Pneumonia is an infection of the lungs caused by a bacteria, virus, or fungus. In healthy individuals, pneumonia is not usually life-threatening and does not require hospitalization. Those at higher risk, such as the very young or old, patients with compromised immune systems, or who already have a respiratory comorbidity, may require inpatient care and treatment.
Hospital-acquired pneumonia (HAP), which presents after the patient has been admitted for 48 hours, is often attributed to antibiotic resistance. Healthcare-associated pneumonia (HCAP) develops in patients in other healthcare settings, such as nursing homes. Patients admitted to intensive care units receiving ventilator support are at risk for ventilator-associated pneumonia (VAP). These critically ill patients have a high mortality rate of 25-50%.
Community-acquired pneumonia (CAP) occurs outside of the hospital or facility setting. Droplets often spread the bacteria or virus through coughing or sneezing, which the person then inhales. Touching an infected object and touching your nose or mouth can also transfer the germs.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Spontaneous Ventilation
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Risk For Infection
Nursing Process
Pneumonia is one of the most frequent infections the nurse will encounter and treat. The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment.
Nurses also play a role in preventing pneumonia through education. Patients with compromised immune systems, such as those with COPD, HIV, or autoimmune diseases, should be educated on their risks and how to protect themselves. Smoking further increases the risk of developing pneumonia and should be avoided. Nurses should assess for and encourage pneumonia vaccines for eligible populations.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to pneumonia.
Review of Health History
1. Assess the patient’s general symptoms.
Symptoms may vary depending on the cause, patient’s age, and overall health. These include:
- Productive cough with yellowish to greenish sputum
- Fever
- Excessive sweating
- Chills
- Dyspnea
- Tachypnea
- Sharp chest pain during breathing or coughing
- Fatigue
- Anorexia
- Nausea and vomiting in children
- Confusion in older patients
2. Identify the patient’s risk.
The following patient populations have a higher risk of contracting pneumonia:
- Adults over age 65
- Babies and children two years old or younger
- Those with a compromised immune system
3. Consider sources of possible exposure.
Legionnaires’ disease is a type of pneumonia caused by contaminated water sources. Some fungi sources found in soil may also cause pneumonia. Assess potential causes by inquiring about:
- Recent travel
- Occupation or living situation (military barracks, prison systems, nursing homes)
- Environmental exposures (air pollution or fumes)
- Animal exposure (birds may carry and transmit bacteria to humans)
4. Determine the patient’s risk of aspiration.
Patients at risk for aspiration have a higher rate of developing pneumonia. The risk of aspiration may be related to:
- Alcoholism
- Altered mental status
- Anatomic defect
- Difficulty swallowing (dysphagia)
- Gastroesophageal reflux disease (GERD)
- Seizure disorders
5. Review the medical history.
Conduct a comprehensive review of the patient’s medical conditions that increase the risk for pneumonia, such as:
- Asthma
- COPD
- Cystic fibrosis
- RSV
- Diabetes
- Heart failure
- Sickle cell disease
- Smoking
- Compromised immune system
6. Check the medication list.
Bacteria resistant to antibiotics, such as methicillin-resistant Staphylococcus aureus (MRSA), is a common cause of HAP and HCAP.
7. Track the patient’s past surgeries.
Postoperative pneumonia is the third most prevalent complication of all surgical procedures. Risk factors include older age, COPD, emergency surgery, prolonged ventilation, low albumin levels, and bed rest.
Physical Assessment
1. Monitor the vital signs.
Note the following vital sign alterations, such as:
- Tachypnea (respiratory rate >20 breaths per minute)
- Tachycardia (pulse rate >100 beats per minute)
- Fever (100.4 F (38 C) or greater)
Note: Patients who are immunocompromised may not present with a fever.
2. Assess the respiratory status.
Observe the following physical findings:
- Palpation: increased tactile fremitus
- Percussion: dullness
- Auscultation: decreased breath sounds or rales, crackles, rhonchi, or wheezes
3. Note systemic signs and symptoms.
Pneumonia may also cause:
- Chills
- Lethargy
- Anorexia (loss of appetite)
- Muscle pain (myalgia)
- Altered mentation
- Weakness
- Dehydration (diarrhea, vomiting, headache)
4. Observe the sputum characteristics.
Purulent or (rarely) blood-tinged sputum is a sign of bacterial pneumonia. Watery or occasionally mucopurulent sputum is a characteristic of viral pneumonia.
5. Assess the gag reflex.
Aspiration occurs when food, drink, vomit, or saliva enters the lungs. Elicit the glossopharyngeal nerve to test the gag reflex by gently touching the back of the tongue with a cotton swab or tongue blade.
