Nursing Diagnosis of Pneumonia: Comprehensive Guide and Care Plans

Pneumonia, an inflammatory condition affecting the lung parenchyma, is characterized by alveolar edema and congestion, significantly impairing gas exchange. This infection, primarily caused by bacterial or viral pathogens transmitted via droplets or direct contact, stands as a major global health concern. In the United States, it ranks as the sixth leading cause of death, underscoring the critical need for effective nursing care and management strategies.

While the prognosis for pneumonia is generally favorable for individuals with healthy lungs and robust immune systems, certain populations are at a heightened risk. These include the very young, the elderly, smokers, those confined to bed, individuals suffering from malnutrition, hospitalized patients, immunocompromised individuals, and those exposed to multidrug-resistant organisms like MRSA. Effective nursing interventions, guided by accurate nursing diagnoses, are crucial in mitigating risks and improving patient outcomes.

For an in-depth exploration of the pathophysiology, medical, and surgical management of pneumonia, please refer to our comprehensive Pneumonia nursing study guide.

Pneumonia is clinically categorized into several types, each with distinct epidemiological and etiological characteristics:

Type of Pneumonia	Description	Common Causes
Community-Acquired Pneumonia (CAP)	Pneumonia acquired outside of healthcare facilities, or within 48 hours of hospital admission in patients who were not recently hospitalized. Predominantly affects individuals under 60 without comorbidities and those over 60 with comorbidities. Older adults exhibit a high incidence.	Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, viruses (e.g., respiratory syncytial virus, adenovirus), and fungal pathogens.
Health Care–Associated Pneumonia (HCAP)	Pneumonia developing in patients residing in long-term care facilities or receiving care in outpatient settings such as dialysis centers or infusion clinics. Often caused by multidrug-resistant (MDR) pathogens, necessitating prompt and targeted antibiotic therapy.	Multidrug-resistant bacteria including Pseudomonas aeruginosa and Methicillin-resistant Staphylococcus aureus (MRSA).
Hospital-Acquired Pneumonia (HAP)	Pneumonia that arises 48 hours or more after admission to a hospital. Associated with higher mortality rates due to virulent and resistant organisms. Commonly seen in patients with chronic illnesses, prolonged hospital stays, or those using medical devices such as respiratory equipment.	Enterobacter species, Escherichia coli, Klebsiella species, Proteus species, Staphylococcus aureus (including MRSA), and Pseudomonas aeruginosa.
Ventilator-Associated Pneumonia (VAP)	A subtype of HAP that occurs in patients who have been mechanically ventilated for at least 48 hours. The incidence increases with the duration of ventilation.	Early-onset VAP is often caused by antibiotic-sensitive bacteria, while late-onset VAP is frequently associated with MDR bacteria.
Pneumonia in Immunocompromised Host	Pneumonia occurring in individuals with compromised immune systems, such as those undergoing immunosuppressant therapy, chemotherapy, or living with AIDS. These patients experience higher morbidity and mortality rates.	Pneumocystis jiroveci, fungi, Mycobacterium tuberculosis, and gram-negative bacilli including Klebsiella, E. coli, and Pseudomonas.
Aspiration Pneumonia	Pneumonia resulting from the inhalation of foreign substances, such as bacteria or gastric contents, into the lungs. The causative pathogens vary depending on the nature of the aspirate. Can occur in both community and hospital settings.	Anaerobic bacteria, Staphylococcus aureus, Streptococcus species, and gram-negative bacilli like E. coli and Klebsiella.

Nursing Care Plans and Management for Pneumonia

Effective nursing care for patients with pneumonia begins with a comprehensive assessment, including a detailed medical history, a thorough respiratory assessment conducted at least every four hours, physical examinations, and Arterial Blood Gas (ABG) analysis. Supportive nursing interventions are paramount and include oxygen therapy, suctioning techniques, encouraging coughing, deep breathing exercises, ensuring adequate hydration, and in severe cases, mechanical ventilation. Further specific nursing interventions are detailed within the nursing diagnoses sections below, tailored to address the unique needs of each patient.

