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.
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.
Here are 11 nursing diagnosis common to pneumonia nursing care plans (NCP), they are as follows:
- Ineffective Airway Clearance
- Impaired Gas Exchange
- Ineffective Breathing Pattern
- Risk for Infection
- Acute Pain
- Activity Intolerance
- Risk for Deficient Fluid Volume
- Risk for Imbalanced Nutrition: Less Than Body Requirements
- Deficient Knowledge
- Deficient Fluid Volume
Impaired Gas Exchange
This nursing diagnosis for pneumonia nursing care plans is usually written as Impaired Gas Exchange related to retained secretions and inflammatory pulmonary.
- Impaired Gas Exchange
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
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
- Restlessness, irritability, changes in mentation
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%.
|Assess respirations: note quality, rate, rhythm, depth, use of accessory muscles, ease, and position assumed for easy breathing.||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 exchange.
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.
|Observe color of skin, mucous membranes, and nail beds, noting presence of peripheral cyanosis (nail beds) or central cyanosis (circumoral).||As oxygenation and perfusion become impaired, peripheral tissues become cyanotic. Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (“warm membranes”) is indicative of systemic hypoxemia.|
|Assess mental status, restlessness, and changes in level of consciousness.||Restlessness, irritation, confusion, and somnolence may reflect hypoxemia and decreased cerebral oxygenation and may require further intervention. Check pulse oximetry results with any mental status changes in older adults.|
|Assess anxiety level and encourage verbalization of feelings and concerns.||Anxiety is a manifestation of psychological 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.|
|Monitor heart rate and rhythm and blood pressure.||Tachycardia is usually present as a result of fever and/or dehydration but may represent a response to hypoxemia. Initial hypoxia and hypercapnia increases BP and HR. As hypoxia becomes more severe, BP may drop while HR tends to continue to be rapid with dysrhythmias.|
|Monitor body temperature, as indicated. Assist with comfort measures to reduce fever and chills: addition or removal of bedcovers, comfortable room temperature, tepid or cool water sponge bath.||High fever (common in bacterial pneumonia and influenza) greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation.|
|Observe for deterioration in condition, noting hypotension, copious amounts of bloody sputum, pallor, cyanosis, change in LOC, severe dyspnea, and restlessness.||Shock and pulmonary edema are the most common causes of death in pneumonia and require immediate medical intervention.|
|Monitor ABGs, pulse oximetry.||Follows progress of disease process and facilitates alterations in pulmonary therapy. Pulse oximetry detects changes in oxygenation. O2 sats should be at 90% or greater.|
|Maintain bedrest by planning activity and rest periods to minimize energy use. Encourage use of relaxation techniques and diversional activities.||Prevents over exhaustion and reduces oxygen demands to facilitate resolution of infection. Relaxation techniques helps conserve energy that can be used for effective breathing and coughing efforts.|
|Elevate head and encourage frequent position changes, deep breathing, and effective coughing.||These measures promote maximum chest expansion, mobilize secretions and improve ventilation.|
|Administer oxygen therapy by appropriate means: nasal prongs, mask, Venturi mask.||The purpose of oxygen therapy is to maintain PaO2 above 60 mmHg. Oxygen is administered by the method that provides appropriate delivery within the patient’s tolerance. Note: Patients with underlying chronic lung diseases should be given oxygen cautiously.|
You may also like the following posts and care plans:
- Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
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.
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]
Originally published January 10, 2010.