Nursing assessment and interventions
Nursing Respiratory Assessment
Nursing assessment is critical to early detection of hospital acquired pneumonia, important cues may include:
- Pneumonia risk factors and comorbidities.
- Signs and symptoms of infection: fever, chills, shivering or night sweats.
- Clinical presentation of pneumonia may include cough, pleuritic pain, tachycardia/bradycardia, tachypnea, and fatigue, use of accessory muscles for breathing, coughing, purulent sputum and occasionally hemoptysis.
- Sputum amount, odor, and color of secretions.
- Frequency and severity of cough.
- Degree of tachypnea or shortness of breath.
- Changes in chest x-ray findings.
When pneumonia is suspected, elderly patients should be frequently assessed for altered: mental status, dehydration, unusual behavior, excessive fatigue, and concomitant heart failure (Belleza, 2019).
Nursing interventions (pneumonia) |
- Instruct patient and family about the cause of pneumonia,
management of symptoms, signs, and symptoms,
testing and the importance of follow-up.
- Monitor vital signs
- Monitor level of consciousness
- Monitor respiratory status: labored respirations, cyanosis,
and cold and clammy skin.
- Monitor pulse oximetry.
- Administer oxygen as prescribed.
- Encourage/assist removal of excess secretions
- Chest physiotherapy for patients who have difficulty
clearing their own secretions: percussion, postural drainage.
- Monitor and record the color, consistency, and amount of sputum.
- Prevent the spread of infection by hand washing and the proper disposal of secretions.
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- Elevate head of bed at 45 degree angle/ semi fowlers position for SOB.
- Administer antibiotics and other medications as prescribed.
- Monitor (Intake and Output) and encourage hydration up to 3 L per day to thin secretions unless contraindicated.
- Encourage appropriate nutrition- high-calorie nutrient rich foods. and liquids to maintain energy.
- Provide a balance of rest and activity, increasing activity gradually.
- Assist the patient with ambulation when appropriate.
- Monitor for complications
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Instant Feedback:
Which of the following assessments should a nurse carry out on a patient with suspected pneumonia?
References:
Belleza, M. (2019). Pneumonia: Nursing Care Management. Nurses Labs. https://nurseslabs.com/pneumonia/.
Ostergaard L, Huniche B, Andersen PL. Relative bradycardia in infectious diseases. J Infect. 1996 Nov;33(3):185-91
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