Pneumonia is essentially when fluid or pus gets trapped in the alveoli of the lungs (pictured below) and impaired gas exchange results. This can impact one or both lungs. Below are the important differentiations of pneumonia. Establishing the kind of pneumonia is essential, in that the treatment course can differ.
The first picture below is normal, unobstructed gas exchange. If you look to the second picture, you see the alveoli have an accumulation of fluid in them, which impairs the gas exchange that should occur to provide appropriate oxygenation into circulation. What results is coughing (many times producing phlegm), fever, chills, chest pain or pain when coughing, or cold/flu like symptoms. Inflammation can also occur. Antibiotics are administered, and the choice of which is dependent upon the offending pathogen, any other medical conditions going on with the patient, and if there are any antibiotic resistances present . Oral antibiotics are given typically for community-acquired pneumonia, however if the patient is hospitalized, they will most likely receive IV antibiotics. Steroids are typically administered to address inflammation.
Pneumonia can be caused by a virus, bacteria, fungus, or from inhaling something (a chemical, inhalant, or aspirating on food or fluid). This can be of particular risk to those with a weakened immune system or unable to keep your own airway clear (for example, unable to cough or maintain consciousness due to neurological or other injury).
Resolve the infection, optimize gas exchange, minimize impact from impaired gas exchange.
Obtain appropriate labs (antibiotic troughs, sputum cultures, ABGs, etc.)
Gives us a baseline; identifies pathogens, and enables us to evaluate if interventions are effective
Complete a full respiratory assessment to detect changes or further decompensation as early as possible, and notify MD as indicated
Enables quicker interventions and may change them (for example, wheezing noted on auscultation would potentially indicate steroids and a breathing treatment, while crackles could require suctioning, repositioning, and potential fluid restriction)
Promote normothermia (warm patient if hypothermic, cool patient and administer antipyretics if hyperthermic)
Normothermia optimizes oxygen consumption
Activity intolerance is common because of decreased gas exchange; cluster your care to conserve your patient’s energy for essential tasks like ambulation, coughing and deep breathing, and eating
Promote airway clearance
We want to encourage coughing to remove phlegm; do not suppress cough unless clinically indicated. If patient is able to clear their own airway, continue to encourage this. If not, suction frequently and consider an advanced airway to ensure a patent airway, which ultimately maximizes gas exchange. Getting phlegm out is important.
Optimize fluid balance
Patients with pneumonia may not be consuming adequate oral intake due to fatigue or not feeling well, but hydration is essential to healing. Patients may need IV fluids if PO intake is inadequate.
Assess and treat pain
If patients are not coughing because of pain, it will only allow fluid to continue to build. Treat pain appropriately and encourage them to cough to clear phlegm.
Encouraging coughing and deep breathing
Coughing and deep breathing encourages expectoration, which enables better gas exchange
Patients with pneumonia typically tire easily and have poor appetites, but need appropriate nutrition and hydration to heal
Administer supplemental oxygen as appropriate
Due to the impaired gas exchange, oxygen doesn’t make it into circulation as easily. Providing additional oxygen supports this as much as possible. Use caution in patients with underlying lung conditions.
Ensure patent airway
If a patient has unmanageable secretions or is unable to maintain consciousness and keep their airway clear, they must be supported (positioning, advanced airway, etc) to ensure adequate oxygen delivery
Energy conservation is essential; patients should focus on breathing, providing self care, coughing/deep breathing, and ambulation. Patients cannot adequately participate in these important activities if they are not maximizing their time to rest. Appropriate sleep promotes healing.
Administer antibiotics in a timely fashion, draw troughs appropriately
Patients may be on antibiotics, therefore it’s essential to ensure they are administered at the appropriate time and not delayed, as this will impair their efficacy. Also, trough levels will most likely to be ordered to assess if the patient is getting too much, too little, or just enough of the antibiotic. The timing of these labs related to administration times are essential for accuracy.
Prevent further infection
Patients may have invasive lines like a internal urinary catheter, central venous catheter, endotracheal tube, and so forth. It is essential to care for these devices properly to prevent further infection.
Educate patient and loved ones on the importance of energy conservation, effective airway clearance, nutrition, as well as coughing and deep breathing
Patients must be aware of how these aspect of recovery are pertinent so they will be more likely to participate and remain compliant.
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All right guys, let’s work through an example Nursing Care Plan for a patient with pneumonia. So again, the first step is to gather all information. Now, in these examples, we’re using a hypothetical patient and we’re just assuming that the only problem they have is pneumonia. Now, in theory, even with this, you’d have all of this extra information, but right now we’re just going to talk about relevant information for a pneumonia patient. So what kind of subjective data would we have? Here’s a patient who has pneumonia. What are they telling you? Well, they might tell you that they are short of breath and maybe they have had a fever. So their temp is high. That’s objective and chills, right? Chills are subjective. And maybe you’re noticing that they’re having this increased work of breathing and working really, really hard, or their respiratory rate is really high. Um, maybe they have a cough that you can actually hear, or possibly they reported one. Either way you’re going to see sputum, and especially if they’ve got a bad pneumonia and it’s infected, you’re gonna see green sputum, which is gross. Um, you might hear some ronchi because remember what’s happening in pneumonia. They have a ton of fluid in their lungs, might even have an infection. So you’re going to hear some ronchi. You might even hear some wheezing.
