Nursing Care Plan for Pneumonia
Pneumonia
Pneumonia is an inflammation of the lung, usually caused by an infection. Three common causes are bacteria, viruses and fungi. You can also get pneumonia by accidentally inhaling a liquid or chemical. People most at risk are older than 65 or younger than 2 years of age, or already have health problems.
If you have pneumonia, you may have difficulty breathing and have a cough and a fever. A physical exam and history can help determine if you have pneumonia. Chest x-rays and blood tests can help determine what is wrong. Treatment depends on what made you sick. If bacteria are the cause, antibiotics should help. Viral pneumonia may get better with rest and drinking liquids.
Preventing pneumonia is always better than treating it. The best preventive measures include washing your hands frequently, not smoking, and wearing a mask when cleaning dusty or moldy areas. There is a vaccine for pneumococcal pneumonia, a bacterial infection which accounts for up to a quarter of all pneumonias.nlm.nih.gov
Assessment
Objective :
- T= 39.2°C, P= 150,RR= 46
- nasal flaring with shallow breathing
- use of accessory muscles
- crackles auscultated in upper lobe
- productive cough with thick purulent sputum
- diaphoresis and pallor
- increased WBC count
- CXR= patchy diffusion in upper and middle lobes
Nursing Diagnosis
Ineffective breathing pattern related to inflammatory effects of pneumonia
Goal
Within 8 hours, patient will exhibit normal and effective respiratory pattern as evidenced by :
- respirations within acceptable range
- absence of signs and symptoms of cyanosis
- normal ABG and O2 saturation levels
Nursing Intervention
- Obtained resting vital signs
Rational : Baseline data is important to help determine patient’s current health status
and evaluate efficacy of nursing interventions rendered. - Assessed patient’s
vital signs and observed for signs and symptoms of cyanosis q2h
Rational : Frequent assessment provides information about any improvement or deterioration in patient’s condition. - Established rapport
Rational : Rapport is important to gain patient’s cooperation and reduce anxiety. - Placed patient in a semi-Fowler’s to high- Fowler’s position
Rational : An upright position promotes lung expansion and mobilization of secretions. - Maintained a quiet, comfortable environment
Rational : Promotes rest and sleep and prevents anxiety thereby decreasing the patient’s oxygen demands - Administered medications as ordered: antibiotics, mucolytics, expectorants, and bronchodilators
Rational : Bronchodilators aid in reduction of bronchospasm. Mucolytics and expectorants mobilize secretions. Antibiotic therapy is prescribed for pneumonia (except lipid and viral pneumonia). - Administered supplemental oxygen via face mask as ordered
Rational : upplemental oxygen aids in ventilation and minimizes the risk for hypoxemia.