Nursing Diagnosis Care Plans for Pneumonia: A Comprehensive Guide

What is Pneumonia?

Pneumonia is an inflammatory condition affecting the lung parenchyma, characterized by alveolar edema and congestion. This inflammation significantly impairs gas exchange within the lungs. Primarily caused by bacterial or viral infections, pneumonia spreads through respiratory droplets or direct contact. In the United States, it ranks as the sixth leading cause of death, highlighting its severity and prevalence.

For individuals with healthy lungs and robust immune systems prior to infection, the prognosis for pneumonia is generally favorable. However, pneumonia poses a greater risk to vulnerable populations, including infants and the elderly, smokers, individuals who are bedridden, malnourished, hospitalized, immunocompromised, or those exposed to Methicillin-resistant Staphylococcus aureus (MRSA).

For an in-depth understanding of the pathophysiology, medical treatments, and surgical interventions for pneumonia, please refer to our comprehensive Pneumonia nursing study guide.

Pneumonia is classified into several types based on its origin and the patient’s condition:

Type of Pneumonia	Description	Common Causes
Community-Acquired Pneumonia (CAP)	Pneumonia acquired in community settings or within 48 hours of hospital admission. Most prevalent in individuals under 60 without co-existing conditions and those over 60 with comorbidities. Older adults are at a higher risk.	Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, viruses (e.g., respiratory syncytial virus, adenovirus), fungal pathogens.
Health Care–Associated Pneumonia (HCAP)	Pneumonia that develops in patients residing in long-term care facilities or outpatient settings. Often caused by multidrug-resistant (MDR) pathogens, necessitating immediate and targeted antibiotic therapy.	Multidrug-resistant bacteria such as Pseudomonas aeruginosa, MRSA.
Hospital-Acquired Pneumonia (HAP)	Pneumonia that occurs 48 hours or more after hospital admission. Frequently associated with higher mortality rates due to virulent and resistant organisms. Common in patients with chronic illnesses, prolonged hospital stays, or use of medical devices like respiratory equipment.	Enterobacter, Escherichia coli, Klebsiella, Proteus, Staphylococcus aureus (including MRSA), Pseudomonas aeruginosa.
Ventilator-Associated Pneumonia (VAP)	A subtype of HAP, specifically occurring in patients who have been on mechanical ventilation for at least 48 hours. The incidence increases with prolonged ventilation.	Early-onset VAP is often caused by antibiotic-sensitive bacteria, while late-onset VAP is typically associated with MDR bacteria.
Pneumonia in Immunocompromised Host	Pneumonia that is common in individuals with weakened immune systems, such as those on immunosuppressants, chemotherapy, or with AIDS. This type has higher morbidity and mortality rates.	Pneumocystis jiroveci, fungi, Mycobacterium tuberculosis, gram-negative bacilli (Klebsiella, Escherichia coli, Pseudomonas).
Aspiration Pneumonia	Pneumonia resulting from the inhalation of foreign substances, including bacteria or gastric contents, into the lungs. Common pathogens can vary depending on the nature of the aspirate and can occur in both community and hospital settings.	Anaerobes, Staphylococcus aureus, Streptococcus species, gram-negative bacilli (Escherichia coli, Klebsiella).

Nursing Care Plans and Management

Effective nursing care plans and management for patients with pneumonia begin with a thorough assessment. This includes reviewing the patient’s medical history, conducting respiratory assessments every four hours, performing physical examinations, and analyzing arterial blood gas (ABG) measurements. Essential supportive interventions include oxygen therapy, suctioning, encouraging coughing, deep breathing exercises, ensuring adequate hydration, and, in some cases, mechanical ventilation. Further nursing interventions are elaborated within the nursing diagnoses sections that follow.

Prioritized Nursing Problems

The primary nursing priorities for patients diagnosed with pneumonia are:

• Enhancing airway patency
• Improving activity tolerance
• Maintaining fluid balance
• Preventing potential complications

Comprehensive Nursing Assessment

The primary clinical manifestations of pneumonia include cough, sputum production, pleuritic chest pain, shaking chills, rapid and shallow breathing, fever, and shortness of breath. Untreated pneumonia can lead to serious complications such as hypoxemia, respiratory failure, pleural effusion, empyema, lung abscess, and bacteremia. Initially, patients may present with a dry, irritating cough with minimal mucoid sputum. Early symptoms can also include sternal soreness, fever or chills, night sweats, headache, and general malaise. As the infection progresses, patients may develop increased shortness of breath, audible abnormal breathing sounds (inspiratory stridor and expiratory wheeze), and produce purulent sputum. In severe cases, blood-streaked secretions may occur due to irritation of the airway mucosa.

