11 Pneumonia Nursing Care Plans

Ineffective Airway Clearance

Ineffective Airway Clearance is a common NANDA-I 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

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 a patent airway with breath sounds clearing; absence of dyspnea, cyanosis, as evidenced by keeping a patent airway and effectively clearing secretions.

Nursing Assessment and Rationales

The following nursing assessment for pneumonia and nursing interventions promote airway patency, increase fluid intake, and teach and encourage effective cough and deep-breathing techniques.

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

2. Assess cough effectiveness and productivity
Coughing is the most effective way to remove secretions. Pneumonia may cause thick and tenacious secretions in patients.

3. 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, expiration due to fluid accumulation, thick secretions, and airway spasms and obstruction.

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

5. Assess the patient’s hydration status.
Airway clearance is hindered by inadequate hydration and the thickening of secretions.

Nursing Interventions and Rationales

This section contains ineffective airway clearance nursing interventions and actions for pneumonia and its rationales or scientific explanations.

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

2. Teach and assist the patient with proper deep-breathing exercises. Demonstrate proper splinting of the chest and effective coughing while in an upright position. Encourage the patient to do so often.

• 2.1. Deep breathing exercises facilitate the maximum expansion of the lungs and smaller airways and improve the productivity of cough.
• 2.2. Coughing is a reflex and a natural self-cleaning mechanism that assists the cilia in maintaining patent airways. It is the most helpful way to remove most secretions.
• 2.3. Splinting reduces chest discomfort and an upright position favors deeper and more forceful cough effort making it more effective.

3. Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway secretions.
Stimulates cough or mechanically clears airway in a patient who cannot do so because of ineffective cough or decreased level of consciousness. Note: Suctioning can cause increased hypoxemia; hyper oxygenate before, during, and after suctioning.

4. Maintain adequate hydration by forcing fluids to at least 3000 mL/day unless contraindicated (e.g., heart failure). Offer warm, rather than cold, fluids.
Fluids, especially warm liquids, aid in the mobilization and expectoration of secretions. Fluids help maintain hydration and increase ciliary action to remove secretions and reduce viscosity. Thinner secretions are easier to cough out.

5. 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.

• 5.1. Nebulizers humidify the airway to thin secretions and facilitate liquefaction and expectoration of secretions.
• 5.2. Postural drainage may not be as effective in interstitial pneumonias or those causing alveolar exudate or destruction.
• 5.3. Incentive spirometry serves to improve deep breathing and helps prevent atelectasis.
• 5.4. Chest percussion helps loosen and mobilize secretions in smaller airways that cannot be removed by coughing or suctioning.
• 5.5. Coordination of treatments and oral intake reduces the likelihood of vomiting with coughing and expectorations.

6. Encourage ambulation.
Helps mobilize secretions and reduces atelectasis.

7. Administer medications, as indicated:

• 7.1. Mucolytics increase or liquefy respiratory secretions.
• 7.2. Expectorants increase productive cough to clear the airways by liquefying lower respiratory tract secretions and reducing their viscosity.
• 7.3. Bronchodilators are medications used to facilitate respiration by dilating the airways.
• 7.4. Analgesics are given to improve cough effort by reducing discomfort but should be used cautiously because they can decrease cough effort and depress respirations.

8. Use humidified oxygen or humidifier at the bedside.
Increasing the humidity will decrease the viscosity of secretions. Clean the humidifier before use to avoid bacterial growth.

9. Monitor serial chest x-rays, ABGs, and pulse oximetry readings.
Follows progress and effects and extent of pneumonia. A therapeutic regimen may facilitate necessary alterations in therapy. Oxygen saturation should be maintained at 90% or greater. Imbalances in PaCO2 and PaO2 may indicate respiratory fatigue.

10. Assist with bronchoscopy and thoracentesis, if indicated.

• 10.1. Bronchoscopy is occasionally needed to remove mucous plugs, drain purulent secretions, and obtain lavage samples for culture and sensitivity.
• 10.2. Thoracentesis is done to drain associated pleural effusions and prevent atelectasis.

11. Anticipate the need for supplemental oxygen or intubation if the patient’s condition deteriorates.
These measures are needed to correct the hypoxemia. Intubation is needed for deep suctioning efforts and provides a source for augmenting oxygenation.

12. Urge all bedridden and postoperative patients to frequently perform deep breathing and coughing exercises.
To promote full aeration and drainage of secretions.