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
Ineffective Breathing Pattern
In this case, the nursing diagnosis Ineffective Breathing Pattern is related to compensatory tachypnea due to an inability to meet metabolic demands. It is experienced by many clients with pneumonia. Changes in breathing pattern occur because affected alveoli cannot effectively exchange oxygen and carbon dioxide, as a result of chest pain, and increased body temperature.
- Ineffective Breathing Pattern
Common related factors for ineffective breathing pattern:
- Alteration of patient’s O2/CO2 ratio
- Decreased lung expansion
- Inflammatory process
The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- 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
- Decreased breath sounds over affected lung areas
- Ineffective cough
- Purulent sputum
- Infiltrates seen on chest x-ray film
- Reduced vital capacity
Common goals and outcomes for ineffective breathing pattern:
- Patient maintains an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnea.
- Patient’s respiratory rate remains within established limits.
Nursing Interventions and Rationales
The following are nursing actions to address ineffective breathing pattern. These interventions include: positioning the client to facilitate effective breathing (raising head of bed to 45 degrees), teaching how to splint chest wall with a pillow, and use of incentive spirometry.
|Assess and record respiratory rate and depth at least every 4 hours.||The average rate of respiration for adults is 10 to 20 breaths per minute. It is important to take action when there is an alteration in the pattern of breathing to detect early signs of respiratory compromise.|
|Assess ABG levels, according to facility policy.||This monitors oxygenation and ventilation status.|
|Observe for breathing patterns.||Unusual breathing patterns may imply an underlying disease process or dysfunction. Cheyne-Stokes respiration signifies bilateral dysfunction in the deep cerebral or diencephalon related with brain injury or metabolic abnormalities. Apneusis and ataxic breathing are related with failure of the respiratory centers in the pons and medulla.|
|Auscultate breath sounds at least every four (4) hours.||This is to detect decreased or adventitious breath sounds.|
|Assess for use of accessory muscle.||Work of breathing increases greatly as lung compliance decreases.|
|Monitor for diaphragmatic muscle fatigue or weakness (paradoxical motion).||Paradoxical movement of the abdomen (an inward versus outward movement during inspiration) is indicative of respiratory muscle fatigue and weakness.|
|Observe for retractions or flaring of nostrils.||These signs signify an increase in respiratory effort.|
|Place patient with proper body alignment for maximum breathing pattern.||A sitting position permits maximum lung excursion and chest expansion.|
|Encourage sustained deep breaths by:
|These techniques promotes deep inspiration, which increases oxygenation and prevents atelectasis. Controlled breathing methods may also aid slow respirations in patients who are tachypneic. Prolonged expiration prevents air trapping.|
|Encourage diaphragmatic breathing for patients with chronic disease.||This method relaxes muscles and increases the patient’s oxygen level.|
|Maintain a clear airway by encouraging patient to mobilize own secretions with successful coughing.||This facilitates adequate clearance of secretions.|
|Suction secretions, as necessary.||This is to clear blockage in airway.|
|Stay with the patient during acute episodes of respiratory distress.||This will reduce the patient’s anxiety, thereby reducing oxygen demand.|
|Ambulate patient as tolerated with doctor’s order three times daily.||Ambulation can further break up and move secretions that block the airways.|
|Encourage frequent rest periods and teach patient to pace activity.||Extra activity can worsen shortness of breath. Ensure the patient rests between strenuous activities.|
|Encourage small frequent meals.||This prevents crowding of the diaphragm.|
|Help patient with ADLs, as necessary.||This conserves energy and avoids overexertion and fatigue.|
|Avail a fan in the room.||Moving air can decrease feelings of air hunger.|
|Educate patient or significant other proper breathing, coughing, and splinting methods.||These allow sufficient mobilization of secretions.|
|Teach patient about:
|These measures allow patient to participate in maintaining health status and improve ventilation.|
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.