Nursing Diagnosis for Pneumonia & Care Plan Assignment Help
Written by
Ishita BhatiaUpdated:
15 mins read
- What Is Nursing Diagnosis?
- What Is Pneumonia?
- Which Is The Most Common Nursing Diagnosis For Pneumonia?
- Impaired Gas Exchange as a Nursing Diagnosis for Pneumonia
- Ineffective Air Clearance as a Nursing Diagnosis for Pneumonia
- Acute Pain as a Nursing Diagnosis for Pneumonia
- What Is The Difference Between A Nursing Diagnosis And A Medical Diagnosis?
- Frequently Asked Questions
- Bottom Line
Do you know there is a big difference between nursing diagnosis and medical diagnosis? Although both try to diagnose the same condition, they differ significantly.
This article will major in nursing diagnosis for pneumonia. It will specifically define nursing diagnosis and pneumonia, look at three nursing diagnoses related to pneumonia, and offer a complete nursing care plan, including the nursing interventions for pneumonia. The article will wrap up by explaining the difference between medical and nursing diagnoses.
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What Is Nursing Diagnosis?
A nursing diagnosis is a nurse's decision regarding the pathophysiology (physical and functional changes) of a certain disease or disorder or due to a risk associated with the pathophysiology. For instance, one pathophysiology a patient suffering from pneumonia has is poor airflow. A nursing diagnosis will thus be “ineffective air clearance.” After a diagnosis, a nursing care plan for pneumonia should be devised to manage this pathophysiology.
The nursing diagnosis aims to understand a bodily change affecting a patient and select the best nursing intervention to deal with the issue. Nursing diagnosis is arrived at by conducting a nursing assessment, which facilitates the development of an NCP.
Other benefits of a nursing diagnosis are:
- Assists in determining nursing priorities
- Offers an avenue for nursing specialists to communicate with other healthcare professionals
- Sharpens nursing students' skills in critical thinking and problem solving
What Is Pneumonia?
Pneumonia is a widespread respiratory condition that mainly affects the lung parenchyma. It typically leads to alveolar congestion and edema that bring difficulties in gas exchange and airway flow. This health condition is mainly caused by bacteria or viruses spread by contact or droplets.
The prognosis is primarily good for people with enough host defenses and normal lungs when they are contracting the disease. There is a poor prognosis for people with the following aspects:
- Very young or very old
- Immunocompromised
- Smokers
- Hospitalized
- Malnourished
What Are The Types Of Pneumonia?
Pneumonia is categorized depending on various factors. The common ones include
- Microbiologic etiology: Pneumonia can be caused by several microorganisms, such as viruses, bacterium, mycobacteria, protozoa, mycoplasma, and others.
- Means of transmission: Pneumonia can be classified as hospital-acquired (HAP, also known as nosocomial pneumonia) or community-acquired pneumonia.
- Area of infections: The microorganisms may affect different sections of the respiratory system, which radiological images can visualize. Depending on the area of infection, we have interstitial pneumonia, bronchopneumonia, and alveolar pneumonia.
What Are Pneumonia Signs And Symptoms?
Pneumonia signs and symptoms can be mild or lethal. The typical ones are:
- Chills and sweating
- Coughing with phlegm production
- Appetite loss
- Headaches
- Nausea or vomiting
- Chest pain during coughing or breathing
- Fatigue
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Which Is The Most Common Nursing Diagnosis For Pneumonia?
According to most laws, general nurses cannot diagnose pneumonia in a patient. In fact, they cannot diagnose a majority of health conditions. This type of diagnosis, for a health condition, is left to the physicians.
Nonetheless, this does not mean nurses are useless to patients suffering from pneumonia or other health conditions. They can help the patients by diagnosing their abnormal bodily changes (pathophysiology) and enforcing interventions to assist them. This further improves the patient’s quality of life.
