From: Elvie Dulnuan <geejay.dulnuan@yahoo.

com>
Subject: Nursing Process of Pneumonia
Date: 17 July 2014 22:42:53 BST
To: "Gle5bhie@aol.com" <Gle5bhie@aol.com>
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NURSIN
G
PROCES
S:
THE
PATIENT
WITH
PNEUM
ONIA
Assessm
ent
1ursing
assessment
is critica! in
&etecting
pneumonia-
% fe#er,
chi!!s, or
night
sweats in a
patient who
a!so has
respiratory
symptoms
shou!& a!ert
the nurse
to the
possibi!ity
of bacteria!
pneumonia-
%
respiratory
assessment
wi!! further
i&entify the
c!inica!
manifestati
ons of
pneumonia2
p!euritic?
type pain,
fatigue,
tachypnea,
use of
accessory
musc!es for
breathing,
bra&ycar&ia
or re!ati#e
bra&ycar&ia
, coughing,
an&
puru!ent
sputum- It
is
important
to
i&entify the
se#erity,
!ocation,
an& cause
of the chest
pain, a!ong
with any
me&ications
or
proce&ures
that pro#i&e
re!ief- "he
nurse
shou!&
monitor the
fo!!owing2
@
Changes in
temperatur
e an& pu!se
@
%mount,
o&or, an&
co!or of
secretions
@
FreAuency
an&
se#erity of
cough
@
Begree of
tachypnea
or
shortness
of breath
@
Changes in
physica!
assessment
Cn&ings
3primari!y
assesse&
by
inspecting
an&
auscu!tatin
g the
chest5
@
Changes in
the chest =?
ray Cn&ings
In a&&ition,
it is
important
to assess
the e!&er!y
patient for
unusua!
beha#ior,
a!tere&
menta!
status,
&ehy&ration
, e=cessi#e
fatigue,
an&
concomitan
t heart
fai!ure-
Diagnosi
s
1DSI1*
BI%*1(SES
Base& on
the
assessment
&ata, the
patientEs
maFor
nursing
&iagnoses
may
inc!u&e2
@
IneGecti#e
airway
c!earance
re!ate& to
copious
tracheobron
chia!
secretions
@
%cti#ity
into!erance
re!ate& to
impaire&
respiratory
function
@
isk for
&eCcient
Hui&
#o!ume
re!ate& to
fe#er an&
&yspnea
@
Imba!ance&
nutrition2
!ess than
bo&y
reAuiremen
ts
@
BeCcient
know!e&ge
about the
treatment
regimen
an&
pre#enti#e
hea!th
measures
C(LL%B(%
"I7E
+(BLEMS,
+("E1"I%L
C(M+LIC%"I
(1S
Base& on
the
assessment
&ata,
co!!aborati#
e prob!ems
or potentia!
comp!icatio
ns that may
occur
inc!u&e2
@
Continuing
symptoms
after
initiation of
therapy
@
Shock
@
espiratory
fai!ure
@
%te!ectasis
@
+!eura!
eGusion
@
Confusion
@
Superinfect
ion
Planning
an
Goals
"he maFor
goa!s for
the patient
may
inc!u&e
impro#e&
airway
patency,
rest to
conser#e
energy,
maintenanc
e of proper
Hui&
#o!ume,
maintenanc
e of
a&eAuate
nutrition,
an
un&erstan&
ing of
the
treatment
protoco!
an&
pre#enti#e
measures,
an&
absence of

comp!icatio
ns-
N!"sing
Inte"#en
tions
IM+(7I1*
%I)%$
+%"E1C$
emo#ing
secretions
is important
because
retaine&
secretions
interfere
with gas
e=change
an& may
s!ow
reco#ery-
"he nurse
encourages
hy&ration
3< to 0
L,&ay5
because
a&eAuate
hy&ration
thins an&
!oosens
pu!monary
secretions-
Humi&iCcat
ion may be
use& to
!oosen
secretions
an&
impro#e
#enti!ation-
%
highhumi&i
ty
facemask
3using
either
compresse
& air or
o=ygen5
&e!i#ers
warm,
humi&iCe&
air to the
tracheobro
nchia! tree,
he!ps to
!iAuefy
secretions,
an& re!ie#es
tracheobron
chia!
