y is to maintain PaO2 above 60 mmHg.

Oxygen is administered by the method

that provides appropriate delivery within the patients tolerance. Note: Patients
with underlying chronic lung diseases should be given oxygen cautiously.

3. Risk for Deficient Fluid Volume

Nursing Diagnosis

Risk for Deficient Fluid Volume

Risk factors may include

Excessive fluid loss (fever, profuse diaphoresis, mouth

breathing/hyperventilation, vomiting)

Decreased oral intake

Desired Outcomes

Demonstrate fluid balance evidenced by individually appropriate

parameters, e.g., moist mucous membranes, good skin turgor, prompt
capillary refill, stable vital signs.

Nursing Interventions

Rationale

Assess vital sign changes: increasing

Elevated temperature and prolonged

temperature, prolonged fever,

fever increases metabolic rate and

orthostatic hypotension, tachycardia.

fluid loss through evaporation.

Orthostatic BP changes and
increasing tachycardia may indicate
systemic fluid deficit.

Assess skin turgor, moisture of

Indirect indicators of adequacy of fluid

mucous membranes.

volume, although oral mucous

membranes may be dry because of
mouth breathing and supplemental
oxygen.

Investigate reports of nausea and

Presence of these symptoms reduces

Nursing Interventions

Rationale

vomiting.

oral intake.

Monitor intake and output (I&O),

Provides information about adequacy

noting color, character of urine.

of fluid volume and replacement

Calculate fluid balance. Be aware of

needs.

insensible losses. Weigh as indicated.

Force fluids to at least 3000 mL/day or

Meets basic fluid needs, reducing risk

as individually appropriate.

of dehydration and to mobilize

secretions and promote expectoration.

Administer medications as indicated:

To reduce fluid losses.

antipyretics, antiemetics.
Provide supplemental IV fluids as

In presence of reduced intake and/or

necessary.

excessive loss, use of parenteral route

may correct deficiency.

4. Imbalanced Nutrition
Nursing Diagnosis

Risk for Imbalanced Nutrition Less Than Body Requirements

Risk factors may include

Increased metabolic needs secondary to fever and infectious process

Anorexia associated with bacterial toxins, the odor and taste of sputum,
and certain aerosol treatments

Abdominal distension/gas associated with swallowing air during dyspneic

episodes

Desired Outcomes

Demonstrate increased appetite.

Maintain/regain desired body weight.

Nursing Interventions

Rationale

Identify factors that are contributing to

Choice of interventions depends on

nausea or vomiting: copious sputum,

the underlying cause of the problem.

aerosol treatments, severe dyspnea,

pain.
Provide covered container for sputum

Eliminates noxious sights, tastes,

and remove at frequent intervals.

smells from the patient environment

Assist and encourage oral hygiene

and can reduce nausea.

after emesis, after aerosol and

postural drainage treatments, and
before meals.
Schedule respiratory treatments at

Reduces effects of nausea associated

least 1 hr before meals.

with these treatments.

Maintain adequate nutrition to offset

To replenish lost nutrients.

hypermetabolic state secondary to

infection. Ask the dietary department
to provide a high-calorie, high-protein
diet consisting of soft, easy-to-eat
foods.
Consider limiting use of milk products

Milk products may increase sputum

production.

Elevate the patients head and neck,

To prevent aspiration. Note: Dont give

and check for tubes position during

large volumes at one time; this could

NG tube feedings.

cause vomiting. Keep the patients

head elevated for at least 30 minutes
after feeding. Check for residual
formula regular intervals.

Nursing Interventions

Rationale

Auscultate for bowel sounds. Observe

Bowel sounds may be diminished if

for abdominal distension.

the infectious process is

severe. Abdominal distension may
occur as a result of air swallowing or
reflect the influence of bacterial toxins
on the gastrointestinal (GI) tract.

Provide small, frequent meals,

These measures may enhance intake

including dry foods (toast, crackers)

even though appetite may be slow to

and/or foods that are appealing to

return.

patient.
Evaluate general nutritional state,

Presence of chronic conditions

obtain baseline weight.

(COPD or alcoholism) or financial

limitations can contribute to
malnutrition, lowered resistance to
infection, and/or delayed response to
therapy.

5. Acute Pain
Nursing Diagnosis

Acute Pain

May be related to

Inflammation of lung parenchyma

Cellular reactions to circulating toxins

Persistent coughing

Possibly evidenced by

Reports of pleuritic chest pain, headache, muscle/joint pain

Guarding of affected area

Distraction behaviors, restlessness

Desired Outcomes

Verbalize relief/control of pain.

