Pneumonia Nursing Care Plan Interventions
Pneumonia Nursing Care Plan Interventions Question
An elderly client with pneumonia has a temperature of 102.2 F (39 C), blood pressure 98/66 mm Hg, pulse 115/min, and respirations 30/min. Assessment reveals crackles in the right lower lobe, dusky nail beds, and dry mucus membranes. Arrange the nursing actions chronologically to prioritize care. All options must be used.
Pneumonia nursing care actions to arrange
Levofloxacin 750 mg intravenous (IV) every 24 hours
Blood cultures x 2 for temperature >102 F (38.9 C)
Oxygen per nasal cannula at 4 L/min
Teaching incentive spirometer use
Normal saline (NS) solution at 125 mL/hr
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Pneumonia Nursing Care Plan Interventions Response
Correct Response/Chronology
Oxygen per nasal cannula at 4 L/min
Normal saline (NS) solution at 125 mL/hr
Blood cultures x 2 for temperature >102 F (38.9 C)
Levofloxacin 750 mg intravenous (IV) every 24 hours
Teaching incentive spirometer use
Pneumonia Nursing Care Plan Interventions Explanation:
The nurse prioritizes nursing actions for the hospitalized client with pneumonia in the following order:
Oxygen per nasal cannula at 4 L/min – This client is in respiratory distress (respirations 30/min, dusky nail beds). Oxygen administration is the priority action.
NS at 125 mL/hr – Most elderly clients with pneumonia present with dehydration (dry mucus membranes, low blood pressure). Initiation of IV fluids is important to thin secretions, facilitate expectoration of mucus, and provide access for antibiotic therapy.
Blood cultures x 2 for temperature >102 F (38.9 C) – Cultures should always be drawn before antibiotic administration, as these can be inaccurate if drawn afterward. Identifying the causative pathogen is necessary to ensure that the appropriate antibiotic is prescribed. Cultures are drawn x 2 (from 2 different venipuncture sites) to rule out contaminants.
Levofloxacin 750 mg IV every 24 hours – Levofloxacin (Levaquin) is a fluoroquinolone antibiotic recommended for the treatment of pneumococcal pneumonia. Antibiotics should be administered as soon as possible after the pneumonia diagnosis is made and cultures have been drawn.
Incentive spirometer every 2 hours – Deep breathing can be performed after the initiation of antibiotics. Incentive spirometry increases alveolar expansion, facilitates removal of secretions, and prevents atelectasis.
Educational objective:
The nurse must prioritize nursing actions appropriately by identifying the client’s current health status and acuity level, threats to survival (airway, breathing, circulation), safety issues (infection), and desired outcomes.
