Client Assessment Database
A
CTIVITY/R
EST•Fatigue, weakness
•Insomnia
•Prolonged immobility and bedrest
C
IRCULATION•History of recent or chronic heart failure (HF)
F
OOD/F
LUID•Loss of appetite
•Nausea, vomiting
•May be receiving intestinal, gastric feedings
N
EUROSENSORY•Frontal headache (influenza)
•Lethargy
•Decreased tolerance to activity
•Tachycardia
•Flushed appearance, pallor, central cyanosis
•Distended abdomen
•Hyperactive bowel sounds
•Dry skin with poor turgor
•Cachectic appearance (malnutrition)
•Changes in mentation, such as confusion, somnolence
•Changes in behavior such as irritability, restlessness, lethargy
D I A G N O S T I C D I V I S I O N
CHAPTER 5
RESPIRA
T
OR
Y—PNEUMONIA
Client Assessment Database
(continued)P
AIN/D
ISCOMFORT•Headache
•Chest pain (pleuritic) aggravated by cough
•Substernal chest pain (influenza)
•Myalgia, arthralgia
•Abdominal pain
R
ESPIRATION•History of recurrent or chronic upper respiratory infections
(URIs), tuberculosis, COPD, cigarette smoking
•Progressive shortness of breath
•Presence of tracheostomy, endotracheal tube
•Current treatment with mechanical ventilator
•Cough is dry and hacking (initially), progressing to produc-
tive cough
S
AFETY•Recurrent chills
•History of altered immune system, such as systemic lupus
erythematosis (SLE), AIDS, active malignancies, neurological disease, HF, diabetes, steroid or chemotherapy use; institu- tionalization, general debilitation
T
EACHING/L
EARNING•Recent surgery, chronic alcohol use or long history of
alcoholism, intravenous (IV) drug therapy or abuse, chemotherapy or other immunosuppressive therapy
•Use of herbal supplements, such as garlic, ginkgo, licorice,
onion, turmeric, horehound, marshmallow, mullein, wild cherry bark, astragalus, echinacea, elderberry, goldenseal, Oregon grape root
D
ISCHARGEP
LANC
ONSIDERATIONS•Assistance with self-care, homemaker tasks
•Supplemental oxygen, especially if recovery is prolonged or
other predisposing condition exists
➧Refer to section at end of plan for postdischarge
considerations.
•Splinting, guarding over affected area
•Position—commonly lies on affected side to restrict movement
• Respirations:Tachypnea, shallow grunting respirations
•Use of accessory muscles, nasal flaring
•Breath sounds are diminished or absent over involved area
• Bronchial breath sounds over area(s) of consolidation • Coarse inspiratory crackles
• Color:Pallor or cyanosis of lips or nailbeds
• Sputum:Scanty or copious; pink, rusty, or purulent (green, yellow, or white)
• Percussion:Dull over consolidated areas
• Fremitus:Tactile and vocal, gradually increases with consolidation
•Pleural friction rub
•Diaphoresis
•Shaking
•Rash, in cases of rubeola or varicella
•Fever of 102°F to 104°F (39°C to 40°C)
D I A G N O S T I C D I V I S I O N
Nursing Priorities
1. Maintain or improve respiratory function.
2. Prevent complications.
3. Support recuperative process.
4. Provide information about disease process, prognosis,
and treatment.
T E S T
W H Y I T I S D O N E
W H AT I T T E L L S M E
Diagnostic Studies
B
LOODT
ESTS• Complete blood count (CBC):Battery of screening tests that typically includes hemoglobin (Hgb); hematocrit (Hct); red blood cell (RBC) count, morphology, indices, and distribution width index; platelet count and size; white blood cell (WBC) count and differential. Provides baseline data about the hematologic system and yields information related to oxygenation and infection.
• Electrolytes:An electrolyte is a substance that will dissociate into ions in solution and acquire the capacity to conduct electricity. Common electrolytes include sodium, potassium, chloride, calcium, and phosphate. Provides baseline data and can be used to evaluate and monitor fluid and electrolyte balance.
• Erythrocyte sedimentation rate (ESR):Nonspecific test done to detect illnesses associated with acute infection and inflammation.
• Serologic studies (viral or Legionella titers, cold
agglutinins):Assist in differential diagnosis of specific organism.
• Arterial blood gases (ABGs):Measure oxygen and carbon dioxide levels to rule out hypoxemia or hypercapnia.
O
THERD
IAGNOSTICS
TUDIES• Chest x-ray:Evaluates organs and structures within the chest.
