Nursing Interventions
Nursing Interventions
Nursing Interventions
for Pneumonia
Intervention and Rationale:
I. Assess for:
Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of accesory muscles, and diminished breath sounds,
rhonchi or crackles on auscultation - provides data baseline.
Changes in mental status, skin color, cyanosis - indicates possible decrease in oygenation.
!uality of cough and ability to raise secretions including consistency and characteristics od sputum - removal of secretions prevents obstruction of
airways and stasis leading to further infection and consolidation of lungs" clearing airways facilitates breathing.
II. #onitor, record, describe:
Respiratory rate, $uality and breath sounds $%-$& - indicates airway resistance, air movement, severity of disease.
A'(s, oimeter reading - decreased oygen levels result in hypoemia.
III. Administer:
)ygen therapy via cannula - maintain optimal oygen level.
Antitussives*epectorants +terpin hydrate, guaifenesin, - acts on bronchial cells to increase fluid production and promote epectoration" guaifenesin
reduces surface tension of secretions" both relieve non-productive cough
#ucolytic +acetylcysteine, - decrease viscosity of mucus for easier removal.
Antibiotic +ampicillin, cephalein, - acts by binding to cell wall organisms preventing synthesis and destroying pathogens.
I-. .erform or .rovide:
.osition of comfort in semi or high fowlers and change position $%h - facilitates breathng and allows for full epansion of lungs.
/ncourage coughing if sounds is moist" if dry and hacking, increase fluid intake and administer cough suppresant - reduces continual irritation to
throat and li$uefies secretions.
Coughing and deep breathing eercise $%h" use incintive spirometer 0-12 breaths if tolerated - coughing clears airway by propelling secretions to
mouth deep breathing promoes ventilation and prolongs epiratory phase.
Assist with coughing by splinting chest" humidified air with cool mist - loosens seretions and improves ventilation, moistens mucous membranes
.ostural drainage and percussion .R3 - mobili4es secretion.
5uction secretions if cough ineffective - removal if unable to bring up secretions.
)ral care after epectoration and provide tissues and bag for disposal - promotes comfort and prevents transmission of organisms to others.