Pneumonia is an infection that fills the air sacs with fluid or pus. Clients struggle to clear secretions and to oxygenate. Your focus is the airway, oxygenation, and treating the infection.
A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation
Each care plan below follows the nursing process (ADPIE).
CARE PLAN 1 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Ineffective Airway Clearance
Related to
- Thick secretions
- Weak cough and fatigue
As evidenced by
- Crackles or rhonchi
- Productive cough with colored sputum
- Shortness of breath
Short-term goals
- Client coughs up secretions effectively within 24 hours
- Lung sounds improve
Long-term goals
- Lungs are clear by discharge
- Lung sounds every shift
- Sputum color, amount, and thickness
- Respiratory rate and work of breathing
| INTERVENTION | RATIONALE |
|---|---|
| Encourage coughing, deep breathing, and incentive spirometer use | These open the airways and move secretions. |
| Encourage fluids unless restricted | Hydration thins secretions. |
| Position upright and turn every 2 hours | Positioning helps the lungs expand and drain. |
| Suction if the client cannot clear secretions | Clears the airway when coughing fails. |
EVALUATION
- Breath sounds are clearer
- Client coughs up secretions on their own
CARE PLAN 2 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Impaired Gas Exchange
Related to
- Fluid in the alveoli
As evidenced by
- SpO2 below 92%
- Restlessness or confusion
- Abnormal blood gases
Short-term goals
- SpO2 at or above the ordered goal
Long-term goals
- Client breathes comfortably on room air
- SpO2 continuously or as ordered
- Mental status
- Blood gases as ordered
| INTERVENTION | RATIONALE |
|---|---|
| Give oxygen as ordered | Supplemental oxygen raises blood oxygen levels. |
| Give antibiotics on time | Treating the infection clears the alveoli. |
| Space activities | Rest lowers oxygen demand. |
EVALUATION
- SpO2 meets the goal
- Client is calm and oriented
Practice this in SBAR Shift Master
Take report on a client with pneumonia and pick the right actions.
Play SBAR Shift MasterQuick answers
Medical vs. nursing diagnosis for pneumonia?
The medical diagnosis is pneumonia. Nursing diagnoses describe the client's response, like Ineffective Airway Clearance or Impaired Gas Exchange.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.