- Pneumonia is an infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles.
- The edema associated with inflammation stiffens the lung, decreases lung compliance and vital capacity, and causes hypoxemia.
- Pneumonia can be community acquired or hospital acquired.
- The chest x-ray film shows diffuse patches throughout the lungs or consolidation in a lobe.
- A sputum culture identifies the organism.
- The white blood cells and the erythrocyte sedimentation rate are elevated.
- Primary pneumonia is caused by the patient’s inhaling or aspirating a pathogen such as bacteria or a virus. Bacterial pneumonia, often caused by staphylococcus, streptococcus, or klebsiella, usually occurs when the lungs’ defense mechanisms are impaired by such factors as suppressed cough reflex, decreased cilia action, decreased activity of phagocytic cells, and the accumulation of secretions. Viral pneumonia occurs when a virus attacks bronchiolar epithelial cells and causes interstitial inflammation and desquamation, which eventually spread to the alveoli.
- Secondary pneumonia ensues from lung damage that was caused by the spread of bacteria from an infection elsewhere in the body or by a noxious chemical. Aspiration pneumonia is caused by the patient’s inhaling foreign matter such as food or vomitus into the bronchi. Factors associated with aspiration pneumonia include old age, impaired gag reflex, surgical procedures, debilitating disease, and decreased level of consciousness.
- Community-acquired pneumonia is caused by bacteria that are divided into two groups: typical and atypical. Organisms that cause typical pneumonia include Streptococcus pneumonia (pneumococcus) and Haemophilus and Staphylococcus species. Organisms that cause atypical pneumonia include Legionella, Mycoplasma, and Chlamydia species.
- Cigarette smoking
- Recent viral respiratory infection (common cold, laryngitis, influenza)
- Difficulty swallowing (due to stroke, dementia, Parkinson’s disease, or other neurological conditions)
- Chronic lung disease (COPD, bronchiectasis, cystic fibrosis)
- Cerebral palsy
- Other serious illnesses, such as heart disease, liver cirrhosis, or diabetes mellitus
- Living in a nursing facility
- Impaired consciousness (loss of brain function due to dementia, stroke, or other neurologic conditions)
- Recent surgery or trauma
- Immune system problem
- Elevated temperature
- Pleuritic pain
- Rhonchi and wheezes
- Use of accessory muscles for breathing
- Mental status changes
- Sputum production
- Respiratory failure, which requires a breathing machine or ventilator
- Empyema or lung abscesses. These are infrequent, but serious, complications of pneumonia. They occur when pockets of pus form inside or around the lung. These may sometimes need to be drained with surgery.
- Sepsis, a condition in which there is uncontrolled swelling (inflammation) in the body, which may lead to organ failure
- Acute respiratory distress syndrome (ARDS), a severe form of respiratory failure
Primary Nursing Diagnosis
- Ineffective airway clearance related to increased production of secretions and increased viscosity
- Sputum cultures and sensitivities reveals presence of infecting organisms. Cultures identify organism; sensitivity testing identifies how resistant or sensitive the bacteria are to antibiotics.
- Chest x-ray reveals areas of increased density, (can be a lung segment, lobe, one lung, or both lungs). Findings reflect areas of infection and consolidation.
- Antibiotics are prescribed based on Gram stain results and antibiotic guidelines (resistance patterns, risk factors, etiology must be considered). Combination therapy may be used.
- Supportive treatment includes hydration, antipyretics, antihistamines, or nasal decongestants.
- Best rest is recommended until infection shows signs of clearing.
- Oxygen therapy is given for hypoxemia.
- Respiratory support includes endotracheal intubation, high inspiratory oxygen concentrations, and mechanical ventilation.
- Treatment of atelectasis, pleural effusion, shock, respiratory failure, superinfection is instituted, if needed.
- For groups of high risk for community-acquired pneumonia, pneumococcal vaccination is advised.
- Initial antibiotic: macrolides including erythromycin, azithromycin, roxithromycin and clarithyromycin. Macrolides provide coverage for likely organisms in community-acquired bacterial pneumonia.
- Other antibiotics: Penicillin G for streptococcal pneumonia; nafcillin or oxacillin for staphylococcal pneumonia; aminoglycoside or a cephalosporin for klebsiella pneumonia; penicillin G or clindamycin for aspiration pneumonia .Alternatives: amoxicillin and clavulanate (Augmentin); doxycycline; trimethoprim and sulfamethoxazole (Bactrim DS, Septra); levofloxacin (Levaquin)
- Administer oxygen as prescribed.