Conduct a thorough assessment to identify the following subjective and objective data:

• Changes in respiratory rate and depth
• Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
• Use of accessory muscles for breathing
• Presence of dyspnea and tachypnea
• Character of cough: effective or ineffective, productive or non-productive
• Cyanosis
• Decreased breath sounds over affected lung areas
• Ineffective cough effort
• Purulent sputum characteristics
• Hypoxemia (low blood oxygen levels)
• Infiltrates evident on chest X-ray
• Reduced vital capacity

Assess for factors related to the etiology of pneumonia:

• Imbalance in patient’s oxygen/carbon dioxide ratio and hypoxia
• Reduced lung expansion and fluid accumulation in alveoli
• Inflammatory processes, tracheal and bronchial inflammation, edema formation, increased sputum production
• Pleuritic pain and changes in the alveolar-capillary membrane
• Altered oxygen-carrying capacity of the blood or impaired oxygen release at the cellular level
• Impaired oxygen delivery and hypoventilation
• Accumulation of mucus in the airways

Nursing Diagnoses for Pneumonia

Nursing diagnoses for pneumonia are formulated based on comprehensive patient assessments and the nurse’s professional clinical judgment. These diagnoses are individualized to each patient’s unique condition. While the application of nursing diagnoses may vary across different healthcare settings, the nurse’s expertise is critical in shaping the care plan to effectively address the patient’s prioritized needs. Based on thorough assessment data, common nursing diagnoses for pneumonia include:

• Ineffective Airway Clearance related to excessive secretions and ineffective cough.
• Impaired Gas Exchange related to alveolar-capillary membrane changes and fluid accumulation in the lungs.
• Ineffective Breathing Pattern related to pain and inflammatory processes.
• Hyperthermia related to infectious process.
• Activity Intolerance related to decreased oxygenation and fatigue.
• Acute Pain related to inflammation and coughing.
• Deficient Fluid Volume related to increased respiratory rate and fever.
• Imbalanced Nutrition: Less Than Body Requirements related to increased metabolic demands and decreased appetite.
• Risk for Infection spread related to inadequate primary defenses and environmental exposure.
• Deficient Knowledge related to lack of information about condition, treatment, and prevention.

Nursing Goals for Pneumonia Patients

The goals and expected outcomes for patients with pneumonia are designed to address their specific needs and improve their overall respiratory health. These may include:

• The patient will exhibit improved ventilation and oxygenation of tissues, maintaining ABG levels within acceptable limits and demonstrating no signs of respiratory distress within 48 hours of interventions.
• The patient will maintain optimal gas exchange, as evidenced by stable ABG levels and oxygen saturation consistently above 92% within 24 hours.
• The patient will actively engage in interventions to maximize oxygenation, such as performing deep breathing exercises and adhering to prescribed oxygen therapy within 24 hours.
• The patient will identify and demonstrate effective airway clearance behaviors, including effective coughing and use of an incentive spirometer, within 48 hours.
• The patient will maintain a patent airway with clear breath sounds and absence of dyspnea or cyanosis, indicated by effective secretion clearance within 24 hours.
• The patient will report a pain level that is managed or reduced to a tolerable level within a specified timeframe, allowing for effective breathing and participation in care activities.
• The patient will maintain adequate hydration, evidenced by balanced fluid intake and output, stable vital signs, and moist mucous membranes throughout the duration of care.
• The patient will demonstrate understanding of pneumonia management, including medication regimen, importance of follow-up, and preventive measures against recurrence.
• The patient will achieve a body temperature within normal limits within 24-48 hours, indicating effective response to treatment and infection control.
• The patient will progressively increase activity tolerance, participating in daily activities without significant shortness of breath or fatigue.

Nursing Interventions and Rationales

Therapeutic nursing interventions and actions for patients with pneumonia are designed to address the specific nursing diagnoses and achieve the established patient goals. These interventions are crucial for managing symptoms, improving respiratory function, and preventing complications.

1. Managing Ineffective Airway Clearance

To effectively manage excessive secretions and ineffective coughing associated with pneumonia, nursing interventions focus on promoting secretion mobilization and enhancing cough effectiveness.

Nursing Diagnosis

Ineffective Airway Clearance related to excessive secretions and ineffective cough.

Expected Outcomes

• Patient will maintain or improve airway patency, evidenced by effective coughing, reduced sputum production, clear lung sounds upon auscultation, and oxygen saturation maintained at 90% or above.
• Patient will demonstrate effective airway clearance and stable respiratory status, with no recurrence of pneumonia symptoms throughout the recovery period.

