Pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange. The prognosis is typically good for people who have normal lungs and adequate host defenses before the onset of pneumonia. It is the sixth leading cause of death in the United States.
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 Plans
Nursing care for patients with pneumonia includes supportive measures like humidified oxygen therapy for hypoxemia, mechanical ventilation for respiratory failure, a high calorie diet and adequate fluid intake. Interventions should include bed rest and analgesic to relieve pleuritic chest pain.
- Ineffective Airway Clearance
- Impaired Gas Exchange
- Risk for Deficient Fluid Volume
- Risk for Imbalanced Nutrition: Less Than Body Requirements
- Acute Pain
- Activity Intolerance
- Risk for Infection
- Deficient Knowledge
- Ineffective Breathing Pattern
- Other Nursing Care Plans
- See Also and Further Reading
Ineffective Airway Clearance
Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
- 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
- Identify/demonstrate behaviors to achieve airway clearance.
- Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis.
|Assess the rate and depth of respirations and chest movement.||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 or absent airflow and adventitious breath sounds: crackles, wheezes.||Decreased airflow occurs in areas with 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 spasms and obstruction.|
|Elevate head of bed, change position frequently.||Doing so would lower the diaphragm and promote chest expansion, aeration of lung segments, mobilization and expectoration of secretions.|
|Teach and assist patient with proper deep-breathing exercises. Demonstrate proper splinting of chest and effective coughing while in upright position. Encourage him to do so often.||Deep breathing exercises facilitates 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 contraindicated, as in heart failure). Offer warm, rather than cold, fluids.||Fluids, especially warm liquids, aid in mobilization and expectoration of secretions.|
|Assist and monitor effects of nebulizer treatment and other respiratory physiotherapy: incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate.||Nebulizers and other respiratory therapy facilitates liquefaction and expectoration of secretions. Postural drainage may not be as effective in interstitial pneumonias or those causing alveolar exudate or destruction. Coordination of treatments and oral intake reduces likelihood of vomiting with coughing, expectorations.|
|Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics.||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 and depress respirations.|
|Provide supplemental fluids: IV.||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.||Followers progress and effects of the disease process, therapeutic regimen, and may facilitate necessary alterations in therapy.|
|Assist with bronchoscopy and/or thoracentesis, if indicated.||Occasionally needed to remove mucous plugs, drain purulent secretions, and/or prevent atelectasis.|
|Urge all bedridden and postoperative patients to perform deep breathing and coughing exercises frequently.||To promote full aeration and drainage of secretions.|