Many nursing diagnoses can be made on pneumonia-related abnormal bodily changes. Some common nursing diagnoses are:
- Impaired gas exchange
- Ineffective air clearance
- Acute Pain
This article will discuss each one of these three diagnoses in detail. In each diagnosis, we will walk you through the following items:
- Associated factors
- Central characteristics
- Anticipated outcome
- Nursing assessment
- Nursing intervention
In a snapshot, this article will cover the details provided in the Table below (swipe left for more details):
| Impaired gas exchange | Ineffective air clearance | Acute Pain | |
| Associated factors | - Inflammation of alveoli and airways- Mucus and fluid in the alveoli- Hypoventilation | - Excessive mucus and sputum- Reduced energy- Poor cough reflex- Underlying conditions, i.e. asthma and COPD | - Frequent coughing- Inflammations in the chest cavity |
| Central characteristics | LethargyConfusionRestlessnessDyspneaDisorientationPale skin colorationTachycardia | - Altered respiratory rhythm and rate- Reduced lung sounds- Restlessness- Cyanosis- Hypoxemia- Using accessory muscles | - Raised blood pressure- Restlessness and irritability- Pain in other areas, such as muscles, joints, and head- Tachycardia and tachypnea |
| Anticipated outcome | - Patient will partake in activities that enhance ventilation and oxygenation - Patient will demonstrate sufficient oxygenation levels |
- Patient will present behaviors for accomplishing airway clearance - Patient will demonstrate patent airway |
- Patient will rate their pain score as less than 4 - Patient will engage in activities appropriately and show a relaxed manner |
| Nursing assessment | - Vital signs and lung sounds- Cognitive functions- Oxygen saturation and ABGs- Check for worsening of the health issue | - Sputum- Respiratory alterations- Cough output and effectiveness- Hydration degree | - Vital Signs- Features of pain |
| Nursing intervention | - Advocate for rest- Administer prescribed oxygen therapy- Proper body positioning | - Utilize respiratory techniques- Conduct suctioning- Administering prescribed medication | - Encourage coughing- Administer prescribed analgesics- Offer comfort measures |
Impaired Gas Exchange as a Nursing Diagnosis for Pneumonia
One common nursing diagnosis for pneumonia is impaired gas exchange. Below are its associated factors, central characteristics, anticipated outcomes, and nursing interventions.
Associated Factors
- Inflammation of alveoli and airways
- Mucus and fluid in the alveoli
- Hypoventilation (altered oxygen delivery)
Central Characteristics
- Lethargy
- Confusion
- Restlessness
- Dyspnea
- Disorientation
- Pale skin coloration
- Tachycardia
Anticipated Outcomes
- The patient will partake in activities that enhance ventilation and oxygenation
- The patient will demonstrate sufficient oxygenation levels as evidenced by ABGs ranges and the lack of symptoms indicative of respiratory suffering
Nursing Assessment
Below are some assessments nursing professionals can do to diagnose impaired gas exchange.
1. Assess vital signs and lung sounds
Measure heart rate, blood pressure, respiratory rate and depth, capillary refill, and breath sounds. These assessments help in noting clinical manifestations of perfusion changes and hypoxia.
2. Assess cognitive functions
Irritation, restlessness, and confusion may indicate reduced cerebral oxygenation and hypoxemia. These assessments should be done mainly among older adults.
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4. Evaluate oxygen saturation and ABGs
Monitoring ABGs and sp02 assists in reflecting hypoxia. If the ranges of these elements are abnormal, the oxygenation function of the lungs is poor.
5. Check for worsening of the health issue
Assess whether the central characteristics of this nursing diagnosis are deteriorating. The widespread causes of death in pneumonia patients are pulmonary edema and shock.
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Nursing Intervention for Impaired Gas Exchange
Treatment for this nursing diagnosis for pneumonia – impaired gas exchange – can be achieved by the following interventions:
1. Advocate for rest
Patients should not exert themselves when they have impaired gas exchange. Nurses should encourage them to rest as much as possible as it allows maximum oxygen consumption. Their daily activities also need to be spread out, like therapy and meeting with their families.
2. Administer prescribed oxygen therapy
Oxygen can be administered through many means, such as venture masks and nasal prongs. Care should be taken, precisely for patients with underlying issues, as certain types of oxygen delivery may damage their tissues.
3. Proper body positioning
Patients need to position themselves in specific ways to achieve optimum gas exchange. It includes elevating their heads and beds and regularly changing their position.
Ineffective Air Clearance as a Nursing Diagnosis for Pneumonia
Patients with pneumonia mainly have excessive secretions of mucus or sputum, which blocks the airways. This thus leads to ineffective air clearance, which the nurses can diagnose among the patients. This section will closely examine the nursing care plan for pneumonia, specifically the diagnosis: ineffective air clearance.
Associated Factors
Some key factors related to ineffective air clearance are:
- Excessive mucus and sputum
- Reduced energy
- Poor cough reflex
- Underlying conditions, such as asthma and COPD
Central Characteristics
- Altered respiratory rhythm and rate
- Reduced lung sounds
- Restlessness
- Cyanosis
- Hypoxemia
- Using accessory muscles
Anticipated Outcomes
- The patient will present behaviors for accomplishing airway clearance
- The patient will demonstrate patent airway as proven by normal respiratory rate and clear breathing sounds
Nursing Assessment for Ineffective Air Clearance
Below are the tests a nursing specialist can do to identify ineffective air clearance in a patient with pneumonia.
1. Analyze sputum
Assess the physical attributes of sputum that may indicate infection. This includes features like odor, viscosity, and color. Abnormal sputum has an odor or is tenacious and discolored. Also, a culture test can be done on a sample of sputum. The patient can expectorate the sputum if they are coughing, or it can be obtained through suctioning if they are not coughing.
