Pneumonia Nursing Diagnoses

Nursing Diagnoses

  • Impaired gas exchange
  • Ineffective breathing pattern related to inflammation and chest discomfort
  • Acute pain (chest) related to inflammation and ineffective pain management and/or comfort measures
  • Activity intolerance related to chest discomfort, inflammation, shortness of breath, generalized weakness

Planning

  • Clear breath sounds
  • Normal breathing patterns
  • No signs of hypoxia
  • Normal chest x-ray
  • Normal white blood cell (WBC) count
  • Absence of complications related to pneumonia.

Nursing implementation

  • Health Promotion
    • Teach hygiene, nutrition, rest, regular exercise to maintain natural resistance
    • Cough or sneeze into elbow, not hands
    • Avoid cigarette smoke
    • Prompt treatment of URIs
    • Influenza and pneumococcal vaccination
  • Prevent pneumonia in at risk patients
    • Proper positioning to prevent aspiration
    • Reposition patient every 2 hours
    • Strict adherence to ventilator bundle to prevent VAP
    • Elevate head-of-bed 30 degrees and have sit up for all meals
    • Assist with eating, drinking, taking meds as needed
    • Assess for gag reflex
    • Early mobilization
    • Incentive spirometry
    • Twice-daily oral hygiene
    • Pain management
    • Strict medical asepsis
    • Hand hygiene
    • Respiratory devices
    • Suctioning
    • Avoid unnecessary antibiotic usage
  • Ambulatory care
    • Teach the patient about
      • Importance of taking every dose of the prescribed antibiotic, any drug-drug and food-drug interactions for the prescribed antibiotic, and the need for adequate rest to facilitate recovery.
      • Drink plenty of liquids (at least 6 to 10 glasses/day, unless contraindicated) and to avoid alcohol and smoking.
      • A cool mist humidifier or warm bath may help the patient breathe easier.
      • Explain that a follow-up chest x-ray may be done in 6 to 8 weeks to evaluate resolution of pneumonia
      • Information about available influenza and pneumococcal vaccines.

Evaluation

  • Effective respiratory rate, rhythm, and depth of respirations
  • Lungs clear to auscultation
  • Reports pain control
  • SpO2 ≥ 95
  • Free of adventitious breath sounds
  • Clear sputum from airway