Nursing Care Plans & Management
Nursing Care Plans & Management
Nursing care plan (NCP) and care management for patients with pneumonia start with assessing the patient’s medical history, performing a respiratory assessment every four (4) hours, physical examination, and ABG measurements. Supportive interventions include oxygen therapy, suctioning, coughing, deep breathing, adequate hydration, and
mechanical ventilation. Other nursing interventions are detailed on the nursing diagnoses in the subsequent sections.
Nursing Problem Priorities
The following are the nursing priorities for patients with pneumonia:
- Improving airway patency
- Improving tolerance to activity
- Maintaining proper fluid volume
- Measures to prevent complications
Nursing Assessment
The main symptoms of pneumonia are coughing, sputum production, pleuritic chest
pain, shaking chills, rapid shallow breathing, fever, and shortness of breath. If left untreated, pneumonia could complicate
hypoxemia, respiratory failure, pleural effusion, empyema, lung abscess, and bacteremia. Initially, pneumonia patients experience a dry, irritating
cough with minimal mucoid sputum. Symptoms may include sternal soreness, fever or chills, night sweats, headache, and general malaise. As the infection progresses, patients may develop shortness of breath, audible breathing sounds (inspiratory stridor and expiratory wheeze), and produce purulent sputum. In severe cases,
blood-streaked secretions may occur due to airway mucosa irritation.
Assess for the following subjective and objective data:
- Changes in rate, depth of respirations
- Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
- Use of accessory muscles
- Dyspnea, tachypnea
- Cough, effective or ineffective; with/without sputum production
- Cyanosis
- Decreased breath sounds over affected lung areas
- Ineffective cough
- Purulent sputum
- Hypoxemia
- Infiltrates seen on chest x-ray film
- Reduced vital capacity
Assess for factors related to the cause of pneumonia:
- Alteration of patient’s O2/CO2 ratio and hypoxia
- Decreased lung expansion and fluid-filled alveoli
- Inflammatory process, tracheal and bronchial inflammation, edema formation, increased sputum production
- Pleuritic pain and alveolar-capillary membrane changes
- Altered oxygen-carrying capacity of blood/release at cellular level
- Altered delivery of oxygen and hypoventilation
- Collection of mucus in airways
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