Pneumonia is an infection of the lungs caused by a bacteria or virus. In healthy individuals, pneumonia is not usually life-threatening and does not require hospitalization. Those at higher risk, such as the very young or old, patients with compromised immune systems, or who already have a respiratory comorbidity, may require inpatient care and treatment.
Pneumonia can be hospital-acquired, which presents after the patient has been admitted for 2 days. This is most common in intensive care units usually resulting from intubation and ventilation support. These critically ill patients have a high mortality rate of 25-50%.
Community-acquired pneumonia occurs outside of the hospital or facility setting. The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. Touching an infected object and then touching your nose or mouth can also transfer the germs.
The Nursing Process
Pneumonia will be one of the most frequent infections the nurse will encounter and treat. The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment.
Nurses also play a role in preventing pneumonia through education. Patients with compromised immune systems such as those with COPD, HIV, or autoimmune diseases should be educated on the risk and how to protect themselves. Smoking further increases the risk of developing pneumonia and should be avoided. Nurses should assess for and encourage pneumonia vaccines for eligible populations.
Nursing Care Plans Related to Pneumonia
Ineffective Airway Clearance Care Plan
Pneumonia may increase sputum production causing difficulty in clearing the airways.
Nursing Diagnosis: Ineffective Airway Clearance
- Poor cough reflex
- Secretions in the bronchi or alveoli
- Excessive mucus
- Comorbidities: COPD, asthma, cystic fibrosis
As evidenced by:
- Shortness of breath
- Diminished lung sounds or crackles/rhonchi
- Ineffective cough
- Observed sputum production
- Changes in respiratory rate and rhythm
- Patient will maintain a patent airway
- Patient will demonstrate appropriate airway clearance techniques
- Patient will display improvement in airway clearance as evidenced by clear breath sounds and an even and unlabored respiratory rate
Ineffective Airway Clearance Assessment
1. Monitor for respiratory changes.
Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop.
2. Assess the ability and effectiveness of cough.
Pneumonia infection causes inflammation and increased sputum production. The patient needs to be able to effectively remove these secretions to maintain a patent airway. Patients who are weak or lack a cough reflex may not be able to do so. This also increases the risk for aspiration pneumonia.
3. Obtain a sputum sample for culture.
If the patient can cough, have them expectorate sputum for testing. If they cannot, sputum can be obtained via suctioning. Sputum samples can be cultured to appropriately treat the type of bacteria causing infection.
Ineffective Airway Clearance Interventions
1. Assist with respiratory devices and techniques.
Flutter valves mobilize secretions facilitating airway clearance while incentive spirometers expand the lungs. The nurse should instruct on how to properly use these devices and encourage their use hourly. The nurse can also teach coughing and deep breathing exercises.
2. Suction as needed.
Patients who have a tracheostomy may need frequent suctioning to keep airways clear. Patients who are weak or fatigued with an ineffective cough can be taught how to suction themselves.
3. Administer nebulizer treatments and other medications.
Nebulizer treatments can loosen secretions in the lungs while mucolytics and expectorants can help thin mucus and make it easier to cough up.
4. Encourage movement and positioning.
Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. Immobile patients or those who need assistance should be turned every 2 hours, assisted into an upright position, or transferred into a chair to promote lung expansion.
Impaired Gas Exchange Care Plan
Impaired gas exchange is closely tied to Ineffective airway clearance. Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation.
Nursing Diagnosis: Impaired Gas Exchange
- Fluid and mucus in the alveoli
- Hypoventilation causing a lack of oxygen delivery
As evidenced by:
- Patient will display appropriate oxygenation through ABGs within normal limits
- Patient will demonstrate appropriate actions to promote ventilation and oxygenation
Impaired Gas Exchange Assessment
1. Assess lung sounds and vital signs.
Assess breath sounds, respiratory rate and depth, sp02, blood pressure and heart rate, and capillary refill to monitor for signs of hypoxia and changes in perfusion.
2. Assess for mental status changes.
Poor oxygenation leads to decreased perfusion to the brain resulting in a decreased level of consciousness, restlessness, agitation, and lethargy.
