Pneumonia
Nursing Diagnosis Nursing Interventions Rationale
INDEPENDENT:
Teach the patient the proper The most convenient way to remove
Ineffective airway clearance ways of coughing and most secretions is coughing. So it is
(related to copious breathing. (e.g., take a deep necessary to assist the patient during
tracheobronchial secretions.) breath, hold for 2 seconds, this activity. Deep breathing, on the
and cough two or three other hand, promotes oxygenation
times in succession). before controlled coughing.
Position the patient upright Upright position limits abdominal
if tolerated. Regularly check contents from pushing upward and
the patient’s position to inhibiting lung expansion. This
prevent sliding down in bed. position promotes better lung
expansion and improved air
exchange.
Perform nasotracheal Suctioning is needed when patients
suctioning as necessary, are unable to cough out secretions
especially if cough is properly due to weakness, thick
ineffective. mucus plugs, or excessive or
tenacious mucus production.
Encourage patient to Fluids help minimize mucosal
increase fluid intake to 3 drying and maximize ciliary action
liters per day within the to move secretions.
limits of cardiac reserve and
renal function.
DEPENDENT:
Maintain humidified oxygen Increasing humidity of inspired air
as prescribed. will reduce thickness of secretions
and aid their removal.
Give medications as A variety of medications are
prescribed, such as prepared to manage specific
antibiotics, mucolytic problems. Most promote clearance
agents, bronchodilators, of airway secretions and may reduce
expectorants, noting airway resistance.
effectiveness and side
effects.
Coordinate with a Chest physiotherapy includes the
respiratory therapist for techniques of postural drainage and
chest physiotherapy and chest percussion to mobilize
nebulizer management as secretions from smaller airways that
indicated. cannot be eliminated by means of
coughing or suctioning.