Prioritized Nursing Problems for Pneumonia

The primary nursing priorities for individuals diagnosed with pneumonia are centered on:

• Enhancing and maintaining airway patency.
• Improving activity tolerance and managing fatigue.
• Maintaining optimal fluid balance and preventing dehydration.
• Implementing measures to prevent potential complications associated with pneumonia.

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. Accompanying symptoms may include sternal soreness, fever or chills, night sweats, headache, and a general feeling of malaise. As the infection progresses, patients may develop increasing shortness of breath, abnormal breath sounds (such as inspiratory stridor and expiratory wheeze), and produce purulent sputum. In severe instances, blood-streaked secretions may occur due to irritation of the airway mucosa.

Chest X-ray showing pneumonia

Key Assessment Parameters:

• Subjective and Objective Data to Evaluate:

  • Changes in respiratory rate and depth, noting any abnormalities.
  • Presence of abnormal breath sounds, such as rhonchi, bronchial lung sounds, and egophony.
  • Observation of accessory muscle use during respiration.
  • Assessment of dyspnea and tachypnea.
  • Characterization of cough, including its effectiveness and presence of sputum production.
  • Evaluation for cyanosis.
  • Identification of decreased breath sounds over affected lung areas.
  • Assessment of cough effectiveness.
  • Description of sputum characteristics, including purulence.
  • Measurement of oxygen saturation and identification of hypoxemia.
  • Review of chest x-ray findings for infiltrates.
  • Measurement of reduced vital capacity.

• Factors Related to Pneumonia Etiology:

  • Assessment of alterations in the patient’s O2/CO2 ratio and hypoxia levels.
  • Evaluation of decreased lung expansion and presence of fluid-filled alveoli.
  • Identification of inflammatory processes, tracheal and bronchial inflammation, edema formation, and increased sputum production.
  • Assessment of pleuritic pain and changes in the alveolar-capillary membrane.
  • Evaluation of altered oxygen-carrying capacity of the blood and oxygen release at the cellular level.
  • Assessment of altered oxygen delivery and hypoventilation.
  • Identification of mucus accumulation in the airways.

Common Nursing Diagnoses for Pneumonia

Nursing diagnoses for pneumonia are derived from a comprehensive assessment and the nurse’s clinical judgment. These diagnoses are individualized to each patient’s specific condition and guide the development of a personalized care plan. The application of nursing diagnoses may vary across different healthcare settings, but the nurse’s expertise is central to prioritizing patient needs and shaping effective care strategies. Based on thorough assessment data, common nursing diagnoses for pneumonia include:

• Impaired Gas Exchange related to alveolar-capillary membrane changes and fluid accumulation in the alveoli.
• Ineffective Airway Clearance related to increased sputum production and decreased energy/fatigue.
• Ineffective Breathing Pattern related to pain, inflammation, and decreased lung expansion.
• Acute Pain related to inflammation and the coughing process.
• Activity Intolerance related to decreased oxygenation and fatigue.
• Hyperthermia related to infectious process.
• Deficient Fluid Volume related to increased respiratory rate and fever.
• Risk for Infection (secondary) related to compromised primary defenses (e.g., stasis of secretions).
• Deficient Knowledge regarding the condition, treatment, and prevention strategies.

Nursing Goals and Expected Outcomes for Pneumonia

The overarching goals and expected outcomes for patients with pneumonia are designed to achieve optimal respiratory function and overall well-being. These goals are patient-centered and measurable, guiding the nursing interventions and evaluating their effectiveness. Examples of nursing goals and expected outcomes include:

• Improved Ventilation and Oxygenation: The patient will demonstrate improved ventilation and oxygenation of tissues, evidenced by maintaining ABG values within acceptable limits and exhibiting no signs of respiratory distress within 48 hours of intervention.
• Optimal Gas Exchange Maintenance: The patient will maintain optimal gas exchange, demonstrated by stable ABG levels and oxygen saturation above 92% within 24 hours.
• Active Participation in Oxygenation Strategies: The patient will actively engage in interventions to maximize oxygenation, such as deep breathing exercises and adherence to prescribed oxygen therapy, within 24 hours.
• Effective Airway Clearance Achievement: The patient will identify and demonstrate at least three effective behaviors to achieve airway clearance, such as effective coughing techniques and using an incentive spirometer, within 48 hours.
• Patent Airway Maintenance: The patient will maintain a patent airway, characterized by clear breath sounds and absence of dyspnea or cyanosis, as evidenced by effective secretion clearance within 24 hours.

