Nursing Care Plan Pneumonia

Nursing care plan: Pneumonia Pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange. Pneumonia is caused by a bacterial or viral infection that is spread by droplets or by contact and is the sixth leading cause of death in the United States. 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 There are two types of pneumonia: community-acquired pneumonia (CAP), or hospitalacquired pneumonia (HAP) or also known as nosocomial pneumonia. Pneumonia may also be classified depending on its location and radiologic appearance. Bronchopneumonia (bronchial pneumonia) involves the terminal bronchioles and alveoli. Interstitial (reticular) pneumonia involves inflammatory response within lung tissue surrounding the air spaces or vascular structures rather than the area passages themselves. Alveolar (or acinar) pneumonia involves fluid accumulation in the lung’s distal air spaces. Necrotizing pneumonia causes the death of a portion of lung tissue surrounded by a viable tissue. 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. Signs and Symptoms 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. Here are 11 nursing diagnosis common to pneumonia nursing care plans (NCP), they are as follows: 1. Ineffective Airway Clearance 2. Impaired Gas Exchange 3. Ineffective Breathing Pattern 4. Risk for Infection 5. Acute Pain 6. Activity Intolerance 7. Hyperthermia 8. Risk for Deficient Fluid Volume 9. Risk for Imbalanced Nutrition: Less Than Body Requirements 10. Deficient Knowledge 11. Deficient Fluid Volume Ineffective Airway Clearance Ineffective Airway Clearance is a common NANDA nursing diagnosis for pneumonia nursing care plans. This diagnosis is related to excessive secretions and ineffective cough or nonproductive coughing. Inflammation and increased secretions in pneumonia make it difficult to maintain a patent airway. Nursing Diagnosis  Ineffective Airway Clearance Related Factors The following are the common related factors for the nursing diagnosis Ineffective Airway Clearance related to pneumonia:  Tracheal bronchial inflammation, edema formation, increased sputum production  Pleuritic pain  Decreased energy, fatigue  Aspiration 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.  Changes in rate, depth of respirations  Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)  Use of accessory muscles  Dyspnea, tachypnea  Cough, effective or ineffective; with/without sputum production  Cyanosis  Decreased breath sounds over affected lung areas  Ineffective cough  Purulent sputum  Hypoxemia  Infiltrates seen on chest x-ray film Desired Outcomes Below are the common expected outcomes for ineffective airway clearance secondary to pneumonia:  Patient will identify/demonstrate behaviors to achieve airway clearance.  Patient will display/maintain patent airway with breath sounds clearing; absence of dyspnea, cyanosis, as evidenced by keeping a patent airway and effectively clearing secretions. Nursing Interventions and Rationale 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 deepbreathing techniques. Nursing Interventions Rationale Assessment Assess the rate, rhythm, and depth of respiration, chest movement, and use of accessory muscles. Tachypnea, shallow respirations and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung due to a compensatory response to airway obstruction. Altered breathing pattern may occur together with use of accessory muscles to increase chest excursion to facilitate effective breathing. Assess cough effectiveness and productivity Coughing is the most effective way to remove secretions. Pneumonia may cause thick and tenacious secretions to patients. Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes. 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 spasms and obstruction. Observe the sputum color, viscosity, and odor. Report changes. Changes in sputum characteristics may indicate infection. Sputum that is discolored, tenacious, or has an odor may increase airway resistance and may warrant further intervention. Assess the patient’s hydration status. Airway clearance is hindered with inadequate hydration and thickening of secretions. Therapeutic Interventions Elevate head frequently. of bed, change position Doing so would lower the diaphragm and promote chest expansion, aeration of lung segments, mobilization and expectoration of Nursing Interventions Rationale secretions. Teach and assist patient with proper deepbreathing exercises. Demonstrate proper splinting of chest and effective coughing while in upright position. Encourage him to do so often.  Deep breathing exercises facilitates maximum expansion of the lungs and smaller airways, and improves the productivity of cough.  Coughing is a reflex and a natural self-cleaning mechanism that assists the cilia to maintain patent airways. It is the most helpful way to remove most secretions. Splinting reduces chest discomfort and an upright position favors deeper and more forceful cough effort making it more effective. Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough or decreased level of consciousness. Note: Suctioning can cause increased hypoxemia; hyper oxygenate before, during, and after suctioning. Fluids, especially warm liquids, aid in mobilization and expectoration of secretions. Fluids help maintain hydration and increases ciliary action to remove secretions and reduces the viscosity of secretions. Thinner secretions are easier to cough out.  Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway secretions. Maintain adequate hydration by forcing fluids to at least 3000 mL/day unless contraindicated (e.g., heart failure). Offer warm, rather than cold, fluids. 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.  Nebulizers humidify the airway to thin secretions and facilitates liquefaction and expectoration of secretions.  Postural drainage may not be as effective in interstitial pneumonias or those causing alveolar exudate or destruction.  Incentive spirometry serves to improve deep breathing and helps Nursing Interventions Rationale 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. Helps mobilize secretions and reduces atelectasis.  Encourage ambulation.  Mucolytics increase or respiratory secretions.  Expectorants increase productive cough to clear the airways. They liquefy lower respiratory tract secretions by reducing its viscosity.  Bronchodilators are medications used to facilitate respiration by dilating the airways. Administer medications as indicated:  mucolytics  expectorants  bronchodilators  analgesics Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort and depress respirations. Increasing the humidity will decrease the viscosity of secretions. Clean the humidifier before use to avoid bacterial growth. Follows progress and effects and extent of pneumonia. Therapeutic regimen, and may facilitate necessary alterations in therapy. Oxygen saturation should be maintain at 90% or greater. Imbalances in PaCO2 and PaO2 may indicate respiratory fatigue.  Use humidified oxygen bedside. Monitor serial chest oximetry readings. liquefy or humidifier x-rays, ABGs, at pulse Assist with bronchoscopy and/or thoracentesis, if indicated. Bronchoscopy is occasionally needed to remove mucous plugs, drain purulent secretions, obtain lavage samples for culture and sensitivity. Nursing Interventions Rationale Thoracentesis is done to drain associated pleural effusions and prevent atelectasis. Anticipate the need for supplemental oxygen or intubation if patient’s condition deteriorates. These measures are needed to correct hypoxemia. Intubation is needed for deep suctioning efforts and provide a source for augmenting oxygenation. Urge all bedridden and postoperative patients to perform deep breathing and coughing exercises frequently. To promote full aeration and drainage of secretions. See Also You may also like the following posts and care plans:  Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!  Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale. Related Nursing Care Plans Related nursing diagnoses you can use to craft another pneumonia nursing care plans.  Impaired Dentition. May be related to dietary habits, poor oral hygiene, chronic vomiting, possibly evidenced by erosion of tooth enamel, multiple carries, abraded teeth.  Impaired oral mucous membrane. Maybe related to breathing through the mouth, malnutrition or vitamin deficiency, poor oral hygiene, chronic vomiting, possibly evidenced by sore, inflamed buccal mucosa, swollen salivary glands, ulcerations, and reports of sore mouth and/or throat.  Legacy care plans (via Scribd): Ineffective Airway Clearance, Risk for Infection, Ineffective Breathing Pattern, Impaired Gas Exchange, Hyperthermia