Nursing Diagnosis for Pneumonia NANDA: A Comprehensive Guide for Effective Care

Pneumonia, an inflammatory condition affecting the lung parenchyma, is characterized by alveolar edema and congestion. This inflammation significantly impairs gas exchange, making it a serious respiratory ailment. Primarily caused by bacterial or viral infections transmitted via droplets or direct contact, pneumonia ranks as the sixth leading cause of mortality in the United States. Effective nursing care is crucial in managing pneumonia and improving patient outcomes. This guide delves into nursing diagnoses for pneumonia, specifically focusing on NANDA-I (North American Nursing Diagnosis Association International) classifications, to facilitate comprehensive and targeted care planning.

Understanding Pneumonia and its Impact

Pneumonia’s prognosis is generally favorable for individuals with healthy lungs and robust immune systems prior to infection. However, it poses a significant threat to high-risk populations, including the very young and elderly, smokers, individuals with limited mobility, those malnourished, hospitalized patients, immunocompromised individuals, and those exposed to multidrug-resistant organisms.

For a deeper understanding of the pathophysiology, medical, and surgical management of pneumonia, refer to detailed resources available in nursing study guides dedicated to pneumonia.

Pneumonia is clinically categorized based on its acquisition:

Type of Pneumonia	Description	Common Causes
Community-Acquired Pneumonia (CAP)	Contracted in community settings or within 48 hours of hospital admission. Predominantly affects individuals under 60 without comorbidities and those over 60 with existing health issues. Older adults are particularly susceptible.	Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, viruses (e.g., Respiratory Syncytial Virus, Adenovirus), fungal pathogens.
Health Care–Associated Pneumonia (HCAP)	Develops in patients within long-term care or outpatient facilities. Often caused by multidrug-resistant pathogens, necessitating immediate and targeted antibiotic therapy.	Multidrug-resistant bacteria such as Pseudomonas aeruginosa, MRSA (Methicillin-resistant Staphylococcus aureus).
Hospital-Acquired Pneumonia (HAP)	Onset occurs 48 hours or more after hospital admission. Associated with higher mortality due to virulent and resistant organisms. Common in patients with chronic illnesses, prolonged hospital stays, or use of medical devices like ventilators.	Enterobacter, Escherichia coli, Klebsiella, Proteus, Staphylococcus aureus (including MRSA), Pseudomonas aeruginosa.
Ventilator-Associated Pneumonia (VAP)	A subtype of HAP, specifically in patients mechanically ventilated for 48 hours or more. Incidence increases with prolonged ventilation duration.	Early-onset: antibiotic-sensitive bacteria. Late-onset: multidrug-resistant bacteria.
Pneumonia in Immunocompromised Host	Frequent in individuals with compromised immune systems (e.g., those on immunosuppressants, chemotherapy, or with AIDS). Higher morbidity and mortality rates.	Pneumocystis jiroveci, fungi, Mycobacterium tuberculosis, gram-negative bacilli (Klebsiella, Escherichia coli, Pseudomonas).
Aspiration Pneumonia	Results from inhaling foreign substances (e.g., bacteria, gastric contents) into the lungs. Causative pathogens vary based on the nature of the aspirated material. Can occur in both community and hospital settings.	Anaerobes, Staphylococcus aureus, Streptococcus species, gram-negative bacilli (Escherichia coli, Klebsiella).

Nursing Care Planning: Prioritizing Patient Needs

Effective nursing care plans for pneumonia begin with a thorough patient assessment, including medical history, respiratory assessments conducted every four hours, physical examinations, and Arterial Blood Gas (ABG) analysis. Supportive interventions are crucial and include oxygen therapy, suctioning, encouraging coughing, deep breathing exercises, ensuring adequate hydration, and in severe cases, mechanical ventilation. Further nursing interventions are guided by specific nursing diagnoses, ensuring a patient-centered approach.