- Monitor respiratory status.
- Monitor for labored respirations, cyanosis, and cold and clammy skin.
- Encourage coughing and deep breathing and use of incentive spirometer.
- Position client in semi-Fowler position to facilitate breathing and lung expansion.
- Change client’s position frequently and ambulate as tolerated to mobilize secretions
- Provide CPT
- Perform nasotracheal suctioning if the client is unable to clear secreations.
- Monitor pulse oximetry.
- Monitor and record color, consistency, and amount of sputum.
- Provide a high-calorie, high protein diet with small frequent meals.
- Encourage fluids up to 3 L a day to thin secretions unless contraindicated.
- Provide a balance of rest and activity, increasing activity gradually.
- Administer antibiotics as prescribed.
- Administer antipyretics, bronchodilators, cough suppressants, mucolytic agents, and expectorants as prescribed.
- Prevent the spread of infection by hand washing and the proper disposal of secretions.
- Physical findings of chest assessment: Respiratory rate and depth, auscultation findings, chest tightness or pain, vital signs
- Assessment of degree of hypoxemia: Lips and mucous membrane color, oxygen saturation by pulse oximetry
- Response to deep-breathing and coughing exercises, color and amount of sputum
- Response to medications: Body temperature, clearing of secretions
Discharge and Home Healthcare Guidelines
- Be sure the patient understands all medications, including dosage, route, action, and adverse effects.
- The patient and family or significant other need to understand the importance of avoiding fatigue by limiting activity and taking frequent rests.
- Advise small, frequent meals to maintain adequate nutrition.
- Fluid intake should be maintained at approximately 3000 mL/day so that the secretions remain thin.
- Teach the patient to maintain pulmonary hygiene measures of coughing, deep breathing, and incentive spirometry at home.
- Provide information about how to stop smoking.
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Nursing Care Plan
- Ineffective Airway Clearance
May be related to
- Tracheal bronchial inflammation, edema formation, increased sputum production
- Pleuritic pain
- Decreased energy, fatigue
Possibly evidenced by
- Changes in rate, depth of respirations
- Abnormal breath sounds, use of accessory muscles
- Dyspnea, cyanosis
- Cough, effective or ineffective; with/without sputum production
- Identify/demonstrate behaviors to achieve airway clearance.
- Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis.
- Assess the rate and 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.
- Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes.
- Rationale: Decreased airflow occurs in areas with consolidated fluid. Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spams and obstruction.
- Elevate head of bed, change position frequently.
- Rationale: Doing so would lower the diaphragm and promote chest expansion, aeration of lung segments, mobilization and expectoration of secretions.
- Teach and assist patient with proper deep-breathing exercises. Demonstrate proper splinting of chest and effective coughing while in upright position. Encourage him to do so often.
- Rationale: Deep breathing exercises facilitates maximum expansion of the lungs and smaller airways. Coughing is a reflex and a natural self-cleaning mechanism that assists the cilia to maintain patent airways. Splinting reduces chest discomfort and an upright position favors deeper and more forceful cough effort.
- Suction as indicated: frequent coughing, 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.
- 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.
- Assist and monitor effects of nebulizer treatment and other respiratory physiotherapy: incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate.
- Rationale: Nebulizers and other respiratory therapy facilitates liquefaction and expectoration of secretions. Postural drainage may not be as effective in interstitial pneumonias or those causing alveolar exudate or destruction. Coordination of treatments and oral intake reduces likelihood of vomiting with coughing, expectorations.
- 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 and depress respirations.
- Provide supplemental fluids: IV.
- Rationale: Room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection.
- Monitor serial chest x-rays, ABGs, pulse oximetry readings.
- Rationale: Followers progress and effects of the disease process, therapeutic regimen, and may facilitate necessary alterations in therapy.
- Assist with bronchoscopy and/or thoracentesis, if indicated.
- Rationale: Occasionally needed to remove mucous plugs, drain purulent secretions, and/or prevent atelectasis.
- Urge all bedridden and postoperative patients to perform deep breathing and coughing exercises frequently.
- Rationale: To promote full aeration and drainage of secretions.
