Pneumonia is the inflammation of the lung caused by bacteria in which the air sacs become filled

with inflammatory cells and the lung becomes solid. The symptoms include those of any
infection (fever, malaise, headache, etc.,) together with cough and chest pain.

It is estimated that, worldwide, some 4 million children under five years of age, die each year
from acute respiratory infection (ARI) with the most of these deaths caused by pneumonia in
developing countries.

In 1989, when the program for Control Acute Respiratory Infections (CARI) of the Philippines
was launched, the death toll from pneumonia among children under the age of five years was
25,000. The latest statistics (2006) disclosed that almost 60 out of 1000 children under five
children suffer from pneumonia and five in every 11,000 die from the disease. The Department
of Health believes that if health workers used a standard method of detecting and managing
ARI’s specially pneumonia, infant deaths could be cut by half, saving 50,000 lives a year.
Pneumonia can be categorized by type of infiltrate: lobar pneumonia and bronchopneumonia.

View our gallery of nursing care plans

1 Ineffective Airway Clearance

Mucus is produced at all times by the membranes lining the air passages. When the membranes
are irritated or inflamed, excess mucus is produced and it will retain in tracheobronchial tree.
The inflammation and increased in secretions block the airways making it difficult for the person
to maintain a patent airway. In order to expel excessive secretions, cough reflex will be
stimulated. An increased in RR will also be expected as a compensatory mechanism of the body
due to obstructed airways.

Assessment Nursing Planning Nursing Rationale Expected

Diagnosis Interventions Outcome
S>(none) O> Ineffective SHORT > Monitor and > To obtain SHORT
airway TERM: record vital baseline data TERM: After
>Restlessness clearance r/t After 3-4 signs > Assess > To know 3-4 hours of
with nasal accumulation of hours of NI, patient’s the patient’s NI, pt. shall
flaring tracheobronchia pt.’s SO condition. general have
l secretions will be able condition demonstrated
> With rales to > Elevate head improve
on both lung demonstrat of bed and > To promote airway
fields e improve encourage maximal clearance
airway frequent inspiration, AEB
> warm, clearance position enhance reduction of
flushed skin AEB changes. expectoration congestion
reduction of of secretions with breath
>minimal congestion > Keep back dry in order to sounds clear
colorless with breath and loosen improve and RR
nasal sounds
 clear and improve
secretions RR clothing ventilation
improve LONG
>tachypnea >Auscultate > To promote TERM:
AEB LONG breath sounds comfort and
RR=53bpm TERM: and assess air adequate After 2-3 days
movement ventilation of NI, pt. shall
>DOB After 2-3 have
days of NI, >Monitor child > To established
>tachycardia pt. will be for feeding ascertain and
able to intolerance and status and to maintained
>irritability establish abdominal note progress airway
and distention patency.
>chest maintain > To avoid
indrawing airway > Instruct the compromisin
patency. SO to provide g the airway
>cough an increased
fluid intake for > To help
>cyanosis the child liquefy the
secretions
>noisy > Instruct the
breathing SO to provide > Rest will
prevent
>pallor adequate rest fatigue and
periods for the decrease
>changes in child oxygen
RR and demands for
rhythm > Give metabolic
expectorants demands
>risk for and
infection bronchodilators > To further
as ordered. mobilize
>orthopnea secretions
> Administer
>tachypnea oxygen therapy > To clear
and other airway when
medications as secretions are
ordered. blocking the
airway

indicated to
increase
oxygen
saturation.
2 Impaired Gas Exchange
The exchange in oxygenation and carbon dioxide gases is impeded due to the obstruction caused
by the accumulation of bronchial secretions in the alveoli. Oxygen cannot diffuse easily.

