Pneumonia Nursing Diagnosis, Care Plans, and Nursing Interventions

Overview

Pneumonia is an acute or chronic infection of the lungs characterized by inflammation of the alveoli, often caused by bacteria, viruses, fungi, or aspiration of foreign substances. The infection results in fluid or pus filling the alveolar spaces, leading to impaired oxygen exchange. It can range from mild to life-threatening, especially in older adults, infants, and those with weakened immune systems.

Causes (Related to)

  • Bacterial infection (e.g., Streptococcus pneumoniae, Haemophilus influenzae)
  • Viral infection (e.g., influenza virus, RSV)
  • Fungal infection
  • Aspiration of gastric contents or foreign material
  • Weakened immune system
  • Chronic respiratory conditions
  • Smoking or prolonged exposure to pollutants

Signs and Symptoms (As evidenced by)

Subjective: Cough (productive or dry), chest pain, fatigue, shortness of breath, chills, loss of appetite.

Objective: Fever, tachypnea, tachycardia, hypoxia, decreased breath sounds, crackles or wheezes, cyanosis, changes in mental status in older adults.

Nursing Diagnosis

  1. Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by hypoxia and abnormal ABG results.
  2. Ineffective Airway Clearance related to increased mucus production as evidenced by coarse crackles and productive cough.
  3. Ineffective Breathing Pattern related to inflammation and pain as evidenced by tachypnea and use of accessory muscles.
  4. Risk for Infection related to compromised immune defenses.
  5. Acute Pain related to inflammation and pleuritic chest pain.
  6. Imbalanced Nutrition: Less Than Body Requirements related to decreased appetite and fatigue.
  7. Anxiety related to hospitalization and shortness of breath.
  8. Deficient Knowledge related to lack of information about disease process and self-care.

Expected Outcomes

  • Patient will maintain adequate oxygenation as evidenced by normal ABG values and SpO₂ above 92%.
  • Patient will demonstrate effective coughing and clear lung sounds.
  • Patient will report decreased pain levels.
  • Patient will maintain adequate nutritional intake.
  • Patient and family will verbalize understanding of the pneumonia diagnosis, treatment plan, and preventive strategies.

Nursing Interventions and Rationales

1. Promote Adequate Oxygenation

  • Monitor respiratory rate, depth, and effort regularly. Rationale: Early detection of respiratory distress allows for prompt intervention.
  • Administer supplemental oxygen as prescribed. Rationale: Supports oxygenation and prevents hypoxia.
  • Position patient in semi-Fowler’s or high-Fowler’s position. Rationale: Maximizes lung expansion and eases breathing.

2. Improve Airway Clearance

  • Encourage deep breathing and coughing exercises every 2 hours. Rationale: Promotes mobilization and clearance of secretions.
  • Maintain adequate hydration (oral or IV) to thin secretions. Rationale: Easier clearance reduces airway obstruction.
  • Perform chest physiotherapy if indicated. Rationale: Facilitates mucus drainage.

3. Manage Infection

  • Administer prescribed antibiotics or antivirals promptly. Rationale: Early initiation improves outcomes and reduces complications.
  • Monitor temperature, white blood cell count, and sputum characteristics. Rationale: Tracks infection progress and response to therapy.
  • Implement proper hand hygiene and isolation precautions when appropriate. Rationale: Prevents spread of infection.

4. Relieve Pain

  • Assess pain level using a standardized scale. Rationale: Guides appropriate interventions.
  • Provide prescribed analgesics and evaluate effectiveness. Rationale: Pain relief improves breathing pattern and mobility.
  • Teach splinting techniques during coughing. Rationale: Reduces discomfort and encourages effective cough.

5. Maintain Nutrition and Hydration

  • Offer small, frequent, nutrient-rich meals. Rationale: Conserves energy while maintaining caloric intake.
  • Monitor intake and output. Rationale: Ensures adequate hydration and prevents imbalances.

6. Reduce Anxiety

  • Provide clear explanations of procedures and progress. Rationale: Reduces fear and promotes cooperation.
  • Involve family in care and decision-making when possible. Rationale: Enhances support system and emotional comfort.

7. Patient and Family Education

  • Teach the importance of completing the full course of prescribed medications.
  • Educate on pneumonia prevention measures: vaccinations, smoking cessation, hand hygiene, and avoiding respiratory irritants.
  • Instruct on recognizing early signs of recurrence or worsening condition.

Sample Nursing Care Plans

Care Plan #1: Impaired Gas Exchange

Goal: Patient will maintain SpO₂ > 92% within 24 hours.

Interventions: Oxygen therapy, semi-Fowler’s positioning, regular monitoring, incentive spirometer use.

Evaluation: Patient maintains oxygen saturation and reports improved breathing.

Care Plan #2: Ineffective Airway Clearance

Goal: Patient will demonstrate effective coughing and clear lung sounds within 48 hours.

Interventions: Hydration, deep breathing exercises, chest physiotherapy, suctioning if needed.

Evaluation: Lung sounds clear; minimal secretions.

Care Plan #3: Acute Pain

Goal: Patient will report pain score ≤ 3 within 30 minutes of intervention.

Interventions: Analgesics, splinting during cough, rest periods.

Evaluation: Patient verbalizes comfort improvement.

Care Plan #4: Imbalanced Nutrition

Goal: Patient will consume 75% of meals during hospitalization.

Interventions: Small frequent meals, preferred food items, rest before meals.

Evaluation: Adequate caloric intake maintained.

Care Plan #5: Deficient Knowledge

Goal: Patient will verbalize understanding of pneumonia prevention and management before discharge.

Interventions: One-on-one teaching sessions; provide easy-to-read educational materials.

Evaluation: Patient accurately describes prevention strategies and when to seek help.

Conclusion

Pneumonia requires timely nursing interventions to optimize oxygenation, manage infection, reduce complications, and educate patients for long-term health. Comprehensive nursing care plans tailored to individual needs improve recovery and help prevent recurrence.

Back to blog