NURSING CARE PLAN FOR PNEUMONIA

NURSING CARE PLAN FOR PNEUMONIA

NURSING CARE PLAN FOR PNEUMONIA

NURSING CARE PLAN ON PNEUMONIA

Pneumonia

Definition: Pneumonia is an inflammatory condition of the lung, primarily affecting the alveoli. It can be caused by infections (bacterial, viral, or fungal) or non-infectious agents (aspiration of food or chemicals).

Types of Pneumonia:

Community-Acquired Pneumonia (CAP):

• Acquired outside of healthcare settings.
• Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae.

Hospital-Acquired Pneumonia (HAP):

• Develops 48 hours or more after hospital admission.
• Often caused by multidrug-resistant organisms.

Ventilator-Associated Pneumonia (VAP):

• Occurs in patients on mechanical ventilation.
• Commonly associated with organisms such as Pseudomonas aeruginosa.

Aspiration Pneumonia:

• Results from inhalation of food, liquid, or vomit into the lungs.
• Can lead to anaerobic bacterial infections.

Causes of Pneumonia:

Bacterial Infections:

• Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella pneumoniae, Mycoplasma pneumoniae.

Viral Infections:

• Influenza virus, respiratory syncytial virus (RSV), coronaviruses.

Fungal Infections:

• Histoplasmosis, coccidioidomycosis, cryptococcosis.

Non-infectious Causes:

• Inhalation of irritants, chemical fumes, or food.

Symptoms:

Respiratory Symptoms:

• Cough (productive or dry)
• Shortness of breath (dyspnea)
• Chest pain (especially with deep breathing or coughing)
• Wheezing

Systemic Symptoms:

• Fever and chills
• Fatigue and weakness
• Sweating
• Confusion (especially in older adults)

Risk Factors:

Age:

• Very young children and older adults are at higher risk.

Chronic Conditions:

• Asthma, chronic obstructive pulmonary disease (COPD), diabetes, heart disease.

Immunocompromised State:

• Conditions that weaken the immune system (HIV/AIDS, cancer treatment).

Smoking:

• Increases susceptibility to lung infections.

Recent Hospitalization:

• Higher risk for HAP and VAP.

Diagnosis:

Clinical Assessment:

• Physical examination (auscultation for crackles, decreased breath sounds).
• Assessment of vital signs (fever, tachypnea, low oxygen saturation).

Imaging:

• Chest X-ray: May show infiltrates, consolidations, or pleural effusions.
• CT scan may be used for further evaluation.

Laboratory Tests:

• Sputum culture: To identify causative organisms.
• Blood cultures: Particularly in severe cases.
• Complete blood count (CBC): To check for elevated white blood cell count.

Pulse Oximetry:

• To assess oxygen saturation levels.

Nursing Care Plan for Pneumonia

Patient Information:

• Name: [Patient’s Name]
• Age: [Age]
• Diagnosis: Pneumonia
• Date: [Date]

Nursing Diagnosis:

• Ineffective Airway Clearance related to inflammation and increased mucus production as evidenced by productive cough, wheezing, and abnormal lung sounds.
• Impaired Gas Exchange related to alveolar-capillary membrane changes and fluid in the lungs as evidenced by dyspnea, cyanosis, and low oxygen saturation levels.
• Activity Intolerance related to impaired oxygen transport and fatigue as evidenced by shortness of breath on exertion and increased respiratory rate.
• Risk for Dehydration related to fever, increased respiratory rate, and poor oral intake.

Assessment Data:

Subjective Data:

• The patient reports shortness of breath, chest pain, and a productive cough with green/yellow sputum.
• Complains of fatigue and difficulty completing daily activities.
• Reports a history of fever and chills.

Objective Data:

• Vital signs: Temperature: 38.5°C, Respiratory rate: 28 breaths/min, Oxygen saturation: 90% on room air.
• Auscultation reveals crackles and diminished breath sounds in lower lung lobes.
• Chest X-ray shows infiltrates consistent with pneumonia.
• Elevated white blood cell count.

