ishes an actual diagnosis.]
- Achieve timely resolution of current infection without complications.
- Knowledge: Infection Control
- Identify interventions to prevent/reduce risk/spread of/secondary infection.
Pneumonia (NCP) Nursing Care Plan
|Monitor vital signs closely, especially during initiation of therapy.||During this period of time, potentially fatal complications (hypotension/shock) may develop.|
|Instruct patient concerning the disposition of secretions (e.g., raising and expectorating versus swallowing) and reporting changes in color, amount, odor of secretions.||Although patient may find expectoration offensive and attempt to limit or avoid it, it is essential that sputum be disposed of in a safe manner. Changes in characteristics of sputum reflect resolution of pneumonia or development of secondary infection.|
|Demonstrate/encourage good handwashing technique.||Effective means of reducing spread or acquisition of infection.|
|Change position frequently and provide good pulmonary toilet.||Promotes expectoration, clearing of infection.|
|Limit visitors as indicated.||Reduces likelihood of exposure to other infectious pathogens.|
|Institute isolation precautions as individually appropriate.||Dependent on type of infection, response to antibiotics, patient’s general health, and development of complications, isolation techniques may be desired to prevent spread/protect patient from other infectious processes.|
|Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake.||Facilitates healing process and enhances natural resistance.|
|Monitor effectiveness of antimicrobial therapy.||Signs of improvement in condition should occur within 24–48 hr.|
|Investigate sudden changes/deterioration in condition, such as increasing chest pain, extra heart sounds, altered sensorium, recurring fever, changes in sputum characteristics.||Delayed recovery or increase in severity of symptoms suggests resistance to antibiotics or secondary infection. Complications affecting any/all organ systems include lung abscess/empyema, bacteremia, pericarditis/endocarditis, meningitis/encephalitis, and superinfections.|
|Administer antimicrobials as indicated by results of sputum/blood cultures: e.g., penicillins: erythromycin (E-Mycin), tetracycline (Achromycin), doxycycline hyclate (Vibramycin), amikacin (Amikin); cephalosporins: ceftriaxone (Rocephin); amantadine (Symmetrel); sparfloxacin (Zagam); macrolide derivatives, e.g, azithromycin (Zithromax).||These drugs are used to combat most of the microbial pneumonias. Combinations of antiviral and antifungal agents may be used when the pneumonia is a result of mixed organisms. Note: Vancomycin and third-generation cephalosporins are the treatment of choice for penicillin-resistant streptococcal pneumonia.|