- Impaired Gas Exchange
May be related to
- 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)
Possibly evidenced by
- Dyspnea, cyanosis
- Restlessness/changes in mentation
- Demonstrate improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.
- Participate in actions to maximize oxygenation.
- Assess respiratory rate, depth, and ease.
- Rationale: Manifestations of respiratory distress are dependent on/and indicative of the degree of lung involvement and underlying general health status.
- Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nail beds) or central cyanosis (circumoral).
- Rationale: 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.
- Rationale: Restlessness, irritation, confusion, and somnolence may reflect hypoxemia and decreased cerebral oxygenation.
- Monitor heart rate and rhythm.
- Rationale: Tachycardia is usually present as a result of fever and/or dehydration but may represent a response to hypoxemia.
- 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.
- Rationale: High fever (common in bacterial pneumonia and influenza) greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation.
- Maintain bedrest. Encourage use of relaxation techniques and diversional activities.
- Rationale: Prevents over exhaustion and reduces oxygen demands to facilitate resolution of infection.
- Elevate head and encourage frequent position changes, deep breathing, and effective coughing.
- Rationale: These measures promote maximum chest expansion, mobilize secretions and improve ventilation.
- Assess anxiety level and encourage verbalization of feelings and concerns.
- Rationale: 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.
- Observe for deterioration in condition, noting hypotension, copious amounts of bloody sputum, pallor, cyanosis, change in LOC, severe dyspnea, and restlessness.
- Rationale: Shock and pulmonary edema are the most common causes of death in pneumonia and require immediate medical intervention.
- Monitor ABGs, pulse oximetry.
- Rationale: Follows progress of disease process and facilitates alterations in pulmonary therapy.
- Administer oxygen therapy by appropriate means: nasal prongs, mask, Venturi mask.
- Rationale: 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.
- Risk for Deficient Fluid Volume
Risk factors may include
- Excessive fluid loss (fever, profuse diaphoresis, mouth breathing/hyperventilation, vomiting)
- Decreased oral intake
- Demonstrate fluid balance evidenced by individually appropriate parameters, e.g., moist mucous membranes, good skin turgor, prompt capillary refill, stable vital signs.
- Assess vital sign changes: increasing temperature, prolonged fever, orthostatic hypotension, tachycardia.
- Rationale: Elevated temperature and prolonged fever increases metabolic rate and fluid loss through evaporation. Orthostatic BP changes and increasing tachycardia may indicate systemic fluid deficit.
- Assess skin turgor, moisture of mucous membranes.
- Rationale: Indirect indicators of adequacy of fluid volume, although oral mucous membranes may be dry because of mouth breathing and supplemental oxygen.
- Investigate reports of nausea and vomiting.
- Rationale: Presence of these symptoms reduces oral intake.
- Monitor intake and output (I&O), noting color, character of urine. Calculate fluid balance. Be aware of insensible losses. Weigh as indicated.
- Rationale: Provides information about adequacy of fluid volume and replacement needs.
- Force fluids to at least 3000 mL/day or as individually appropriate.
- Rationale: Meets basic fluid needs, reducing risk of dehydration and to mobilize secretions and promote expectoration.
- Administer medications as indicated: antipyretics, antiemetics.
- Rationale: To reduce fluid losses.
- Provide supplemental IV fluids as necessary.
- Rationale: In presence of reduced intake and/or excessive loss, use of parenteral route may correct deficiency.
- Risk for Imbalanced Nutrition Less Than Body Requirements
Risk factors may include
- 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
- Demonstrate increased appetite.
- Maintain/regain desired body weight.
- Identify factors that are contributing to nausea or vomiting: copious sputum, aerosol treatments, severe dyspnea, pain.
- Rationale: Choice of interventions depends on the underlying cause of the problem.
- Provide covered container for sputum and remove at frequent intervals. Assist and encourage oral hygiene after emesis, after aerosol and postural drainage treatments, and before meals.
- Rationale: Eliminates noxious sights, tastes, smells from the patient environment and can reduce nausea.
- Schedule respiratory treatments at least 1 hr before meals.
- Rationale: Reduces effects of nausea associated with these treatments.
- Maintain adequate nutrition to offset hypermetabolic state secondary to infection. Ask the dietary department to provide a high-calorie, high-protein diet consisting of soft, easy-to-eat foods.
- Rationale: To replenish lost nutrients.
