• Sputum studies: Often necessary to determine the etiology of pneumonia, type of infecting organisms, and sensitivity to antibiotics. Serial sputum studies may be necessary to determine response to treatment.
More than one type of organism may be pres ent. Fifty percent of pneumonia cases are believed to be caused by viruses and tend to result in less severe illness than pneumonias triggered by bacteria. Mycoplasma pneumonia is one of the most common causes of aty pi cal pneumonia. Opportunistic pneumonias (organisms causing disease in a host whose re sis tance to fi ght infection is diminished) consist of Pneumocystis carinii, cytomegalovirus, and tuberculosis (TB) (Benito et al, 2012).
Note: Sputum cultures may not identify all offending organ- isms. Blood cultures may show transient bacteremia.
RSV washing: Detects virus that is being shed in the respiratory/nasal secretions of an infected child usually between age 6 months to 2 years.
Rapid results help guide treatment options and pos si ble need for further testing if results are negative in a symptomatic child.
• Serologic studies (viral or Legionella titers, cold aggluti- nins): Assist in differential diagnosis of specifi c organism.
Provide information on the specifi c organism causing the pneumonia or can rule out other diseases.
• Arterial blood gases (ABGs): Mea sure oxygen and carbon dioxide levels to rule out hypoxemia or hypercapnia.
Abnormalities may be pres ent, depending on extent of lung involvement and under lying lung disease.
• Pulse oximetry: Noninvasive mea sure of arterial blood oxygen diffusion and saturation.
• Bronchoscopy: Insertion of a fl exible scope into the airways allows direct visualization of tracheobronchial tree for abnormalities and to obtain sputum for cytological examination.
The percentage expressed is the ratio of oxygen to Hgb. Pulse oximetry less than 90% indicates hypoxia. Abnormally low levels (<88%) indicate impaired gas exchange and impending respiratory failure.
May be both diagnostic (qualitative cultures) and therapeutic (reexpansion of lung segment).
N U R S I N G D I A G N O S I S :
in effec tive Airway Clearance
May Be Related To
Infection—[tracheal bronchial inflammation, edema formation]; under lying chronic obstructive pulmonary disease Exudate in alveoli
Possibly Evidenced By Changes in respiratory rate
Diminished/adventitious breath sounds Dyspnea, cyanosis
In effec tive cough
Desired Outcomes/Evaluation Criteria— Client Will Respiratory Status: Airway Patency NOC
Identify and demonstrate be hav iors to achieve airway clearance.
Display patent airway with breath sounds clearing and absence of dyspnea and cyanosis.
CHAPTER 3 Respiratory: Pneumonia
ACTIONS/INTERVENTIONS RATIONALE
Airway Management NIC In de pen dent
Assess rate and depth of respirations and chest movement. Tachypnea, shallow respirations, and asymmetric chest movement are frequently pres ent because of discomfort of moving chest wall or fluid in lung.
Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds, such as crackles and wheezes.
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.
Monitor for signs of respiratory failure, for example, cyanosis and severe tachypnea.
When pneumonia is severe, the client may require endotra- cheal intubation and mechanical ventilation to keep airways clear.
Elevate head of bed; change position frequently. Keeping the head elevated lowers diaphragm, promoting chest expansion, aeration of lung segments, and mobili- zation of secretions to keep the airway clear.
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.
Deep breathing facilitates maximum expansion of the lungs and smaller airways. Coughing is a natu ral 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.
Perform treatments between meals and limit fluids when appropriate.
Coordination of treatments, schedules, and oral intake reduces likelihood of vomiting with coughing and expectorations.
Suction, only as needed, for example, oxygen desaturation related to airway secretions.
Stimulates cough or mechanically clears airway in client who is unable to do so because of in effec tive cough or decreased level of consciousness.
Force fluids to at least 2500 mL per day, unless contraindi- cated, as in HF. Offer warm, rather than cold, fluids.
Fluids, especially warm liquids, aid in mobilization and expectoration of secretions.
Collaborative
Assist with and monitor effects of nebulizer treatments and other respiratory physiotherapy, such as incentive spirometer, intermittent positive- pressure breathing (IPPB), percussion, and postural drainage.
Facilitates liquefaction and removal of secretions. Note:
Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudates or destruction.
Administer medi cations, as indicated, for example, expecto- rants, bronchodilators, and analgesics.
Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort but should be used cautiously because they can decrease cough effort and depress respirations.
Provide supplemental fluids such as IV, humidified oxygen, and room humidification.
Fluids are required to replace losses, including insensible losses, 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.
Monitor serial chest x- rays, ABGs, and pulse oximetry readings. (Refer to ND: impaired Gas Exchange, following.)
