Interventions Rationale

Administer medications as indicated:


To reduce fluid losses.
antipyretics, antiemetics.

In presence of reduced intake and/or excessive


Provide supplemental IV fluids as necessary. loss, use of parenteral route may correct
deficiency.

9. Risk for Imbalanced Nutrition: Less Than


Body Requirements
Dyspnea is a common risk factor for the risk nursing diagnosis Imbalanced
Nutrition: Less Than Body Requirements in pneumonia.

Nursing Diagnosis

 Risk for Imbalanced Nutrition: Less Than Body Requirements: At risk


for intake of nutrients insufficient to meet metabolic needs.

Risk Factors

The following are the common risk factors for this nursing diagnosis:

 Dyspnea
 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

Here are the expected outcomes for this nursing diagnosis:


 Patient demonstrates increased appetite.
 Patient maintains/regains desired body weight.

Nursing Interventions and Rationale

Here are the nursing interventions and actions for this pneumonia nursing care plans.

Nursing Interventions Rationale

Assessment

Identify factors that are contributing to nausea


Choice of interventions depends on the
or vomiting: copious sputum, aerosol
underlying cause of the problem.
treatments, severe dyspnea, pain.

Therapeutic Interventions

Provide covered container for sputum and


remove at frequent intervals. Assist and
Eliminates noxious sights, tastes, smells from
encourage oral hygiene after emesis, after
the patient environment and can reduce nausea.
aerosol and postural drainage treatments, and
before meals.

Schedule respiratory treatments at least 1 hr Reduces effects of nausea associated with these
before meals. treatments.

Maintain adequate nutrition to offset


hypermetabolic state secondary to infection.
Ask the dietary department to provide a high- To replenish lost nutrients.
calorie, high-protein diet consisting of soft,
easy-to-eat foods.

Milk products may increase sputum


Consider limiting use of milk products
production.

To prevent aspiration. Note: Don’t give large


Elevate the patient’s head and neck, and check
volumes at one time; this could cause vomiting.
Nursing Interventions Rationale

for tube’s position during NG tubefeedings. Keep the patient’s head elevated 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.

Provide small, frequent meals, including dry


These measures may enhance intake even
foods (toast, crackers) and/or foods that are
though appetite may be slow to return.
appealing to patient.

Presence of chronic conditions (COPD or


alcoholism) or financial limitations can
Evaluate general nutritional state, obtain
contribute to malnutrition, lowered resistance
baseline weight.
to infection, and/or delayed response to
therapy.

10. Deficient Knowledge


Deficient Knowledge nursing diagnosis for pneumonia nursing care plan includes all
the teaching plan and interventions for the patient and caregiver to achieve
understanding of the disease condition and prognosis.

Nursing Diagnosis

 Deficient Knowledge: Absence or deficiency of cognitive information


related to specific topic.

Related Factors
Common related factors:

 Lack of exposure
 Misinterpretation of information
 Altered recall
 Unfamiliarity with the disease process and/or transmission of disease

Defining Characteristics

The common assessment cues that could serve as defining characteristics or part of
your “as evidenced by” in your diagnostic statement.

 Requests for information


 Questions to health care team
 Statement of misconception
 Failure to improve/recurrence
 Confusion about treatment
 Inability to comply with treatment regimen, including appropriate isolation
procedures

Desired Outcomes

Common goals and expected outcomes for Deficient Knowledge nursing diagnosis:

 Patient and caregiver will verbalize understanding of condition, disease


process, and prognosis.
 Patient and caregiver will verbalize understanding of therapeutic regimen.
 Patient will initiate necessary lifestyle changes.
 Patient will participate in treatment program.

Nursing Interventions Rationale

Assessment
Nursing Interventions Rationale

Determine patient’s understanding of


pneumonia complications and its treatment Provides a starting point in education.
regimen.

Promotes understanding of current situation


Review normal lung function, pathology of
and importance of cooperating with treatment
condition.
regimen.

