Nursing Care Plans | 01/12/2012, 10:49 pm

5 Pneumonia Nursing Care Plans


NCP-PneumoniaPneumonia is an inflammatory illness of the lung. It is often described as lung parenchyma or alveolar inflammation leading to abnormal alveolar filling with fluid. Pneumonia can result from a variety of causes, including infection with microorganisms like bacteria, viruses, fungi, or parasites, and chemical or physical injury to the lungs.

Incidences of Pneumonia

Pneumonia is a common illness in all parts of the world in all age groups. Majority of deaths occur in the newborn period in children, with over two million deaths a year worldwide.

  • The World Health Organization estimates that one out of three newborn infant deaths is due to pneumonia.
  • It kills more children than any other illness, accounting for 19% of all under-five deaths.
  • According to the National Statistical Coordination Board of the Philippines, there are 776,562 of pneumonia in the country in 2004 alone. This could be an implication that pneumonia is one of the leading causes of morbidity and mortality in the country.
  • World Health Organization notes Invasive Pneumococcal Disease deaths at 1.6 million people each year.
  • Of these, 700,000 to one million are children under five years old and over 90 percent of these deaths occur in developing countries.
  • Pneumonia is a top killer in India,China,Nigeria,Pakistan,Bangladesh,Indonesia, and Brazil.

Additional & Updated Nursing Care Plans for Pneumonia

1. Ineffective Airway Clearance

NDx: Ineffective airway clearance related to presence of secretions secondary to pneumonia.

The inflammation and increased secretions make it difficult to maintain a patent airway, which is cause by decrease ability to expel the excessive mucus produced that will lead to extensive obstruction of the airway.

ASSESSMENT

OBJECTIVES

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOMES

  • With unproductive cough
  • With wheezes and crackles auscultated on left lower lungfield.
  • Presence of clear watery discharge from her nose
  • Restlessness
  • Irritability

 

Short Term: After 3-4 hours of nursing interventions, the patient’s respiration will improve and difficulty of breathing will be relieved. Long Term:

After 3 – 4 days of nursing interventions, the patient will maintain a patent airway.

  1. Establish rapport to patient and SO
  2. Assess patient’s condition
  3. Monitor and record V/S
  4.  Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds
  5. Assist patient to change position every 30 minutes
  6. Elevate head of bed and align head in the middle
  7. Provide health teachings regarding effective coughing and deep breathing exercise.
  8. Encourage to increase fluid intake.
  9. Encourage steam inhalation
  10. Administer meds as ordered

 

  1. To gain the trust and cooperation
  2. To know and determine patient’s needs
  3. To establish base line data
  4. To identify areas of consolidation and determine possible bronchospasm or obstruction.
  5. To mobilize secretions
  6. To facilitate breathing
  7. To expel the mucous
  8. To liquefy secretions
  9. To moisten secretions and alleviate congestion
  10. To reduce bronchospasm and mobilize secretion
Short Term:  After 3-4 hours of nursing interventions, the patient’s respiration shall have improved and difficulty of breathing shall have been relieved.

 

 

Long Term:

After 3 – 4 days of nursing interventions, the patient will have been able to maintain a patent airway.

2. Ineffective Breathing Pattern

Nursing Diagnosis: Ineffective breathing pattern related to presence of tracheo-bronchial secretions and nasal secretions

Alteration on the client’s O2:CO2 ratio due to decreased absorbed oxygen and poor gas exchage related to presence to exudates on the alveolar spaces causes the body to cope by increasing respiratory rate or by hyperventilation. The increase in respiratory rate is elicited to cause an increase in the tidal volume of air that in inspired in order to absorb more oxygen. The increase in respiratory rate may need the assistance of accessory muscle that would be evident by the rising and falling of the shoulders during inspiration and expiration.