Nursing Interventions and Rationales:

1. Assess respiratory rate, rhythm, depth, chest movement, and use of accessory muscles.

• Rationale: Tachypnea, shallow respirations, and asymmetric chest movement are common due to chest discomfort and lung fluid, reflecting the body’s compensatory response to airway obstruction. Altered breathing patterns and accessory muscle use indicate increased effort to facilitate effective breathing.

2. Evaluate cough effectiveness and productivity.

• Rationale: Coughing is the primary mechanism for clearing secretions. Pneumonia often leads to thick, tenacious secretions that require effective removal to prevent impaired gas exchange and delayed recovery. Encourage hydration of 2 to 3 liters per day, if not contraindicated, to help thin and loosen secretions.

3. Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds (crackles, wheezes).

• Rationale: Decreased airflow indicates areas of fluid consolidation. Bronchial breath sounds may also be present in these areas. Crackles, rhonchi, and wheezes are heard during inspiration and expiration due to fluid accumulation, thick secretions, and airway spasms or obstruction.

4. Observe sputum color, viscosity, and odor; report any changes.

• Rationale: Changes in sputum characteristics can indicate infection progression or secondary infections. Discolored, tenacious, or odorous sputum suggests increased airway resistance and the need for further intervention.

5. Assess patient’s hydration status.

• Rationale: Inadequate hydration thickens secretions, hindering airway clearance. Maintaining proper hydration is crucial for thinning secretions and facilitating expectoration.

6. Elevate the head of the bed and encourage frequent position changes.

• Rationale: Elevating the head and frequent repositioning lower the diaphragm, promoting chest expansion, aeration of lung segments, and mobilization and expectoration of secretions.

7. Perform suctioning as indicated by frequent coughing, adventitious breath sounds, or desaturation related to airway secretions.

• Rationale: Suctioning mechanically clears the airway in patients unable to cough effectively due to weakness, ineffective cough, or decreased level of consciousness. Note: Suctioning can induce hypoxemia; hyperoxygenate before, during, and after suctioning.

8. Maintain adequate hydration by encouraging fluid intake of at least 3000 mL/day unless contraindicated (e.g., heart failure). Offer warm fluids rather than cold.

• Rationale: Adequate hydration, especially with warm liquids, aids in mobilizing and expectorating secretions. Fluids maintain hydration, enhance ciliary action to remove secretions, and reduce viscosity, making secretions easier to cough out.

9. Utilize humidified oxygen or a bedside humidifier.

• Rationale: Increased humidity reduces the viscosity of secretions, facilitating easier expectoration. Ensure humidifiers are cleaned regularly to prevent bacterial growth. Humidification aids in secretion loosening and enhances ventilation by delivering warm, humidified air to the tracheobronchial tree, liquefying secretions and alleviating irritation.

10. Monitor serial chest X-rays, ABGs, and pulse oximetry readings.

• Rationale: These monitoring tools track the progress and extent of pneumonia, guiding adjustments in therapy. Oxygen saturation should be maintained at 90% or greater. Imbalances in PaCO2 and PaO2 may indicate respiratory fatigue and the need for further intervention.

11. Assist with and monitor effects of nebulizer treatments and other respiratory physiotherapy (incentive spirometry, IPPB, percussion, postural drainage). Perform treatments between meals and limit fluids when appropriate.

• Rationale:
  • Nebulizers humidify the airway, thinning secretions and facilitating liquefaction and expectoration.
  • Postural drainage aids in gravity-assisted removal of secretions, though its effectiveness may vary in different types of pneumonia.
  • Incentive spirometry promotes deep breathing, preventing atelectasis and improving lung function.
  • Chest percussion loosens and mobilizes secretions in smaller airways that are difficult to clear by coughing or suctioning.
  • Coordinating treatments with meal times and fluid intake minimizes the risk of vomiting during coughing and expectoration.

12. Assist with bronchoscopy and thoracentesis if indicated.

• Rationale: Bronchoscopy may be necessary to remove secretions or foreign bodies directly, while thoracentesis may be needed to drain pleural effusions, improving lung expansion and function.

13. Anticipate the need for supplemental oxygen or intubation if the patient’s condition deteriorates.

• Rationale: These interventions address hypoxemia and enhance oxygenation. Intubation may be required for deep suctioning and to provide maximal oxygen support in severe cases of respiratory distress. Oxygen therapy is administered and adjusted according to patient needs and clinical parameters to maintain adequate oxygenation.

Nurse assisting patient with incentive spirometer for deep breathing exercises.

2. Managing Impaired Gas Exchange

Effective management of impaired gas exchange is crucial for ensuring adequate oxygenation in patients with pneumonia. This involves nursing diagnoses, goals, and interventions aimed at optimizing respiratory function.

