Pneumonia Nursing Care Plan
Pneumonia is an infection of the lungs involving alveoli that are in contact with bronchioles or complete lobes. The disease is identified by the causative agents that may be bacterial, viral, fungal, or protozoan and may be termed lobar or bronchopneumonia.
Pneumonia Nursing Diagnosis: Ineffective airway clearance related to decreased energy and fatigue resulting in decreased coughing and accumulation of secretions; tracheobronchial secretions related to inflammation resulting in increased mucus accumulation. Ineffective breathing pattern related to pain caused by positioning and coughing; decreased energy and fatigue caused by inflammatory process; decreased lung expansion caused by pain and fatigue resulting in hypoventilation.
Expected Outcomes: Adequate ventilation evidenced by respiratory rate, depth and ease within baseline limits.
Intervention and Rationale:
I. Assess for:
- Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of accesory muscles, and diminished breath sounds, rhonchi or crackles on auscultation – provides data baseline.
- Changes in mental status, skin color, cyanosis – indicates possible decrease in oxygenation.
- Quality of cough and ability to raise secretions including consistency and characteristics od sputum – removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airways facilitates breathing.
II. Monitor, record, describe:
Respiratory rate, quality and breath sounds q2-q4 – indicates airway resistance, air movement, severity of disease.
- ABGs, oximeter reading – decreased oxygen levels result in hypoxemia.
- Oxygen therapy via cannula – maintain optimal oxygen level.
- Antitussives/expectorants (terpin hydrate, guaifenesin) – acts on bronchial cells to increase fluid production and promote expectoration; guaifenesin reduces surface tension of secretions; both relieve non-productive cough
- Mucolytic (acetylcysteine) – decrease viscosity of mucus for easier removal.
- Antibiotic (ampicillin, cephalexin) – acts by binding to cell wall organisms preventing synthesis and destroying pathogens.
IV. Perform or Provide:
- Position of comfort in semi or high fowlers and change position q2h – facilitates breathng and allows for full expansion of lungs.
- Encourage coughing if sounds is moist; if dry and hacking, increase fluid intake and administer cough suppresant – reduces continual irritation to throat and liquefies secretions.
- Coughing and deep breathing exercise q2h; use incintive spirometer 5-10 breaths if tolerated – coughing clears airway by propelling secretions to mouth deep breathing promoes ventilation and prolongs expiratory phase.
- Assist with coughing by splinting chest; humidified air with cool mist – loosens seretions and improves ventilation, moistens mucous membranes
- Postural drainage and percussion PRN – mobilizes secretion.
- Suction secretions if cough ineffective – removal if unable to bring up secretions.
- Oral care after expectoration and provide tissues and bag for disposal – promotes comfort and prevents transmission of organisms to others.