And of course this patient’s gonna be exhausted. If you’ve ever had pneumonia, you know that you’re really, really tired. And then if they’re having really low oxygen levels, then you might actually also see some decreased LOC. So again, when you’re gathering information on a patient, you’re also gonna have bowel sounds and urine output and you’re also gonna have a blood pressure and all of this other information. So part of putting together a care plan is picking out the relevant information, which is part of step two. So step two is analyze the information. And so we’re just going to go ahead and say we’ve analyzed, we’ve determined we don’t need this. This is the information we’re looking at specifically for a patient with pneumonia. So we analyze the information, we gather everything and we decide what of the things I’ve come up with.
What is actually a problem. So here we have a patient with pneumonia. So what’s their problem? Well, their problem is they have an infection in their lungs, right? They’ve got all this fluid and possibly even infection. That of course puts them at risk for something like Sepsis, right? If the infection gets too bad, they can definitely get a lot worse. Let’s see, what other problems do we have while we have that ronchi and all that extra sputum. We’ve got all those extra secretions in the airway, right? So these are problems. This is, this is a significant problem for this patient. And we saw that their SpO2 was low. So what needs to be improved is their SpO2, their SpO2 level is really low and I’d like to see it higher, right? So really we’re just analyzing what’s actually a problem, what’s going on with this patient, what do we need to fix and what can we do? And then we’re going to establish what’s my priority? Well, listen, as easy as it is, guys, we can just go ABCs here, right? So this is infection. This is airway, this is oxygenation, which is kind of have to do with breathing a little bit. So hey listen, airway comes first right? So that just makes our life a whole lot easier because the ABC’s always happen. So keeping their airway protected, allowing them to get the oxygen that they need, that’s definitely going to be our priority. So now we can ask our how questions. So for each one we’re going to ask how we knew it was a problem. And this is just where we start linking our data together. So we’re going to link our data, we’re going to link specific data to a specific problem and then give it a specific intervention. So that’s where we talk about how we’re actually going to address the problem.
So I have a patient, they have a ton of secretions, they have ronchi in their lungs, they have an infection in their lungs and their oxygenation is poor. So what kinds of things am I going to do? Right? Well, I can give them oxygen, right? I’m probably going to monitor their oxygen as well. Monitor SpO2. I can do some sputum cultures and then give antibiotics after that, right? To try to treat that infection. Um, maybe I can encourage them to cough and deep breathe cause that’s going to help them clear those secretions out. Right? What other things can we do for those two to help open their airways? Can we do incentive spirometers right? That’s going to help open up their airway. Um, I can monitor their airway clearance. Remember, they’re fatigued. So what if I would actually promote rest, because they’re gonna be really tired.
They’re not gonna be oxygenating well. So clustering my care, promoting rest, that’s going to be really helpful. So these are all little things that we can do for this patient to try to address those problems we already identified. And then how are we going to know it gets better? Well, one of the big things we said was the problem was their airway clearance, right? So maybe we say they have a patent airway or they’re able to clear their own airway. Right? What about that oxygen level? We can say that their SpO2 increases or maybe that it’s greater than 92, whatever your goal is that you want to set for your patient. And then we talked about their infection, didn’t we? There were a little bit worried about the fact that they have an infection. Um, and so maybe we could say that their signs and symptoms of infection decrease or maybe just that they don’t develop sepsis.
That’s always a good thing, right? So these are all things you know, ronchi. So I could say their lungs are clear. There’s a lot of things I could do that would give me evidence that this patient is better or that my interventions are working. So from there we’re going to translate, we’re going to get it into the terms that we need to use and we’re going to be able to concisely communicate what the problem is for this patient. And again, here at NRSNG we love to use nursing concepts because we live think they give you big picture priorities instead of forcing you to drill down to really, really specific issues. So just use whatever you are required to use if there’s something specific. Otherwise just come up with some top things. So for this case we said Airway was our biggest issue, didn’t we?
So we said I think our number one would be airway clearance, right? If got a ton of sputum, a ton of secretions, they’ve got ronchi in their lungs, we really need to make sure their airways are open because if you give oxygen to somebody with a closed airway, doesn’t do anything for them, does it? So speaking of oxygen, I would say that oxygenation is probably our second issue. If I have a ton of fluid in my lungs, um, I’m not really going to be able to oxygenate appropriately. So I would say that we could fairly say that’s our second problem. And we know with pneumonia, oftentimes there’s infection involved. So I think it’s fair to say infection control would be another problem. So here we are, we’ve translated it, we’ve said, all right, my top three priorities for this patient are airway clearance, oxygenation and infection control.
So now we take those top things and the information we’ve gathered. And We link everything together. So we’re able to link our specific problem to the data, to the intervention, to the rationale, and to the expected outcome for that intervention. So again, we said our primary problems are airway clearance, oxygenation and infection control. So let’s take everything we just talked about and let’s just transcribe it. We’re just getting it on paper. We’re concisely communicating it in one place.