irritation-
Coughing
can be
initiate&
either
#o!untari!y
or by reHe=-
Lung
e=pansion
maneu#ers,
such as
&eep
breathing
with an
incenti#e
spirometer,
may in&uce
a cough- %
&irecte&
cough may
be
necessary
to impro#e
airway
patency-
"he nurse
encourages
the patient
to perform
an
eGecti#e,
&irecte&
cough,
which
inc!u&es
correct
positioning,
a &eep
inspiratory
maneu#er,
g!ottic
c!osure,
contraction
of the
e=piratory
musc!es
against the
c!ose&
g!ottis,
su&&en
g!ottic
opening,
an& an
e=p!osi#e
e=piration-
In some
cases, the
nurse may
assist the
patient by
p!acing
both han&s
on the
patientEs
!ower rib
cage
3anterior!y
or
posterior!y5
to focus the
patient on
a s!ow &eep
breath, an&
then
manua!!y
assisting
the patient
by app!ying
e=terna!
pressure
&uring the
e=piratory
phase-
Chest
physiothera
py
3percussion
an&
postura!
&rainage5 is
important
in
!oosening
an&
mobi!iIing
secretions
3see Chap-
<.5-
In&ications
for chest
physiothera
py inc!u&e
sputum
retention
not
responsi#e
to
spontaneou
s or
&irecte&
cough, a
history of
pu!monary
prob!ems
pre#ious!y
treate&
with chest
physiothera
py,
continue&
e#i&ence of
retaine&
secretions
3&ecrease&
or
abnorma!
breath
soun&s,
change in
#ita! signs5,
abnorma!
chest =?ray
Cn&ings
consistent
with
ate!ectasis
or
inC!trates,
or
&eterioratio
n in
o=ygenatio
n- "he
patient is
p!ace& in
the proper
position to
&rain
the
in#o!#e&
!ung
segments,
an& then
the chest is
percusse&
an&
#ibrate&
either
manua!!y or
with a
mechanica!
percussor-
%fter each
position
change, the
nurse
encourages
the patient
to breathe
&eep!y an&
cough- If
the patient
is too weak
to cough
eGecti#e!y,
the nurse
may nee&
to remo#e
the mucus
by
nasotrache
a!
suctioning
3see Chap-
<.5- It may
take time
for
secretions
to mobi!iIe
an& mo#e
into the
centra!
airways for
e=pectorati
on-
"hus, it is
important
for the
nurse to
monitor the
patient for
cough an&
sputum
pro&uction
after the
comp!etion
of chest
physiothera
py-
"he nurse
a&ministers
an& titrates
o=ygen
therapy as
prescribe&-
"he
eGecti#ene
ss of
o=ygen
therapy is
monitore&
by
impro#eme
nt in
c!inica!
signs an&
symptoms,
an&
a&eAuate
o=ygenatio
n
#a!ues
measure&
by pu!se
o=imetry or
arteria!
b!oo& gas
ana!ysis-
+(M("I1
* ES"
%1B
C(1SE7I1
* E1E*$
"he nurse
encourages
the
&ebi!itate&
patient to
rest an&
a#oi&
o#ere=ertio
n an&
possib!e
e=acerbatio
n of
symptoms-
"he patient
shou!&
assume a
comfortab!
e position
to promote
rest an&
breathing
3eg, semi?
Fow!erEs5
an& shou!&
change
positions
freAuent!y
to
enhance
secretion
c!earance
an&
#enti!ation,
perfusion in
the
!ungs- It is
important
to instruct
outpatients
not to
o#ere=ert
themse!#es
an& to
engage in
on!y
mo&erate
acti#ity
&uring the

initia!
phases of
treatment-
+(M("I1
* FLDIB
I1"%JE
"he
respiratory
rate of a
patient with
pneumonia
increases
because
of the
increase&
work!oa&
impose& by
!abore&
breathing
an& fe#er-
%n
increase&
respiratory
rate !ea&s
to an
increase in
insensib!e
Hui&
!oss &uring
e=ha!ation
an& can
!ea& to
&ehy&ratio
n-
"herefore,
it
is
important
to
encourage
increase&
Hui& intake
3at !east <
L,&ay5,
un!ess
contrain&ic
ate&-
M%I1"%I1I1
*
1D"I"I(1
+atients
with
shortness of
breath an&
fatigue
often ha#e
a &ecrease&
appetite
an& wi!!
take on!y
Hui&s-
F!ui&s with
e!ectro!ytes
3commercia
!!y a#ai!ab!e
&rinks,
such as
*atora&e5
may he!p
pro#i&e
Hui&,
ca!ories,
an&
e!ectro!ytes
- (ther
nutritiona!!