Diagnostic Procedures
1. Obtain blood for testing.
Blood tests assess severity, inflammation, and other complications. Blood testing may include:
- Complete blood count with differential
- Coagulation studies
- Serum electrolytes
- Renal panel
- Liver panel
- Serum lactate level
- C-reactive protein (CRP) level
- Procalcitonin
2. Assess blood and sputum cultures.
Obtain blood (and sputum cultures when possible) before initiating antibiotic therapy.
3. Investigate the oxygenation of the blood.
Blood gas analysis assesses the degree of respiratory compromise, gas exchange, and acid-base balance in the blood.
4. Obtain lower respiratory secretions if needed.
Ventilator-associated pneumonia (VAP) develops several days after admission. Taking airway samples for stains and cultures may help guide antibiotic therapy. Nowadays, fiberoptic bronchoscopy is used instead of transtracheal aspiration to acquire lower respiratory secretions.
5. Prepare the patient for imaging scans.
Chest radiography (X-ray) is the standard approach to diagnose the presence of the following:
- Infiltrates
- Pleural effusion
- Parapneumonic pleural fluid
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with pneumonia.
Manage the Infection
1. Identify the type of pneumonia.
The first step in managing pneumonia is through identifying its type. CAP, VAP, and HAP have different treatment approaches depending on the severity and risk. Consider the following:
- Outpatient treatment
- Need for hospitalization
- Admission to ICU
2. Administer antibiotic therapy as ordered.
The cornerstone of treatment for bacterial pneumonia is antibiotic therapy. Administer empiric treatment as recommended. Tailor antibiotic therapy if the pathogen is known.
3. Provide oxygen as recommended.
Supplemental oxygen may be necessary for patients who are hypoxic or experiencing dyspnea.
4. Start fluid resuscitation.
Volume depletion is common among patients with pneumonia. Patients who are hypotensive may need intravenous therapy. Take caution when administering IV fluids to patients with heart disease or kidney failure.
5. Administer medications as prescribed.
- Corticosteroids
- Pain and fever reducers (aspirin, NSAIDs, or acetaminophen)
- Cough suppressants and/or expectorants
6. Collaborate with respiratory therapy.
Collaborate with the respiratory therapist in administering breathing treatments, chest physiotherapy, oxygen, or ventilatory support.
7. Mobilize secretions.
Breathing exercises, movement, and devices aid in loosening and expelling secretions. The following strategies can help strengthen the lungs:
- Diaphragmatic breathing
- Deep breathing and coughing
- Use of spirometry or flutter valves
- Early ambulation
8. Encourage moisture and fluids.
Encourage patients with pneumonia to increase fluid intake, especially warm liquids, and to use a humidifier or steamy shower/bath to open the airways and make breathing easier.
Prevent Pneumonia
1. Avoid smoking.
Smoking harms the lungs and increases the chance of lung infection. This also includes avoiding secondhand smoke.
2. Encourage vaccination.
Pneumonia vaccines are recommended for anyone over age 65 or those younger than age 65 who are at increased risk for pneumonia. The patient should also receive other recommended vaccines against influenza, COVID-19, or respiratory syncytial virus, as these respiratory infections can develop into pneumonia.
3. Reduce the risk of exposure.
Teach the patient about proper handwashing and the use of hand sanitizer. Avoid contact with those who are ill, and consider a mask if traveling or in crowded areas. Boost the immune system through a healthy diet, exercise, and regular sleep.
4. Implement aspiration precautions.
If the patient is at risk for aspiration, implement the following measures to reduce the risk of aspiration and subsequent pneumonia:
- Encourage small bites when eating
- Avoid distractions during meals
- Allow plenty of time for chewing and swallowing
- Ensure the patient is sitting upright when eating
- Do not lay the patient down for 30 minutes after meals
- Monitor for pocketing of food or pills in the mouth
- Monitor for choking or gagging while eating
- Consider thickened liquids or pureed diets
- Request evaluation by a speech therapist
Reduce the Risk of Ventilator-Acquired Pneumonia (VAP)
1. Provide oral hygiene.
Patients on a ventilator must receive frequent oral care to reduce the risk of bacterial growth.
2. Suction as needed.
Secretions can pool in the mouth and lead to aspiration. The nurse and respiratory therapist can provide subglottic suctioning to prevent aspiration.
3. Position appropriately.
Elevate the head of the bed by 30 to 45 degrees to prevent reflux and VAP.
4. Ambulate as tolerated.
If the patient isn’t sedated, assist in ambulating, sitting on the side of the bed, or marching in place to reduce VAP.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for pneumonia, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for pneumonia.
Impaired Gas Exchange
Impaired gas exchange is closely tied to Ineffective airway clearance. Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Inflammation
- Fluid and mucus in the alveoli
- Hypoventilation causing a lack of oxygen delivery
As evidenced by:
- Dyspnea
- Hypoxemia
- Confusion
- Restlessness
- Lethargy
- Alterations in breathing pattern
Expected outcomes:
- Patient will display appropriate oxygenation through ABGs within normal limits.
