Pneumonia Nursing Diagnosis Care Plan NCLEX Review
Nursing Study Guide for Pneumonia
Pneumonia is an infection of the lungs that can be caused by bacteria, fungi, or viruses. It involves the inflammation of the air sacs called alveoli.
When inflamed, the air sacs may produce fluid or pus which can cause productive cough and difficulty breathing.
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Pneumonia can be mild but can also be fatal if left untreated. Severe pneumonia can be life-threatening for patients who are very young, very old (age 65 and above), and immunocompromised (e.g. cancer patients or COPD patients).
Signs and Symptoms of Pneumonia
- Productive cough (viral pneumonia may present as dry cough at first)
- Shortness of breath
- Tachypnea or rapid breathing
- Tachycardia or fast heartbeat
- Myalgia or muscle pain
Types and Causes of Pneumonia
Types of Pneumonia According to Origin
- Community-Acquired Pneumonia. This type of pneumonia refers to getting the infection at home, in the workplace, in school, or other places in the community outside a hospital or care facility.
- Hospital-Acquired Pneumonia. Also called nosocomial pneumonia, this type of pneumonia originates from being admitted in the hospital. Hospital acquired pneumonia may be due to an infected tracheostomy tube, a weakened immune system, or an infected breathing machine, such as a ventilator. Ventilator-associated pneumonia is one of the subtypes of hospital-acquired pneumonia. The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia.
Types of Pneumonia According to Causative Agent
Bacterial Pneumonia. This type of pneumonia can spread through droplet transmission, that is, when an infected person sneezes or coughs, and the other person breathes the air droplets through the nasal or oral airways.
Streptococcus pneumoniae is the causative agent for most of the cases of adult community-acquired pneumonia.
Other bacteria that can cause pneumonia include H. influenzae, Mycoplasma pneumonia, Legionella pneumonia, and Chlamydia pneumoniae.
A less severe form of bacterial pneumonia is called walking or atypical pneumonia, in which the symptoms are very mild and the infected person can do his/her activities of daily living as normal.
Viral pneumonia. Viruses such as RSV (common cause in infants age 1 and below), flu and cold viruses can cause viral pneumonia, which is the second most common type of pneumonia.
It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug.
Fungal pneumonia. Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals.
Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals.
Complications of Pneumonia
- Pleural effusion. If left untreated, pneumonia may cause excessive fluid buildup in the pleural cavity, which is the space between the lungs and the chest cavity. The fluid may also contain the pathogen, leading to pleuritis.
- Bacteremia. The bacteria may enter the blood stream and cause bacteremia, sepsis, or organ failure.
- Trouble sleeping. Coughing and difficulty of breathing may cause insomnia and difficulty to fall asleep. Some patients require to be attached to a breathing machine to allow healing of the lungs.
- Lung abscess. Pockets of pus may form inside the lungs or on their outer layers.
Diagnosis of Pneumonia
- Physical examination and vital signs – fever, tachypnea, tachycardia, and decreased oxygen saturation levels
- Blood tests – elevated white blood cell count may be a sign of an ongoing infection
- Sputum culture – to determine the causative agent
- Imaging – chest X-ray to determine active infection and its severity; bronchoscopy to check any blockage of the airways; CT scan for a more detailed lung imaging
- Arterial blood gas (ABG) test –using an arterial blood sample to measure the oxygen level
- Pleural fluid culture – taking a pleural fluid sample by inserting a needle between the pleural cavity and the ribs in order to determine the causative agent
Treatment of Pneumonia
- Antibiotics. The type of antibiotic is determined after a sputum culture result is obtained and the specific type of bacteria is known. If there is no improvement with the symptoms, the doctor may prescribe a different type of antibiotic. Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. Other antibiotics that may be used for pneumonia include doxycycline, levofloxacin, and combination of macrolide and beta-lactam (amoxicillin or amoxicillin/clavulanate known as Augmentin).
- Cough suppressants. To help alleviate cough and allow the patient to rest, cough suppressants may be given at low doses.
- Fever reducers and pain relievers. Medications such as paracetamol, ibuprofen, and acetaminophen can help lower body temperature and alleviate discomfort.
Nursing Care Plans for Pneumonia
Nursing Care Plan 1
Nursing Diagnosis: Hyperthermia related to the disease process of bacterial pneumonia as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, and profuse sweating.
Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.
|Assess the patient’s vital signs at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Tylenol) administered.|
|Remove excessive clothing, blankets and linens. Adjust the room temperature.||To regulate the temperature of the environment and make it more comfortable for the patient.|
|Administer the prescribed antibiotic and anti-pyretic medications.||Use the antibiotic to treat the bacterial pneumonia, which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.|
|Offer a tepid sponge bath.||To facilitate the body in cooling down and to provide comfort.|
|Elevate the head of the bed.||Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.|
Nursing Care Plan 2
Nursing Diagnosis: Ineffective Airway Clearance related to the disease process of bacterial pneumonia as evidenced by shortness of breath, wheeze, SpO2 level of 85%, productive cough, difficulty to expectorate greenish phlegm
Desired Outcome: The patient will be able to maintain airway patency and improved airway clearance as evidenced by being able to expectorate phlegm effectively, have respiratory rates between 12 to 20 breaths per minutes, oxygen saturation above 96%, and verbalize ease of breathing.
|Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment.|
|Encourage coughing up of phlegm. Suction secretions as needed. Perform steam inhalation or nebulization as required/ prescribed.||To help clear thick phlegm that the patient is unable to expectorate.|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value of at least 96%.|
|Administer the prescribed airway medications (e.g. bronchodilators) and antibiotic medications.||Bronchodilators: To dilate or relax the muscles on the airways. Steroids: To reduce the inflammation in the lungs. Antibiotics: To treat bacterial pneumonia.|
|Elevate the head of the bed and assist the patient to assume semi-Fowler’s position.||Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively.|
Other possible nursing diagnoses:
- Impaired Gas Exchange
- Activity Intolerance
- Ineffective Breathing Pattern