Nursing Diagnosis

Impaired Gas Exchange related to alveolar-capillary membrane changes and fluid accumulation in the lungs.

Expected Outcomes

• Patient will demonstrate improved gas exchange, evidenced by oxygen saturation levels maintained at or above a specified level, reduced cyanosis, and effective deep breathing in a comfortable position.
• Patient will maintain stable oxygenation and respiratory function, evidenced by clear ABG results, absence of cyanosis, regular respiratory rate and depth, and ability to perform daily activities without significant dyspnea.

Nursing Interventions and Rationales:

1. Assess respirations: note quality, rate, rhythm, depth, use of accessory muscles, ease, and position for breathing.

• Rationale: Respiratory distress manifestations vary with the extent of lung involvement and overall health. Patients adapt breathing patterns to optimize gas exchange. Rapid, shallow breathing and hypoventilation directly impair gas exchange. Hypoxia is indicated by increased breathing effort. Tripod positioning suggests significant dyspnea.

2. Observe skin, mucous membranes, and nail bed color for peripheral (nail beds) or central cyanosis (circumoral).

• Rationale: Impaired oxygenation and perfusion lead to peripheral cyanosis. Nail bed cyanosis may indicate vasoconstriction or fever/chills response, while cyanosis of earlobes, mucous membranes, and circumoral skin (“warm membranes”) signifies systemic hypoxemia.

3. Assess mental status, restlessness, and changes in consciousness.

• Rationale: Restlessness, irritability, confusion, and somnolence can reflect hypoxemia and reduced cerebral oxygenation, requiring intervention. Check pulse oximetry with mental status changes, especially in older adults.

4. Assess anxiety level and encourage verbalization of feelings and concerns.

• Rationale: Anxiety is both a psychological and physiological response to hypoxia. Reassurance and security can reduce psychological stress, lowering oxygen demand and adverse physiological responses.

5. Monitor heart rate and rhythm, and blood pressure.

• Rationale: Tachycardia is common due to fever and/or dehydration or as a response to hypoxemia. Initial hypoxia and hypercapnia increase BP and HR. Severe hypoxia may cause BP to drop, while HR remains rapid with dysrhythmias.

6. Monitor body temperature. Implement comfort measures to reduce fever and chills: adjust bedcovers, room temperature, tepid sponge baths.

• Rationale: High fever (common in bacterial pneumonia and influenza) increases metabolic demands and oxygen consumption, altering cellular oxygenation.

7. Observe for deterioration: hypotension, copious bloody sputum, pallor, cyanosis, LOC changes, severe dyspnea, restlessness.

• Rationale: Shock and pulmonary edema are major causes of pneumonia-related deaths, requiring immediate medical intervention.

8. Monitor ABGs, pulse oximetry.

• Rationale: These monitor disease progression and guide therapy adjustments. Pulse oximetry detects oxygenation changes; maintain O2 saturation ≥ 90%.

9. Enforce bed rest, plan activity and rest periods to minimize energy use. Encourage relaxation techniques and diversional activities.

• Rationale: Bed rest prevents overexertion, reduces oxygen demand, and aids infection resolution. Relaxation techniques conserve energy for effective breathing and coughing.

10. Elevate head of bed, encourage frequent position changes, deep breathing, and effective coughing.

• Rationale: These actions maximize chest expansion, mobilize secretions, and improve ventilation.

11. Administer oxygen therapy via nasal prongs, mask, or Venturi mask as prescribed.

• Rationale: Oxygen therapy aims to maintain PaO2 above 60 mmHg. Choose delivery method based on patient tolerance and needs. Caution: Use oxygen cautiously in patients with chronic lung diseases.

3. Promoting Effective Breathing Pattern and Breathing Exercises

Nursing Diagnosis

Ineffective Breathing Pattern related to pain and inflammatory processes.

Expected Outcomes

Patient will demonstrate a normal respiratory rate and depth, and engage in effective breathing techniques to improve oxygenation.

Nursing Interventions and Rationales:

Teach and encourage regular deep-breathing exercises, incentive spirometer use, and diaphragmatic breathing.

• Rationale: These techniques enhance oxygenation, prevent atelectasis, and mobilize secretions by maximizing lung expansion and promoting effective coughing.

Demonstrate and assist with splinting the chest during coughing in an upright position.

• Rationale: Splinting minimizes pain, and upright position supports deeper, more effective coughs for airway clearance.

Monitor respiratory rate, depth, and accessory muscle use every 4 hours; auscultate breath sounds and observe for retractions or nasal flaring.