- Consider limiting use of milk products
- Rationale: Milk products may increase sputum production.
- Elevate the patient’s head and neck, and check for tube’s position during NG tube feedings.
- Rationale: To prevent aspiration. Note: Don’t give large volumes at one time; this could cause vomiting. Keep the patient’s head elevated for at least 30 minutes after feeding. Check for residual formula regular intervals.
- Auscultate for bowel sounds. Observe for abdominal distension.
- Rationale: Bowel sounds may be diminished if the infectious process is severe. Abdominal distension may occur as a result of air swallowing or reflect the influence of bacterial toxins on the gastrointestinal (GI) tract.
- Provide small, frequent meals, including dry foods (toast, crackers) and/or foods that are appealing to patient.
- Rationale: These measures may enhance intake even though appetite may be slow to return.
- Evaluate general nutritional state, obtain baseline weight.
- Rationale: Presence of chronic conditions (COPD or alcoholism) or financial limitations can contribute to malnutrition, lowered resistance to infection, and/or delayed response to therapy.
- Acute Pain
May be related to
- Inflammation of lung parenchyma
- Cellular reactions to circulating toxins
- Persistent coughing
Possibly evidenced by
- Reports of pleuritic chest pain, headache, muscle/joint pain
- Guarding of affected area
- Distraction behaviors, restlessness
- Verbalize relief/control of pain.
- Demonstrate relaxed manner, resting/sleeping and engaging in activity appropriately.
- Assess pain characteristics: sharp, constant, stabbing. Investigate changes in character, location, or intensity of pain.
- Rationale: Chest pain, usually present to some degree with pneumonia, may also herald the onset of complications of pneumonia, such as pericarditis and endocarditis.
- Monitor vital signs.
- Rationale: Changes in heart rate or BP may indicate that patient is experiencing pain, especially when other reasons for changes in vital signs have been ruled out.
- Provide comfort measures: back rubs, position changes, quite music, massage. Encourage use of relaxation and/or breathing exercises.
- Rationale: Non-analgesic measures administered with a gentle touch can lessen discomfort and augment therapeutic effects of analgesics. Patient involvement in pain control measures promotes independence and enhances sense of well-being.
- Offer frequent oral hygiene.
- Rationale: Mouth breathing and oxygen therapy can irritate and dry out mucous membranes, potentiating general discomfort.
- Instruct and assist patient in chest splinting techniques during coughing episodes.
- Rationale: Aids in control of chest discomfort while enhancing effectiveness of cough effort.
- Administer analgesics and antitussives as indicated.
- Rationale: These medications may be used to suppress non productive cough or reduce excess mucus, thereby enhancing general comfort.
- Activity intolerance
May be related to
- Imbalance between oxygen supply and demand
- General weakness
- Exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing, and dyspnea
Possibly evidenced by
- Verbal reports of weakness, fatigue, exhaustion
- Exertional dyspnea, tachypnea
- Tachycardia in response to activity
- Development/worsening of pallor/cyanosis
- Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs within patient’s acceptable range.
- Determine patient’s response to activity. Note reports of dyspnea, increased weakness and fatigue, changes in vital signs during and after activities.
- Rationale: Establishes patient’s capabilities and needs and facilitates choice of interventions.
- Provide a quiet environment and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate.
- Rationale: Reduces stress and excess stimulation, promoting rest
- Explain importance of rest in treatment plan and necessity for balancing activities with rest.
- Rationale: Bedrest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity restrictions thereafter are determined by individual patient response to activity and resolution of respiratory insufficiency.
- Assist patient to assume comfortable position for rest and sleep.
- Rationale: Patient may be comfortable with head of bed elevated, sleeping in a chair, or leaning forward on overbed table with pillow support.
- Assist with self-care activities as necessary. Provide for progressive increase in activities during recovery phase. and demand.
- Rationale: Minimizes exhaustion and helps balance oxygen supply and demand.
- Risk for [Spread] of Infection
Risk factors may include
- Inadequate primary defenses (decreased ciliary action, stasis of respiratory secretions)
- Inadequate secondary defenses (presence of existing infection, immunosuppression), chronic disease, malnutrition
- Achieve timely resolution of current infection without complications.
- Identify interventions to prevent/reduce risk/spread of/secondary infection.
- Monitor vital signs closely, especially during initiation of therapy.