• Fiberoptic bronchoscopy:Allows direct visualization of tracheobronchial tree for abnormalities and to obtain sputum for cytological examination.
• Pulmonary function studies:Various tests measure lung function, provide information on the extent of the pulmonary abnormality, and determine if there is airway obstruction or trapping in the lungs.
• Pulse oximetry:Noninvasive measure of arterial blood oxygen diffusion and saturation.
• Gram stain and cultures:Sputum collection; needle aspira- tion of empyema, pleural, and transtracheal or transthoracic fluids; and lung biopsies and blood cultures may be done to recover causative organism.
Leukocytosis with a left shift is usually present in bacterial pneumonia, although a low WBC count may be present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia.
Sodium and chloride levels may be low.
Elevated levels may be present in bacterial infections.
Provide information on the specific organism causing the pneumonia or can rule out other diseases.
Abnormalities may be present, depending on extent of lung involvement and underlying lung disease.
Identifies structural distribution of pneumonia, such as lobar or bronchial. May show scattered or localized infiltration (bacterial) or diffuse and extensive nodular infiltrates (more often viral). In
Mycoplasma pneumonia, chest x-ray may be clear.
May be both diagnostic (qualitative cultures) and therapeutic (reexpansion of lung segment).
Lung volumes may be decreased (congestion and alveolar collapse). Airway pressure may be increased and compliance decreased. Shunting is present (hypoxemia).
The percentage expressed is the ratio of oxygen to Hgb. Pulse oximetry less than 90% indicates significant hypoxia.
Abnormally low levels (<88%) indicate impaired gas exchange and impending respiratory failure.
More than one type of organism may be present; common bacte-
ria include Diplococcus pneumoniae, S. aureus,-hemolytic
streptococcus, H. influenzae, and CMV. Note: Sputum cultures may not identify all offending organisms. Blood cultures may show transient bacteremia.
Discharge Goals
1. Ventilation and oxygenation adequate for individual needs.
2. Complications prevented or minimized.
3. Disease process, prognosis, and therapeutic regimen
understood.
4. Lifestyle changes identified and initiated to prevent
recurrence.
CHAPTER 5 RESPIRA T OR Y—PNEUMONIA May be related to
Tracheal bronchial inflammation, edema formation, increased sputum production Pleuritic pain
Decreased energy, fatigue Possibly evidenced by
Changes in rate, depth of respirations
Abnormal breath sounds, use of accessory muscles Dyspnea, cyanosis
Cough, effective or ineffective; with or without sputum production
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Airway PatencyIdentify and demonstrate behaviors to achieve airway clearance.
Display patent airway with breath sounds clearing and absence of dyspnea and cyanosis.
NOC
N U R S I N G D I A G N O S I S :
ineffective Airway Clearance
ACTIONS/INTERVENTIONS
RATIONALE
Airway Management Independent
Assess rate and depth of respirations and chest movement. Monitor for signs of respiratory failure; for example, cyanosis and severe tachypnea.
Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds, such as crackles and wheezes.
Elevate head of bed; change position frequently.
Assist client with frequent deep-breathing exercises. Demonstrate and help client, as needed; learn to perform activity, such as splinting chest and effective coughing while in upright position.
Suction, as indicated; for example, oxygen desaturation related to airway secretions.
Force fluids to at least 2,500 mL per day, unless contraindicated, as in HF. Offer warm, rather than cold, fluids.
Collaborative
Assist with and monitor effects of nebulizer treatments and other respiratory physiotherapy, such as incentive spirome- ter, intermittent positive-pressure breathing (IPPB), percus- sion, and postural drainage. Perform treatments between meals and limit fluids when appropriate.
Administer medications, as indicated, for example mucolytics, expectorants, bronchodilators, and analgesics.
Provide supplemental fluids such as IV, humidified oxygen, and room humidification.
Monitor serial chest x-rays, ABGs, and pulse oximetry readings. (Refer to ND: impaired Gas Exchange, following.)
NIC
Tachypnea, shallow respirations, and asymmetric chest move- ment are frequently present because of discomfort of mov- ing chest wall or fluid in lung. When pneumonia is severe, the client may require endotracheal intubation and mechanical ventilation to keep airways clear.
Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and expiration in response to fluid accumulation, thick secretions, and airway spasm or obstruction.
Keeping the head elevated lowers diaphragm, promoting chest expansion, aeration of lung segments, and mobilization and expectoration of secretions to keep the airway clear. Deep breathing facilitates maximum expansion of the lungs and smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. Note: Cough associated with pneumonias may last days, weeks, or even months.