Key Nursing Priorities for Pneumonia

Nursing priorities for patients diagnosed with pneumonia are focused on:

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

Comprehensive Nursing Assessment for Pneumonia

The hallmark symptoms of pneumonia include coughing, sputum production, pleuritic chest pain, shaking chills, rapid and shallow breathing, fever, and shortness of breath. Untreated pneumonia can lead to severe 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, potentially accompanied by sternal soreness, fever or chills, night sweats, headache, and general malaise. As the infection progresses, symptoms can escalate to shortness of breath, audible abnormal breath sounds (inspiratory stridor and expiratory wheeze), and the production of purulent sputum. In severe instances, blood-streaked secretions may occur due to irritation of the airway mucosa.

Essential Assessment Data:

Subjective Data:

Reports of shortness of breath and difficulty breathing
Chest pain that worsens with breathing or coughing
Fatigue and weakness
History of cough, sputum production, and fever
Past medical history including respiratory conditions or immunocompromised status

Objective Data:

Changes in respiratory rate, depth, and pattern
Abnormal breath sounds such as rhonchi, crackles, wheezes, or bronchial breath sounds
Use of accessory muscles for breathing
Dyspnea, tachypnea, cyanosis
Characteristics of cough and sputum (productive or non-productive, color, consistency)
Hypoxemia as indicated by pulse oximetry or ABGs
Presence of infiltrates on chest X-ray
Reduced vital capacity

Related Factors to Assess:

Altered oxygen/carbon dioxide ratio and hypoxia
Reduced lung expansion due to inflammation and fluid accumulation in alveoli
Inflammatory processes causing tracheal and bronchial inflammation, edema, and increased sputum production
Pleuritic pain and changes in the alveolar-capillary membrane
Altered oxygen-carrying capacity of blood
Impaired oxygen delivery and hypoventilation
Accumulation of mucus in the airways

NANDA Nursing Diagnoses for Pneumonia

Nursing diagnoses are crucial for guiding individualized patient care. Based on thorough assessment data and clinical judgment, nurses formulate diagnoses tailored to each patient’s unique condition. Utilizing the NANDA-I framework ensures standardized language and facilitates effective communication among healthcare providers. Here are examples of common NANDA nursing diagnoses relevant to pneumonia:

Impaired Gas Exchange related to alveolar-capillary membrane changes secondary to pneumonia.
Ineffective Airway Clearance related to increased production of secretions and decreased energy/fatigue secondary to pneumonia.
Ineffective Breathing Pattern related to inflammatory process and pain secondary to pneumonia.
Activity Intolerance related to imbalance between oxygen supply and demand secondary to impaired respiratory function.
Acute Pain related to inflammation of the pleura and frequent coughing secondary to pneumonia.
Hyperthermia related to infectious process secondary to pneumonia.
Deficient Fluid Volume related to increased insensible fluid loss (fever, tachypnea) and decreased oral intake secondary to illness.
Risk for Infection (secondary infection) related to compromised primary defenses (stasis of secretions, decreased ciliary action).
Disturbed Sleep Pattern related to dyspnea, cough, and discomfort secondary to pneumonia.
Anxiety related to dyspnea and change in health status.
Deficient Knowledge regarding pneumonia, treatment, and prevention.

Establishing Nursing Goals and Expected Outcomes

Setting clear goals and expected outcomes is essential for evaluating the effectiveness of nursing interventions. For patients with pneumonia, these goals may include:

The patient will demonstrate improved ventilation and oxygenation, evidenced by ABGs within acceptable limits and absence of respiratory distress symptoms within 48 hours.
The patient will maintain optimal gas exchange, indicated by stable ABG levels and oxygen saturation above 92% within 24 hours.
The patient will actively participate in interventions to maximize oxygenation, such as deep breathing exercises and oxygen therapy, within 24 hours.
The patient will achieve effective airway clearance, demonstrated by clear breath sounds and absence of dyspnea or cyanosis, within 24 hours.
The patient will identify and implement behaviors to enhance airway clearance, such as effective coughing and using an incentive spirometer, within 48 hours.

Nursing Interventions and Rationales: NANDA-Aligned Care

The following sections detail nursing interventions aligned with common NANDA nursing diagnoses for pneumonia, along with their rationales.

