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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.
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
Pneumonia is also classified based on its microbiologic etiology – they can be viral,
bacterial, fungal, protozoan, mycobacterial, mycoplasmal, or rickettsial in origin.
Aspiration pneumonia, another type of pneumonia, results from vomiting
and aspiration of gastric or oropharyngeal contents into the trachea and lungs.
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.
Nursing Diagnosis
Related Factors
The following are the common related factors for the nursing diagnosis Ineffective
Airway Clearance related to pneumonia:
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.
Desired Outcomes
Below are the common expected outcomes for ineffective airway clearance secondary
to pneumonia:
In this section are the ineffective airway clearance nursing interventions and actions
for pneumonia together with its rationales or scientific explanations. The following
nursing assessment for pneumonia and nursing interventions are measures to promote
airway patency, increase fluid intake, and teaching and encouraging effective cough
and deep-breathing techniques.
Assessment
Therapeutic Interventions
Elevate head of bed, change position Doing so would lower the diaphragm and
frequently. promote chest expansion, aeration of lung
segments, mobilization and expectoration of
Nursing Interventions Rationale
secretions.
destruction.
Incentive spirometry serves to
improve deep breathing and helps
prevent atelectasis.
Chest percussion helps loosen and
mobilize secretions in smaller
airways that cannot be removed by
coughing or suctioning.
Coordination of treatments and oral
intake reduces likelihood of vomiting
with coughing, expectorations.
This nursing diagnosis for pneumonia nursing care plans is usually written
as Impaired Gas Exchange related to retained secretions and inflammatory
pulmonary.
Nursing Diagnosis
Related Factors
The following are the common related factors for impaired gas exchange related to
pneumonia:
Defining Characteristics
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
Cyanosis
Tachycardia
Restlessness, irritability, changes in mentation
Hypoxemia
Hypotension
Disorientation
Desired Outcomes
Assessment
Therapeutic Interventions
Elevate head and encourage frequent position These measures promote maximum chest
Nursing Interventions Rationale
changes, deep breathing, and effective expansion, mobilize secretions and improve
coughing. ventilation.
Nursing Diagnosis
Related Factors
The common assessment cues that could serve as defining characteristics or part of
your “as evidenced by” in your diagnostic statement.
Desired Outcomes
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.
Auscultate breath sounds at least every four This is to detect decreased or adventitious breath
(4) hours. sounds.
Therapeutic Interventions
Place patient with proper body alignment for A sitting position permits maximum lung
maximum breathing pattern. excursion and chest expansion.
Encourage sustained deep breaths by: These techniques promotes deep inspiration,
which increases oxygenation and prevents
atelectasis. Controlled breathing methods may
Using demonstration: highlighting also aid slow respirations in patients who are
slow inhalation, end tachypneic. Prolonged expiration prevents air
holding
trapping.
inspiration for a few seconds, and
passive exhalation
Utilizing incentive spirometer
Requiring the patient to yawn
Encourage diaphragmatic breathing for This method relaxes muscles and increases the
patients with chronic disease. patient’s oxygen level.
Maintain a clear airway by
encouraging patient to mobilize own This facilitates adequate clearance of secretions.
secretions with successful coughing.
Suction secretions, as necessary. This is to clear blockage in airway.
This will reduce the patient’s anxiety, thereby
Stay with the patient during acute episodes of
respiratory distress. reducing oxygen demand.
Ambulate patient as tolerated with doctor’s Ambulation can further break up and move
order three times daily. secretions that block the airways.
Extra activity can worsen shortness of breath.
Encourage frequent rest periods and teach
Ensure the patient rests between strenuous
patient to pace activity.
activities.
Encourage small frequent meals. This prevents crowding of the diaphragm.
This conserves energy and avoids overexertion
Help patient with ADLs, as necessary.
and fatigue.
Avail a fan in the room. Moving air can decrease feelings of air hunger.
Educate patient or significant other proper
These allow sufficient mobilization of secretions.
breathing, coughing, and splinting methods.
Teach patient about:
pursed-lip breathing
abdominal breathing
performing relaxation techniques
performing relaxation techniques
These measures allow patient to participate in
taking prescribed medications maintaining health status and improve
(ensuring accuracy of dose and ventilation.
frequency and monitoring adverse
effects)
scheduling activities to avoid
fatigue and provide for rest periods
Risk for Infection
The NANDA nursing diagnosis Risk for Infection is chosen to prevent the spread of
infection.
Nursing Diagnosis
Risk Factors
Desired Outcomes
Goals and expected outcomes for Risk for Infection secondary to pneumonia.
