Pneumonia - 4 Nursing Diagnosis with Interventions

Pneumonia is an illness that affects one or both lungs and that used to be one of the main causes of death 2 centuries ago. It is caused by microorganisms that attack the tissue from the lungs, causing it to inflammate and leading to a severe condition if the infection is not treated in time.

Some pneumonia is diagnosed only after an examination by a doctor reveals crackling sounds or coarse breathing in the chest. There may also be breathlessness, wheezing or the breathing sounds may be diminished in certain parts of the chest. A chest x-ray is the definitive way to diagnose the pneumonia, however sputum samples, blood tests and bronchoscopies can typically be ordered as well. The sputum samples can determine what the exact cause of the pneumonia is and determine the course of medical treatment. The blood work can help to determine how serious the infection is and may also provide a clue as to whether it is caused by a virus, bacteria or fungi.

Nursing Diagnosis for Pneumonia

1. Impaired Gas Exchange related to impaired oxygen delivery.
2. Risk for Infection related to inadequate primary defenses.
3. Ineffective airway clearance related to the formation of edema.
4. Activity Intolerance related to insufficiency of oxygen for everyday activities.

Nursing Interventions for Pneumonia

Intervention and Rationale:
I. Assess for:

• Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of accesory muscles, and diminished breath sounds, rhonchi or crackles on auscultation - provides data baseline.
• Changes in mental status, skin color, cyanosis - indicates possible decrease in oxygenation.
• Quality of cough and ability to raise secretions including consistency and characteristics od sputum - removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airways facilitates breathing.

II. Monitor, record, describe:
Respiratory rate, quality and breath sounds q2-q4 - indicates airway resistance, air movement, severity of disease.

• ABGs, oximeter reading - decreased oxygen levels result in hypoxemia.

III. Administer:

• Oxygen therapy via cannula - maintain optimal oxygen level.
• Antitussives/expectorants (terpin hydrate, guaifenesin) - acts on bronchial cells to increase fluid production and promote expectoration; guaifenesin reduces surface tension of secretions; both relieve non-productive cough
• Mucolytic (acetylcysteine) - decrease viscosity of mucus for easier removal.
• Antibiotic (ampicillin, cephalexin) - acts by binding to cell wall organisms preventing synthesis and destroying pathogens.

IV. Perform or Provide:

• Position of comfort in semi or high fowlers and change position q2h - facilitates breathng and allows for full expansion of lungs.
• Encourage coughing if sounds is moist; if dry and hacking, increase fluid intake and administer cough suppresant - reduces continual irritation to throat and liquefies secretions.
• Coughing and deep breathing exercise q2h; use incintive spirometer 5-10 breaths if tolerated - coughing clears airway by propelling secretions to mouth deep breathing promoes ventilation and prolongs expiratory phase.
• Assist with coughing by splinting chest; humidified air with cool mist - loosens seretions and improves ventilation, moistens mucous membranes
• Postural drainage and percussion PRN - mobilizes secretion.
• Suction secretions if cough ineffective - removal if unable to bring up secretions.
• Oral care after expectoration and provide tissues and bag for disposal - promotes comfort and prevents transmission of organisms to others.

Source : http://nanda-nursinginterventions.blogspot.com/2011/05/nursing-interventions-for-pneumonia.html