1. Managing Ineffective Airway Clearance

NANDA Nursing Diagnosis: Ineffective Airway Clearance related to increased production of secretions and decreased energy/fatigue.

Expected Outcomes:

Patient will maintain a patent airway, evidenced by effective coughing, reduced sputum production, clear breath sounds upon auscultation, and oxygen saturation ≥ 90%.
Patient will demonstrate effective airway clearance and stable respiratory status, with no recurrence of pneumonia symptoms.

Nursing Interventions and Rationales:

Assess respiratory rate, rhythm, depth, chest movement, and accessory muscle use.
Rationale: Tachypnea, shallow respirations, and asymmetric chest movement are common due to chest wall discomfort and fluid in the lungs. Accessory muscle use indicates increased work of breathing.
Evaluate cough effectiveness and productivity.
Rationale: Coughing is vital for clearing secretions. Pneumonia can cause thick secretions, making effective removal essential. Encourage hydration (2-3 liters/day if not contraindicated) to thin secretions.
Auscultate lung fields for decreased airflow and adventitious breath sounds (crackles, wheezes, rhonchi).
Rationale: Decreased airflow indicates consolidation. Adventitious sounds indicate fluid accumulation, thick secretions, and airway obstruction.
Monitor sputum color, viscosity, and odor; report changes.
Rationale: Changes may indicate infection progression or secondary infection. Discolored, tenacious, or odorous sputum increases airway resistance.
Assess hydration status.
Rationale: Inadequate hydration thickens secretions, hindering airway clearance.
Elevate head of bed and reposition frequently.
Rationale: Promotes chest expansion, lung segment aeration, secretion mobilization, and expectoration by lowering the diaphragm.
Suction as needed (frequent coughing, adventitious sounds, desaturation).
Rationale: Mechanically clears airway when patient cannot cough effectively. Caution: Hyperoxygenate before, during, and after suctioning to prevent hypoxemia.
Maintain hydration with at least 3000 mL/day of fluids (unless contraindicated). Offer warm fluids.
Rationale: Fluids, especially warm liquids, mobilize and thin secretions, aiding expectoration and ciliary action.
Use humidified oxygen or bedside humidifier.
Rationale: Humidification reduces secretion viscosity. Clean humidifier regularly to prevent bacterial growth.
Monitor serial chest X-rays, ABGs, and pulse oximetry.
Rationale: Tracks pneumonia progression and treatment effectiveness. Oxygen saturation should be ≥ 90%. ABG imbalances indicate respiratory fatigue.
Assist with nebulizer treatments and respiratory physiotherapy (incentive spirometry, IPPB, percussion, postural drainage). Schedule treatments between meals and limit fluids if needed.
Rationale:
- Nebulizers: Humidify airways, thin secretions.
- Postural drainage: May be less effective in interstitial pneumonia.
- Incentive spirometry: Improves deep breathing, prevents atelectasis.
- Chest percussion: Loosens secretions in smaller airways.
- Timing treatments reduces vomiting risk with coughing.
Assist with bronchoscopy and thoracentesis, if indicated.
Rationale: Bronchoscopy for secretion removal or diagnosis; thoracentesis for pleural effusion drainage or analysis.
Anticipate supplemental oxygen or intubation for deteriorating patients.
Rationale: Addresses hypoxemia. Intubation allows deep suctioning and oxygen support. Administer and adjust oxygen therapy per guidelines, monitoring effectiveness.

Alt Text: Chest X-ray image illustrating lung infiltrates characteristic of pneumonia, a key diagnostic finding.

2. Managing Impaired Gas Exchange

NANDA Nursing Diagnosis: Impaired Gas Exchange related to alveolar-capillary membrane changes secondary to pneumonia.

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 engage in daily activities without significant dyspnea.