Stimulates cough or mechanically clears airway in client who is unable to do so because of ineffective cough or decreased level of consciousness.
Fluids, especially warm liquids, aid in mobilization and expec- toration of secretions.
Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudates or destruction. Coordination of treatments, schedules, and oral intake reduces likelihood of vomiting with coughing and expectorations.
Aids in reduction of bronchospasm and mobilization of secre- tions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort and depress respirations.
Fluids are required to replace losses, including insensible, and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection.
Follows progress and effects of disease process and therapeutic regimen, and facilitates necessary alterations in therapy.
May be related to
Alveolar-capillary membrane changes—inflammatory effects
Altered oxygen-carrying capacity of blood or release at cellular level—fever, shifting oxyhemoglobin curve Altered delivery of oxygen—hypoventilation
Possibly evidenced by Dyspnea, cyanosis Tachycardia
Restlessness and changes in mentation Hypoxia
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas ExchangeDemonstrate improved ventilation and oxygenation of tissues by ABGs within client’s acceptable range and absence of symptoms of respiratory distress.
Participate in actions to maximize oxygenation.
NOC
N U R S I N G D I A G N O S I S :
impaired Gas Exchange
ACTIONS/INTERVENTIONS
RATIONALE
Respiratory Monitoring Independent
Assess respiratory rate, depth, and ease.
Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nailbeds) or central cyanosis (circumoral).
Assess mental status.
Monitor heart rate and rhythm.
Monitor body temperature, as indicated. Assist with comfort measures to reduce fever and chills, such as addition or removal of bedcovers, comfortable room temperature, and tepid or cool water sponge bath.
Maintain bedrest. Encourage use of relaxation techniques and diversional activities.
Elevate head and encourage frequent position changes, deep breathing, and effective coughing.
Assess level of anxiety. Encourage verbalization of concerns and feelings. Answer questions honestly. Visit frequently and arrange for significant other (SO) and visitors to stay with client as indicated.
Observe for deterioration in condition, noting hypotension, copious amounts of pink or bloody sputum, pallor, cyanosis, change in level of consciousness, severe dyspnea, and restlessness.
Collaborative
Monitor ABGs and pulse oximetry.
Oxygen Therapy
Administer oxygen therapy by appropriate means, for example, nasal prongs, mask, Venturi mask.
Prepare for and transfer to critical care unit if indicated.
NIC NIC
Manifestations of respiratory distress are dependent on, and indicative of, the degree of lung involvement and underlying general health status.
Cyanosis of nailbeds may represent vasoconstriction or the body’s response to fever or chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (“warm membranes”) is indicative of systemic hypoxemia. Restlessness, irritation, confusion, and somnolence may reflect
hypoxemia or decreased cerebral oxygenation.
Tachycardia is usually present as a result of fever and dehy- dration, but may represent a response to hypoxemia. High fever, common in bacterial pneumonia and influenza,
greatly increases metabolic demands and oxygen con- sumption and alters cellular oxygenation.
Prevents exhaustion and reduces oxygen consumption and demands to facilitate resolution of infection.
These measures promote maximal inspiration and enhance expectoration of secretions to improve ventilation. (Refer to ND: ineffective Airway Clearance.)
Anxiety is a manifestation of psychological concerns and physiological responses to hypoxia. Providing reassurance and enhancing sense of security can reduce the psychologi- cal component, thereby decreasing oxygen demand and adverse physiological responses.
Shock and pulmonary edema are the most common causes of death in pneumonia and require immediate medical intervention.
Identifies problems, such as ventilatory failure; follows progress of disease process or improvement; and facilitates alterations in pulmonary therapy.
The purpose of oxygen therapy is to maintain PaO2above 60 mm Hg, or greater than 90% O2saturation. Oxygen is administered by the method that provides appropriate delivery within the client’s tolerance.
Intubation and mechanical ventilation may be required in the event of severe respiratory insufficiency. (Refer to CP: Ventilatory Assistance [Mechanical].)
CHAPTER 5
RESPIRA
T
OR
Y—PNEUMONIA
Risk factors may include
Inadequate primary defenses—decreased ciliary action, stasis of respiratory secretions
Inadequate secondary defenses—presence of existing infection, immunosuppression; chronic disease, malnutrition Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Infection Status
Achieve timely resolution of current infection without complications. Knowledge: Infection Control
Identify interventions to prevent and reduce risk and spread of a secondary infection.
NOC NOC