Which is the priority nursing intervention when caring for a client with pneumonia?

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Nov.08.2021

Clinical Description

• Care of the hospitalized child experiencing an infection of the pulmonary parenchyma that occurs as either a primary disease or as a complication of another condition.

Key Information

• Knowledge of previous antimicrobial therapy exposure and drug resistance patterns in the patient’s local area may influence choice of empiric antimicrobial therapy (e.g., methicillin, beta-lactam, macrolide).

• De-escalated (narrowing antibiotic therapy or changing from combination to monotherapy) rather than fixed antibiotic regimens are suggested for patients with hospital-acquired pneumonia and ventilator-associated pneumonia.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:

• Fluid Balance

• Resolution of Infection Signs and Symptoms

• Effective Oxygenation and Ventilation

B. Patient, family or significant other will teach back or demonstrate education topics and points:

• Education: Overview
• Education: Self Management
• Education: When to Seek Medical Attention

Correlate Health Status

• Correlate health status to:

  • history, comorbidity, congenital anomaly
  • age, developmental level
  • sex, gender identity
  • baseline assessment data
  • physiologic status
  • response to medication and interventions
  • psychosocial status, social determinants of health
  • barriers to accessing care and services
  • child and family/caregiver:
  • health literacy
  • cultural and spiritual preferences
  • safety risks
  • family interaction
  • plan for transition of care

Fluid Imbalance

Signs/Symptoms/Presentation: Fluid Deficit

• capillary refill delayed
• eyes sunken
• fatigue
• fontanel sunken (infant)
• irritability
• listless
• mucous membranes dry
• peripheral pulse strength decreased
• skin turgor decreased
• tearing decreased or absent
• thirst
• urinary output decreased
• urine concentration increased

Signs/Symptoms/Presentation: Fluid Excess

• acute weight gain
• bounding pulses
• breath sounds change
• crackles in lungs
• edema
• neck and hand veins distended
• positive fluid balance
• restlessness
• shortness of breath
• wheezing

Vital Signs

• heart rate increased or decreased
• blood pressure increased or decreased

Laboratory Values

• BUN (blood urea nitrogen) abnormal
• Hct (hematocrit) abnormal
• serum sodium abnormal
• urine specific gravity abnormal

Problem Intervention

Monitor and Manage Fluid Balance

• Assess fluid requirements to determine fluid therapy strategy.
• Keep accurate intake, output and daily weight; monitor trends.
• Monitor laboratory value trends and need for treatment adjustment.
• Assess need for ongoing intravenous fluid therapy; encourage oral intake when able.
• Assess neurologic status frequently due to risk of hyponatremia.

• Fluid/Electrolyte Management

Infection

Signs/Symptoms/Presentation

• appetite change
• capillary refill delayed
• chest discomfort
• chills
• diaphoresis
• fatigue
• feeding pattern and tolerance change
• irritability
• lethargic
• listless
• lymphadenopathy
• malaise
• mental status change
• night sweats
• pallor
• respiratory pattern change
• restlessness
• shivering
• skin cool and moist
• skin flushed
• skin mottled
• skin warm
• sleepiness
• urinary output decreased

Vital Signs

• heart rate increased
• respiratory rate increased
• blood pressure increased or decreased
• SpO2 (peripheral oxygen saturation) decreased
• body temperature elevated

Laboratory Values

• ABG (arterial blood gas) abnormal
• CBC (complete blood count) with differential abnormal
• blood glucose level abnormal
• CRP (C-reactive protein) elevated
• culture positive
• ESR (erythrocyte sedimentation rate) elevated
• gram stain positive
• PCT (procalcitonin) increased
• serum lactate elevated

Diagnostic Results

• chest ultrasound abnormal
• CXR (chest x-ray) abnormal

Problem Intervention

Prevent Infection Progression

• Implement transmission-based precautions and isolation, as indicated, to prevent spread of infection.
• Obtain cultures prior to initiating antimicrobial therapy when possible. Do not delay treatment for laboratory results in the presence of high suspicion or clinical indicators.
• Administer ordered antimicrobial therapy promptly; reassess need regularly.
• Monitor laboratory value, diagnostic test and clinical status trends for signs of infection progression.
• Identify early signs of sepsis, such as increased heart rate or temperature, as well as changes in mental state, respiratory pattern or peripheral perfusion.
• Prepare for rapid sepsis management, including lactate level, intravenous access, fluid administration and oxygen therapy.
• Provide fever-reduction and comfort measures.

• Fever Reduction/Comfort Measures
• Infection Management
• Isolation Precautions

Respiratory Compromise

Signs/Symptoms/Presentation

• breath sounds abnormal
• breathing pattern ineffective
• breathlessness
• confusion
• cough impaired
• cough increased
• cyanosis
• feeding difficulty
• irritability
• restlessness
• shortness of breath
• sputum (amount, color or consistency) change
• swallow function impaired
• work of breathing increased

Vital Signs

• heart rate increased
• respiratory rate increased
• SpO2 (peripheral oxygen saturation) decreased

Laboratory Values

• ABG (arterial blood gas) abnormal

Diagnostic Results

• chest ultrasound abnormal
• CXR (chest x-ray) abnormal

Problem Intervention

Promote Airway Secretion Clearance

• Assess the effectiveness of pulmonary hygiene and ability to perform airway clearance techniques.
• Promote early mobility or ambulation; match activity to ability and tolerance.
• Encourage deep breathing and lung expansion therapy to prevent atelectasis; adjust treatment to patient’s response.
• Anticipate the need to splint chest or abdominal wall with cough to minimize discomfort; assist if needed.
• Initiate cough-enhancement and airway-clearance techniques with instruction.
• Consider pharmacologic therapy, such as beta-2 agonist, mucolytic, corticosteroid, antimicrobial, that may improve inflammation, mucus clearance, cough response and air flow.

• Breathing Techniques/Airway Clearance
• Cough And Deep Breathing

Problem Intervention

Optimize Oxygenation and Ventilation

• Assess and monitor airway, breathing and circulation for effective oxygenation and ventilation; consider oxygenation and ventilation parameters and goal.
• Maintain head of bed elevation with regular position changes to minimize ventilation-perfusion mismatch and breathlessness; consider prone positioning to maximize alveolar recruitment.
• Provide oxygen therapy judiciously to avoid hyperoxemia; adjust to achieve oxygenation goal.
• Monitor fluid balance closely to minimize the risk of fluid overload.
• Consider positive pressure ventilation to enhance oxygenation and ventilation, as well as reduce work of breathing.

• Airway/Ventilation Management
• Head of Bed (HOB) Positioning

Education

Overview

• description

• signs/symptoms

Self Management

• activity

• fluid/food intake

• immunizations

• infection prevention

• medication management

• pulmonary hygiene

• tobacco use, smoke exposure

• VTE prevention

When to Seek Medical Attention

• unresolved/worsening symptoms

• VTE symptoms

General Education

• admission, transition of care

• orientation to care setting, routine

• advance care planning

• diagnostic tests/procedures

• diet modification

• opioid medication management

• oral health

• medication management

• pain assessment process

• safe medication disposal

• tobacco use, smoke exposure

• treatment plan

Safety Education

• call light use

• equipment/home supplies

• fall prevention

• harm prevention

• infection prevention

• MDRO (multidrug-resistant organism) care

• personal health information

• resources for support

References

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Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

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