Nursing Care Plan for Pneumonia Sample and Overview

Written by: Marie Hasty, BSN, RN Content Writer

If your patient has lung crackles, a fever, and tachycardia, it might be time to create a nursing care plan for pneumonia. This lung infection is a primary reason for about 1.4 million emergency department visits and 41,000 deaths per year in the U.S. We’ll explore the ins and outs of caring for patients with pneumonia.

The nursing process is a workflow that includes the steps of assessment, diagnosis, planning, intervention, and evaluation. Pneumonia is a medical diagnosis, while nursing diagnoses focus on problems, risks, syndromes, and health maintenance issues. Check out our breakdown and example pneumonia nursing care plan below.

What Is Pneumonia?

Pneumonia is a lung infection that’s one the leading causes of death in the U.S. and is a common issue in many nursing care settings. It’s a broad term for diseases that can be caused by bacteria, viruses, or fungi, and can be acquired in three different ways:

Community-acquired pneumonia (CAP): Initial infection occurs outside the hospital, commonly due to the flu and strep.
Hospital-acquired pneumonia (HAP): Infection occurs within 48 hours of inpatient admission to a hospital, assisted-living facility, rehab, or other healthcare facility. This can include aspiration pneumonia.
Ventilator-associated pneumonia (VAP): Acquired within 48 hours of endotracheal intubation, this most commonly occurs in intensive care units.

In its mildest form, pneumonia symptoms can resemble a long flu or cold. Other, more intense signs may include the following:

Chest pain while breathing or coughing
Changes in mentation or new confusion (most common in older adults)
Cough, which may be productive
Fatigue
Sweating and chills
Fever or abnormally low body temperature
Diarrhea, nausea, and vomiting
Dyspnea (shortness of breath)

Note that pneumonia may not be obvious in infants and newborns. They may present no symptoms or have vomiting, cough, fever, dyspnea, restlessness, or fatigue. These patients have less energy reserves to fight infection, so paying attention to subtle signs and changes is essential. A nursing care plan for pneumonia in infants will include close monitoring for worsening status.

Pneumonia is diagnosed through symptom assessment and the following tests:

Blood tests: Confirm an infection through an elevated immune response.
Chest X-ray: Determine the location and severity of infection.
Pulse oximetry: Look for a decreased oxygen level.
Sputum test: Fluid from the lungs can be tested for bacteria, viruses, or fungi.

What complications should nurses be concerned about for patients with pneumonia? Lung infection can lead to complete respiratory failure, lung abscess, multi-organ dysfunction, and sepsis. Populations at the greatest risk of death from pneumonia are young children, older adults, and those who are immunocompromised. If your patient is struggling to breathe, has low pulse oximetry, or experiences a change in consciousness, alert your rapid response team (RRT).

Settings Where You’re Likely to Need Nursing Care Plans for Pneumonia

Pneumonia is common, especially during flu season. Nurses in a variety of settings are likely to see this respiratory illness:

Sample Nursing Care Plan for Pneumonia

Any nursing care plan for a patient with pneumonia will prioritize airway, breathing, and circulation. Patients with mild pneumonia may be able to recover at home, while at-risk populations and those with more severe cases may be seen in the acute care setting.

1. Assessment

Cornelius is an 82-year-old male who comes to the emergency department with his wife. He complains of chest tightness when he breathes in deeply, as well as some shortness of breath. He feels very tired. His wife reports being sick with a positive flu test last week.

Cornelius’ nursing assessment includes the following:

Vital signs, including pulse oximetry
Physical assessment, including heart and lung sounds
Cough and sputum assessment (color does not necessarily indicate pneumonia)
Auscultating lung sounds
Level of consciousness and orientation

Additionally, Cornelius’ medical provider will likely order a chest X-ray, labs, and a sputum test. In patients with chest pain, an electrocardiogram and other testing may also be ordered to rule out cardiac issues.

2. Diagnosis

Based on the findings of his assessment, Cornelius’ nurse chooses the following nursing diagnoses for him:

Impaired gas exchange: In extreme pneumonia, the alveoli in the lungs can fill with pus, and oxygen cannot be exchanged. This can result in dead spaces in the lungs, where little to no ventilation is occurring despite an increased respiratory rate.

Here are some common nursing interventions for impaired gas exchange:

Performing chest percussion
Encouraging early mobilization
Applying oxygen therapy as appropriate
Using continuous pulse oximetry for ongoing monitoring
Taking frequent vital signs

Ineffective airway clearance: Lung inflammation leads to sputum production, which can be difficult to dislodge and cough up. The airway may be partially obstructed, further inhibiting oxygen exchange in the lungs.

Nursing interventions for a patient with ineffective airway clearance may include the following:

Encouraging cough and fluids to loosen secretions
Encouraging the use of an incentive spirometer
Sitting up the head of the bed
Performing airway suction

Ineffective breathing pattern: Tachypnea, use of accessory muscles, abdominal breathing, and hypoxemia all indicate that the current breathing pattern is not effective. Initially, patients with pneumonia may compensate by increasing the work and rate of breathing, but eventually their status may worsen as their body can no longer tolerate low oxygen levels.

The following nursing interventions may be required for ineffective breathing patterns:

Administering bronchodilators as ordered
Administering antibiotics as ordered
Monitoring work of breathing and symptoms

3. Planning

Next, Cornelius’ nurse uses the nursing diagnoses to plan care. The first priority is the patient’s safety — his advanced age puts him at higher risk for complications. Interventions will focus on treatment and education to detect a worsening status.

The nurse also sets the following goals for Cornelius by the end of this shift:

The patient will experience an improvement in symptoms.
The patient will not experience a worsening in vital signs and oximetry.
The patient and family will verbalize understanding of treatment methods and signs of emergency.

4. Intervention

Now, it’s time to put our nursing care plan for pneumonia into action. While clustering care, Cornelius’ nurse takes the following steps during their next visit to the room:

Applying continuous pulse oximetry
Applying oxygen therapy as ordered
Administering antibiotics and bronchodilators as ordered
Encouraging fluids and activity
Teaching the family about percussion techniques to loosen sputum

5. Evaluation

Several hours later, Cornelius is reporting a lessening of his chest tightness. He is on a lower flow of oxygen, and his pulse oximetry has not dropped below 90% in the last hour. However, due to his risk status, the medical team is advising him and his wife to stay overnight. The nurse prepares Cornelius for transfer to a med-surg unit.

Put a Nursing Care Plan For Pneumonia to Work

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