• Rationale: Early detection of altered breathing patterns or abnormal sounds identifies respiratory compromise or muscle fatigue.

Monitor ABG levels and observe breathing patterns for signs of dysfunction.

• Rationale: Monitoring ensures detection of respiratory issues and provides data on oxygenation and ventilation status.

Encourage sustained deep breaths and controlled breathing techniques (slow inhalation, breath-holding, passive exhalation) and teach yawning.

• Rationale: Promotes deep inspiration to increase oxygenation and prevent air trapping and tachypnea.

Ambulate patient as tolerated and assist with ADLs, ensuring frequent rest periods.

• Rationale: Ambulation mobilizes secretions, while rest prevents overexertion and conserves energy.

Teach proper deep-breathing exercises.

• Rationale: Deep breathing maximizes lung expansion, improves ventilation in smaller airways, and enhances cough effectiveness.

4. Administering Medications and Pharmacological Support

Nursing Diagnosis

Risk for Complications related to ineffective pharmacological management.

Expected Outcomes

Patient will receive and respond appropriately to prescribed medications, demonstrating clinical improvement and understanding of medication regimen.

Nursing Interventions and Rationales:

Administer prescribed antibiotics as ordered.

• Rationale: Pneumonia treatment includes administering appropriate antibiotics based on culture and sensitivity results when available. For community-acquired pneumonia, empiric antibiotic selection follows guidelines considering resistance patterns, common pathogens, patient risk factors, and treatment setting.

Medication Type	Function/Action	Example Drug Names
Mucolytics	Liquefy respiratory secretions.	Acetylcysteine (Mucomyst), Dornase alfa (Pulmozyme)
Expectorants	Increase productive cough by liquefying lower respiratory tract secretions and reducing viscosity.	Guaifenesin (Mucinex, Robitussin)
Bronchodilators	Dilate airways to facilitate respiration.	Albuterol (Ventolin, ProAir), Salmeterol (Serevent), Ipratropium (Atrovent), Theophylline
Analgesics	Reduce discomfort to improve cough effort, use cautiously as they can depress respirations and cough reflex.	Acetaminophen (Tylenol), Ibuprofen (Advil, Motrin)

Administer prescribed antibiotics per culture and sensitivity results.

• Rationale: Targeted treatment improves effectiveness and reduces antibiotic resistance risk.

Monitor patient’s response to antibiotic therapy (temperature, heart rate, respiratory rate, blood pressure, oxygen saturation).

• Rationale: Monitors improvement, complications, and guides therapy adjustments.

Educate patient and family on completing the full antibiotic course.

• Rationale: Ensures infection eradication, prevents recurrence, and reduces antibiotic resistance.

Assess patient’s readiness to switch from IV to oral antibiotics based on hemodynamic stability and clinical improvement.

• Rationale: Facilitates earlier discharge and maintains effective treatment with convenient oral administration.

5. Initiating Measures for Infection Control & Management

Nursing Diagnosis

Risk for Infection spread related to inadequate primary defenses and environmental exposure.

Expected Outcomes

Patient will remain free from secondary infections and demonstrate understanding and practice of infection control measures.

Nursing Interventions and Rationales:

Monitor vital signs closely, especially during therapy initiation, noting potential complications (hypotension, shock).

• Rationale: Early detection and intervention for potentially fatal complications.

Instruct patient on sputum disposal and reporting changes in sputum characteristics.

• Rationale: Safe sputum disposal and monitoring changes indicate resolution or secondary infection.

Assess patient’s immunization status.

• Rationale: Immunizations reduce pneumonia risk.

Demonstrate and encourage good hand hygiene techniques.

• Rationale: Handwashing is the most effective way to prevent infection spread.

Encourage frequent position changes and good pulmonary hygiene.

• Rationale: Promotes expectoration, clearing of infection, and prevents atelectasis.

Implement isolation precautions as appropriate. Limit visitors as indicated.

• Rationale: Prevents infection spread, especially in vulnerable patients.

Encourage balanced rest and moderate activity, and adequate nutritional intake.

• Rationale: Facilitates healing and enhances natural resistance.

Monitor antimicrobial therapy effectiveness.

• Rationale: Signs of improvement should appear within 24–48 hours; monitor for changes.

Investigate sudden changes in condition (chest pain, extra heart sounds, altered sensorium, recurring fever, sputum changes).

• Rationale: Delayed recovery or worsening symptoms may indicate antibiotic resistance or secondary infection.

Prepare for and assist with diagnostic studies as indicated (fiberoptic bronchoscopy).

• Rationale: FOB may be needed for non-responsive patients to clarify diagnosis and therapy.

