Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall?

This guide has pneumonia nursing care plans and nursing diagnosis, nursing interventions, and nursing assessments for pneumonia. Nursing interventions for pneumonia and care plan goals for patients with pneumonia include measures to assist in effective coughing, maintaining a patent airway, decreasing viscosity and tenaciousness of secretions, and assisting in suctioning.

What is Pneumonia?

Pneumonia is an inflammation of the lung parenchyma associated with alveolar edema and congestion that impair gas exchange. Pneumonia is caused by a bacterial or viral infection spread by droplets or by contact and is the sixth leading cause of death in the United States.

The prognosis is typically good for people who have normal lungs and adequate host defenses before the onset of pneumonia. Pneumonia is a particular concern in high-risk patients: persons who are very young or very old, people who smoke, bedridden, malnourished, hospitalized, immunocompromised, or exposed to MRSA.

Types of Pneumonia

There are two types of pneumonia: community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP), known as nosocomial pneumonia.

Pneumonia may also be classified depending on its location and radiologic appearance. Bronchopneumonia (bronchial pneumonia) involves the terminal bronchioles and alveoli. Interstitial (reticular) pneumonia involves an inflammatory response within lung tissue surrounding the air spaces or vascular structures rather than the area passages themselves. Alveolar (or acinar) pneumonia involves fluid accumulation in the lung’s distal air spaces. Necrotizing pneumonia causes the death of a portion of lung tissue surrounded by viable tissue.

Pneumonia is also classified based on its microbiologic etiology – it can be viral, bacterial, fungal, protozoan, mycobacterial, mycoplasmal, or rickettsial.

Aspiration pneumonia, another type of pneumonia, results from vomiting and aspiration of gastric or oropharyngeal contents into the trachea and lungs.

Signs and Symptoms

The main symptoms of pneumonia are coughing, sputum production, pleuritic chest pain, shaking chills, rapid shallow breathing, fever, and shortness of breath. If left untreated, pneumonia could complicate hypoxemia, respiratory failure, pleural effusion, empyema, lung abscess, and bacteremia.

Nursing care plan (NCP) and care management for patients with pneumonia start with assessing the patient’s medical history, performing a respiratory assessment every four (4) hours, physical examination, and ABG measurements. Supportive interventions include oxygen therapy, suctioning, coughing, deep breathing, adequate hydration, and mechanical ventilation. Other nursing interventions are detailed on the nursing diagnoses in the subsequent sections.

Here are 11 nursing diagnoses common to pneumonia nursing care plans (NCP). They are as follows: 

1. Ineffective Airway Clearance
2. Impaired Gas Exchange
3. Ineffective Breathing Pattern
4. Risk for Infection
5. Acute Pain
6. Activity Intolerance
7. Hyperthermia
8. Risk for Deficient Fluid Volume
9. Risk for Imbalanced Nutrition: Less Than Body Requirements
10. Deficient Knowledge
11. Deficient Fluid Volume

1. Ineffective Airway Clearance

Ineffective Airway Clearance

Ineffective Airway Clearance is a common NANDA-I nursing diagnosis for pneumonia nursing care plans. This diagnosis is related to excessive secretions and ineffective cough or nonproductive coughing. Inflammation and increased secretions in pneumonia make it difficult to maintain a patent airway.

Nursing Diagnosis

• Ineffective Airway Clearance

Related Factors

The following are the common related factors for the nursing diagnosis Ineffective Airway Clearance related to pneumonia:

• Tracheal, bronchial inflammation, edema formation, increased sputum production
• Pleuritic pain
• Decreased energy, fatigue
• Aspiration

Defining Characteristics

Here are the common assessment cues that could serve as defining characteristics or “as evidenced by” for ineffective airway clearance secondary to pneumonia.