3. Monitor ABGs and oxygen saturation.
Decreasing sp02 signifies hypoxia. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. If abnormal, the lungs are not oxygenating adequately causing poor perfusion of the tissues.
Impaired Gas Exchange Interventions
1. Encourage rest and limit exertion.
Patients may not be able to tolerate too much activity. Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption.
2. Use narcotics and sedatives with caution.
Narcotics for pain control or anti-anxiety medications should be monitored closely as they can further suppress the respiratory system.
3. Administer oxygen.
Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels.
Risk For Infection Care Plan
Pneumonia is an infection itself but a risk for infection nursing diagnosis is appropriate as untreated pneumonia can progress into a secondary infection or sepsis.
Nursing Diagnosis: Risk For Infection
- Inadequate primary defenses: decreased ciliary action, respiratory secretions
- Invasive procedures: suctioning, intubation
- Presence of existing infection
- Worsening in condition leading to immobility, immunosuppression, and malnutrition
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention.
- Patient will not develop a secondary infection or sepsis
- Patient will display improvement in infection evidenced by vital signs and lab values within normal limits
Risk For Infection Assessment
1. Monitor for worsening signs of infection or sepsis.
Dropping blood pressure, hypothermia or hyperthermia, elevated heart rate, and tachypnea are signs of sepsis that require immediate attention.
2. Assess lab values.
An elevated white blood count is indicative of infection. This is an expected finding with pneumonia, but should not continue to rise with treatment. If sepsis is suspected, a blood culture can be obtained.
3. Consider sources of infection.
Any inserted lines such as IVs, urinary catheters, feedings tubes, suction tubing, or ventilation tubes are potential sources of infection. Remove unnecessary lines as soon as possible. Surgical incisions and any skin breakdown should be monitored for redness, warmth, drainage, or odor that signals an infection.
Risk For Infection Interventions
1. Administer antibiotics.
A diagnosis of pneumonia will warrant antibiotic treatment. If the patient’s condition worsens or lab values do not improve, they may not be receiving the correct antibiotic for the bacteria causing infection.
2. Encourage fluid intake and nutrition.
Hydration is vital to prevent dehydration and supports homeostasis. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. Encouraging oral fluids will mobilize respiratory secretions. Proper nutrition promotes energy and supports the immune system.
3. Implement precautions to prevent infection.
Proper handwashing is the best way to prevent and control the spread of infection. The patient may have a limit to visitors to prevent the transmission of infections. Always maintain sterility or aseptic techniques when performing any invasive procedure.
4. Promote skin integrity.
The skin is the body’s first barrier against infection. Skin breakdown allows pathogens to enter the body. If a patient is immobile they must be repositioned every 2 hours to maintain skin integrity. Keep skin clean and dry through frequent perineal care or linen changes.
References and Sources
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- Pneumonia. (n.d.). Better Health Channel. Retrieved February 9, 2022, from https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pneumonia
- Pneumonia: Symptoms, Treatment, Causes & Prevention. (2020, June 15). Cleveland Clinic. Retrieved February 9, 2022, from https://my.clevelandclinic.org/health/diseases/4471-pneumonia
- Popkin, B. M., D’Anci, K. E., & Rosenberg, I. H. (2010). Water, hydration, and health. Nutrition reviews, 68(8), 439–458. https://doi.org/10.1111/j.1753-4887.2010.00304.x
- Shetty, K., & Brusch, J. L. (2021, April 15). Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. Medscape Reference. Retrieved February 9, 2022, from https://emedicine.medscape.com/article/234753-overview#a4
- Testing for Sepsis. (2022, January 26). Sepsis Alliance. Retrieved February 9, 2022, from https://www.sepsis.org/sepsis-basics/testing-for-sepsis/
- Yang, Fang1#; Yang, Yi1#; Zeng, Lingchan2; Chen, Yiwei1; Zeng, Gucheng1 Nutrition Metabolism and Infections, Infectious Microbes & Diseases: September 2021 – Volume 3 – Issue 3 – p 134-141 doi: 10.1097/IM9.0000000000000061 (Pneumonia: Symptoms, Treatment, Causes & Prevention, 2020)