6. Managing Acute Pain and Promoting Comfort

Nursing Diagnosis

Acute Pain related to inflammation and coughing.

Expected Outcomes

Patient will report pain is managed or reduced to a tolerable level, allowing for comfort and effective breathing.

Nursing Interventions and Rationales:

Assess pain characteristics (sharp, constant, stabbing) and changes in pain with breathing or coughing.

• Rationale: Chest pain is common with pneumonia and may indicate complications like pericarditis or endocarditis.

Monitor vital signs regularly.

• Rationale: Changes in heart rate or BP may indicate pain, especially when other causes are ruled out.

Provide non-pharmacologic comfort measures: back rubs, position changes, quiet music, massage, relaxation/breathing exercises.

• Rationale: Non-pharmacologic measures lessen discomfort and augment analgesic effects. Patient involvement promotes independence and well-being.

Offer frequent oral hygiene.

• Rationale: Mouth breathing and oxygen therapy can dry mucous membranes; oral care maintains comfort.

Instruct and assist with chest splinting during coughing.

• Rationale: Splinting manages chest discomfort and improves cough effectiveness.

Administer antitussives as needed (avoid suppressing productive coughs) and moderate analgesics for pleuritic pain.

• Rationale: Reduces nonproductive coughing and discomfort while maintaining productive cough effectiveness.

Administer analgesics as prescribed, before pain becomes severe.

• Rationale: Timely pain management allows for better pain control, effective breathing and coughing, and prevents exacerbation of discomfort.

7. Promoting Rest and Improving Activity Tolerance

Nursing Diagnosis

Activity Intolerance related to decreased oxygenation and fatigue.

Expected Outcomes

Patient will demonstrate improved activity tolerance, gradually increasing participation in activities without excessive fatigue or dyspnea.

Nursing Interventions and Rationales:

Assess patient’s baseline function and activity tolerance.

• Rationale: Establishes baseline for planning interventions and monitoring progress.

Monitor patient’s response to activity (dyspnea, weakness, fatigue, vital sign changes).

• Rationale: Identifies activity limitations and need for care plan adjustments.

Provide a quiet environment and limit visitors during the acute phase.

• Rationale: Conserves energy and promotes rest, facilitating recovery.

Assist with self-care activities, gradually increasing activity levels.

• Rationale: Promotes independence and prevents deconditioning, while gradual increase builds endurance.

Explain the importance of rest and balanced activity.

• Rationale: Rest during acute phase reduces metabolic demands and conserves energy. Balance rest and activity during recovery to prevent overexertion.

Pace activities for patients with reduced activity tolerance.

• Rationale: Prevents exhaustion and fatigue during activities like coughing.

Assist patient to assume a comfortable position for rest and sleep (semi-Fowler’s).

• Rationale: Comfortable positioning supports rest and breathing, and promotes lung function.

8. Maintaining Normal Body Thermoregulation

Nursing Diagnosis

Hyperthermia related to infectious process.

Expected Outcome

Patient will maintain a core body temperature within normal limits (≤ 37.5°C or ≤ 99.5°F).

Nursing Interventions and Rationales:

Monitor heart rate, blood pressure, and tympanic or rectal temperature every 4 hours.

• Rationale: HR and BP increase with hyperthermia. Tympanic or rectal temperatures accurately reflect core temperature.

Determine patient’s age and weight.

• Rationale: Extremes of age or weight increase thermoregulation risk.

Monitor fluid intake and urine output. Measure central venous or pulmonary artery pressure in unconscious patients.

• Rationale: Fluid resuscitation may be needed for dehydration. Dehydrated patients lose sweating ability needed for cooling.

Review serum electrolytes, especially serum sodium.

• Rationale: Sodium losses occur with profuse sweating.

Adjust environmental factors: room temperature, bed linens.

• Rationale: Adjust room temperature and linens to regulate patient temperature.

Eliminate excess clothing and covers. Encourage lightweight clothing and comfortable room temperature.

• Rationale: Exposing skin to room air decreases warmth and increases evaporative cooling.

Administer antipyretic medications as prescribed.

• Rationale: Antipyretics lower body temperature by blocking prostaglandin synthesis in the hypothalamus.

Prepare oxygen therapy for extreme cases.

• Rationale: Hyperthermia increases metabolic oxygen demand.

Encourage plenty of fluids to prevent dehydration.

• Rationale: Adequate fluids are needed for thermoregulation and to replace fluid lost due to fever.

Provide tepid sponge baths as necessary.

• Rationale: Tepid sponge baths help reduce fever and improve comfort.