ASSESSMENT

OBJECTIVES

INTERVENTIONS

RATIONALE

EXPECTED OUTCOMES

  • Increase in respiratory rate of 31 cpm
  • Shortness of breath (orthopnea)
  • Dyspnea
  • Use of accessory muscles in breathing
  • Altered chest excursion
  • Nasal Flaring
  • Increased anterior-posterior diameter
SHORT TERMAfter 2-3 hours of nursing intervention, patient will be able to verbalize understanding and demonstrate proper deep breathing technique to facilitate proper oxygenation to alleviate hyperventilation

LONG TERM

After 2-3 days of nursing intervention, patient will be free of cyanosis and establish normal breathing pattern

  1. Establish rapport with patient
  2. Instruct patient to increase oral fluid intake to 8-10 glasses
  3. Instruct patient to do deep breathing exercise after demonstrating proper technique
  4. Keep environment allergen free (dust, feather pillows, smoke, pollen)
  5. Take and VS
  6. Suction naso, tracheal/oral PRN
  7. Educate proper hand washing
  8. Position the patient in semi fowler’s position
  9. Encourage patient to eat nutritious foods such as green leafy vegetables and lean meat
  10. Review client’s chest x-ray for severity of acute/ chronic conditions
  1. To gain patient’s trust and cooperation
  2. Increased mucus and sputum secretions can lead to dehydration; increased water intake can help dissolve secretions
  3. Deep breathing exercise increases oxygen intake and can help alleviate dyspnea
  4. Presence may trigger allergic response that may cause further increase in mucus secretion
  5. To get baseline data
  6. These may compromise airway. A distended abdomen can interfere with normal diaphragm expansion
  7. To increase feeling of comfort
  8. To enable the body to recuperate and repair
  9. To prevent infections such as nosocomial infections
  10. To prevent allergic reactions that can cause respiratory distres
SHORT TERMClient shall verbalize understanding and demonstrate proper deep breathing technique to facilitate proper oxygenation to alleviate hyperventilation

LONGTERM

Patient shall be free of cyanosis and establish normal breathing pattern

3. Impaired Gas Exchange

NDx: Impaired gas exchange related to alveolar capillary membrane changes secondary to inflammation.

Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions and infections. Bronchospasm can sometimes be detected by stethoscope when wheezing or diminished breath sounds are heard. Increase mucous production along with decrease mucous ciliary’s action, contributes to further reduction in the caliber of the bronchi and results in decrease air flow and decrease gas exchange.

ASSESSMENT

OBJECTIVES

INTERVENTIONS

RATIONALE

EXPECTED OUTCOME

  • restlessness
  • irritability
  • nasal flaring
  • diaphoresis
  • tachycardia
  • dyspnea
Short term:After 6 hours of nursing interventions the patient will demonstrate ease in breathing.

Long term:

After 2-3 days of nursing interventions the patient’s S.O will verbalize understanding of the causative factors that could aggravate the condition and appropriate factors that could help the patient relive from gas exchange impairment.

  1. Monitor vital signs and assess patient’s conditions.
  2. Auscultate lungs for crackles , consolidation and pleural friction rub.
  3. Assess LOC, distress and irritability.
  4. Observe skin color and capillary refill.
  5. Encourage rest.
  6. Encourage elevated HOB.
  7. Perform chest physiotherapy after nebulization.
  8. Administer oxygen as ordered.
  1. To establish baseline data.
  2. Determine adequacy of gas exchange and detect areas of consolidation and pleural friction rub.
  3. This signs may indicate hypoxia.
  4. Determine circulatory adequacy, which is necessary for gas exchange to tissues.
  5. Rest prevents tissue oxygen demand and enhances tissue oxygen perfusion.
  6. To facilitate lung expansion to enhance breathing.
  7. To dislodge the secretions, for easy expectoration
  8. Improves gas-exchange decrease work of breathing.
Short term:The patient shall have demonstrated ease in breathing.

Long term:

The patient’s S.O will verbalized understanding of the causative factors that could aggravate the condition and appropriate factors that could help the patient relive from gas exchange impairment.

