Pneumonia Mind Map Nursing

Therapeutic management
Blood Gas
Impaired Gas Exchange
Ineffective Airway Clearace
Signs and Symptoms
increated WBCs
positive aputum culture
change in character of sputum
Acess Vs tamp flactations
Asseses purbo on
Amess lung rounds
Asses WRC count
Asses hylaties
Asses effecttveness of antibtacis
chect X ray
Asses WBC count
administer abx
administer antyhypyretics
administer OZ and bronchodlation as
Signs and Symptoms
Adventitious lung sounds
shortness of breath
Infiltrates in C Xray
Purulent Sputum
Nursing Interventions
Assess respiratory status
Assess Cough
Observe sputum for color, amount,
Teach re: positioning, coughing and deep
Suction oropharynx prn
Assist with IS
Teach re: Pacing activities
Consilt RT CPT and nebulizer
Signs and Symptoms
Nursing Interventions
PI will mairtain eqtimal gas cncharge as cvidenceal eviddenceal repinstion
between 12-24 min. ABCs WNI (specify ranges here); and no further
reduction in mermal statex stste stabel ABG
Asscs repirations: note quality, rate, rhythm, depth: are of seecounry
Assess VS charges
Assess skin color for cyarbis
Assess chages in ceienftion and increating resfeoree
Assess ABC and 02 sal
Mxintain 02. sveial high <>in COPD ptx
Respirations: Most PNA pts have hypoxemia
and respirator alkalosis
Hyperventilation = breathing too fast leads
Blowing off all your CO2 (acid loss) leads to...
Acute alkalosis (left shift)
Less intake of 02 combined with...
Increased affinity for 02 = less tissue
Reduced 02. Increased affinity leads to
Less 02 starts hypotension, vasodilation leads
Lack of 02 to brain = confusion, headache,
blurred vision leads to
Low 02 to myocardium = bradycardia,
arrhythmias = ischemia, coma
Interventions: Vents
Increase FiO2 (21% on RA) to obtain PO2 (ABG
80-100 about 4-5 times FiO2)
At 100% 02 and ratio of "21%" to "80 to 100%"
PO2 should be 400-500!
Increase minute ventilation to remove excess
CO2 and increase TV to clear more CO2
(16 BPM x TV 400 cc = 6400CC)
High levels of FiO2 > 60% oxygen is considered
toxic and causes fibrotic lung damage
Trade PEEP for 02 reducing the amount of
oxygen given on a vent
Use pressure-limited ventilation. Pressure
controlled or Pressure support.
1. Antibiotic terapy, analgesics. antipyretics
2. Oxygen therapy to treat hypoxemia, suctioning
as necessary
3.Maintain patent airway: monitor respiratory and
oxygenation status
4. Provide supplemental oxygen as indicated
5. Be prepared to initiate mechanical ventilatory
6. Provide nutritional support and fluids(2 liters
per 24 hours or greater if no trainclications) via
appropriate route
7. Provide adeuate opportunities for physical rest
8. For all hospitalized Clients, take measures to
prevent Pneumonia
9. Macrolides: erythromycin, axithromycin;
penicillin G: aminoglycosides or cephalosporins
10. Alternatives: Augmentin: doxycycline; Bactrim;
11. Medication therapy: antibiotics or other
antimicrobials as indicated, analgesics,
1. Acute infirammaton of lower lung parenchyma (aiveill and
respratory bronchioies, aspration, inhaiation, or contaminated
respratory equipment
2. Classified viral versus bacterial,
community-acquired versus hospital-acquired
atypical, or pneumocystis
3. Causative agent can be infectious (bacteria,
viruses, fungi, and other microbes) or
noninfectious (aspirated or inhaled substances)
4. Most common organism for both community-
acquired and hospital-acquired pneumonia is
the Gram-positive bacteria Streptococus
5. Other common organisms associated with
community-acquired pneumonia in-clude
Klebsiella pneumoniae, Pseudomonas
aeruginosa. Escherichia con, haemophilus
influenzae, and other influenzae viruses
7. Antigen-antibody response damages mucous
membranes of bronchioles and alveoli resulting
in edema
8. Microbe cellular debris and exudate fill
alveoli and can impair gas exchange
6. Spread of microbes in alveoli activates
inflammatory and immune response
1. Viral
2. Bacterial
a. Fever: low-grade
b. Cough: nonproductive
C. White blood cell count: normal to low
d. Chest X-ray: minimal changes evident
e. Clinical course: less severe than pneumonia
of bacterial origing=
a. Fever: high
b. Cough: Productive
C. White blood cell count: high elevation
d. Chest x-ray: obvious infiltrates
e. Clinical course: more severe than pneumonia
of viral origin
Decreased PaO2
Increased PaCO2
Decreased activity tolerance
Disorientation or confusion in older adults,
functional decline with or without fever
Loss of appetite
Lung conslidation
Pacc activies to reduce exygen need fstigue
Articipate need for intutation and needarical verlation if curaliftion
8.1 Identify clinents at high risk for pneumonia
8.2 Maintain appropriate infection control measures
8.3 Maintain adequate nutrition
8.4 Initiate aspiration precautions for clients at risk
(ex: stroke)
8.5 Encourage activity and mobility as soon as
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