Nursing Interventions and Rationales for Pneumonia

Therapeutic nursing interventions and actions for patients with pneumonia are focused on addressing the identified nursing diagnoses and achieving the desired patient outcomes. These interventions are evidence-based and tailored to the individual needs of each patient.

1. Nursing Interventions for Impaired Airway Clearance

To effectively manage impaired airway clearance resulting from excessive secretions and ineffective coughing in pneumonia patients, nursing interventions are crucial. These include promoting hydration, utilizing humidification, encouraging both voluntary and reflex coughing, and instructing patients on effective directed coughing techniques. Lung expansion maneuvers and external pressure assistance may also be employed to enhance airway clearance.

Nursing Diagnosis: Ineffective Airway Clearance related to excessive secretions and ineffective cough.

Expected Outcomes:

• The patient will achieve and maintain a patent airway, as evidenced by effective coughing, reduced sputum production, clear lung sounds upon auscultation, and oxygen saturation levels consistently at 90% or above.
• The patient will demonstrate effective airway clearance and maintain a stable respiratory status, with no recurrence of pneumonia symptoms.

Nursing Interventions and Rationales:

1. Assess respiratory rate, rhythm, depth, chest movement, and accessory muscle use.
   Rationale: Tachypnea, shallow respirations, and asymmetrical chest movement are common due to chest wall discomfort and lung fluid, representing a 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, necessitating effective removal to prevent gas exchange impairment and delayed recovery. Encourage hydration of 2 to 3 liters per day to thin secretions, unless contraindicated.

3. Auscultate lung fields, noting decreased or absent airflow and adventitious sounds (crackles, wheezes).
   Rationale: Decreased airflow indicates consolidated fluid areas. 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, airway spasms, and obstruction.

4. Observe sputum color, viscosity, and odor; report changes.
   Rationale: Changes in sputum characteristics may indicate infection progression or secondary infection. Discolored, tenacious, or odorous sputum increases airway resistance and necessitates intervention.

5. Assess patient hydration status.
   Rationale: Inadequate hydration thickens secretions, hindering airway clearance.

6. Elevate the head of the bed and encourage frequent position changes.
   Rationale: Elevating the head and frequent repositioning lowers the diaphragm, promoting chest expansion, lung segment aeration, secretion mobilization, and expectoration.

7. Suction as needed for frequent coughing, adventitious sounds, desaturation from secretions.
   Rationale: Suctioning stimulates cough or mechanically clears the airway when patients cannot cough effectively due to weakness or decreased consciousness. Note: Suctioning can induce hypoxemia; hyperoxygenate before, during, and after.

8. Maintain hydration by encouraging fluids to at least 3000 mL/day, unless contraindicated (e.g., heart failure). Offer warm fluids.
   Rationale: Fluids, especially warm liquids, aid in secretion mobilization and expectoration. They maintain hydration, enhance ciliary action, and reduce secretion viscosity, making them easier to cough out.

9. Use humidified oxygen or bedside humidifier.
   Rationale: Increased humidity reduces secretion viscosity. Clean humidifiers to prevent bacterial growth. Humidification facilitates secretion loosening and enhances ventilation. High-humidity face masks with compressed air or oxygen deliver warm, humidified air, liquefying secretions and alleviating tracheobronchial irritation.

10. Monitor serial chest x-rays, ABGs, and pulse oximetry readings.
    Rationale: Monitors pneumonia progression and treatment effects, guiding therapy adjustments. Maintain oxygen saturation at 90% or greater. PaCO2 and PaO2 imbalances may indicate respiratory fatigue.

11. Assist with and monitor effects of nebulizer treatment and respiratory physiotherapy: incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate.
    Rationale:

    • Nebulizers: Humidify airways to thin secretions, facilitating liquefaction and expectoration.
    • Postural drainage: May be less effective in interstitial pneumonias or those with alveolar exudate or destruction.
    • Incentive spirometry: Improves deep breathing, preventing atelectasis.
    • Chest percussion: Loosens secretions in smaller airways.
    • Coordinating treatments and oral intake reduces vomiting risk during coughing.