Nursing Interventions and Rationales:

Assess respirations: quality, rate, rhythm, depth, accessory muscle use, ease, and position for breathing.
Rationale: Respiratory distress manifestations indicate lung involvement and overall health status. Breathing patterns adapt to facilitate gas exchange. Rapid, shallow breathing and hypoventilation impair gas exchange.
Observe skin, mucous membranes, and nail bed color for peripheral or central cyanosis.
Rationale: Cyanosis indicates impaired oxygenation and perfusion. Central cyanosis (circumoral) indicates systemic hypoxemia.
Assess mental status, restlessness, and consciousness level changes.
Rationale: Restlessness, irritability, confusion, and somnolence may indicate hypoxemia and decreased cerebral oxygenation. Check pulse oximetry with mental status changes, especially in older adults.
Assess anxiety level and encourage verbalization of feelings.
Rationale: Anxiety is a physiological and psychological response to hypoxia. Reassurance and security can reduce psychological distress and oxygen demand.
Monitor heart rate and rhythm, and blood pressure.
Rationale: Tachycardia may be due to fever, dehydration, or hypoxemia. Initial hypoxia and hypercapnia increase BP and HR. Severe hypoxia may cause hypotension and rapid heart rate with dysrhythmias.
Monitor body temperature. Implement comfort measures for fever/chills (adjust linens, room temperature, tepid sponge baths).
Rationale: High fever increases metabolic demands and oxygen consumption.
Observe for condition deterioration: hypotension, bloody sputum, pallor, cyanosis, LOC changes, severe dyspnea, restlessness.
Rationale: Shock and pulmonary edema are critical complications requiring immediate intervention.
Monitor ABGs and pulse oximetry.
Rationale: Tracks disease progression and guides therapy adjustments. Oxygen saturation should be ≥ 90%.
Promote bed rest with planned activity and rest periods. Encourage relaxation techniques and diversional activities.
Rationale: Prevents overexertion, reduces oxygen demand, and promotes infection resolution. Relaxation techniques conserve energy.
Elevate head of bed, encourage frequent position changes, deep breathing, and effective coughing.
Rationale: Maximizes chest expansion, mobilizes secretions, and improves ventilation.
Administer oxygen therapy (nasal cannula, mask, Venturi mask).
Rationale: Maintains PaO2 above 60 mmHg. Choose appropriate delivery method based on patient tolerance. Caution: Use cautiously in patients with chronic lung disease.

Alt Text: Image depicting a nurse administering oxygen therapy to a patient with pneumonia to improve oxygenation and manage impaired gas exchange.

3. Promoting Effective Breathing Pattern

NANDA Nursing Diagnosis: Ineffective Breathing Pattern related to inflammatory process and pain secondary to pneumonia.

Expected Outcomes: Patient will demonstrate a relaxed respiratory rate at their baseline with improved depth of respirations and absence of dyspnea.

Nursing Interventions and Rationales:

Teach and encourage deep-breathing exercises, incentive spirometer use, and diaphragmatic breathing.
Rationale: Enhances oxygenation, prevents atelectasis, and mobilizes secretions. Regular practice maintains lung expansion and airway clearance.
Demonstrate and assist with splinting chest during coughing in upright position.
Rationale: Minimizes discomfort and supports deeper, more effective coughs.
Monitor respiratory rate, depth, accessory muscle use every 4 hours; auscultate breath sounds, observe for retractions or nasal flaring.
Rationale: Early detection of altered breathing patterns or abnormal sounds indicates respiratory compromise.
Monitor ABG levels and observe breathing patterns for dysfunction.
Rationale: Detects respiratory issues and provides data on oxygenation and ventilation status.
Encourage sustained deep breaths and controlled breathing techniques (slow inhalation, holding, passive exhalation), teach yawning.
Rationale: Promotes deep inspiration, increases oxygenation, and prevents air trapping and tachypnea.
Ambulate patient as tolerated, assist with ADLs, ensure rest periods.
Rationale: Ambulation mobilizes secretions. Rest prevents overexertion and conserves energy.
Teach and assist with proper deep-breathing exercises.
Rationale: Maximizes lung expansion, improves ventilation, and enhances cough effectiveness.

4. Medication Administration and Pharmacological Support

NANDA Nursing Diagnosis: Deficient Knowledge regarding pneumonia treatment and medication regimen.

Expected Outcomes: Patient will verbalize understanding of medication regimen, including purpose, dosage, and side effects.