Demonstrate relaxed manner, resting/sleeping and engaging in activity

appropriately.

Nursing Interventions

Rationale

Assess pain characteristics: sharp,

Chest pain, usually present to some

constant, stabbing. Investigate

degree with pneumonia, may also

changes in character, location, or

herald the onset of complications of

intensity of pain.

pneumonia, such as pericarditis and

endocarditis.

Monitor vital signs.

Changes in heart rate or BP may

indicate that patient is experiencing
pain, especially when other reasons
for changes in vital signs have been
ruled out.

Provide comfort measures: back rubs,

Non-analgesic measures

position changes, quite music,

administered with a gentle touch can

massage. Encourage use of

lessen discomfort and augment

relaxation and/or breathing exercises.

therapeutic effects of analgesics.

Patient involvement in pain control
measures promotes independence
and enhances sense of well-being.

Offer frequent oral hygiene.

Mouth breathing and oxygen therapy

can irritate and dry out mucous
membranes, potentiating general
discomfort.

Instruct and assist patient in chest

Aids in control of chest discomfort

Nursing Interventions

Rationale

splinting techniques during coughing

while enhancing effectiveness of

episodes.

cough effort.

Administer analgesics and

These medications may be used to

antitussives as indicated.

suppress non productive cough or

reduce excess mucus, thereby
enhancing general comfort.

6. Activity Intolerance
Nursing Diagnosis

Activity intolerance

May be related to

Imbalance between oxygen supply and demand

General weakness

Exhaustion associated with interruption in usual sleep pattern because of

discomfort, excessive coughing, and dyspnea

Possibly evidenced by

Verbal reports of weakness, fatigue, exhaustion

Exertional dyspnea, tachypnea

Tachycardia in response to activity

Development/worsening of pallor/cyanosis

Desired Outcomes

Report/demonstrate a measurable increase in tolerance to activity with

absence of dyspnea and excessive fatigue, and vital signs within patients
acceptable range.

Nursing Interventions

Rationale

Determine patients response to

Establishes patients capabilities and

activity. Note reports of dyspnea,

needs and facilitates choice of

Nursing Interventions

Rationale

increased weakness and fatigue,

interventions.

changes in vital signs during and after

activities.
Provide a quiet environment and limit

Reduces stress and excess

visitors during acute phase as

stimulation, promoting rest

indicated. Encourage use of stress

management and diversional activities
as appropriate.
Explain importance of rest in

Bedrest is maintained during acute

treatment plan and necessity for

phase to decrease metabolic

balancing activities with rest.

demands, thus conserving energy for

healing. Activity restrictions thereafter
are determined by individual patient
response to activity and resolution of
respiratory insufficiency.

Assist patient to assume comfortable

Patient may be comfortable with head

position for rest and sleep.

of bed elevated, sleeping in a chair, or

leaning forward on overbed table with
pillow support.

Assist with self-care activities as

Minimizes exhaustion and helps

necessary. Provide for progressive

balance oxygen supply and demand.

increase in activities during recovery

phase. and demand.

7. Risk for Infection

Nursing Diagnosis

Risk for [Spread] of Infection

Risk factors may include

Inadequate primary defenses (decreased ciliary action, stasis of

respiratory secretions)

Inadequate secondary defenses (presence of existing infection,

immunosuppression), chronic disease, malnutrition

Desired Outcomes

Achieve timely resolution of current infection without complications.

Identify interventions to prevent/reduce risk/spread of/secondary

infection.

Nursing Interventions

Rationale

Monitor vital signs closely, especially

During this period of time, potentially

during initiation of therapy.

fatal complications (hypotension,

shock) may develop.

Instruct patient concerning the

Although patient may find

disposition of secretions: raising and

expectoration offensive and attempt to

expectorating versus swallowing; and

limit or avoid it, it is essential that

reporting changes in color, amount,

sputum be disposed of in a safe

odor of secretions.

manner. Changes in characteristics of

sputum reflect resolution of
pneumonia or development of
secondary infection.

Demonstrate and encourage good

Effective means of reducing spread or

handwashing technique.

acquisition of infection.

Change position frequently and

Promotes expectoration, clearing of

provide good pulmonary toilet.

infection.

Limit visitors as indicated.