12. Assist with bronchoscopy and thoracentesis, if indicated.
    Rationale: Bronchoscopy may be needed for secretion removal or diagnostic purposes. Thoracentesis may be necessary to drain pleural effusions.

13. Anticipate need for supplemental oxygen or intubation if condition deteriorates.
    Rationale: Addresses hypoxemia and enhances oxygenation. Intubation may be required for deep suctioning and increased oxygen support. Administer and adjust oxygen therapy as per guidelines, monitoring effectiveness via clinical signs, patient comfort, and pulse oximetry or ABG analysis to maintain adequate oxygenation.

2. Nursing Interventions for Impaired Gas Exchange

Managing impaired gas exchange is crucial for pneumonia patients to ensure adequate oxygenation. Nursing diagnoses, goals, and key interventions are essential to enhance respiratory function.

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

Expected Outcomes:

• The patient will demonstrate improved gas exchange, as evidenced by specific measurable indicators such as oxygen saturation levels maintained at or above 92%, reduced cyanosis, and effective deep breathing while in a comfortable position.
• The patient will maintain stable oxygenation and respiratory function, demonstrated by clear ABG results, absence of cyanosis, regular respiratory rate and depth, and the ability to engage in daily activities without significant dyspnea.

Nursing Interventions and Rationales:

1. Assess respirations: note quality, rate, rhythm, depth, accessory muscle use, ease, and breathing position.
   Rationale: Respiratory distress manifestations depend on lung involvement and general health. Patients adapt breathing patterns to facilitate gas exchange. Rapid, shallow breathing and hypoventilation directly impair gas exchange. Hypoxia is indicated by increased breathing effort. Tripod positioning signifies significant dyspnea.

2. Observe skin, mucous membrane, and nail bed color for peripheral (nail beds) or central cyanosis (circumoral).
   Rationale: Impaired oxygenation and perfusion cause peripheral cyanosis. Nail bed cyanosis may indicate vasoconstriction or response to fever/chills; however, cyanosis of earlobes, mucous membranes, and mouth skin (“warm membranes”) indicates systemic hypoxemia.

3. Assess mental status, restlessness, and consciousness changes.
   Rationale: Restlessness, irritation, confusion, and somnolence may reflect hypoxemia and decreased cerebral oxygenation, requiring intervention. Check pulse oximetry with mental status changes, especially in older adults.

4. Assess anxiety level and encourage verbalization of feelings.
   Rationale: Anxiety is a psychological and physiological response to hypoxia. Reassurance and security can reduce psychological components, decreasing 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 hypoxemia response. Initial hypoxia and hypercapnia increase BP and HR. Severe hypoxia may drop BP and cause rapid HR with dysrhythmias.

6. Monitor body temperature. Use comfort measures to reduce fever/chills: adjust covers, 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, bloody sputum, pallor, cyanosis, LOC change, severe dyspnea, restlessness.
   Rationale: Shock and pulmonary edema are major pneumonia mortality causes, requiring immediate intervention.

8. Monitor ABGs, pulse oximetry.
   Rationale: Tracks disease progress and guides therapy changes. Pulse oximetry detects oxygenation changes. Maintain O2 sats at 90% or above.

9. Maintain bed rest, plan activity and rest periods, encourage relaxation techniques.
   Rationale: Prevents exhaustion and reduces oxygen demands, aiding infection resolution. Relaxation conserves energy for effective breathing and coughing.

10. Elevate head of bed, encourage position changes, deep breathing, and effective coughing.
    Rationale: Maximizes chest expansion, mobilizes secretions, and improves ventilation.

11. Administer oxygen therapy: nasal prongs, mask, Venturi mask.
    Rationale: Oxygen therapy aims to maintain PaO2 above 60 mmHg, using a method appropriate to patient tolerance. Note: Use oxygen cautiously in patients with chronic lung disease.

3. Nursing Interventions for Promoting Effective Breathing Pattern and Breathing Exercises

Nursing Diagnosis: Ineffective Breathing Pattern related to pain and decreased lung expansion.

Expected Outcomes: The patient will demonstrate an effective breathing pattern, characterized by a respiratory rate within normal limits, absence of dyspnea, and effective chest expansion.

