Pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange.
Primary pneumonia is caused by the patient’s inhaling or aspirating a pathogen. Secondary pneumonia ensues from lung damage caused by the spread of bacteria from an infection elsewhere in the body. Likely causes include various infectious agents, chemical irritants (including gastric reflux/aspiration, smoke inhalation), and radiation therapy. This plan of care deals with bacterial and viral pneumonias, e.g., pneumococcal pneumonia, Pneumocystis carinii, Haemophilus influenzae, mycoplasma, and Gram-negative microbes.
Nursing Care Plan for Pneumonia: Microbial
Nursing Care Plan for Pneumonia: Nursing Priorities & Discharge Goals
Nursing Priorities | Nursing Care Plan for Pneumonia
- Maintain/improve respiratory function.
- Prevent complications.
- Support recuperative process.
- Provide information about disease process/prognosis and treatment.
Discharge Goals | Nursing Care Plan for Pneumonia
- Ventilation and oxygenation adequate for individual needs.
- Complications prevented/minimized.
- Disease process/prognosis and therapeutic regimen understood.
- Lifestyle changes identified/initiated to prevent recurrence.
- Plan in place to meet needs after discharge.
Nursing Care Plan for Pneumonia: Nursing Diagnosis of Pneumonia
Nursing Care Plan for Pneumonia | Nursing Diagnosis of Pneumonia
- Airway Clearance, ineffective related to Tracheal bronchial inflammation, edema formation, increased sputum production; Pleuritic pain; Decreased energy, fatigue.
Nursing Care Plan for Pneumonia: Nursing Intervention & Rationale
Nursing Interventions of Pneumonia with Rationale
Airway Management (NIC)
Nursing Interventions of Pneumonia with Rationale: Independent
- Assess rate/depth of respirations and chest movement. Rationale: Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung.
- Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds, e.g., crackles, wheezes. Rationale: Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/obstruction.
- Elevate head of bed, change position frequently. Rationale: Lowers diaphragm, promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions.
- Assist patient with frequent deep-breathing exercises. Demonstrate/help patient learn to perform activity, e.g., splinting chest and effective coughing while in upright position. Rationale: Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort.
- Suction as indicated (e.g., frequent or sustained cough, adventitious breath sounds, desaturation related to airway secretions). Rationale: 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 contraindicated, as in heart failure). Offer warm, rather than cold, fluids. Rationale: Fluids (especially warm liquids) aid in mobilization and expectoration of secretions.
Nursing Interventions of Pneumonia with Rationale
Airway Management (NIC)
Nursing Interventions of Pneumonia with Rationale: Collaborative
- Assist with/monitor effects of nebulizer treatments and other respiratory physiotherapy, e.g., incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate. Rationale: Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudate/destruction. Coordination of treatments/schedules and oral intake reduces likelihood of vomiting with coughing, expectorations.
- Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics. Rationale: Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort/depress respirations.
- Provide supplemental fluids, e.g., IV, humidified oxygen, and room humidification. Rationale: Fluids are required to replace losses (including insensible) and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection.
- Monitor serial chest x-rays, ABGs, pulse oximetry readings. (Refer to ND: Gas Exchange, impaired, following.) Rationale: Follows progress and effects of disease process/therapeutic regimen, and facilitates necessary alterations in therapy.
- Assist with bronchoscopy/thoracentesis, if indicated. Rationale: Occasionally needed to remove mucous plugs, drain purulent secretions, and/or prevent atelectasis.
Nursing Care Plan for Pneumonia: Overview; Nursing Care Plan for Pneumonia: Nursing Priorities & Discharge Goals; Nursing Care Plan for Pneumonia: Nursing Diagnosis; Nursing Care Plan for Pneumonia: Nursing Intervention with Rationale. Nursing Care Plan for Pneumonia