Nursing Interventions and Rationales:

Administer prescribed antibiotics as ordered, based on culture and sensitivity when available.
Rationale: Targets specific causative organism. In CAP, empiric antibiotic therapy is common.
Monitor patient’s response to antibiotics (temperature, heart rate, respiratory rate, blood pressure, oxygen saturation).
Rationale: Identifies improvements or complications, guiding therapy adjustments.
Educate patient and family on completing the full course of antibiotics.
Rationale: Ensures infection eradication, prevents recurrence, and reduces antibiotic resistance.
Assess patient’s readiness to switch from IV to oral antibiotics upon stabilization.
Rationale: Facilitates discharge planning and reduces hospital stay.

Medication Categories for Pneumonia Management:

Medication Type	Function/Action	Example Drug Names
Mucolytics	Liquefy respiratory secretions.	Acetylcysteine (Mucomyst), Dornase alfa (Pulmozyme)
Expectorants	Increase productive cough by liquefying secretions.	Guaifenesin (Mucinex, Robitussin)
Bronchodilators	Dilate airways to ease breathing.	Albuterol (Ventolin, ProAir), Salmeterol (Serevent), Ipratropium (Atrovent), Theophylline
Analgesics	Relieve pain, cautiously used to avoid respiratory depression.	Acetaminophen (Tylenol), Ibuprofen (Advil, Motrin)

5. Implementing Infection Control Measures

NANDA Nursing Diagnosis: Risk for Infection related to compromised primary defenses (stasis of secretions, decreased ciliary action).

Expected Outcomes: Patient will remain free from secondary infection, evidenced by normal vital signs and absence of new signs of infection.

Nursing Interventions and Rationales:

Monitor vital signs closely for complications (hypotension, shock).
Rationale: Early detection of potentially fatal complications.
Instruct patient on sputum disposal (expectorating vs. swallowing) and reporting changes in sputum characteristics.
Rationale: Safe sputum disposal and identification of infection resolution or secondary infection.
Assess patient’s immunization status (pneumococcal, influenza vaccines).
Rationale: Immunizations reduce pneumonia risk.
Demonstrate and encourage hand hygiene.
Rationale: Most effective way to prevent infection spread.
Frequent position changes and pulmonary hygiene.
Rationale: Promotes expectoration, clears infection, prevents atelectasis.
Institute isolation precautions as needed. Limit visitors for high-risk patients.
Rationale: Prevents spread of infection, especially nosocomial pneumonia in immunocompromised patients.
Encourage rest and balanced activity. Promote adequate nutrition.
Rationale: Facilitates healing and enhances natural resistance.
Monitor antimicrobial therapy effectiveness (improvement within 24-48 hours).
Rationale: Tracks treatment success and identifies need for adjustments.
Investigate sudden condition changes (chest pain, extra heart sounds, altered sensorium, recurring fever, sputum changes).
Rationale: May indicate antibiotic resistance or secondary infection.
Prepare for diagnostic studies (fiberoptic bronchoscopy) if needed.
Rationale: Clarifies diagnosis and therapy in non-responsive patients.

6. Managing Acute Pain

NANDA Nursing Diagnosis: Acute Pain related to inflammation of the pleura and frequent coughing secondary to pneumonia.

Expected Outcomes: Patient will report pain is managed to a tolerable level (using a pain scale) and demonstrate comfort.

Nursing Interventions and Rationales:

Assess pain characteristics (sharp, stabbing, location, intensity). Monitor for changes, especially with breathing or coughing.
Rationale: Chest pain is common but may indicate complications like pericarditis.
Monitor vital signs regularly.
Rationale: Changes in heart rate or BP may indicate pain.
Provide non-pharmacologic comfort measures (back rubs, position changes, quiet music, massage, relaxation/breathing exercises).
Rationale: Lessens discomfort and augments analgesics. Patient involvement enhances well-being.
Offer frequent oral hygiene.
Rationale: Mouth breathing and oxygen therapy dry mucous membranes.
Instruct and assist with chest splinting during coughing.
Rationale: Manages chest discomfort and improves cough effectiveness.
Administer antitussives as needed (avoid suppressing productive coughs). Use moderate analgesics for pleuritic pain.
Rationale: Reduces nonproductive cough and discomfort while maintaining productive cough.
Administer analgesics as prescribed, proactively.
Rationale: Timely pain management allows for effective breathing and coughing.