Nursing Interventions and Rationales:

• Teach and encourage regular deep-breathing exercises, incentive spirometer use, and diaphragmatic breathing.
  Rationale: Enhances oxygenation, prevents atelectasis, and promotes secretion mobilization. Regular practice maintains lung expansion and airway clearance. Effective directed coughing clears secretions and improves airway patency.

• Demonstrate and assist with splinting the chest during coughing in an upright position.
  Rationale: Splinting minimizes discomfort, and upright position supports deeper, more effective coughs.

• Monitor respiratory rate, depth, 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.

• Monitor ABG levels and breathing patterns for dysfunction.
  Rationale: Ensures detection of respiratory issues and provides data on oxygenation and ventilation status.

• Encourage sustained deep breaths and controlled breathing (slow inhalation, holding, passive exhalation) and teach yawning.
  Rationale: Promotes deep inspiration, increasing oxygenation and preventing air trapping and tachypnea.

• Ambulate patient as tolerated, assist with ADLs, ensure rest periods.
  Rationale: Ambulation mobilizes secretions, while rest prevents overexertion and conserves energy.

• Teach and assist with proper deep-breathing exercises.
  Rationale: Maximizes lung expansion, improves ventilation, and enhances cough productivity.

4. Nursing Interventions for Medication Administration and Pharmacological Support

Nursing Diagnosis: Potential Complications related to pneumonia, such as ineffective treatment or secondary infections.

Expected Outcomes: The patient will adhere to the prescribed medication regimen and demonstrate clinical improvement, as evidenced by reduced symptoms and resolution of infection.

Nursing Interventions and Rationales:

• Administer prescribed antibiotics as ordered.
  Rationale: Pneumonia treatment includes appropriate antibiotics based on culture and sensitivity. CAP often requires empiric antibiotic therapy.

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 facilitate respiration.	Albuterol (Ventolin, ProAir), Salmeterol (Serevent), Ipratropium (Atrovent), Theophylline
Analgesics	Reduce discomfort to improve cough effort, use cautiously.	Acetaminophen (Tylenol), Ibuprofen (Advil, Motrin)

• Administer antibiotics per culture and sensitivity results.
  Rationale: Ensures targeted treatment, improving effectiveness and reducing antibiotic resistance.

• Monitor response to antibiotics: clinical stability (temperature, heart rate, respiratory rate, blood pressure, oxygen saturation).
  Rationale: Identifies improvements or complications, guiding therapy adjustments.

• Educate patient and family on completing full antibiotic course.
  Rationale: Ensures infection eradication, prevents recurrence, and reduces antibiotic resistance risk.

• Assess ability to switch from IV to oral antibiotics when stable and improving.
  Rationale: Promotes quicker discharge and reduces hospital stay.

5. Nursing Interventions for Infection Control & Management

Nursing Diagnosis: Risk for Infection related to primary infection and compromised lung defenses.

Expected Outcomes: The patient will remain free from secondary infections and demonstrate effective infection control practices.

Nursing Interventions and Rationales:

• Monitor vital signs closely, especially at therapy initiation, for complications (hypotension, shock). Instruct patient on secretion disposal and reporting changes.*
  Rationale:* Early detection of complications. Sputum disposal is crucial. Changes in sputum indicate infection resolution or secondary infection.

• Assess patient’s immunization status.
  Rationale: Pneumococcal and influenza vaccines reduce pneumonia risk.

• Demonstrate and encourage good hand washing techniques.
  Rationale: Handwashing is the most effective infection prevention method.

• Change position frequently and provide pulmonary hygiene.
  Rationale: Promotes expectoration and infection clearance. Pulmonary hygiene clears secretions and prevents atelectasis.

• Institute isolation precautions as needed. Limit visitors for high-risk patients.
  Rationale: Prevents infection spread based on infection type, antibiotic response, and patient health.

• Encourage rest and balanced activity, promote nutritional intake.
  Rationale: Facilitates healing and enhances natural resistance.

• Monitor antimicrobial therapy effectiveness.
  Rationale: Improvement should occur within 24–48 hours. Note any changes.

• Investigate sudden changes: chest pain, extra heart sounds, altered sensorium, recurring fever, sputum changes.
  Rationale: Suggests antibiotic resistance or secondary infection.