Information can enhance coping and help


reduce anxiety and excessive concern.
Discuss debilitating aspects of disease, length Respiratory symptoms may be slow to resolve,
of convalescence, and recovery expectations. and fatigue and weakness can persist for an
Identify self-care and homemaker needs. extended period. These factors may be
associated with depression and the need for
various forms of support and assistance.

Therapeutic regimen will continue after


hospital discharge and home care needs will
Assess potential home care needs. depend on the availability of supportive people
including the patient’s energy level and
cognitive level.

Therapeutic Interventions

Fatigue and depression can affect ability to


Provide information in written and verbal form. assimilate information and follow therapeutic
regimen.

Reinforce importance of continuing


During initial 6–8 wk after discharge, patient is
effective coughing and deep-breathing
at greatest risk for recurrence of pneumonia.
exercises.

Full-course antibiotic treatment is required to


Emphasize necessity for continuing antibiotic
reduce the recurrence of pneumonia and
therapy for prescribed period.
promote a healthy immune system. Early
discontinuation of antibiotics may result in
Nursing Interventions Rationale

failure to completely resolve infectious process


and may cause recurrence or rebound
pneumonia.

Smoking destroys tracheobronchial ciliary


Review the importance of cessation action, irritates bronchial mucosa, and inhibits
of smoking. alveolar macrophages, compromising body’s
natural defense against infection.

Outline steps to enhance general health and


well-being: balanced rest and activity, well- Increases natural defense, limits exposure to
rounded diet, avoidance of crowds during pathogens.
cold/flu season and persons with URIs.

Stress importance of continuing medical


May prevent recurrence of pneumonia and/or
follow-up and obtaining vaccinations as
related complications.
appropriate.

Identify signs and symptoms requiring


notification of health care provider: increasing
Prompt evaluation and timely intervention may
dyspnea, chest pain, prolonged fatigue, weight
prevent complications.
loss, fever, chills, persistence of productive
cough, changes in mentation.

This may results in upper airway colonization


with antibiotic-resistant bacteria. If the patient
Instruct patient to avoid using antibiotics
then develops pneumonia, the organisms
indiscriminately during minor viral infections.
producing the pneumonia may require
treatment with more toxic antibiotics.

Encourage Pneumovax and annual flu shots for


To help prevent occurrence of the disease.
high-risk patients.
Related Nursing Care Plans
Related nursing diagnoses you can use to craft another pneumonia nursing care plans.

 Impaired Dentition. May be related to dietary habits, poor oral hygiene,


chronic vomiting, possibly evidenced by erosion of tooth enamel, multiple
carries, abraded teeth.
 Impaired oral mucous membrane. Maybe related to breathing through the
mouth, 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.
 Legacy care plans (via Scribd): Ineffective Airway Clearance, Risk for
Infection, Ineffective Breathing Pattern, Impaired Gas
Exchange, Hyperthermia

References and Sources


Recommended journals, books, and other interesting materials to help you learn more
about Pneumonia Nursing Care Plans:

 Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical


management for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders
Elsevier. [Link]
 Dempsey, C. L. (1995). Nursing Home‐Acquired Pneumonia: Outcomes
from a Clinical Process Improvement Program. Pharmacotherapy: The
Journal of Human Pharmacology and Drug Therapy, 15(1P2), 33S-38S.
[Link]
 Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket
guide: Diagnoses, prioritized interventions, and rationales. FA Davis.
[Link]
 Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses,
Interventions, and Outcomes. Elsevier Health Sciences. [Link]
 Head, B. J., Scherb, C. A., Reed, D., Conley, D. M., Weinberg, B., Kozel,
M., … & Moorhead, S. (2011). Nursing diagnoses, interventions, and
patient outcomes for hospitalized older adults with pneumonia. Research in
gerontological nursing, 4(2), 95-105. [Link]
 Yoshino, A., Ebihara, T., Ebihara, S., Fuji, H., & Sasaki, H. (2001). Daily
oral care and risk factors for pneumonia among elderly nursing
home patients. Jama, 286(18), 2235-2236. [Link]

This post is updated as of February 2019.