Follows pro gress and effects of disease pro cess and thera- peutic regimen and facilitates necessary alterations in therapy.
ACTIONS/INTERVENTIONS RATIONALE
Respiratory Monitoring NIC In de pen dent
Assess respiratory rate, depth, and ease. Manifestations of respiratory distress are dependent on, and indicative of, the degree of lung involvement and under- lying general health status.
Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nailbeds) or central cyanosis (circumoral).
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.
Assess mental status. Restlessness, irritation, confusion, and somnolence may
reflect hypoxemia or decreased ce re bral oxygenation.
Monitor heart rate and rhythm. Tachycardia is usually pres ent because of fever and dehydra- tion but may represent a response to hypoxemia.
Monitor body temperature, as indicated. Assist with comfort mea sures to reduce fever and chills, such as addition or removal of bedcovers, comfortable room temperature, and tepid or cool water sponge bath.
High fever (common in bacterial pneumonia and influenza) greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation.
Maintain bedrest. Encourage use of relaxation techniques and diversional activities.
Reduces exhaustion (as well as oxygen consumption and demands) to facilitate resolution of infection.
Elevate head and encourage frequent position changes, deep breathing, and effective coughing.
These mea sures promote maximal inspiration and enhance expectoration of secretions to improve ventilation. (Refer to ND: in effec tive Airway Clearance.)
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.
Anxiety is a manifestation of psychological concerns and physiological responses to hypoxia. Providing reassurance and enhancing sense of security can reduce the psycho- logical component, thereby decreasing oxygen demand and adverse physiological responses.
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.
Shock and pulmonary edema are the most common causes of death in pneumonia and require immediate medical intervention.
Collaborative
Monitor ABGs and pulse oximetry. Identifies prob lems, such as ventilatory failure; follows pro gress of disease pro cess or improvement; and facilitates alterations in pulmonary therapy.
N U R S I N G D I A G N O S I S :
impaired Gas Exchange
May Be Related To
Alveolar- capillary membrane changes [such as in acute respiratory distress]
Possibly Evidenced By
Abnormal breathing pattern (e.g., rate, rhythm, depth); nasal flaring Dyspnea, abnormal skin color (e.g., pale, dusky)
Tachycardia; dysrhythmias Restlessness; confusion; irritability Abnormal arterial blood gases (ABGs)
Desired Outcomes/Evaluation Criteria— Client Will Respiratory Status: Gas Exchange NOC
Demonstrate improved ventilation and oxygenation of tissues by ABGs within client’s acceptable range and absence of symptoms of respiratory distress.
Participate in treatment regimen (e.g., breathing exercises, effective coughing, use of oxygen) within level of ability or situation.
(continues on page 154)
CHAPTER 3 Respiratory: Pneumonia
ACTIONS/INTERVENTIONS RATIONALE
Infection Control NIC In de pen dent
Monitor vital signs closely, especially during initiation of therapy.
During this period, potentially fatal complications, such as hypotension or shock, may develop.
Instruct client concerning the disposition of secretions (e.g., raising and expectorating versus swallowing) and report- ing changes in color, amount, and odor of secretions.
Although client 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 develop- ment of secondary infection.
Demonstrate and encourage good hand- washing technique. Effective means of reducing spread or acquisition of infection.
Change position frequently and provide good pulmonary toilet.
Promotes expectoration, clearing of infection.
Perform proper suctioning technique for ventilated clients as appropriate.
Secretions that accumulate below and above the endotra- cheal (ET) tube cuff are an ideal growth medium for pathogens. Numerous studies are currently being carried out to determine what factors influence the incidence of VAP. Results are inconclusive, but efforts are continuing to find a way to reduce infections and improve patient outcomes. This includes actions regarding suctioning (e.g., timing and type of suctioning [closed or open] and types of ET tubes). It also involves specific care interventions (e.g., raising or lowering the head of bed, subglottic suctioning, use of special mouthwashes and antibiotics) (Damas et al, 2015; Klompas, 2015).
Limit visitors as indicated. Reduces likelihood of exposure to other infectious pathogens.
Institute isolation precautions as individually appropriate (e.g., masks and gloves, possibly gowns) during client contact.
Depending on type of infection, response to antibiotics, client’s general health, and development of complica- tions, isolation techniques may be instituted to prevent spread and protect client from other infectious pro cesses.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Oxygen Therapy NIC
Administer oxygen therapy by appropriate means, for example, nasal prongs, mask.
The purpose of oxygen therapy is to maintain PaO2 above 60 mm Hg, or greater than 90% O2 saturation. Oxygen is administered by the method that provides appropriate delivery within the client’s tolerance.