7. Promoting Rest and Activity Tolerance

NANDA Nursing Diagnosis: Activity Intolerance related to imbalance between oxygen supply and demand secondary to impaired respiratory function.

Expected Outcomes: Patient will participate in activities of daily living (ADLs) within their tolerance level and report reduced fatigue.

Nursing Interventions and Rationales:

Assess baseline function and activity tolerance.
Rationale: Establishes baseline for planning and monitoring progress.
Monitor response to activity (dyspnea, weakness, fatigue, vital sign changes).
Rationale: Identifies limitations and need for care plan adjustments.
Provide quiet environment, limit visitors during acute phase.
Rationale: Conserves energy and promotes rest.
Assist with self-care activities, gradually increase activity levels.
Rationale: Promotes independence and prevents deconditioning.
Explain importance of rest and balanced activity.
Rationale: Bed rest reduces metabolic demands. Gradual activity increase builds endurance.
Pace activity for patients with reduced tolerance.
Rationale: Prevents exhaustion and ineffective coughing due to fatigue.
Assist patient to assume comfortable position for rest and sleep (semi-Fowler’s, chair, leaning forward).
Rationale: Supports rest and breathing.

8. Maintaining Normal Body Temperature

NANDA Nursing Diagnosis: Hyperthermia related to infectious process secondary to pneumonia.

Expected Outcomes: Patient will maintain a normal body temperature (≤ 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/rectal temperature accurately reflects core temperature.
Determine patient’s age and weight.
Rationale: Extremes of age/weight increase thermoregulation risk.
Monitor fluid intake and urine output. Assess fluid status.
Rationale: Fluid resuscitation may be needed for dehydration. Dehydrated patients lose evaporative cooling capacity.
Review serum electrolytes, especially sodium.
Rationale: Sodium loss occurs with sweating.
Adjust room temperature and linens.
Rationale: Environmental adjustments regulate temperature.
Remove excess clothing and covers; encourage lightweight clothing.
Rationale: Exposing skin promotes evaporative cooling.
Administer antipyretics as prescribed.
Rationale: Lowers body temperature by blocking prostaglandin synthesis.
Prepare for oxygen therapy in extreme cases.
Rationale: Hyperthermia increases oxygen demand.
Encourage fluid intake to prevent dehydration.
Rationale: Adequate fluids regulate temperature and prevent dehydration caused by fever.
Provide tepid sponge baths as needed.
Rationale: Reduces fever and improves comfort.

9. Promoting Optimal Nutrition and Fluid Balance

NANDA Nursing Diagnosis: Deficient Fluid Volume related to increased insensible fluid loss and decreased oral intake.

Expected Outcomes: Patient will maintain adequate hydration, evidenced by balanced intake/output, urine output ≥ 30 mL/hour, and moist mucous membranes.

Nursing Interventions and Rationales:

Assess vital signs for changes (increased temperature, prolonged fever, orthostatic hypotension, tachycardia).
Rationale: Indicate fluid loss and dehydration.
Assess skin turgor and mucous membrane moisture.
Rationale: Indirect indicators of fluid volume.
Investigate reports of nausea and vomiting.
Rationale: Reduces oral intake.
Monitor intake and output (I&O), urine characteristics, fluid balance, weigh patient.
Rationale: Provides data on fluid status and replacement needs.
Force fluids to at least 3000 mL/day (unless contraindicated).
Rationale: Meets fluid needs, reduces dehydration risk, mobilizes secretions.
Administer antipyretics and antiemetics as indicated.
Rationale: Reduces fluid losses.
Provide supplemental IV fluids if needed.
Rationale: Corrects fluid deficits.
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, before meals.
Rationale: Reduces nausea triggers.
Schedule respiratory treatments 1 hour before meals.
Rationale: Reduces nausea related to treatments.
Maintain adequate nutrition (high-calorie, high-protein, soft, easy-to-eat diet).
Rationale: Offsets hypermetabolic state.
Evaluate need to limit milk products in patients with excessive mucus.
Rationale: Consider individual response to dairy.
Elevate head and neck, check tube position during NG tube feedings. Small, frequent feedings. Keep head elevated after feeding. Check residuals.
Rationale: Prevents aspiration.
Auscultate bowel sounds, observe for abdominal distension.
Rationale: Indicates GI function.
Provide small, frequent meals, dry foods, and appealing foods.
Rationale: Enhances intake despite decreased appetite.
Evaluate nutritional state, baseline weight.
Rationale: Identifies malnutrition risks.
Monitor and record I&O accurately. Observe urine color and output.
Rationale: Assesses fluid balance. Reduced urine output indicates deficit.
Weigh patient daily at the same time.
Rationale: Tracks fluid balance changes.
Assess skin turgor and mucous membranes for dehydration.
Rationale: Identifies fluid volume deficit.
Monitor and record vital signs.
Rationale: Changes indicate hypovolemia.
Encourage frequent oral hygiene.
Rationale: Moistens mucous membranes, stimulates thirst.
Advise patient to increase fluid intake (≥ 2.5 L/day).
Rationale: Maintains hydration.
Maintain IV fluid therapy as indicated.
Rationale: Prevents shock.
Provide humidified oxygen therapy.
Rationale: Reduces moisture loss during oxygen therapy.

10. Patient Education and Health Teachings

NANDA Nursing Diagnosis: Deficient Knowledge regarding pneumonia, treatment, and prevention.

Expected Outcomes: Patient will demonstrate understanding of pneumonia, treatment regimen, and preventive measures.

Nursing Interventions and Rationales:

Assess patient’s understanding of pneumonia and treatment.
Rationale: Establishes baseline for education.
Review normal lung function and pneumonia pathology.
Rationale: Promotes understanding and cooperation with treatment.
Identify self-care and homemaker needs.
Rationale: Enhances coping and reduces anxiety.
Assess potential home care needs.
Rationale: Plans for post-discharge care.
Provide written and verbal information.
Rationale: Addresses fatigue and potential cognitive impairment.
Reinforce effective coughing and deep-breathing exercises.
Rationale: Reduces recurrence risk post-discharge.
Emphasize completing antibiotic therapy.
Rationale: Prevents recurrence and antibiotic resistance.
Review smoking cessation importance.
Rationale: Smoking impairs lung defenses.
Outline general health enhancement (rest, diet, avoiding crowds).
Rationale: Increases natural defenses.
Stress medical follow-up and vaccinations.
Rationale: Prevents recurrence and complications.
Identify signs/symptoms requiring provider notification (dyspnea, chest pain, fatigue, fever, cough changes).
Rationale: Promotes timely intervention.
Instruct patient to avoid indiscriminate antibiotic use for viral infections.
Rationale: Prevents antibiotic resistance.
Encourage pneumococcal and flu shots for high-risk patients.
Rationale: Effective prevention measures.

11. Monitoring for Potential Complications

NANDA Nursing Diagnosis: Risk for Complications related to pneumonia (sepsis, respiratory failure, pleural effusion, empyema).

Expected Outcomes: Patient will be monitored closely for complications, and interventions will be initiated promptly if complications arise.

Nursing Interventions and Rationales:

Assess and monitor for signs of shock and respiratory failure (hypotension, altered mental status, severe dyspnea, hypoxemia).
Rationale: Early detection allows for immediate intervention (IV fluids, medications, intubation, mechanical ventilation).
Assess and monitor for pleural effusion and empyema (decreased breath sounds, chest pain, fever, cough).
Rationale: Pleural effusion is a common complication; empyema is a severe form requiring extended treatment. Monitor for signs and prepare for thoracentesis or chest tube insertion.
Assess and monitor for delirium, especially in older adults (using CAM).
Rationale: Delirium is a poor prognostic indicator. Address underlying causes (hypoxemia, fever, dehydration, sepsis) and ensure patient safety.