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Nursing Care Plan for Pneumonia: Overview

Nursing Care Plan fo Pneumonia

Pneumonia

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Pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange.

Primary pneumonia is caused by the patient’s inhaling or aspirating a pathogen. Secondary pneumonia ensues from lung damage caused by the spread of bacteria from an infection elsewhere in the body. Likely causes include various infectious agents, chemical irritants (including gastric reflux/aspiration, smoke inhalation), and radiation therapy. This plan of care deals with bacterial and viral pneumonias, e.g., pneumococcal pneumonia, Pneumocystis carinii, Haemophilus influenzae, mycoplasma, and Gram-negative microbes.

Nursing Care Plan for Pneumonia: Microbial

Nursing Care Plan for Pneumonia: Nursing Priorities & Discharge Goals

Nursing Priorities | Nursing Care Plan for Pneumonia

  1. Maintain/improve respiratory function.
  2. Prevent complications.
  3. Support recuperative process.
  4. Provide information about disease process/prognosis and treatment.

Discharge Goals | Nursing Care Plan for Pneumonia

  1. Ventilation and oxygenation adequate for individual needs.
  2. Complications prevented/minimized.
  3. Disease process/prognosis and therapeutic regimen understood.
  4. Lifestyle changes identified/initiated to prevent recurrence.
  5. Plan in place to meet needs after discharge.

Nursing Care Plan for Pneumonia: Nursing Diagnosis

Nursing Care Plan for Pneumonia | Nursing Diagnosis of Pneumonia

  • Airway Clearance, ineffective related to Tracheal bronchial inflammation, edema formation, increased sputum production; Pleuritic pain; Decreased energy, fatigue.

Nursing Care Plan for Pneumonia: Nursing Intervention & Rationale

Nursing Interventions of Pneumonia with Rationale

Airway Management (NIC)

Nursing Interventions of Pneumonia with Rationale: Independent

  1. Assess rate/depth of respirations and chest movement. Rationale: Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung.
  2. Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds, e.g., crackles, wheezes. Rationale: Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/obstruction.
  3. Elevate head of bed, change position frequently. Rationale: Lowers diaphragm, promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions.
  4. Assist patient with frequent deep-breathing exercises. Demonstrate/help patient learn to perform activity, e.g., splinting chest and effective coughing while in upright position. Rationale: Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort.
  5. Suction as indicated (e.g., frequent or sustained cough, adventitious breath sounds, desaturation related to airway secretions). Rationale: Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough or decreased level of consciousness.
  6. Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer warm, rather than cold, fluids. Rationale: Fluids (especially warm liquids) aid in mobilization and expectoration of secretions.

Nursing Interventions of Pneumonia with Rationale

Airway Management (NIC)

Nursing Interventions of Pneumonia with Rationale: Collaborative

  1. Assist with/monitor effects of nebulizer treatments and other respiratory physiotherapy, e.g., incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate. Rationale: Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudate/destruction. Coordination of treatments/schedules and oral intake reduces likelihood of vomiting with coughing, expectorations.
  2. Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics. Rationale: Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort/depress respirations.
  3. Provide supplemental fluids, e.g., IV, humidified oxygen, and room humidification. Rationale: Fluids are required to replace losses (including insensible) and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection.
  4. Monitor serial chest x-rays, ABGs, pulse oximetry readings. (Refer to ND: Gas Exchange, impaired, following.) Rationale: Follows progress and effects of disease process/therapeutic regimen, and facilitates necessary alterations in therapy.
  5. Assist with bronchoscopy/thoracentesis, if indicated. Rationale: Occasionally needed to remove mucous plugs, drain purulent secretions, and/or prevent atelectasis.

Nursing Care Plan for Pneumonia: Overview; Nursing Care Plan for Pneumonia: Nursing Priorities & Discharge Goals; Nursing Care Plan for Pneumonia: Nursing Diagnosis; Nursing Care Plan for Pneumonia: Nursing Intervention with Rationale. Nursing Care Plan for Pneumonia

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