So what tells me that I have a problem with airway clearance. My patient has a cough, they have a lot of secretions. Um, and I have heard ronchi in their lungs. And again, you might’ve heard ronchi, you might’ve heard wheezes either way. If you’ve got airways filled with fluid and secretions, then we can’t get the oxygen in it. All right? So first thing is clear out the airway, then we give the oxygen.
So what am I going to do? We kind of talked about this already. I’m going to assess that cough. I’m going to make sure that it’s getting better. I’m going to make sure it’s improving. I’m going to assess those lung sounds and I’m probably gonna use incentive spirometer. [00:08:00] And I might even use, um, turn cough, deep breathe. I might even just encourage that cough, because it really helps them to clear those things out of their airway. I know coughing can be very uncomfortable, especially in these moments where you’ve been coughing and coughing and coughing. But telling your patient, Hey, if we can cough and get this stuff out, you’re gonna feel a lot better. So increased sputum means increased risk for aspiration, but also just poor oxygenation, right? So we need to be able to assess whether or not they have improved or worsened.
And we can’t do that if we don’t assess, right? So that’s why we’re gonna make sure we do those assessments. And then we do things like an incentive spirometer or turn cough, deep breathe to help open up the lungs and open up the airways. Encourage coughing and clearing secretions. So expected outcome. Again, we’re still talking about airway clearance here, right? This is where we link everything. We line everything up. So expected outcomes. My patient has a patent Airway, my patient can clear their own secretions and my lungs are clear to Auscultation, CTA, clear to auscultation. So again, we’re just lining up our data and our priorities here. We’ve already gathered everything. Now we’re just putting it on paper. So oxygenation data, my SpO2 was low. Maybe they had a high respiratory rate or work of breathing because their body’s like, oh my gosh, give me more oxygen. Right?
And that fatigue, a lot of times that fatigue is caused by Hypoxia. So what are we going to do? Well, we’re going to assess that respiratory rate. We’re going to watch that SpO2, we’re going to promote rest. We’re going to cluster our care because of this fatigue, because again, it’s just exhausting to not have enough oxygen. Um, and then we’re going to give oxygen if we need to. This PRN is as needed. Make sure that you know what your orders are, um, so that you know what you’re aiming for, right? Get provider orders for oxygen if you don’t have them. So why do we do the assessments? Well, we need to track progress and how they’re doing. We see fatigue with low oxygen like we said, so that’s why we’re going to promote rest and cluster care. And then of course giving supplemental oxygen is going to help keep that SpO2 up.
So what are our expected outcomes. Again, we’re just linking data, right? So I want to see that respiratory rate within normal limits. I want my patient to tell me they feel better, right? Report decreased work of breathing, report decreased fatigue and I want to see that SpO2 stay above 92 so all of these are things that are going to tell me that this is no longer a problem. All of these things are going to tell me that this airway clearance is no longer a problem. All right, last one. Infection control. Patient had fever, chills, we saw green sputum and hey, we may even have seen like an increased white blood cell count or an x ray that was whited out with fluid in the lungs, right? There’s a lot of things that could have told us there was infection happening. So what am I going to do?
I’m going to check cultures. I always do cultures first, right? Because if I give antibiotics before I do cultures, I’m going to skew the results, right? So cultures I’m going to give antibiotics, I might give antipyretics for that fever and I’m going to monitor their symptoms. I want to make sure that they’re getting better. So again, rationales – cultures to determine the organism, antibiotics and antipyretics to treat the infection and the symptoms and monitor temp because we really want to make sure that we are controlling that fever. So decreased signs of infection, no signs of Sepsis, cause that would be bad. That would mean they progressed and got worse. And we want to make sure we get their temp to within normal limits. Now, normal is relative, make sure you know what your targets are either for your facility or from your provider.
So just to recap on the five steps of writing an excellent nursing care plan, collect all your information, analyze that information, pick out what’s relevant to that patient or those problems that you have determined. Plan your interventions and figure out how you’re going to evaluate them. So that’s asking your how questions and then translate it, put it into whatever terms you need to use, transcribe it, get it on paper, use whatever form or template you prefer or you need to use. Just get it on paper.
So again, remember we are just looking at this isolated pneumonia patient where pneumonia is the only problem that they have. Remember that it might be that they have pneumonia, but they also have hypertension and they also have a pressure ulcer. And so you can look at every piece of information you have, all of your assessment data, and then determine your priorities. So Airway and oxygenation is still probably gonna be at the top, but it’s probably more important that I, you know, assess or you know, prevent them from getting a worsened pressure ulcer than it is that I educate them on cough and deep breathe. Right? So there’s different, definitely going to be crossover priorities for this, but for this case, this was just a patient with isolated pneumonia. So I hope that was helpful. Definitely check out the rest of the examples of nursing care plans and check out our nursing care plan library, 130 plus nursing care plan examples. All right, guys, go out and be your best selves today and as always, happy nursing.