Prepare for and transfer to critical care unit if indicated. Intubation and mechanical ventilation may be required in the event of severe respiratory insufficiency. (Refer to CP:
Respiratory Failure/Ventilatory Assistance.)
N U R S I N G D I A G N O S I S :
risk for Infection [spread]
Possibly Evidenced By
Inadequate primary defenses— decreased ciliary action, stasis of body fluids [respiratory secretions]
Inadequate secondary defenses—[presence of existing infection], immunosuppression; chronic disease, malnutrition;
inadequate vaccination
[Exposure to multiple healthcare workers]
Desired Outcomes/Evaluation Criteria— Client Will Infection Severity NOC
Achieve timely resolution of current infection without complications.
Risk Control: Infectious Pro cess NOC
Identify interventions to prevent and reduce risk and spread of a secondary infection.
ACTIONS/INTERVENTIONS RATIONALE Energy Management NIC
In de pen dent
Evaluate client’s response to activity. Note reports of dyspnea, increased weakness and fatigue; changes in oxygen saturation (O2 sat, per pulse oximetry) and vital signs during and after activities.
Establishes client’s capabilities and needs and facilitates choice of interventions.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
RSV (which is highly contagious) and certain other infective agents that cause pneumonia in children require that caregivers, family, and visitors be protected.
Encourage adequate rest balanced with moderate activity.
Promote adequate nutritional intake.
Facilitates healing pro cess and enhances natu ral re sis tance.
Monitor effectiveness of antimicrobial therapy. Signs of improvement in condition should occur within 24 to 48 hours.
Investigate sudden changes or deterioration in condition, such as increasing chest pain, extra heart sounds, altered sensorium, recurring fever, and changes in sputum characteristics.
Delayed recovery or increase in severity of symptoms suggests re sis tance to antibiotics or secondary infection.
Complications affecting any organ system include lung abscess, empyema, bacteremia, pericarditis, endocarditis, meningitis, encephalitis, and superinfections.
Collaborative
Administer antimicrobials, as indicated, by results of sputum and blood cultures, for example, macrolides such as azithromycin (Zithromax), clarithromycin (Biaxin), and erythromycin (E- Mycin); penicillin combinations, for example, amoxicillin (Amoxil) and clavulanate (Augmentin);
tetracyclines, for example, doxycycline (Doryx, Bio- Tab) and minocycline (Minocin); cephalosporins, for example, cefepime (Maxipime) and cefuroxime (Kefurox, Zinacef);
ketolides, for example, telithromycin (KETEK); and oxazolidinones, for example, linezolid (Zyvox).
These drugs are used to combat most of the microbial pneumonias. Combinations of drugs can be used when the pneumonia is a result of mixed organisms.
Provide influenza antiviral therapy (e.g., oseltamivir [Tamiflu]), as indicated.
Should be administered as soon as pos si ble to child with moderate to severe CAP consistent with influenza virus infection during widespread local circulation of influenza viruses (Bradley et al, 2011).
Prepare for and assist with additional diagnostic studies, as indicated.
Fiberoptic bronchoscopy may be done for clients who do not respond in a reasonable amount of time to antimicrobial therapy to clarify diagnosis and therapeutic needs.
N U R S I N G D I A G N O S I S :
Activity Intolerance
May Be Related To
Imbalance between oxygen supply and demand General weakness
Possibly Evidenced By
Report of weakness, fatigue, exertional dyspnea Tachypnea
Abnormal heart rate response to activity
Desired Outcomes/Evaluation Criteria— Client Will Activity Tolerance NOC
Report and demonstrate a mea sur able increase in tolerance to activity with absence of dyspnea and excessive fatigue, with vital signs within client’s acceptable range.
(continues on page 156)
CHAPTER 3 Respiratory: Pneumonia
ACTIONS/INTERVENTIONS RATIONALE
Pain Management: Acute NIC In de pen dent
Determine pain characteristics, such as sharp, constant, and stabbing. Investigate changes in character, location, and intensity of pain.
Chest pain, usually pres ent to some degree with pneumonia, may also herald the onset of complications of pneumo- nia, such as pericarditis and endocarditis.
Monitor vital signs. Changes in heart rate or blood pressure (BP) may indicate
that client is experiencing pain, especially when other reasons for changes in vital signs have been ruled out.
Provide comfort mea sures, such as back rubs, change of position, and quiet music or conversation. Encourage use of relaxation and breathing exercises.
Nonanalgesic mea sures administered with a gentle touch can lessen discomfort and augment therapeutic effects of analgesics. Client involvement in pain control mea sures promotes in de pen dence and enhances sense of well- being.
