Last updated on December 28th, 2023
Here we have formulated a sample nursing care plan for pneumonia based on a hypothetical case scenario.
It will include three sample nursing care plans with NANDA nursing diagnoses, nursing assessment, expected outcome, nursing interventions, and rationales.
Click here to see more NANDA nursing niagnoses for Respiratory Disorders.
Hypothetical Case Scenario for Pneumonia
A 72-year old woman presents to the ED with complaints of shortness of breath, fatigue, and nausea. The patient reports that she developed a cold last week and does not seem to be improving. She has a productive cough and reports yellow/tan mucus. When asked about a fever, the patient said she does not own a thermometer but says that she feels “very hot one minute and very cold the next minute.”
Upon assessment, the patient appears diaphoretic. Her temperature is 38.5 C, heart rate is 114 BPM, blood pressure is 105/75 mmHg, respiratory rate is 28 breaths per minute, and oxygen saturation is 90% on room air. The patient has a weak cough and is observed taking fast, shallow breaths. Crackles are auscultated throughout her lungs.
The patient’s labs are normal but white blood cells are elevated at 13.3 K/mcL. A chest x-ray is ordered and reveals bilateral lobar consolidations. Suspecting pneumonia, a sputum sample is sent to the lab for analysis and the culture later reveals streptococcus pneumoniae.
The patient is admitted to the hospital for Pneumonia.
#1 Sample Nursing Care Plan for Pneumonia – Impaired gas exchange
Nursing Assessment
Subjective Data:
- The patient complains of shortness of breath
Objective Data:
- The patient is tachypneic and tachycardic
- Oxygen saturation is 90% on room air
- Bilateral lobar consolidations are seen on the chest x-ray
- Streptococcus pneumoniae was found in the sputum culture
Nursing Diagnosis
Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath, low SPO2, and bacteria found in sputum culture.
Goal/Desired Outcome
Short-term goal: The patient will remain free from signs of respiratory distress and her oxygen saturation will remain higher than 96% for the duration of the shift.
Long-term goal: The patient will finish the full course of antibiotics and pneumonia will completely resolve
Nursing interventions with rationales for Impaired gas exchange
| Nursing Interventions | Rationales |
| Administer oxygen as needed | Patient’s with pneumonia sometimes require supplemental oxygen to prevent hypoxemia and maintain an oxygen saturation above 95% |
| Monitor oxygen saturation and arterial blood gases as needed | An SPO2 below 90% or a partial pressure of oxygen less than 80 mmHg indicates severe respiratory dysfunction and should be treated promptly |
| Administer antibiotics | Antibiotics will kill the bacteria and treat the underlying cause of pneumonia |
| Administer cough suppressants at night | To promote sleep, a low-dose cough suppressant can be administered at night. It’s important not to eliminate the cough completely because coughing moves and loosens mucus in the lungs. |
| Administer bronchodilators or inhaled steroids | Inhaled bronchodilators work by relaxing the airway muscles, and inhaled steroids work by decreasing inflammation in the airway. |
#2 Sample Nursing Care Plan for Pneumonia – Ineffective airway clearance
Nursing Assessment
Subjective Data:
- The patient reports a productive cough with yellow/tan mucus
Objective Data:
- The patient is tachypneic and taking fast and shallow breaths
- Crackles are auscultated throughout
- Bilateral lobar consolidations are seen on the chest x-ray
Nursing Diagnosis
Ineffective airway clearance related to mucous production as evidenced by tachypnea, crackles, and consolidations on x-ray
Goal/Desired Outcome
Short-term goal: The patient will correctly demonstrate the use of an incentive spirometer and her oxygen saturation will remain higher than 96% for the duration of the shift.
Long-term goal: Pneumonia will resolve and the patient will exhibit clear breath sounds
Nursing interventions with rationales for Ineffective airway clearance
| Nursing Interventions | Rationales |
| Suction as needed | Suctioning is indicated for patients with a weak cough or hard to clear secretions. It’s important to pre-oxygenate and provide breaks in between. |
| Encourage the patient to sit in an upright position | Sitting upright facilitates maximum lung expansion and encourages postural drainage due to gravity |
| Educate the patient about incentive spirometer use | An incentive spirometer is a device that encourages the patient to take slow, deep breaths. This exercises the lungs and helps with a quicker recovery from the infection |
| If tolerated, encourage activity and movement | Movement helps mobilize lung secretions. If ambulation is not tolerated, turning from side to side every 2 hours is still helpful. |
| Utilize strategies such as percussion or vibration | Both of these strategies are proven techniques to break up and mobilize secretions |
#3 Sample Nursing Care Plan for Pneumonia – Ineffective thermoregulation
Nursing Assessment
Subjective Data:
- The patient reports feeling “very hot one minute and very cold the next minute.”
Objective Data:
- The patient is diaphoretic and has a temperature of 38.5 C
Nursing Diagnosis
Ineffective thermoregulation related to lung infection as evidenced by chills and fever
Goal/Desired Outcome
Short-term goal: The patient will utilize temperature management strategies and will be normothermic by the end of the shift.
Long-term goal: The patient will obtain a home thermometer and will be able to verbalize a few situations in which she would check her temperature at home
Nursing interventions with rationales for Ineffective thermoregulation
| Nursing Interventions | Rationales |
| Utilize temperature management strategies | A cooling blanket or ice packs can both be utilized to decrease fever. For hypothermic patients, a forced-air warming blanket such as a bair hugger can be used |
| Closely monitor temperature | Temperature should be checked at least every 4 hours or as frequently as the patient’s condition dictates. Continuous temperature monitoring may also be warranted. |
| Administer antipyretics as needed | Antipyretics such as acetaminophen or ibuprofen should be administered every 6 hours as needed for fever. |
| Encourage fluids | Fluids help prevent mucosal drying and help the cilia in the respiratory tract mobilize secretions |
| Provide a lukewarm sponge bath and remove excess clothing or blankets | If the patient is febrile, a sponge bath is an effective strategy for decreasing temperature. Lightweight clothes and blankets are also recommended |
Click here to see more NANDA nursing niagnoses for Respiratory Disorders.
Conclusion
To conclude, we created scenario-based three sample nursing care plans for pneumonia. This nursing care plan includes nursing assessment, NANDA nursing diagnosis, expected outcome, and nursing interventions with rationales.
Reference
Ackley, B., Ladwig, G., Makic, M., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing Diagnoses Handbook: An Evidence-based Guide to Planning Care (12th ed.). Elsevier.
Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.
Swearingen, P. (2016). ALL-IN-ONE CARE PLANNING RESOURCE (4th ed.). Elsevier/Mosby.