- Rationale: During this period of time, potentially fatal complications (hypotension, shock) may develop.
- Instruct patient concerning the disposition of secretions: raising and expectorating versus swallowing; and reporting changes in color, amount, odor of secretions.
- Rationale: Although patient may find expectoration offensive and attempt to limit or avoid it, it is essential that sputum be disposed of in a safe manner. Changes in characteristics of sputum reflect resolution of pneumonia or development of secondary infection.
- Demonstrate and encourage good hand washing technique.
- Rationale: Effective means of reducing spread or acquisition of infection.
- Change position frequently and provide good pulmonary toilet.
- Rationale: Promotes expectoration, clearing of infection.
- Limit visitors as indicated.
- Rationale: Reduces likelihood of exposure to other infectious pathogens.
- Institute isolation precautions as individually appropriate.
- Rationale: Dependent on type of infection, response to antibiotics, patient’s general health, and development of complications, isolation techniques may be desired to prevent spread from other infectious processes.
- Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake.
- Rationale: Facilitates healing process and enhances natural resistance.
- Monitor effectiveness of antimicrobial therapy.
- Rationale: Signs of improvement in condition should occur within 24–48 hr. Note any changes.
- Investigate sudden change in condition, such as increasing chest pain, extra heart sounds, altered sensorium, recurring fever, changes in sputum characteristics.
- Rationale: Delayed recovery or increase in severity of symptoms suggests resistance to antibiotics or secondary infection.
- Prepare and assist with diagnostic studies as indicated.
- Rationale: Fiberoptic bronchoscopy (FOB) may be done in patients who do not respond rapidly (within 1–3 days) to antimicrobial therapy to clarify diagnosis and therapy needs.
- Deficient Knowledge regarding condition, treatment, self-care, and discharge needs
May be related to
- Lack of exposure
- Misinterpretation of information
- Altered recall
Possibly evidenced by
- Requests for information; statement of misconception
- Failure to improve/recurrence
- Verbalize understanding of condition, disease process, and prognosis.
- Verbalize understanding of therapeutic regimen.
- Initiate necessary lifestyle changes.
- Participate in treatment program.
- Review normal lung function, pathology of condition.
- Rationale: Promotes understanding of current situation and importance of cooperating with treatment regimen.
- Discuss debilitating aspects of disease, length of convalescence, and recovery expectations. Identify self-care and homemaker needs.
- Rationale: Information can enhance coping and help reduce anxiety and excessive concern. Respiratory symptoms may be slow to resolve, and fatigue and weakness can persist for an extended period. These factors may be associated with depression and the need for various forms of support and assistance.
- Provide information in written and verbal form.
- Rationale: Fatigue and depression can affect ability to assimilate information and follow therapeutic regimen.
- Reinforce importance of continuing effective coughing and deep-breathing exercises.
- Rationale: During initial 6–8 wk after discharge, patient is at greatest risk for recurrence of pneumonia.
- Emphasize necessity for continuing antibiotic therapy for prescribed period.
- Rationale: Early discontinuation of antibiotics may result in failure to completely resolve infectious process and may cause recurrence or rebound pneumonia.
- Review importance of cessation of smoking.
- Rationale: Smoking destroys tracheobronchial ciliary action, irritates bronchial mucosa, and inhibits alveolar macrophages, compromising body’s natural defense against infection.
- Outline steps to enhance general health and well-being: balanced rest and activity, well-rounded diet, avoidance of crowds during cold/flu season and persons with URIs.
- Rationale: Increases natural defense, limits exposure to pathogens.
- Stress importance of continuing medical follow-up and obtaining vaccinations as appropriate.
- Rationale: May prevent recurrence of pneumonia and/or related complications.
- Identify signs and symptoms requiring notification of health care provider: increasing dyspnea, chest pain, prolonged fatigue, weight loss, fever, chills, persistence of productive cough, changes in mentation.
- Rationale: Prompt evaluation and timely intervention may prevent complications.
- Instruct patient to avoid using antibiotics indiscriminately during minor viral infections.
- Rationale: This may results in upper airway colonization with antibiotic resistant bacteria. If the patient then develops pneumonia, the organisms producing the pneumonia may require treatment with more toxic antibiotics.
- Encourage pneumovax and annual flu shots for high-risk patients.
- Rationale: To help prevent occurrence of the disease.