Goals/Outcomes:

Short-term Goals:

• The patient will demonstrate effective airway clearance as evidenced by productive cough and improved breath sounds within 48 hours.
• The patient’s oxygen saturation will improve to >92% on room air within 24 hours.

Long-term Goals:

• The patient will maintain clear lung sounds and normal respiratory function by discharge.
• The patient will report increased energy and the ability to perform daily activities without excessive fatigue within one week.

Nursing Interventions:

Assess Respiratory Status:

• Monitor respiratory rate, depth, and effort.
• Assess for use of accessory muscles and listen for abnormal lung sounds (crackles, wheezing).

Rationale: Regular monitoring allows for early detection of respiratory distress and worsening of pneumonia.

Administer Oxygen Therapy as Prescribed:

• Provide oxygen via nasal cannula or mask as ordered to maintain SpO₂ > 92%.

Rationale: Oxygen supplementation improves tissue oxygenation and relieves hypoxemia caused by impaired gas exchange.

Encourage Coughing and Deep Breathing Exercises:

• Assist the patient with deep breathing and coughing exercises every 1-2 hours.
• Encourage the use of an incentive spirometer.

Rationale: Deep breathing and coughing help expand the lungs, clear secretions, and prevent atelectasis.

Position the Patient to Optimize Lung Expansion:

• Position the patient in a semi-Fowler’s or high-Fowler’s position to promote lung expansion and decrease the work of breathing.

Rationale: Elevating the head of the bed facilitates easier breathing and reduces pressure on the diaphragm.

Administer Medications as Ordered:

• Administer antibiotics, bronchodilators, and antipyretics as prescribed.
• Monitor for therapeutic and adverse effects.

Rationale: Antibiotics treat the infection, bronchodilators improve airway patency, and antipyretics reduce fever and discomfort.

Encourage Fluid Intake:

• Encourage the patient to drink 2-3 liters of fluids daily unless contraindicated.

Rationale: Adequate hydration helps thin secretions, making them easier to expectorate, and prevents dehydration from fever and increased respiratory effort.

Provide Rest Periods Between Activities:

• Encourage the patient to rest and limit physical activities that cause fatigue or dyspnea.

Rationale: Rest conserves energy and decreases oxygen demand, reducing the strain on the respiratory system.

Monitor for Signs of Complications:

• Assess for signs of worsening infection such as increasing fever, persistent or worsening cough, or pleuritic chest pain.

Rationale: Early detection of complications (e.g., pleural effusion, sepsis) allows for prompt intervention.

Educate the Patient on Proper Hand Hygiene and Respiratory Etiquette:

• Instruct the patient and family members on proper handwashing, coughing into tissues, and using masks to prevent the spread of infection.

Rationale: Pneumonia, especially in cases of viral or bacterial infections, can be contagious and requires infection control measures.

Provide Nutritional Support:

• Offer small, frequent, high-calorie meals to prevent fatigue and support recovery.

Rationale: Adequate nutrition supports immune function and tissue repair during the recovery process.

Evaluation:

• The patient’s oxygen saturation has improved to >92% on room air.
• Breath sounds have improved with diminished crackles, and the patient reports easier breathing.
• The patient is able to expectorate secretions effectively.
• The patient reports reduced fatigue and increased ability to participate in activities of daily living.
• No signs of complications such as sepsis or respiratory failure are noted.

Documentation:

• Date and time of respiratory assessments, including lung sounds, oxygen saturation, and respiratory effort.
• Details of oxygen administration and patient response.
• Medications administered, including antibiotics and their effects.
• Fluid intake and output, as well as signs of dehydration or adequate hydration.
• Patient and family education on pneumonia management and infection prevention.

Signature: [Nurse’s Name]
Date: [Date]