Nursing Nursing Expected

Assessment Planning Rationale
Diagnosis Interventions Outcome
S>O O> Pt Impaired gas SHORT > Monitor and > To obtain SHORT
manifested: exchange TERM: After 6 record vital signs baseline data > TERM:
related to hours of NI, pt > Observe color Cyanosis of nail Patient shall
>Restlessness inflammatio will be able to of skin, mucous beds may demonstrate
>with nasal n of airways demonstrate membranes and represent improvement
flaring and improvement in nail beds, noting vasoconstrictio in gas
accumulatio gas exchange presence of n or the body’s exchange
> With rales n of sputum AEB a decrease peripheral response to AEB a
on both lung affecting O2 in respiratory cyanosis. fever/ chills decrease in
fields and CO2 rate to normal respiratory
transport > Elevate head of > To promote rate to
Patient may LONG TERM: bed and maximal normal
manifest: encourage inspiration,
After 1-2 days frequent position enhance LONG
> Metabolic of NI, pt will be changes. expectoration TERM:
acidosis able to of secretions in
demonstrate >Keep back dry. order to Patient shall
> Circum-oral improve demonstrate
cyanosis improved > Promote ventilation improved
ventilation and ventilation
>DOB adequate adequate rest >To avoid and adequate
oxygenation of periods coughing oxygenation
>tachypnea tissues AEB of tissues
absence of >Change position > Rest will AEB absence
symptoms of q 2 hrs. prevent fatigue of symptoms
respiratory and decrease
distress. > Keep oxygen of respiratory
environment demands for distress.
allergen free metabolic
demands
> Suction
secretions PRN >To promote
drainage of
>Instruct SO to secretions
increase fluid
intake of the child > To reduce
irritant effects
> Administer
 oxygen therapy as on airways
ordered.
> To clear
airway when
secretions are
blocking the
airway

indicated to
increase oxygen
saturation

>To liquefy
secretions

> O2 therapy is
indicated to
increase oxygen
saturation

3 Hyperthermia
A person experiences hyperthermia due to the inflammatory process wherein the body tries to
compensate and adapt to the dse. condition. As a defense mechanism, the body produces host 
inflammatory cells causing fever. Interluekin-1 function as a pyrogens that acts on the
hypothalamus. 1L-1 act as a hormone where it is carried by the inflammation site of production
to the CNS, where it acts directly on the hypothalamic thermal control center, thus elevating the
thermal set point.

Nursing Nursing Expected

Assessment Planning Rationale
Diagnosis Interventions Outcome
S>Ø O> The Hyperthermi Short-term: > Assess pt’s >To have Short-term:
pt manifested a After 3 hours of condition and baseline After 3 hours
nursing monitored vital data. >To of nursing
>Increase interventions signs. >Perform promote heat interventions
body temp. at the pt’s tepid sponge bath loss by the pt’s
37.9ºC temperature evaporation temperature
will be decrease >Instruct the SO and shall have
>Skin is warm to normal limits to provide an conduction. decreased to
to touch. from 37.9 to increase fluid normal limits
37.5ºC intake for the >To support from 37.9 to
>With flushed child. circulating 37.5ºC
skin. Long-term: volume and
>Maintain patent tissue
>Increase in After 3 days of airway and perfusion. Long-term:
RR nursing provide blanket
interventions for the child. >To promote After 3 days
The patient the pt will be pt’s safety of nursing
may manifest: able to maintain >Maintain bed and to avoid interventions
a temp. within rest and adequate chills. the pt shall
>chills normal range . rest periods. be able to
>To reduce maintain a
>lack of >Ask SO to metabolic temp. within
appetite provide high demands/ normal range
caloric diet for Oxygen .
the child consumption.

>Administer >To meet

antipyretics as increase
ordered. metabolic
demands.

>To lower
the
temperature.

4 Disturbed Sleeping Pattern

Sleep is disrupted when a person experiences unpleasant sensation arising from difficulty of
breathing and ineffective expectoration of mucus secretions in the airways.