- Patient will demonstrate appropriate actions to promote ventilation and oxygenation.
Assessment:
1. Assess lung sounds and vital signs.
Assess breath sounds, respiratory rate and depth, sp02, blood pressure and heart rate, and capillary refill to monitor for signs of hypoxia and changes in perfusion.
2. Assess for mental status changes.
Poor oxygenation leads to decreased perfusion to the brain resulting in a decreased level of consciousness, restlessness, agitation, and lethargy.
3. Monitor ABGs and oxygen saturation.
Decreasing sp02 signifies hypoxia. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. If abnormal, the lungs are not oxygenating adequately causing poor perfusion of the tissues.
Interventions:
1. Encourage rest and limit exertion.
Patients may not be able to tolerate too much activity. Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption.
2. Use narcotics and sedatives with caution.
Narcotics for pain control or anti-anxiety medications should be monitored closely as they can further suppress the respiratory system.
3. Administer oxygen.
Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels.
Impaired Spontaneous Ventilation
Severe cases of pneumonia may deteriorate to respiratory failure and the inability to breathe independently.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Related to:
- Underlying conditions (COPD, asthma, HIV)
- Sepsis
- Respiratory muscle fatigue
As evidenced by:
- Dyspnea
- Cyanosis
- Tachycardia
- Restlessness
- Hypoxia
- Accessory muscle use
- Nasal Flaring
- Abnormal ABGs
Expected outcomes:
- Patient will maintain ABGs within acceptable parameters.
- Patient will be free of signs of respiratory distress such as cyanosis, restlessness, or hypoxia.
- Patient will maintain a patent airway.
Assessment:
1. Assess for signs of respiratory distress.
Worsening dyspnea, tachypnea, retractions, accessory muscle use, or cyanosis require immediate intervention.
2. Monitor ABG results.
Blood gas analysis can detect changes in oxygenation and acid-base balance, allowing the healthcare team to plan interventions and intervene before respiratory failure occurs.
3. Identify factors that may complicate the respiratory status.
Chronic conditions such as COPD, asthma, heart failure, cirrhosis, and more may complicate the patient’s breathing abilities and require advanced interventions.
Interventions:
1. Discuss intubation and ventilation.
Explain the process of noninvasive and invasive ventilation to prepare the patient and family and reduce anxiety.
2. Consider the use of noninvasive positive pressure ventilation (NPPV) first.
BiPAP is a type of NPPV that provides noninvasive ventilation with a lower risk of ventilator-associated pneumonia (VAP) than intubation and mechanical ventilation.
3. Reposition as needed.
If not sedated, assist with ambulation. A rotational bed can help with turning to prevent atelectasis and VAP.
4. Implement techniques to reduce VAP.
Keep the head of the bed elevated 30-45 degrees, provide frequent oral care, and suction secretions to prevent aspiration and VAP.
Ineffective Airway Clearance
Pneumonia may increase sputum production causing difficulty in clearing the airways.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Poor cough reflex
- Secretions in the bronchi or alveoli
- Excessive mucus
- Comorbidities: COPD, asthma, cystic fibrosis
As evidenced by:
- Shortness of breath
- Diminished lung sounds or crackles/rhonchi
- Ineffective cough
- Observed sputum production
- Orthopnea
- Changes in respiratory rate and rhythm
- Restlessness
Expected outcomes:
- Patient will maintain a patent airway.
- Patient will demonstrate appropriate airway clearance techniques.
- Patient will display improvement in airway clearance as evidenced by clear breath sounds and an even and unlabored respiratory rate.
Assessment:
1. Monitor for respiratory changes.
Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop.
2. Assess the ability and effectiveness of cough.
Pneumonia infection causes inflammation and increased sputum production. The patient needs to be able to effectively remove these secretions to maintain a patent airway. Patients who are weak or lack a cough reflex may not be able to do so. This also increases the risk for aspiration pneumonia.
3. Obtain a sputum sample for culture.
If the patient can cough, have them expectorate sputum for testing. If they cannot, sputum can be obtained via suctioning. Sputum samples can be cultured to appropriately treat the type of bacteria causing infection.
Interventions:
1. Assist with respiratory devices and techniques.
Flutter valves mobilize secretions facilitating airway clearance while incentive spirometers expand the lungs. The nurse should instruct on how to properly use these devices and encourage their use hourly. The nurse can also teach coughing and deep breathing exercises.
2. Suction as needed.
Patients who have a tracheostomy may need frequent suctioning to keep airways clear. Patients who are weak or fatigued with an ineffective cough can be taught how to suction themselves.