• Prepare for diagnostic studies (fiberoptic bronchoscopy) for non-responders.
  Rationale: Clarifies diagnosis and therapy needs.

6. Nursing Interventions for Managing Acute Pain and Promoting Comfort

Nursing Diagnosis: Acute Pain related to inflammation and coughing.

Expected Outcomes: The patient will report a manageable level of pain and demonstrate comfort through nonverbal cues and pain scales.

Nursing Interventions and Rationales:

• Assess pain characteristics: sharp, constant, stabbing. Investigate changes, location, intensity, pain with breathing/coughing.
  Rationale: Chest pain in pneumonia may indicate complications like pericarditis.

• Monitor vital signs regularly.
  Rationale: Changes in heart rate or BP may indicate pain when other causes are ruled out.

• Provide non-pharmacologic comfort measures: back rubs, position changes, quiet music, massage. Encourage relaxation/breathing exercises.
  Rationale: Non-analgesic measures lessen discomfort and augment analgesics. Patient involvement promotes independence.

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

• Instruct and assist with chest splinting during coughing.
  Rationale: Manages chest discomfort and makes coughing more effective.

• Administer antitussives as needed, avoid suppressing productive coughs. Use moderate analgesics for pleuritic pain relief.
  Rationale: Reduces nonproductive coughing and discomfort while maintaining productive cough effectiveness.

• Administer analgesics as prescribed, before severe discomfort.
  Rationale: Timely pain relief allows better pain control, effective breathing and coughing.

7. Nursing Interventions for Promoting Rest and Improving Activity Tolerance

Nursing Diagnosis: Activity Intolerance related to imbalance between oxygen supply and demand.

Expected Outcomes: The patient will demonstrate improved activity tolerance, evidenced by the ability to perform activities of daily living without excessive fatigue or dyspnea.

Nursing Interventions and Rationales:

• Assess baseline function and activity tolerance.
  Rationale: Establishes baseline for planning interventions and monitoring progress.

• Monitor response to activity: dyspnea, weakness, fatigue, vital sign changes.
  Rationale: Identifies activity limitations and need for care plan adjustments.

• Provide quiet environment and limit visitors during acute phase.
  Rationale: Conserves energy and promotes rest.

• Assist with self-care activities, gradually increase activity during recovery.
  Rationale: Promotes independence and prevents deconditioning.

• Explain rest importance and balance with activity.
  Rationale: Bed rest reduces metabolic demands during acute phase. Gradual activity increase builds endurance.

• Pace activity for patients with reduced activity.
  Rationale: Effective coughing may exhaust compromised patients.

• Assist patient to comfortable position for rest and sleep.
  Rationale: Elevated head of bed or chair sleeping may be comfortable.

8. Nursing Interventions for Maintaining Normal Body Thermoregulation

Nursing Diagnosis: Hyperthermia related to infectious process.

Expected Outcome: The patient will maintain a normal body temperature, indicating effective thermoregulation.

Expected Outcomes:

• The patient will maintain a core body temperature within normal limits (≤ 37.5°C or ≤ 99.5°F).
• The patient will demonstrate effective thermoregulation, evidenced by stable vital signs, adequate hydration, normal fluid intake and output, and absence of fever or related complications.

Nursing Interventions and Rationales:

• Monitor HR, BP, tympanic or rectal temperature every 4 hours.
  Rationale: HR and BP increase with hyperthermia. Rectal/tympanic temperatures are more accurate.

• Determine patient age and weight.
  Rationale: Extremes of age/weight increase risk of thermoregulation issues.

• Monitor fluid intake and urine output. Monitor fluid status in unconscious patients.
  Rationale: Fluid resuscitation may be needed for dehydration. Dehydrated patients cannot sweat effectively.

• Review serum electrolytes, especially serum sodium.
  Rationale: Sodium losses occur with sweating.

• Adjust environmental factors: room temperature, bed linens.
  Rationale: Regulate temperature by adjusting room temperature and linens.

• Eliminate excess clothing/covers. Encourage lightweight clothing, comfortable room temperature.
  Rationale: Exposing skin promotes evaporative cooling and comfort.

• Administer antipyretic medications as prescribed.
  Rationale: Antipyretics lower temperature by blocking prostaglandin synthesis.

