Pneumonia is an acute respiratory infection of the lung parenchyma caused by one or co-infecting pathogens. These pathogens cause the lung parenchyma (alveoli) to become inflamed and fill with pus and fluid, limiting oxygen intake and making gas exchange ineffective. The goal of Pneumonia Nursing Care is to support the respiratory system and improve gas exchange.
In these notes, we’ll be going over the nursing management of patients with pneumonia but before we get into that, make sure that you’ve understood the:
Pneumonia Nursing Assessment: Health History
As we mentioned above, for Pneumonia to develop, the patient would have had to come across a pathogen most likely of bacterial or viral form. These pathogens are contagious and can be transmitted to other individuals within close contact. Until the patient’s diagnosis and the pathogen is confirmed you should take droplet precautions, this will lower the chance of transmitting the pathogen to yourself or individuals around you.
Before approaching the patient it is advised to put on a disposable apron, gloves and surgical gloves. Start by introducing yourself to the patient, and find a private area to initiate the assessment. While talking to the patient keep a distance of 2 meters, and ask the patient to cover their nose and mouth when coughing. Once the patient is comfortable, you can start by asking about their Exposure to Risk Factors. Specific questions about the type, intensity and duration of exposure will give you a clear indication of where they might have contracted the pathogen, which in turn will help you to classify the type of Pneumonia. You might want to ask:
If the patient has been admitted to a hospital setting or healthcare clinic within the last 3 months.
If they are receiving any home-based care
Whether they’ve been in close contact with individuals who recently had respiratory infections
If they have any difficulty swallowing
You should also ask questions to evaluate the severity of your patient’s condition. Check if their symptoms are:
Disturbing their sleeping patterns and eating habits
Affecting their daily activities, work or sports
Next up, you should ask your patient about their past medical history specifically about any previous hospitalisation, respiratory conditions, including allergies, sinus infections or nasal polyps. This should also include their closest family relatives, so note down the patient’s family history concerning respiratory illnesses.
Lastly, you should ask questions to understand the patient’s knowledge as well as their social and familial support system. Once you’ve obtained a thorough medical history, you can move on to the physical assessment to get a better understanding of the patient’s physiological status.
Pneumonia Nursing Assessment: Physical Assessment
Before starting, take a quick look at your patient’s position, both when sitting and standing. If they have shortness of breath they might rest their hands onto their knees to support their breathing. Next up check their:
Fingers for Central Cyanosis
Record everything onto the patient’s file and move on to assessing their Respirations:
Are their respirations forced?
Can the patient finish off a sentence in one breath?
Are they contracting their abdominal muscles, or using their shoulders during inhalation?
Is the expiration time prolonged?
Can you note any unusual breath sounds? (Wheezing/ Crackles)
Some patients will present with a Cough, if you note that it’s productive you should also assess their Sputum in terms of colour, amount and consistency.
You should also check their breath sounds to look for lung consolidation, this would be evident by Tactile Fremitus, Dull percussions, Bronchial breath sounds, Egophony and Whispered Pectoriloquy.
Along with the physical assessment, there’s a series of tests that the patient will be asked to perform. These tests will determine the severity of the disease and guide the medical team when selecting the treatment.
Pneumonia Nursing Assessment: Medical Tests
Sputum Sample: To reveal the pathogen involved in the infection
Blood Cultures: Similar to sputum samples, blood cultures reveal the involved pathogen and aid in the selection of pharmacological treatment.
Arterial Blood Gases check the baseline oxygenation and gas exchange. Respiratory alkalosis (low PaCo2) is the most common early finding in patients with ongoing asthma exacerbation because of hyperventilation
Chest X-ray will exclude any alternative diagnoses.
Pneumonia Nursing Diagnosis
From your assessment, you might find the following nursing diagnosis:
Ineffective airway clearance
Impaired gas exchange
Inadequate nutrition and hydration
Pneumonia Nursing Care Plans
1. Managing Ineffective Airway Clearance
If your patient has ineffective airway clearance it means that they do not have a patent (open) airway. In the case of Pneumonia, this would typically be caused by a build-up of mucus in the airways, narrowing of the airways and a persistent cough.
Instruct your patient to sit in an elevated position, either on the chair or by elevating the bed and have the chin parallel to the floor or tilted slightly upwards to obtain an open airway. Once the position is set, encourage your patient to breathe using the pursed-lip technique. This technique makes it easier to breathe during an exacerbation, reduces air trapping and gives a sense of control to your patient.
The next step would be to help your patient get rid of the build-up of secretions in the airways. Teach them how to cough up secretions effectively and how to perform deep breathing exercises to maximise ventilation. You should also ensure that they’re adequately hydrated, as fluids make secretions less viscous and easier to be expectorated. Chest physiotherapy is very useful in preventing aspiration of secretions and further complications. Lastly, if your patient can not remove secretions alone you should use a Suction Set and remove them manually.
Patients with ineffective airway clearance will likely be prescribed Mucolytic Agents or Expectorants to decrease the viscosity of secretions. Moreover, Oxygen Therapy should be administered accordingly to keep the oxygen saturation within normal range.
2. Managing Ineffective Respirations
As we’ve explained in the Pathophysiology of Pneumonia , the infection causes the airways and alveoli to fill up with mucus making it more difficult for the patient to fully inhale and exhale.