3. Administer nebulizer treatments and other medications.
Nebulizer treatments can loosen secretions in the lungs while mucolytics and expectorants can help thin mucus and make it easier to cough up.
4. Encourage movement and positioning.
Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. Immobile patients or those who need assistance should be turned every 2 hours, assisted into an upright position, or transferred into a chair to promote lung expansion.
Ineffective Breathing Pattern
Pneumonia is an infection of the lungs that can alter respiratory patterns, preventing adequate ventilation.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Increased sputum production
- Pleuritic pain
- Fatigue
- Poor body positioning
- Chronic lung diseases
As evidenced by:
- Changes in the rate and depth of respirations
- Abnormal breath sounds
- Use of accessory muscles
- Dyspnea
- Orthopnea
- Cyanosis
- Productive cough
Expected outcomes:
- Patient will demonstrate effective respirations while in a position of comfort.
- Patient will maintain an even and unlabored breathing pattern.
Assessment:
1. Monitor and measure the respiratory status.
Assess the patient’s respiratory rate, depth, and pattern. Monitor closely for accessory muscle use, nasal flaring, grunting, or orthopnea.
2. Auscultate lung fields.
Inflammation or mucus accumulation in the lungs may cause wheezing, crackles, or rhonchi, disrupting the respiratory pattern.
3. Assess for pain with breathing.
Pneumonia can cause pleuritic chest pain or pain with breathing or coughing that inhibits normal breathing.
Interventions:
1. Elevate the head of the bed and encourage ambulation.
This encourages optimal chest expansion and the mobilization of secretions.
2. Administer oxygen as indicated.
Supplemental oxygen may be necessary to address hypoxia and improve oxygenation. Administer and adjust oxygen therapy per the prescribed orders or guidelines.
3. Encourage deep, controlled breathing and splinting of the chest.
The patient with pleuritic chest pain may be hesitant to cough or breathe normally. Help ease the pain by encouraging deep, slow breaths and using a pillow to splint the chest when breathing or coughing.
4. Promote adequate rest periods and sleep.
Encourage active participation in activities of daily living (ADLs), but remind patients not to overdo themselves. Limit interruptions so the patient receives adequate sleep.
Risk For Infection
Pneumonia is an infection itself but a risk for infection nursing diagnosis is appropriate as untreated pneumonia can progress into a secondary infection or sepsis.
Nursing Diagnosis: Risk For Infection
Related to:
- Inadequate primary defenses: decreased ciliary action, respiratory secretions
- Invasive procedures: suctioning, intubation
- Presence of existing infection
- Worsening in condition leading to immobility, immunosuppression, and malnutrition
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will not develop a secondary infection or sepsis.
- Patient will display improvement in infection evidenced by vital signs and lab values within normal limits.
Assessment:
1. Monitor for worsening signs of infection or sepsis.
Dropping blood pressure, hypothermia or hyperthermia, elevated heart rate, and tachypnea are signs of sepsis that require immediate attention.
2. Assess lab values.
An elevated white blood count is indicative of infection. This is an expected finding with pneumonia, but should not continue to rise with treatment. If sepsis is suspected, a blood culture can be obtained.
3. Consider sources of infection.
Any inserted lines such as IVs, urinary catheters, feedings tubes, suction tubing, or ventilation tubes are potential sources of infection. Remove unnecessary lines as soon as possible. Surgical incisions and any skin breakdown should be monitored for redness, warmth, drainage, or odor that signals an infection.
Interventions:
1. Administer antibiotics.
A diagnosis of pneumonia will warrant antibiotic treatment. If the patient’s condition worsens or lab values do not improve, they may not be receiving the correct antibiotic for the bacteria causing infection.
2. Encourage fluid intake and nutrition.
Hydration is vital to prevent dehydration and supports homeostasis. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. Encouraging oral fluids will mobilize respiratory secretions. Proper nutrition promotes energy and supports the immune system.
3. Implement precautions to prevent infection.
Proper handwashing is the best way to prevent and control the spread of infection. The patient may have a limit to visitors to prevent the transmission of infections. Always maintain sterility or aseptic techniques when performing any invasive procedure.
4. Promote skin integrity.
The skin is the body’s first barrier against infection. Skin breakdown allows pathogens to enter the body. If a patient is immobile they must be repositioned every 2 hours to maintain skin integrity. Keep skin clean and dry through frequent perineal care or linen changes.
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- Yang, Fang1#; Yang, Yi1#; Zeng, Lingchan2; Chen, Yiwei1; Zeng, Gucheng1 Nutrition Metabolism and Infections, Infectious Microbes & Diseases: September 2021 – Volume 3 – Issue 3 – p 134-141 doi: 10.1097/IM9.0000000000000061 (Pneumonia: Symptoms, Treatment, Causes & Prevention, 2020)