Nursing Nursing Expected

Assessment Planning Rationale
Diagnosis Interventions Outcome
S > The mother Disturbed Short Term: -monitor vital -to have a Short Term:
verbalized that her Sleep After 3 hours of signs -encourage comparable After 3 hours
child often wakes Pattern r/t nursing SO to increase baseline data of nursing
up during difficulty interventions intake of warm -to promote interventions
midnight. O> of the SO will be milk for the child drowsiness the SO shall
patient  breathing able to have
manifested: verbalize - provide a quiet -to promote verbalized
understanding environment for comfort and understandin
>changes in of sleep the child relaxation g of sleep
behavior disturbance and /sleep disturbance
(irritability) identify -instruct SO to periods for and identified
interventions to provide a dim the child interventions
>restless promote sleep environment for to promote
for the child. the child -to promote sleep for the
comfort for
 child.
>DOB Long Term: >advise SO to the child
provide blanket Long Term:
>nasal flaring After 3 days of for the child >to avoid
nursing chills and to After 3 days
The patient may interventions, >instruct SO to promote of nursing
manifest: SO will be able elevate HOB comfort interventions,
to report the SO shall
>lack of interest in improvement in > to have reported
food sleep pattern of maximize improvement
the child. lung in sleep
>weight loss expansion of pattern for
the child and the child
>DOB to decrease
DOB
>tachypnea

5 Risk for Infection

Immuno-suppression due to decrease in hemoglobin, leukopenia, and suppress inflammatory
response gives a greater opportunity for pathogenic bacteria to invade and inoculate in a specific
body part of a susceptible human body. Thus, leading to a further damage or infection.

Nursing Expected
Assessment Nursing Diagnosis Planning Rationale
Interventions Outcome
S>  O>the Risk for infection Short term: 1. Monitor v/s 1. To know Short term:
patient (spread) related to After 6 hours closely, potential The patient’s
manifested inadequate of nursing especially fatal S.O shall
secondary interventions during initiation complication have
>fever of defenses(decrease the patient’s of therapy. 2. that may verbalized
38.3ºC hemoglobin, S.O will Instruct the S.O occur. 2. To her
hematocrit and verbalize her concerning promote understandin
>presence of immunosuppression understanding about the safety g of
adventitious ) of individual disposition of disposal of individual
sounds in causative/risk secretions and secretions causative/risk
both lung factors and report changes and to assess factors and
field. demonstrate in color, amount for the demonstrate
lifestyle and odor of resolution of lifestyle
>productive changes to secretions. pneumonia changes to
cough prevent further or prevent
infection. 3. Encourage the development further
>skin pale in SO to perform of secondary infection.
color Long term: good hand infection.
washing Long term:
After 1-2 days 3. To reduce
>restlessness of nursing techniques. spread or The patient
interventions acquisition shall have
The patient the patient will 4. Encourage of infection. been free
may be free from adequate rest. from possible
manifest: possible spread 4. To spread of
of infection. 5. Stress the enhance fast infection.
>activity importance of recovery and
intolerance increasing the regain
child’s strength.
>fever nutritional
intake. 5. A good
>cough and nutritional
colds 6. Encourage the intake can
mother to keep strengthen
>pallor an eye to the body
baby and immune
>cyanosis observe defense.
anything that the
>DOB baby is putting 6. To
in his mouth. prevent entry
>tachypnea of microbes.
7. Ask SO to
>tachycardia provide a good 7. To
hygiene for the eliminate
child. (bed bath) MO

8. Ask SO to 8. To
provide an prevent GI
adequate safe disturbance
drinking
milk/water for 9. To avoid
the child chills and to
prevent the
9. Ask SO to child from
keep the child having fever
warm and to
provide blanket 10. To
combat
10. Administer microbial
antimicrobials pneumonias.
as ordered.

6 Risk for Imbalanced Nutrition

A disruption in the mucosal barrier causes gastric acid to come into contact with gastric tissues
and damage them causing irritation or inflammation. This leads to alteration of the mucosal
barrier impairing the absorption process with in the stomach and putting the patient at high risk
for imbalance nutrition less than body requirements.