• Prepare oxygen therapy for extreme cases.
  Rationale: Hyperthermia increases metabolic oxygen demand.

• Encourage fluids to prevent dehydration.
  Rationale: Adequate fluids regulate temperature. Fever-induced dehydration worsens fever.

• Provide tepid sponge baths as necessary.
  Rationale: Tepid baths reduce fever and improve comfort.

9. Nursing Interventions for Promoting Optimal Nutrition & Fluid Balance

Nursing Diagnosis: Deficient Fluid Volume related to increased respiratory rate and fever.

Expected Outcomes: The patient will maintain adequate hydration and nutritional intake to support recovery.

Expected Outcomes:

• The patient will maintain adequate hydration, evidenced by balanced intake and output, urine output of at least 30 mL/hour, and moist mucous membranes.
• The patient will report improved appetite and increased oral intake, consuming at least 50% of each meal to meet nutritional needs.

Nursing Interventions and Rationales:

• Assess vital sign changes: temperature increase, 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, mucous membrane moisture.
  Rationale: Indirect indicators of fluid volume, though mouth breathing can dry mucous membranes.

• Investigate nausea and vomiting.
  Rationale: These symptoms reduce oral intake.

• Monitor intake and output (I&O), noting urine color/character. Calculate fluid balance. Weigh as indicated.
  Rationale: Provides 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 needed.
  Rationale: Parenteral route corrects deficiency if intake is reduced or loss is excessive.

• Identify nausea/vomiting causes: sputum, aerosol treatments, dyspnea, pain.
  Rationale: Intervention choice depends on underlying cause.

• Provide covered sputum container, remove frequently. Oral hygiene after emesis, treatments, and before meals.
  Rationale: Reduces nausea by eliminating noxious sights, tastes, and smells.

• Schedule respiratory treatments 1 hour before meals.
  Rationale: Reduces nausea associated with treatments.

• Maintain adequate nutrition to offset hypermetabolic state. High-calorie, high-protein, soft diet.
  Rationale: Replenishes lost nutrients.

• Evaluate need to limit milk products for excessive mucus.
  Rationale: Milk-mucus link is inconclusive. Personalize based on patient history.

• Elevate head and neck, check tube position during NG tube feedings. Small volumes, elevate head 30 minutes post-feeding. Check residuals.
  Rationale: Prevents aspiration.

• Auscultate for bowel sounds. Observe for abdominal distension.
  Rationale: Bowel sounds may be diminished in severe infection. Distension may occur due to air swallowing or bacterial toxins.

• Small, frequent meals, dry foods, foods patient prefers.
  Rationale: Enhances intake despite shortness of breath, fatigue, decreased appetite.

• Evaluate nutritional state, baseline weight.
  Rationale: Chronic conditions or financial issues can contribute to malnutrition.

• Monitor and record I&O accurately. Observe urine color, watch for urinary output.
  Rationale: Assesses fluid balance. Output < 30 ml/2 hrs indicates deficit. Dark urine reflects concentration.

• Weigh daily, same time, clothes, scale. Monitor trends (1-1.5 kg/day changes).
  Rationale: Aids in accurate weight measurement. 1-1.5 kg/day change indicates fluid volume deficit.

• Assess skin turgor and mucous membranes for dehydration.
  Rationale: Dry tongue, mucous membranes, tongue furrows indicate deficient fluid volume.

• Monitor and record vital signs.
  Rationale: Hypovolemia signs: increased temperature, heart rate, decreased BP.

• Encourage frequent oral hygiene.
  Rationale: Oral hygiene moistens mucous membranes and addresses thirst.

• Advise patient to increase fluid intake to 2.5 L/day.
  Rationale: Maintains hydration.

• Maintain intravenous fluid therapy as indicated.
  Rationale: Parenteral fluids prevent shock.

• Provide humidified oxygen therapy.
  Rationale: Humidity lessens moisture losses during oxygen therapy.

10. Nursing Interventions for Patient Education & Health Teachings

Nursing Diagnosis: Deficient Knowledge related to pneumonia, treatment, and prevention.

Expected Outcomes: The patient will demonstrate an understanding of pneumonia, its management, and preventive measures.