2. Assess respiratory alterations
Some indicators that can be monitored when making a nursing diagnosis for pneumonia are changes in respiratory depth, rhythm, and rate. An immediate pneumonia nursing intervention is needed when oxygen saturation reduces, breathing becomes laborious, and/or respiratory rate increases.
3. Monitor cough output and effectiveness
Coughing is the most efficient way patients with pneumonia expel the secretions. Pneumonia brings about tenacious and thick secretions in patients.
4. Monitor the hydration degree
One more key cause of ineffective air clearance, apart from thickened and excessive secretions, is insufficient hydration.
Nursing Intervention for Ineffective Air Clearance
The treatments for ineffective air clearance that a nurse can do are listed below:
1. Utilize respiratory techniques and tools
Nurses may utilize several tools to help with airway clearance. It includes tools such as incentive spirometers and flutter valves. These tools will assist in expanding the lungs and activating secretions. The nursing professionals should as well educate the patient about deep breathing and coughing exercises that help with air clearance.
2. Conduct suctioning
Regular suctioning is vital for patients with tracheostomy.
3. Administering prescribed medication
Nurses can administer the following medications once they are prescribed:
- Expectorants: It softens and reduces the viscosity of respiratory tract secretions.
- Bronchodilators: Dilate the airways to facilitate respiration.
- Analgesics: Enhance cough effort.
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Acute Pain as a Nursing Diagnosis for Pneumonia
Most patients with pneumonia have persistent coughing, which results in acute pain. Thus, nursing professionals need to look for a nursing diagnosis of acute pain.
Associated Factors
- Frequent coughing
- Inflammations in the chest cavity
Central Characteristics
- Raised blood pressure
- Restlessness and irritability
- Pain in other areas, such as muscles, joints, and head
- Tachycardia and tachypnea
Anticipated Outcomes
- The patient will rate their pain score less than 4 on a scale of 0 – 10
- The patient will engage in activities appropriately and show a relaxed manner
Nursing Assessment for Acute Pain
Nursing specialists can perform the following tests to detect acute pain in patients with pneumonia.
1. Assess Vital Signs
The key common indicators that a pneumonia patient is experiencing acute pain are alterations in blood pressure and heart rate. The other vital signs may not be good indicators, as they may even be ruled out.
2. Assess the features of pain
Although chest pain is common in someone with pneumonia, it may also mark the onset of pneumonia complications like endocarditis and pericarditis. Nurses can understand more about the pneumonia condition by monitoring the features of the pain: if it is stabbing, constant, or sharp, or its intensity and location.
Nursing Intervention for Acute Pain
Some interventions for treating acute pain in pneumonia patients are as follows.
1. Encourage coughing
Coughing helps facilitate respiratory secretions. Suppressing coughs keeps the secretions retained, eventually resulting in a longer period of pneumonia resolution.
2. Administer prescribed analgesics
Analgesics manage extreme pain, helping the patients cough frequently and take deep breaths.
3. Offer comfort measures
Several types of comfort measures exist. This includes position changes, breathing exercises, massage, and soothing music. Patients need to be involved in all types of pain control measures as it improves their sense of well-being and independence.
What Is The Difference Between A Nursing Diagnosis And A Medical Diagnosis?
Nursing and medical diagnoses differ in their features though they both play significant roles in offering quality patient care; hence, they are critical tools in the healthcare industry.
A medical diagnosis focuses on the pathology, which can be a disease, disorder, or injury. On the other hand, a nursing diagnosis focuses on the psychological or physiological response of the patient’s body to the pathology. A nursing diagnosis deals with the patient's symptoms, while a medical diagnosis deals with the underlying cause of the symptoms.
A physician makes a medical diagnosis, resulting in an intervention meant to treat the medical condition. Thus, a medical diagnosis is specific. Nurses make nursing diagnoses, and their interventions are care focused and holistic.
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Frequently Asked Questions
1. Who Can Help Me In Writing A Nursing Diagnosis for Pneumonia?
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2. What Is The Pneumonia Nursing Care Plan?
It is the comprehensive tools and techniques a nurse uses to assess, diagnose, and holistically improve the quality of life for patients with pneumonia.
3. What Is The Nursing Diagnosis For Short Of Breath?
Many nursing diagnoses can be made for shortness of breath. The two typical ones are impaired gas exchange and ineffective air clearance. These two, together with their associated factors, central characteristics, and interventions, have been discussed above in detail.
4. How Do I Self-Care With Pneumonia?
There are three main ways to self-care when you have pneumonia. They are:
- Drink a lot of fluids
- Get abundant rest
- Take medication as instructed
Bottom Line
Are you wondering what to discuss about the nursing diagnosis for pneumonia? What to include and what not to include? Go through this article to see three common diagnoses you can discuss and the topics you should explain under each diagnosis. The topics are associated factors, central characteristics, assessment, anticipated outcomes, and pneumonia nursing interventions.
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