The following measures are to prevent the spread of infection. These are the nursing
interventions for pneumonia nursing care plans with Risk for Infection nursing
diagnosis:
Assessment
Therapeutic Interventions
Acute Pain
Increased sputum production in pneumonia comes with frequent coughing. Persistent
coughing can be painful therefore the need for Acute Pain nursing diagnosis.
Nursing Diagnosis
Related Factors
Defining Characteristics
The common assessment cues that could serve as defining characteristics or part of
your “as evidenced by” in your diagnostic statement.
Desired Outcomes
The following measures are to address acute pain related to persistent coughing. These
nursing interventions and actions are for pain relief to facilitate effective mobilization
of secretions through coughing and deep breathing exercises.
Nursing Interventions Rationale
Assessment
Assess pain characteristics: sharp, constant, Chest pain, usually present to some degree with
stabbing. Investigate changes in character, pneumonia, may also herald the onset of
location, or intensity of pain. Assess reports of complications of pneumonia, such as
pain with breathing or coughing. pericarditis and endocarditis.
Therapeutic Interventions
Instruct and assist patient in chest splinting Aids in control of chest discomfort while
techniques during coughing episodes. enhancing the effectiveness of cough effort.
Administer analgesics as prescribed. Encourage Medications allow for pain relief and the ability
patient to take analgesics before discomfort to deep breathe and cough. Analgesics help
becomes severe. prevent peak periods of pain.
6. Activity Intolerance
The nursing diagnosis Activity Intolerance is related to decreased oxygen levels for
metabolic demands. For these pneumonia nursing care plans, energy reserves are also
depleted due to insufficient intake of food during periods of dyspnea.
Nursing Diagnosis
Related Factors
Defining Characteristics
The common assessment cues that could serve as defining characteristics or part of
your “as evidenced by” in your diagnostic statement.
Desired Outcomes
Nursing interventions for activity intolerance in this pneumonia nursing care plan
should include assessment of the client’s baseline activity level and response to
activity and noting how well the client tolerates activity. Next is to schedule activities
after treatment or medications and providing emotional support and a quiet
environment to reduce anxiety and promote rest.
Assessment
Therapeutic Interventions
and necessity for balancing activities with rest. energy for healing. Activity restrictions
thereafter are determined by individual patient
response to activity and resolution of
respiratory insufficiency.
Nursing Diagnosis
Related Factors
Dehydration
Infection
Increased metabolic rate
Defining Characteristics
Desired Outcomes
For this pneumonia nursing care plan, interventions for hyperthermia includes
measures to maintain body temperature within normal range.
Assessment
Monitor fluid intake and urine output. If the Fluid resuscitation may be required to correct
patient is unconscious, central venous pressure dehydration. The patient who is significantly
or pulmonary artery pressure should be dehydrated is no longer able to sweat, which is
measured to monitor fluid status. necessary for evaporative cooling.
Review serum electrolytes, especially serum Sodium losses occur with profuse sweating and
sodium. accidental hyperthermia.
Therapeutic Interventions
Nursing Diagnosis
Risk Factors
The following are the common risk factors for the nursing diagnosis Risk for
Deficient Fluid Volume:
Desired Outcomes
Interventions and actions for the nursing diagnosis Risk for Deficient Fluid
Volume in this pneumonia nursing care plan are as follows:
Assessment
Therapeutic Interventions
Nursing Diagnosis
Risk Factors
The following are the common risk factors for this nursing diagnosis:
Dyspnea
Increased metabolic needs secondary to fever and infectious process
Anorexia associated with bacterial toxins, the odor and taste of sputum, and
certain aerosol treatments
Abdominal distension/gas associated with swallowing air during dyspneic
episodes
Desired Outcomes
Here are the nursing interventions and actions for this pneumonia nursing care plans.
Assessment
Therapeutic Interventions
Schedule respiratory treatments at least 1 hr Reduces effects of nausea associated with these
before meals. treatments.
for tube’s position during NG tubefeedings. Keep the patient’s head elevated for at least 30
minutes after feeding. Check for residual
formula regular intervals.
Nursing Diagnosis
Related Factors
Common related factors:
Lack of exposure
Misinterpretation of information
Altered recall
Unfamiliarity with the disease process and/or transmission of disease
Defining Characteristics
The common assessment cues that could serve as defining characteristics or part of
your “as evidenced by” in your diagnostic statement.
Desired Outcomes
Common goals and expected outcomes for Deficient Knowledge nursing diagnosis:
Assessment
Nursing Interventions Rationale
Therapeutic Interventions