9. Promoting Optimal Nutrition & Fluid Balance

Nursing Diagnosis

Deficient Fluid Volume related to increased respiratory rate and fever.
Imbalanced Nutrition: Less Than Body Requirements related to increased metabolic demands and decreased appetite.

Expected Outcomes

• Patient will maintain adequate hydration, evidenced by balanced intake and output, urine output ≥ 30 mL/hour, and moist mucous membranes.
• Patient will report improved appetite and consume at least 50% of meals to meet nutritional needs.

Nursing Interventions and Rationales:

Assess vital sign changes: increased temperature, prolonged fever, orthostatic hypotension, tachycardia.

• Rationale: Elevated temperature and fever increase metabolic rate and fluid loss. Orthostatic BP and tachycardia indicate fluid deficit.

Assess skin turgor and mucous membrane moisture.

• Rationale: Indirect indicators of fluid volume adequacy, although oral membranes may be dry due to mouth breathing and oxygen.

Investigate nausea and vomiting reports.

• Rationale: These symptoms reduce oral intake.

Monitor intake and output (I&O), urine color and character. Calculate fluid balance. Weigh patient as indicated.

• Rationale: Provides data on fluid volume adequacy and replacement needs.

Force fluids to at least 3000 mL/day or as appropriate.

• Rationale: Meets fluid needs, reduces dehydration risk, mobilizes secretions.

Administer medications: antipyretics, antiemetics.

• Rationale: Reduces fluid losses.

Provide supplemental IV fluids as necessary.

• Rationale: Parenteral route corrects deficit when oral intake is insufficient.

Identify factors contributing to nausea/vomiting: sputum, aerosol treatments, dyspnea, pain.

• Rationale: Guides intervention choices.

Provide covered sputum container and remove frequently. Encourage oral hygiene after emesis, treatments, and before meals.

• Rationale: Reduces noxious stimuli and nausea.

Schedule respiratory treatments at least 1 hour before meals.

• Rationale: Reduces nausea associated with treatments.

Maintain adequate nutrition: high-calorie, high-protein diet.

• Rationale: Offsets hypermetabolic state.

Evaluate need to limit milk products in patients with excessive mucus.

• Rationale: Personalize milk restriction based on patient response, as evidence is inconclusive on universal mucus increase.

Elevate head and neck and check NG tube position during feedings to prevent aspiration.

• Rationale: Prevents aspiration during tube feeding.

Auscultate bowel sounds and observe for abdominal distension.

• Rationale: Diminished bowel sounds may indicate severe infection. Distension may be due to air swallowing or bacterial toxins.

Provide small, frequent meals, dry foods, and appealing foods.

• Rationale: Enhances intake despite decreased appetite and shortness of breath.

Evaluate nutritional state and obtain baseline weight.

• Rationale: Chronic conditions or limitations can contribute to malnutrition and delayed recovery.

Accurately monitor and record intake and output, observe urine color, and watch for reduced urinary output.

• Rationale: Helps assess fluid balance and identify fluid volume deficit.

Weigh patient daily at the same time to monitor for weight changes indicative of fluid balance issues.

• Rationale: Aids in accurate weight measurement to detect fluid volume deficits or excesses.

Assess skin turgor and mucous membranes for dehydration.

• Rationale: Identifies signs of fluid volume deficit.

Monitor and record vital signs for indications of hypovolemia.

• Rationale: Detects vital sign changes associated with hypovolemia.

Encourage frequent oral hygiene to moisten mucous membranes and address thirst.

• Rationale: Improves comfort and stimulates thirst sensation.

Advise patient to increase fluid intake to at least 2.5 L/day.

• Rationale: Helps maintain adequate hydration.

Maintain intravenous fluid therapy as indicated to prevent shock.

• Rationale: Parenteral fluids prevent shock in cases of severe dehydration.

Provide humidified oxygen therapy to lessen convective moisture losses.

• Rationale: Reduces moisture loss during oxygen therapy.

10. Providing Patient Education & Health Teachings

Nursing Diagnosis

Deficient Knowledge related to lack of information about condition, treatment, and prevention.

Expected Outcomes

• Patient will demonstrate improved understanding of pneumonia treatment by accurately explaining their medication regimen, including purpose, dosage, and side effects.
• Patient will verbalize the importance of receiving appropriate vaccinations (pneumococcal and influenza) as a preventive measure.

Nursing Interventions and Rationales:

Determine patient’s understanding of pneumonia complications and treatment.

• Rationale: Establishes baseline for patient education and identifies teaching needs.

Review normal lung function and pneumonia pathology.

• Rationale: Promotes understanding of the condition and treatment adherence.

Identify self-care and homemaker needs.