y enriche&
&rinks or
shakes may
be he!pfu!-
In a&&ition,
Hui&s an&
nutrients
may be
a&ministere
&
intra#enous
!y if
necessary-
+(M("I1
* "HE
+%"IE1"ES
J1()LEB*
E
"he
patient an&
fami!y are
instructe&
about the
cause of
pneumonia,
manageme
nt of
symptoms
of
pneumonia,
an& the
nee&
for fo!!ow?
up
3&iscusse&
!ater5- "he
patient a!so
nee&s
informa?
tion about
factors
3both
patient risk
factors an&
e=terna!
factors5
that may
ha#e
contribute&
to
&e#e!oping
pneumonia
an&
strategies
to promote
reco#ery
an& to
pre#ent
recurrence-
If
hospita!iIe&
for
treatment,
the patient
is
instructe&
about the
purpose
an&
importance
of
manageme
nt
strategies
that ha#e
been
imp!ement
e&
an& about
the
importance
of a&hering
to them
&uring
an& after
the hospita!
stay-
E=p!anation
s nee& to
be gi#en
simp!y
an& in
!anguage
that the
patient can
un&erstan&
- If
possib!e,
written
instructions
an&
information
shou!& be
pro#i&e&-
Because of
the se#erity
of
symptoms,
the patient
may
reAuire that
instructions
an&
e=p!anation
s be
repeate&
se#era!
times-
M(1I"(I1
* %1B
M%1%*I1*
+("E1"I%L
C(M+LIC%"I
(1S
Contin!in
g
S$m%toms
A&te"
Initiation
o&
T'e"a%$
+atients
usua!!y
begin to
respon& to
treatment
within <8 to
8/ hours
after
antibiotic
therapy is
initiate&-
"he patient
is obser#e&
for
response to
antibiotic
therapy-
"he patient
is
monitore&
for changes
in physica!
status
3&eteriorati
on of
con&ition or
reso!ution
of
symptoms5
an& for
persistent
recurrent
fe#er,
which
may be &ue
to
me&ication
a!!ergy
3signa!e&
possib!y by
a rash5K
me&ication
resistance
or s!ow
response
3greater
than 8/
hours5
of the
susceptib!e
organism to
therapyK
superinfecti
onK p!eura!
eGusionK or
pneumonia
cause& by
an unusua!
organism,
such as
+- carinii
or
%spergi!!us
fumigatus-
Fai!ure of
the
pneumonia
to reso!#e
or
persistence
of
symptoms
&espite
changes on
the chest
=?ray raises
the
suspicion of
other
un&er!ying
&isor&ers,
such as
!ung cancer-
%s
&escribe&
ear!ier, !ung
cancers
may in#a&e
or
compress
airways,
causing an
obstructi#e
ate!ectasis
that may
!ea& to
a
pneumonia-
In a&&ition
to
monitoring
for
continuing
symptoms
of
pneumonia,
the nurse
a!so
monitors
for other
comp!icatio
ns, such as
shock an&
mu!tisyste
m fai!ure,
ate!ectasis,
p!eura!
eGusion,
an&
superinfecti
on, which
may
&e#e!op
&uring the
Crst few
&ays of
antibiotic
treatment-
S'o() an
Res%i"ato"
$ Fail!"e
"he nurse
assesses
for signs
an&
symptoms
of shock
an&
respiratory
%cti#ity 3/05
FILTERS
%&& to co!!ectione#iew %&& 1oteLike
Beanna Friesen !ike& this
4 thousan& rea&s
4 hun&re& rea&s
Shar!ene %gcanas !ike& this
Bo=s Mich Bi=isiete !ike& this
%ye!e Mamo !ike& this
Lonny So&usta !ike& this
Courtney Carson !ike& this
LeGrey *rinne!! !ike& this
Li!ian Mc*ugan !ike& this
Loa& more
ecommen&e&
+neumonia Concept E7IE I*LESI%S
ncp?#i&a! "I1<M:>4<
+neumonia Care +!an "CDMD+HISH
+neumonia Concept MapNJ+oin&e=ter
J%"IEN+(I1BEM"N.4.8
IneGecti#e %irway C!earance ? +neumonia
1ursing Care +!an 1DSESL%BS
Impaire& *as E=change ? +neumonia 1ursing
Care +!an 1DSESL%BS
1C+ +neumonia )'"(1 B(BE
+athophysio!ogy of +neumonia (MIB%L%L
isk for Infection ? +neumonia 1ursing Care
+!an 1DSESL%BS
1ursing Care +!an 3Impaire& Skin Integrity5
%LEE M%ODEP
%bruptio +!acenta MISS 1

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