4 Risk for Infection

NDx: Risk for infection (spread) related to inadequate secondary defenses(decrease hemoglobin, hematocrit and immunosuppression)

Immuno-suppression due to decrease in hemoglobin, leukopenia, and suppress inflammatory response gives a greater opportunity for pathogenic bacteria to invade and inoculate in a specific body part of a susceptible human body. Thus, leading to a further damage or infection.

ASSESSMENT

OBJECTIVES

INTERVENTIONS

RATIONALE

EXPECTED OUTCOME

  • Fever of 38.4ºC
  • Presence of adventitious sounds in both lung field. Productive cough
  • Skin pale in color
  • Restlessness
  • Body malaise
  • Activity intolerance
  • Decrease oxygen level
Short term:After 6 hours of nursing interventions the patient’s S.O will verbalize her understanding of individual causative/risk factors and demonstrate lifestyle changes to prevent further infection.

Long term:

After 1-2 days of nursing interventions the patient will be free from possible spread of infection.

  1. Monitor v/s closely, especially during initiation of therapy.
  2. Assess depth/rate of respiration and chest movement.
  3. Instruct the S.O concerning about the disposition of secretions and report changes in color, amount and odor of secretions.
  4. Encourage good hand washing techniques.
  5. Encourage adequate rest.
  6. Stress the importance of increasing the childs nutritional intake.
  7. Encourage the mother to keep an eye to the baby and observe anything that the baby is putting in his mouth.
  8. Administer antimicrobials as ordered.
  1. To know potential fatal complication that may occur.
  2. Tachypnea, shallow respiration, and asymmetric chest movement are frequently presented because of discomfort of the moving chest wall and/or fluid in the lungs.
  3. To promote safety disposal of secretions and to assess for the resolution of pneumonia or development of secondary infection.
  4. To reduce spread or acquisition of infection.
  5. To enhance fast recovery and regain strength.
  6. A good nutritional intake can strengthen body immune defense.
  7. To prevent entry of microbes.
  8. To combat microbial pneumonias.
Short term:The patient’s S.O shall have verbalized her understanding of individual causative/risk factors and demonstrate lifestyle changes to prevent further infection.  

Long term:

The patient shall have been free from possible spread of infection.

5 Hyperthermia

Presence of microorganisms stimulates the release of pyrogen from the leukocytes resetting the body’s thermostat to febrile level and then there would be activation of the hypothalamus, which will result in increase in epinephrine and norepinephrine, vasoconstriction of cutaneous vessels. The heat will be produced as peripheral vasodilation results in skin flushing and skin is warm to touch.

ASSESSMENTOBJECTIVESINTERVENTIONSRATIONALEEXPECTED OUTCOME

  • Flushed Skin
  • Skin Warm to Touch
  • Temperature Higher than 37.6C
  • Rales
  • Dehydration
  • Irritability
  Short term: After 4° of NI, the pt’s temperature will drop from 38.4 °C to 37 °C

Long term:

After 2-3 days of NI, the patient will be free from hyperthermia.                                        

  1. Establish Rapport
  2. Monitor VS q 4°.
  3. Provide TSB as a measure.
  4. Instruct SO to provide with loose clothing.
  5. Assess skin temperature and color.
  6. Monitor WBC count.
  7. Encourage fluid intake orally or intravenously as ordered.
  8. Measure intake and output.
  1. To gain trust and have a nurse patient relationship
  2. To establish baseline data of the pt’s
  3. To lower pt’s temperature
  4. To release heat and to provide comfort
  5. Warm, dry, flushed skin may indicate a fever.
  6. eucocytes indicate an inflammatory and infectious process presence.
  7. Replaces fluid lost by insensible loss and perspiration.
  8. Determine fluid balance and need to increase fluid intake.
Short term:After 4° of NI, the pt’s temperature shall drop from 38.4 °C to 37.4 or lower °C.        

Long term:

After 2-3 days of NI, the patient shall be free from hyperthermia.

Other possible nursing care plans can include:

Navigation
  1. Ineffective Airway Clearance
  2. Ineffective Breathing Pattern
  3. Impaired Gas Exchange
  4. Risk for Infection
  5. Hyperthermia & Other Care Plans
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