• Changes in rate, depth of respirations
• Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
• Use of accessory muscles
• Dyspnea, tachypnea
• Cough, effective or ineffective; with/without sputum production
• Cyanosis
• Decreased breath sounds over affected lung areas
• Ineffective cough
• Purulent sputum
• Hypoxemia
• Infiltrates seen on chest x-ray film

Desired Outcomes

Below are the common expected outcomes for ineffective airway clearance secondary to pneumonia:

• Patient will identify/demonstrate behaviors to achieve airway clearance.
• Patient will display/maintain a patent airway with breath sounds clearing; absence of dyspnea, cyanosis, as evidenced by keeping a patent airway and effectively clearing secretions.

Nursing Assessment and Rationales

The following nursing assessment for pneumonia and nursing interventions promote airway patency, increase fluid intake, and teach and encourage effective cough and deep-breathing techniques.

1. Assess the rate, rhythm, and depth of respiration, chest movement, and use of accessory muscles.
Tachypnea, shallow respirations and asymmetric chest movement are frequently present because of the discomfort of moving the chest wall and fluid in the lung due to a compensatory response to airway obstruction. Altered breathing patterns may occur together with accessory muscles to increase chest excursion to facilitate effective breathing.

2. Assess cough effectiveness and productivity
Coughing is the most effective way to remove secretions. Pneumonia may cause thick and tenacious secretions in patients.

3. Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes.
Decreased airflow occurs in areas with consolidated fluid. Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration, expiration due to fluid accumulation, thick secretions, and airway spasms and obstruction.

4. Observe the sputum color, viscosity, and odor. Report changes.
Changes in sputum characteristics may indicate infection. Sputum that is discolored, tenacious, or has an odor may increase airway resistance and warrant further intervention.

5. Assess the patient’s hydration status.
Airway clearance is hindered by inadequate hydration and the thickening of secretions.

Nursing Interventions and Rationales

This section contains ineffective airway clearance nursing interventions and actions for pneumonia and its rationales or scientific explanations.

1. Elevate the head of the bed and change position frequently.
Doing so would lower the diaphragm and promote chest expansion, aeration of lung segments, mobilization, and expectoration of secretions.

2. Teach and assist the patient with proper deep-breathing exercises. Demonstrate proper splinting of the chest and effective coughing while in an upright position. Encourage the patient to do so often.

• 2.1. Deep breathing exercises facilitate the maximum expansion of the lungs and smaller airways and improve the productivity of cough.
• 2.2. Coughing is a reflex and a natural self-cleaning mechanism that assists the cilia in maintaining patent airways. It is the most helpful way to remove most secretions.
• 2.3. Splinting reduces chest discomfort and an upright position favors deeper and more forceful cough effort making it more effective.

3. Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway secretions.
Stimulates cough or mechanically clears airway in a patient who cannot do so because of ineffective cough or decreased level of consciousness. Note: Suctioning can cause increased hypoxemia; hyper oxygenate before, during, and after suctioning.

4. Maintain adequate hydration by forcing fluids to at least 3000 mL/day unless contraindicated (e.g., heart failure). Offer warm, rather than cold, fluids.
Fluids, especially warm liquids, aid in the mobilization and expectoration of secretions. Fluids help maintain hydration and increase ciliary action to remove secretions and reduce viscosity. Thinner secretions are easier to cough out.

5. Assist and monitor effects of nebulizer treatment and other respiratory physiotherapy: incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate.

• 5.1. Nebulizers humidify the airway to thin secretions and facilitate liquefaction and expectoration of secretions.
• 5.2. Postural drainage may not be as effective in interstitial pneumonias or those causing alveolar exudate or destruction.
• 5.3. Incentive spirometry serves to improve deep breathing and helps prevent atelectasis.
• 5.4. Chest percussion helps loosen and mobilize secretions in smaller airways that cannot be removed by coughing or suctioning.
• 5.5. Coordination of treatments and oral intake reduces the likelihood of vomiting with coughing and expectorations.

6. Encourage ambulation.
Helps mobilize secretions and reduces atelectasis.

7. Administer medications, as indicated:

• 7.1. Mucolytics increase or liquefy respiratory secretions.
• 7.2. Expectorants increase productive cough to clear the airways by liquefying lower respiratory tract secretions and reducing their viscosity.
• 7.3. Bronchodilators are medications used to facilitate respiration by dilating the airways.
• 7.4. Analgesics are given to improve cough effort by reducing discomfort but should be used cautiously because they can decrease cough effort and depress respirations.