Reduces likelihood of exposure to

Nursing Interventions

Rationale
other infectious pathogens.

Institute isolation precautions as

Dependent on type of infection,

individually appropriate.

response to antibiotics, patients

general health, and development of
complications, isolation techniques
may be desired to prevent spread
from other infectious processes.

Encourage adequate rest balanced

Facilitates healing process and

with moderate activity. Promote

enhances natural resistance.

adequate nutritional intake.

Monitor effectiveness of antimicrobial

Signs of improvement in condition

therapy.

should occur within 2448 hr. Note

any changes.

Investigate sudden change in

Delayed recovery or increase in

condition, such as increasing chest

severity of symptoms suggests

pain, extra heart sounds, altered

resistance to antibiotics or secondary

sensorium, recurring fever, changes in

infection.

sputum characteristics.
Prepare and assist with diagnostic

Fiberoptic bronchoscopy (FOB) may

studies as indicated.

be done in patients who do not

respond rapidly (within 13 days) to
antimicrobial therapy to clarify
diagnosis and therapy needs.

8. Deficient Knowledge
Nursing Diagnosis

Deficient Knowledge regarding condition, treatment, self-care, and

discharge needs

May be related to

Lack of exposure

Misinterpretation of information

Altered recall

Possibly evidenced by

Requests for information; statement of misconception

Failure to improve/recurrence

Desired Outcomes

Verbalize understanding of condition, disease process, and prognosis.

Verbalize understanding of therapeutic regimen.

Initiate necessary lifestyle changes.

Participate in treatment program.

Nursing Interventions

Rationale

Review normal lung function,

Promotes understanding of current

pathology of condition.

situation and importance of

cooperating with treatment regimen.

Discuss debilitating aspects of

Information can enhance coping and

disease, length of convalescence, and

help reduce anxiety and excessive

recovery expectations. Identify self-

concern. Respiratory symptoms may

care and homemaker needs.

be slow to resolve, and fatigue and

weakness can persist for an extended
period. These factors may be
associated with depression and the
need for various forms of support and
assistance.

Nursing Interventions

Rationale

Provide information in written and

Fatigue and depression can affect

verbal form.

ability to assimilate information and

follow therapeutic regimen.

Reinforce importance of continuing

During initial 68 wk after discharge,

effective coughing and deep-breathing

patient is at greatest risk for

exercises.

recurrence of pneumonia.

Emphasize necessity for continuing

Early discontinuation of antibiotics

antibiotic therapy for prescribed

may result in failure to completely

period.

resolve infectious process and may

cause recurrence or rebound
pneumonia.

Review importance of cessation of

Smoking destroys tracheobronchial

smoking.

ciliary action, irritates bronchial

mucosa, and inhibits alveolar
macrophages, compromising bodys
natural defense against infection.

Outline steps to enhance general

Increases natural defense, limits

health and well-being: balanced rest

exposure to pathogens.

and activity, well-rounded diet,

avoidance of crowds during cold/flu
season and persons with URIs.
Stress importance of continuing

May prevent recurrence of pneumonia

medical follow-up and obtaining

and/or related complications.

vaccinations as appropriate.
Identify signs and symptoms requiring

Prompt evaluation and timely

Nursing Interventions

Rationale

notification of health care

intervention may prevent

provider: increasing dyspnea, chest

complications.

pain, prolonged fatigue, weight loss,

fever, chills, persistence of productive
cough, changes in mentation.
Instruct patient to avoid using

This may results in upper airway

antibiotics indiscriminately during

colonization with antibiotic resistant

minor viral infections.

bacteria. If the patient then develops

pneumonia, the organisms producing
the pneumonia may require treatment
with more toxic antibiotics.

Encourage pneumovax and annual flu

To help prevent occurrence of the

shots for high-risk patients.

disease.

Other Possible Nursing Care Plans

Impaired dentitionmay be related to dietary habits, poor oral hygiene,

chronic vomiting, possibly evidenced by erosion of tooth enamel, multiple
caries, abraded teeth.

Impaired oral mucous membranemay be related to malnutrition or

vitamin deficiency, poor oral hygiene, chronic vomiting, possibly evidenced
by sore, inflamed buccal mucosa, swollen salivary glands, ulcerations, and
reports of sore mouth and/or throat.

See Also

Nursing Care Plans

Pneumonia

6 Bronchopneumonia Nursing Care Plans

5 Pneumonia Nursing Care Plans