Start off by ensuring that your patient has a clear airway and that they’re sitting at an elevated angle, especially when lying in bed. You should instruct the patient to use a pillow and splint their chest when coughing, this will provide support and allow the patient to inhale fully. Use deep breathing techniques to help the patient regulate their respiratory rate, and if necessary administer oxygen therapy as prescribed.
Similar to managing ineffective airway clearance, the patient might be prescribed Mucolytics and Expectorants to clear the sputum and decrease shortness of breath. As well as get Oxygen Therapy as needed.
3. Managing Impaired Gas Exchange
One of the symptoms of pneumonia is the build-up of mucus in the alveoli, and oedema in the mucosal lining. These factors make it difficult for oxygen and carbon dioxide to exchange and they create an imbalance in the Ventilation-Perfusion Ratio
Ensure that the patient’s airway is cleared, continue nursing at an elevated angle and use a splint when coughing. Administer oxygen therapy as prescribed, keeping in mind that if the patient has COPD they use their hypoxic drive to breathe. This means that the oxygen concentration should be as low as possible, and it can easily be done through the use of a Venturi Mask. You should also encourage your patient to use nasal prongs during meal times, and a portable oxygen tank when moving around.
Non-Invasive Positive Pressure Ventilation (NIPPV) Machines might be indicated during sleep or in severe cases even during the day. NIPPV Machines push oxygen into the lungs, forcing it to perfuse through the alveoli and into the blood. This forces the gases to regain their balance allowing the Ventilation-Perfusion Ratio to return to normal.
It’s important to regularly monitor your patient if impaired gas exchange is present as if it’s not treated effectively it will lead to further complications. So lookout for any signs of cyanosis, changes in mental status, abnormal ABG results, or abnormal vital signs because they can all indicate a deterioration in the patient’s physiological status.
4. Managing Hyperthermia
Like any other infection, Pneumonia will most likely cause a spike in temperature and the patient will have a fever for a couple of days.
Fever in Pneumonia is primarily treated with the regular administration of Paracetamol. Moreover, you should try to adjust the environmental factors to lower the patient’s temperature. Remove excess clothes and blankets, adjust the room temperature to avoid overheating and encourage the patient to stay hydrated.
5. Managing Inadequate Nutrition and Hydration
Patients with aggressive pneumonia will often have inadequate nutrition because dyspnoea affects their eating habits. Eating becomes stressful and tiring, so they start to eat smaller portions. Moreover, secretions could also make it difficult for patients to swallow the food.
Ensure that the patient gets a rest period before and after eating, position them upright and maintain a clear airway. Provide high-calorie meals or meal replacements such as shakes that come in small volumes, and encourage the patient to drink sports drinks that have additional electrolytes. You should also provide the patient with nasal prongs to supplement oxygen while they’re eating.
Encourage your patient to drink water as staying hydrated will help to decrease the viscosity of the sputum and lower the patient’s body temperature.
If these steps are not enough, the patient might need additional support such as intravenous fluids and enteral feeding.
6. Managing Activity Intolerance
Much like dyspnoea interferes with eating, it will also interfere with the patient’s activities of daily living and their social life.
Assess the patient’s needs and figure out what their concerns are, and then find coping mechanisms that work for that patient. Teach the patient to plan their activities, so they can schedule a rest period before and after each activity. Explain that they can use energy-conserving techniques such as using an electric wheelchair instead of walking long distances and using assistive devices to pick things up from the floor or high surfaces.
Teach your patients breathing exercises and low impact physical exercises to rebuild their stamina and regain independence. In some hospitals, you could also refer the patient to a pulmonary rehab specialist so they can learn to cope with their condition over time.
7. Managing Knowledge Deficiency
In some cases, pneumonia can be avoided but it’s almost impossible to avoid them if the patient doesn’t understand the disease in the first place.
Once all the urgent diagnoses have been dealt with, you should take time to sit down with your patient and talk about pneumonia. Start by asking the patient and their relatives what they know about the infection, how to avoid it and its treatment.
Taking precautions such as avoiding crowds, hand hygiene and taking the yearly influenza and COVID vaccine will minimise the chances of acquiring pneumonia. Moreover, if the patient is prescribed antibiotics it is crucial to stress the importance of adhering to the full treatment to avoid developing Multi-Drug Resistant pathogens. If you identify any challenges that stop the patient from adhering to the treatment you should discuss ways to overcome them and also inform the medical team.
8. Managing Anxiety
Many patients who have experienced pneumonia say that it felt as if they were suffocating and that they were scared they might die. Such an experience will increase stress and anxiety levels, and unfortunately, most patients would be too scared to open up about these feelings. Often because they do not want to seem childish or they don’t want to burden others with their worries.
As their nurse, you should create a safe space where your patient can voice their feelings and express their concerns. Explain the situation to the patient, what symptoms they have and how you’re treating them. Give them an expected timeline of when they can start to feel relief from the symptoms and how they are progressing. Use deep breathing exercised and the pursed-lip technique to regain control of their breathing, as well as distraction techniques to shift their focus onto other things.
Pneumonia Nursing Discharge
After having gone through all the diagnoses and management, you will need to re-evaluate the situation and see if there’s been any improvement or deterioration in your patient. If you don’t notice any improvement, or you notice that your patient’s overall condition is worsening you will need to contact the medical team and alter the treatment plan accordingly.
But if your patient improves you can plan their discharge to ensure that they regain independence and avoid future infections.