8. Use humidified oxygen or humidifier at the bedside.
Increasing the humidity will decrease the viscosity of secretions. Clean the humidifier before use to avoid bacterial growth.

9. Monitor serial chest x-rays, ABGs, and pulse oximetry readings.
Follows progress and effects and extent of pneumonia. A therapeutic regimen may facilitate necessary alterations in therapy. Oxygen saturation should be maintained at 90% or greater. Imbalances in PaCO2 and PaO2 may indicate respiratory fatigue.

10. Assist with bronchoscopy and thoracentesis, if indicated.

• 10.1. Bronchoscopy is occasionally needed to remove mucous plugs, drain purulent secretions, and obtain lavage samples for culture and sensitivity.
• 10.2. Thoracentesis is done to drain associated pleural effusions and prevent atelectasis.

11. Anticipate the need for supplemental oxygen or intubation if the patient’s condition deteriorates.
These measures are needed to correct the hypoxemia. Intubation is needed for deep suctioning efforts and provides a source for augmenting oxygenation.

12. Urge all bedridden and postoperative patients to frequently perform deep breathing and coughing exercises.
To promote full aeration and drainage of secretions.

1. Ineffective Airway Clearance

Related Nursing Care Plans

Other nursing diagnoses you can use to craft another pneumonia nursing care plan.

• Impaired Dentition. May be related to dietary habits, poor oral hygiene, chronic vomiting, possibly evidenced by erosion of tooth enamel, multiple carries, abraded teeth.
• Impaired oral mucous membrane. May be related to breathing through the mouth, malnutrition or vitamin deficiency, poor oral hygiene, chronic vomiting, possibly evidenced by sore, inflamed buccal mucosa, swollen salivary glands, ulcerations, and reports of sore mouth and/or throat.
• Ineffective Health Management. May be related to deficient knowledge on self-care and therapeutic management of the disease.
• Ineffective Thermoregulation. May be related to infectious process.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

• Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
  An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
• Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
  A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
• NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
  The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
• Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
  Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
  Useful for creating nursing care plans related to mental health and psychiatric nursing.
• Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
  Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
• Maternal Newborn Nursing Care Plans (3rd Edition)
  If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
• Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
  An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
• All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
  Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See Also

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
  Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
  Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Other nursing care plans related to respiratory system disorders:

• Asthma | 8 Care Plans
• Bronchiolitis | 5 Care Plans
• Bronchopulmonary Dysplasia (BPD) | 5 Care Plans
• Chronic Obstructive Pulmonary Disease (COPD) | 7 Care Plans
• Cystic Fibrosis | 5 Care Plans
• Hemothorax and Pneumothorax | 3 Care Plans
• Influenza (Flu) | 5 Care Plans
• Lung Cancer | 5 Care Plans
• Mechanical Ventilation | 6 Care Plans
• Near-Drowning | 5 Care Plans
• Pleural Effusion | 6 Care Plans
• Pneumonia | 11 Care Plans
• Pulmonary Embolism | 4 Care Plans
• Pulmonary Tuberculosis | 5 Care Plans
• Tracheostomy | 5 Care Plans

References and Sources

Recommended journals, books, and other interesting materials to help you learn more about pneumonia nursing care plans and nursing diagnosis:

1. Abe, S., Ishihara, K., Adachi, M., & Okuda, K. (2006). Oral hygiene evaluation for effective oral care in preventing pneumonia in dentate elderly. Archives of gerontology and geriatrics, 43(1), 53-64.
2. Britton, S., Bejstedt, M., & Vedin, L. (1985). Chest physiotherapy in primary pneumonia. Br Med J (Clin Res Ed), 290(6483), 1703-1704.
3. Calverley, P. M., Stockley, R. A., Seemungal, T. A., Hagan, G., Willits, L. R., Riley, J. H., … & Investigating New Standards for Prophylaxis in Reduction of Exacerbations (INSPIRE) Investigators. (2011). Reported pneumonia in patients with COPD: findings from the INSPIRE study. Chest, 139(3), 505-512.
4. Cason, C. L., Tyner, T., Saunders, S., & Broome, L. (2007). Nurses’ implementation of guidelines for ventilator-associated pneumonia from the Centers for Disease Control and Prevention. American journal of critical care, 16(1), 28-37.
5. Eisenhut, M., & Mizgerd, J. P. (2008). Acute lower respiratory tract infection. New Engl J Med, 358, 2413-4.
6. Farrell, J. J., & Petrik, S. C. (2009). Hydration and nosocomial pneumonia: killing two birds with one stone (a toothbrush). Rehabilitation Nursing, 34(2), 47-50.
7. Fujita, J., Touyama, M., Chibana, K., Koide, M., Haranaga, S., Higa, F., & Tateyama, M. (2007). Mechanism of formation of the orange-colored sputum in pneumonia caused by Legionella pneumophila. Internal Medicine, 46(23), 1931-1934.
8. Grief, S. N., & Loza, J. K. (2018). Guidelines for the evaluation and treatment of pneumonia. Primary Care: Clinics in Office Practice, 45(3), 485-503.
9. Gulanick, M., & Myers, J. L. (2011). Nursing care plans: Diagnoses, interventions, and outcomes. Elsevier Health Sciences.
10. HASH, R. B., STEPHENS, J. L., LAURENS, M. B., & VOGEL, R. L. (2000). The relationship between volume status, hydration, and radiographic findings in the diagnosis of community-acquired pneumonia. Journal of Family Practice, 49(9), 833-833.
11. Head, B. J., Scherb, C. A., Reed, D., Conley, D. M., Weinberg, B., Kozel, M., … & Moorhead, S. (2011). Nursing diagnoses, interventions, and patient outcomes for hospitalized older adults with pneumonia. Research in gerontological nursing, 4(2), 95-105.
12. Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing. Wolters kluwer india Pvt Ltd.
13. Ignatavicius, D. D., & Workman, M. L. (2015). Medical-Surgical Nursing-E-Book: Patient-Centered Collaborative Care. Elsevier Health Sciences.
14. Keeley, L. (2007). Reducing the risk of ventilator‐acquired pneumonia through head of bed elevation. Nursing in critical care, 12(6), 287-294.
15. Kubo, T., Osuka, A., Kabata, D., Kimura, M., Tabira, K., & Ogura, H. (2021). Chest physical therapy reduces pneumonia following inhalation injury. Burns, 47(1), 198-205.
16. Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems, Single Volume. Elsevier Health Sciences.
17. Luna, C. M., Famiglietti, A., Absi, R., Videla, A. J., Nogueira, F. J., Fuenzalida, A. D., & Geneé, R. J. (2000). Community-acquired pneumonia: etiology, epidemiology, and outcome at a teaching hospital in Argentina. Chest, 118(5), 1344-1354.
18. Sattar, S. B. A., Sharma, S., & Headley, A. (2021). Bacterial Pneumonia (Nursing). StatPearls [Internet].
19. Scannapieco, F. A. (2006). Pneumonia in nonambulatory patients: the role of oral bacteria and oral hygiene. The Journal of the American Dental Association, 137, S21-S25.
20. See, C. M. E. Urgent Care Evaluation of Pneumonia.
21. Ticona, J. H., Zaccone, V. M., & McFarlane, I. M. (2021). Community-acquired pneumonia: A focused review. American journal of medical case reports, 9(1), 45.
22. Yamaya, M., Yanai, M., Ohrui, T., Arai, H., & Sasaki, H. (2001). Interventions to prevent pneumonia among older adults. Journal of the American Geriatrics Society, 49(1), 85-90.
23. Yoneyama, T., Yoshida, M., Ohrui, T., Mukaiyama, H., Okamoto, H., Hoshiba, K., … & Of The Oral Care Working Group, M. (2002). Oral care reduces pneumonia in older patients in nursing homes. Journal of the American Geriatrics Society, 50(3), 430-433.

Originally published January 10, 2010.