Expected Outcomes:

• The patient will demonstrate improved understanding of pneumonia treatment by explaining medication regimen (purpose, dosage, side effects).
• The patient will verbalize the importance of vaccinations (pneumococcal, influenza) for respiratory infection prevention.

Nursing Interventions and Rationales:

• Determine patient understanding of pneumonia and treatment.
  Rationale: Starting point for patient education, identifies teaching strengths and weaknesses.

• Review normal lung function, pneumonia pathology.
  Rationale: Promotes understanding and treatment regimen cooperation.

• Identify self-care and homemaker needs.
  Rationale: Enhances coping, reduces anxiety. Respiratory symptoms may be prolonged; fatigue can persist.

• Assess potential home care needs.
  Rationale: Therapeutic regimen continues post-discharge.

• Provide written and verbal information.
  Rationale: Fatigue can affect information assimilation.

• Reinforce effective coughing and deep-breathing exercises.
  Rationale: Recurrence risk highest in initial 6–8 weeks post-discharge.

• Emphasize antibiotic therapy completion.
  Rationale: Full course reduces recurrence, promotes healthy immune system. Early discontinuation may cause rebound pneumonia.

• Review smoking cessation importance.
  Rationale: Smoking impairs lung defenses, increases infection risk.

• Outline health enhancement steps: rest, diet, avoid crowds during cold/flu season.
  Rationale: Increases natural defenses, limits pathogen exposure.

• Stress medical follow-up and vaccinations.
  Rationale: Prevents recurrence and complications.

• Identify signs/symptoms requiring provider notification: dyspnea, chest pain, fatigue, weight loss, fever, cough, mentation changes.
  Rationale: Prompt evaluation and intervention prevent complications.

• Instruct patient to avoid indiscriminate antibiotic use for viral infections.
  Rationale: May lead to antibiotic-resistant bacteria.

• Encourage Pneumovax and annual flu shots for high-risk patients.
  Rationale: Pneumococcal vaccination reduces pneumonia cases.

11. Nursing Interventions for Monitoring Potential Pneumonia Complications

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

Expected Outcomes: The patient will be monitored proactively for potential complications of pneumonia, and interventions will be implemented promptly if complications arise.

Nursing Interventions and Rationales:

• Assess and monitor for shock and respiratory failure signs.
  Rationale: Pneumonia complications include hypotension, septic shock, respiratory failure, especially in older adults or those with resistant infections. Monitor vital signs, pulse oximetry, hemodynamic parameters. Report deterioration, administer IV fluids, medications for shock. Intubation/ventilation may be needed for respiratory failure.

• Assess and monitor for pleural effusion and empyema signs.
  Rationale: Pleural effusion is fluid accumulation between lung pleural layers. Parapneumonic effusions occur in bacterial pneumonia. Thoracentesis removes fluid for analysis. Monitor for pneumothorax or recurrence post-thoracentesis. Chest tube may be needed; monitor respiratory status. Empyema is thick, purulent fluid with fibrin. Antibiotics for 4-6 weeks, surgery may be needed.

• Assess and monitor for delirium, especially in older adults.
  Rationale: Confusion Assessment Method (CAM) screens for delirium. Delirium and cognitive changes are poor prognostic indicators. Factors: hypoxemia, fever, dehydration, sleep deprivation, sepsis, comorbidities. Address underlying factors, ensure patient safety.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources to further enhance your understanding and practice.

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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, offering a three-step system for client assessment, nursing diagnosis, and care planning.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Features over two hundred care plans reflecting current evidence-based guidelines, including new content on ICNP diagnoses, LGBTQ health issues, and electrolyte and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
A quick-reference tool that aids in identifying correct diagnoses for efficient patient care planning, with the latest nursing diagnoses and interventions.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
This manual assists in planning, individualizing, and documenting care for over 800 diseases and disorders, providing sample clinical applications, prioritized interventions, and documentation guidance.

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, pediatrics, and psychiatric-mental health, focusing on interprofessional “patient problems”.

See Also

Explore these additional resources on our site for related nursing care plans and information on respiratory system disorders:

References and Sources

Explore these journals, books, and materials for further learning on pneumonia nursing care plans and nursing diagnosis:

Originally published January 10, 2010.

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