VI. Nursing Diagnosis
• Ineffective airway clearance related to copious tracheobronchial secretions.
• Activity intolerance related to impaired respiratory function
• Risk for fluid volume deficit related to fever and dyspnea
• Imbalanced nutrition: less than body requirements
• Knowledge deficit about treatment regimen and preventive health measures
VII. Nursing Management
Improving airway patency
• Encourage hydration: fluid intake (2 to 3 L/day) to loosen secretions.
• Provide humidified air using high-humidity face mask.
• Encourage patient to cough effectively, and provide correct positioning, chest physiotherapy, and incentive spirometry.
• Provide nasotracheal suctioning if necessary.
• Provide appropriate method of oxygen therapy.
• Monitor effectiveness of oxygen therapy.
Promoting fluid intake and maintaining nutrition
Encourage fluids (2 L/day minimum with electrolytes and calories)
Administer intravenous fluids and nutrients, if necessary.
Promoting activity tolerance
• Counsel patient to rest and to avoid overexertion, which may exacerbate symptoms.
• Assist patient into a comfortable position that maximizes breathing (e.g. semi-Fowler’s)
• Change position frequently (particularly in elderly patients).
Informing patient
• Instruct on cause of pneumonia and management of symptoms
• Explain treatments in simple manner and using appropriate language
• Repeat instructions and explanations as needed.
Monitoring and Preventing complications
• Assess for signs and symptoms of shock and respiratory failure (e.g. evaluate vital signs, pulse oximetry, and hemodynamic monitoring parameters).
• Administer intravenous fluids and medications and respiratory support as ordered.
• Initiate preventive measures for atelactasis.
• Assess for atelactasis and pleural effusion.
• Assist with thoracentesis, and monitor patient for pneumothorax after procedure.
• Monitor for superinfection (rise in temperature, increased cough), and assist in therapy.
• Assess for confusion or cognitive changes; assess underlying factors.
Health Teachings
• Instruct patient to continue taking antibiotics until complete.
• Advise patient to increase activities gradually after fever subsides.
• Advise patient that fatigue and weakness may linger.
• Encourage breathing exercises to promote lung expansion and clearing.
• Encourage follow-up chest radiographs.
• Instruct patient to avoid fatigue, sudden changes in temperature, and excessive alcohol intake, which lower resistance to pneumonia.
• Review principles of adequate nutrition and rest.
• Recommend influenza vaccine and Pneumovax to all patients at risk (elderly, cardiac, and pulmonary disease patients)
• Refer patient for home care to facilitate adherence to therapeutic regimen, as indicated.