Offer frequent oral hygiene. Mouth breathing and oxygen therapy can irritate and dry out mucous membranes, potentiating general discomfort.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Provide a quiet environment and limit visitors during acute phase, as indicated. Encourage use of stress management and diversional activities as appropriate.
Reduces stress and excess stimulation, promoting rest.
Explain importance of rest in treatment plan and necessity for balancing activities with rest.
Bed and chair rest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity restrictions thereafter are determined by individual client response to activity and resolution of respiratory insufficiency.
Assist client to assume comfortable position for rest and sleep.
Client may be comfortable with head of bed elevated, sleeping in a chair, or leaning forward on over- bed table with pillow support.
Assist with self- care activities as necessary. Provide for progressive increase in activities during recovery phase.
Reduce intensity level or postpone activities that cause undesired physiological changes.
Minimizes exhaustion and helps balance oxygen supply and demand.
Collaborative
Provide and monitor response to supplemental oxygen, when indicated.
If oxygen saturation (per pulse oximetry) drops with client activity during acute or early recovery phase, oxygen may be needed during activities.
Refer to physical/occupational therapy, as indicated. May be needed/desired to develop individually appropriate exercise/progressive activity plans.
N U R S I N G D I A G N O S I S :
acute Pain
May Be Related To
Biological injury agent (e.g., infection; [inflammation of lung parenchyma, cellular reactions to circulating toxins]);
[per sis tent coughing]
Possibly Evidenced By
Verbal/coded report [pleuritic chest pain, headache, muscle or joint pain]
Guarding be hav ior; positioning to ease pain Expressive be hav ior— restlessness
Desired Outcomes/Evaluation Criteria— Client Will
Pain Level NOC
Verbalize relief or control of pain.
Demonstrate relaxed manner, resting, sleeping, and engaging in activity appropriately.
ACTIONS/INTERVENTIONS RATIONALE
Fluid Management NIC In de pen dent
Assess vital sign changes, such as increased temperature, prolonged fever, tachycardia, and orthostatic hypotension.
Elevated temperature or prolonged fever increases metabolic rate and fluid loss through evaporation. Orthostatic BP changes and increasing tachycardia may indicate systemic fluid deficit.
Assess skin turgor, moisture of mucous membranes— lips and tongue.
Indirect indicators of adequacy of fluid volume, although oral mucous membranes may be dry because of mouth breathing and supplemental oxygen.
Note reports of nausea and vomiting. Presence of these symptoms reduces oral intake.
Monitor intake and output (I&O), noting color and character of urine. Calculate fluid balance. Be aware of insensible losses. Weigh as indicated.
Provides information about adequacy of fluid volume and replacement needs.
Force fluids to at least 3000 mL per day or as individually appropriate.
Meets basic fluid needs, reducing risk of dehydration.
Ensure child is receiving daily maintenance fluids, in addition to covering fluid losses caused by current conditions (e.g., fever, inability to take oral fluids, vomiting).
Basic fluid needs are determined by child’s weight—up to 10 kg: 100 mL/kg/24 hr; 10 to 20 kg: 50 mL/kg/24 hr;
more than 20 kg: 20 mL/24 hr. Note that the smaller the child, the greater the percentage of weight is water.
Collaborative
Administer medi cations, as indicated, such as antipyretics, antiemetics.
Useful in reducing fluid losses.
Provide supplemental IV fluids as necessary. In the presence of reduced intake or excessive loss, use of parenteral route may correct or prevent deficiency.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Instruct and assist client in chest- splinting techniques during coughing episodes.
Aids in control of chest discomfort while enhancing effec- tiveness of cough effort.
Collaborative
Administer analgesics and antitussives, as indicated. These medi cations may be used to suppress body discom- forts (e.g., headache, chest/rib pain) and paroxysmal cough, thus enhancing general comfort and rest.
N U R S I N G D I A G N O S I S :
risk for deficient Fluid Volume
Possibly Evidenced By
Excessive losses through normal routes [e.g., fever, profuse diaphoresis, mouth breathing, hyperventilation]
Factors influencing fluid needs [e.g., hypermetabolic state]; extremes of age or weight; deviations affecting intake of fluids Desired Outcomes/Evaluation Criteria— Client Will
Fluid Balance NIC
Demonstrate fluid balance evidenced by individually appropriate par ameters, such as moist mucous membranes, good skin turgor, prompt capillary refill, and stable vital signs.
N U R S I N G D I A G N O S I S :
deficient Knowledge regarding condition, treatment, self- care, and discharge needs
May Be Related To
Insufficient information; insufficient knowledge of resources Alteration in cognitive functioning or memory
(continues on page 158)
CHAPTER 3 Respiratory: Pneumonia