• Rationale: Enhances coping and reduces anxiety. Respiratory symptoms and fatigue may persist post-discharge.

Assess potential home care needs.

• Rationale: Therapeutic regimen continues at home, and needs depend on support, energy, and cognition.

Provide information in written and verbal form.

• Rationale: Fatigue and depression can impair information processing; written materials reinforce verbal teaching.

Reinforce effective coughing and deep-breathing exercises.

• Rationale: Recurrence risk is highest in the initial 6-8 weeks post-discharge; these exercises are crucial for prevention.

Emphasize completing prescribed antibiotic therapy.

• Rationale: Full course reduces recurrence and promotes immune health. Early discontinuation can lead to rebound pneumonia.

Review smoking cessation importance.

• Rationale: Smoking impairs lung defense mechanisms against infection.

Outline steps for general health: balanced rest and activity, diet, avoiding crowds during flu season, and contact with URIs.

• Rationale: Enhances natural defenses and limits pathogen exposure.

Stress medical follow-up and vaccinations.

• Rationale: Prevents recurrence and related complications.

Identify signs/symptoms requiring healthcare provider notification: dyspnea, chest pain, fatigue, weight loss, fever, chills, persistent cough, mentation changes.

• Rationale: Prompt evaluation and intervention prevent complications.

Instruct patient to avoid indiscriminate antibiotic use for minor viral infections.

• Rationale: Prevents antibiotic-resistant bacteria and potential complications in future pneumonia.

Encourage Pneumovax and annual flu shots for high-risk patients.

• Rationale: Pneumococcal and influenza vaccinations are effective in reducing pneumonia incidence, hospitalizations, and deaths, especially in older adults and high-risk groups.

11. Monitoring Potential Complications of Pneumonia

Nursing Diagnosis

Risk for Complications related to pneumonia and its treatment.

Expected Outcome

Patient will be monitored effectively for potential complications, and interventions will be implemented promptly to minimize adverse effects.

Nursing Interventions and Rationales:

Assess and monitor for signs of shock and respiratory failure.

• Rationale: Pneumonia can lead to hypotension, septic shock, and respiratory failure, especially in older adults or those with comorbidities. Monitor vital signs, pulse oximetry, and hemodynamic parameters for early detection and prompt intervention, including IV fluids, medications, and possible intubation and mechanical ventilation.

Assess and monitor for signs of pleural effusion and empyema.

• Rationale: Pleural effusion (fluid accumulation in pleural space) and empyema (purulent fluid in pleural space) are bacterial pneumonia complications. Monitor for signs and assist with thoracentesis for fluid analysis and drainage. If chest tube is needed, monitor respiratory status and provide appropriate care.

Assess and monitor for signs of delirium, especially in older adults using Confusion Assessment Method (CAM).

• Rationale: Delirium and cognitive changes are unfavorable prognostic indicators. Assess for delirium risk factors like hypoxemia, fever, dehydration, sleep deprivation, sepsis, and comorbidities. Implement interventions to address underlying causes and ensure patient safety.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources:

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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
This handbook is valued for its evidence-based approach to nursing interventions. It offers a three-step system for client assessment, nursing diagnosis, and care planning. It includes step-by-step instructions on implementing care and evaluating outcomes, enhancing diagnostic reasoning and critical thinking skills.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Features over two hundred care plans based on the latest evidence-based guidelines. This edition includes ICNP diagnoses, care plans on LGBTQ health issues, and electrolytes and acid-base balance.

Image alt text: Cover image of the “Nursing Care Plans – Nursing Diagnosis & Intervention” 10th Edition book, showcasing its title and authors.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
A quick-reference tool for identifying correct diagnoses and efficient patient care planning. The 16th edition features the most recent nursing diagnoses and interventions, with an alphabetized listing of diagnoses covering over 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Assists in identifying interventions to plan, personalize, and document care for over 800 diseases and disorders. It uniquely provides subjective and objective data, clinical applications, prioritized actions/interventions with rationales, and documentation sections for each diagnosis.

Image alt text: Cover image of the “Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care” book, emphasizing its focus on care planning and documentation.

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans across medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health settings. Interprofessional “patient problems” approach helps in understanding patient communication.

See Also

Explore these related resources from our site for further information on nursing care plans:

• Impaired Gas Exchange Nursing Care Plan
• Ineffective Airway Clearance Nursing Care Plan
• Ineffective Breathing Pattern Nursing Care Plan
• Risk for Aspiration Nursing Care Plan

References and Sources

Explore these journals, books, and materials to deepen your understanding of pneumonia nursing care plans and nursing diagnosis:

Originally published January 10, 2010.

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