Comprehensive Guide to Nursing Care Plan for Pneumonia

CURB-65 assigns 1 point each for: Confusion (new onset, AMTS ≤8); Urea >7 mmol/L (or BUN >19 mg/dL); Respiratory rate ≥30/min; Blood pressure systolic <90 or diastolic ≤60 mmHg; age ≥65 years. Score interpretation: 0–1: low severity — consider home treatment with close GP follow-up; 2: moderate — hospital admission advised; 3–5: high severity — consider ICU or HDU assessment. The score guides triage, but nursing assessment adds information the score can't capture: SpO2 trajectory (dropping despite O2), work of breathing (accessory muscle use, tripod positioning), mental status changes in the preceding hours, and oral intake. A CURB-65 of 2 in an elderly patient with poor oral intake, declining SpO2 on room air, and unable to take oral antibiotics reliably warrants admission regardless of the number. ICU triggers from a nursing escalation standpoint: SpO2 <90% on ≥4 LPM O2, RR >30 and not responding to treatment, new confusion, hypotension not resolved by fluids, or bilateral consolidation on CXR. Use SBAR format for escalation: Situation (patient X, admitted with CAP, CURB-65 2), Background (comorbidities, day of illness), Assessment (SpO2 dropping to 88% despite 6LPM O2, increasing respiratory rate), Recommendation (review for ICU/HDU step-up). In India, CURB-65 is taught at most nursing colleges but frequently underused on wards — build it into the admission nursing note as a scored checkbox.

Empiric antibiotic selection depends on severity (CURB-65) and whether the patient has comorbidities. Standard CAP (CURB-65 0–2, no comorbidities): amoxicillin 500 mg TID orally (first-line for typical bacterial pneumonia) or doxycycline (if atypical organisms — Mycoplasma, Legionella — suspected); azithromycin 500 mg OD for 5 days is an alternative for atypicals. Moderate-severe CAP (hospital, CURB-65 ≥2): combination of a beta-lactam (amoxicillin-clavulanate or ceftriaxone IV) + a macrolide (azithromycin), covering both typical and atypical organisms. India-specific note: TB must always be in the differential for a consolidation that doesn't respond to 48–72 hours of antibiotics — a non-resolving infiltrate with productive cough and weight loss needs AFB sputum before antibiotics are escalated. HAP (hospital-acquired pneumonia, onset >48 hours post-admission): higher suspicion for MRSA and gram-negative rods (Klebsiella, Pseudomonas in ICU settings); empiric piperacillin-tazobactam or meropenem may be needed pending culture. Nursing monitoring responsibilities: (1) temperature chart Q4H — fever resolution by 48–72 hours is expected with appropriate antibiotics; failure to defervesce signals wrong organism or resistant pathogen; (2) sputum culture result review — report to prescriber if organism identified; (3) IV antibiotic timing — maintain scheduled intervals (never cluster doses); (4) IV site assessment daily for phlebitis; (5) renal function monitoring in patients on aminoglycosides (if used). Antibiotic de-escalation: if cultures return sensitive organisms, nursing should prompt prescriber review to narrow coverage — broad-spectrum antibiotics maintained longer than necessary increase C. diff risk.

Incentive spirometry (IS) is a breathing device that provides visual feedback to encourage deep inhalation — the goal is to recruit collapsed alveoli (atelectasis) and mobilise secretions. Technique: (1) Ensure the patient is sitting upright (Fowler's 60–90°) or at least at 30–45°; (2) The patient seals their lips around the mouthpiece; (3) Breathe in slowly and deeply to raise the piston/ball to the target level — slow inhalation (over 5 seconds) is more effective than rapid; (4) Hold the breath for 5–10 seconds at maximum inhalation; (5) Exhale through pursed lips; (6) Repeat 10 repetitions per hour while awake. Common errors to correct: patients try to exhale through the device (it only measures inhalation), or they inhale too rapidly (the piston rises but lung expansion is incomplete). Controlled coughing (huffing technique): after 3 IS repetitions, use the huff technique — take a medium breath, hold for 2 seconds, then open the mouth and exhale with a 'huff' sound (like fogging a mirror) 2–3 times without straining the throat. This is more effective than forced coughing for moving secretions from lower airways to upper airways where they can be expectorated. Contraindication notes: IS and coughing exercises may increase pain after thoracic surgery — ensure adequate analgesia before the session; patients with rib fractures or recent abdominal surgery need modified technique or splinting with a pillow over the incision during the huff. Goal: in a pneumonia patient, secretion clearance is the primary objective — track whether sputum production changes (color, volume) across sessions and document findings.

Physiological discharge criteria (all should be met): SpO2 ≥92% on room air (or stable on prescribed home oxygen if pre-existing); temperature <37.8°C for at least 24 hours without antipyretics; respiratory rate <24/min; heart rate <100/min; blood pressure within normal range; tolerating oral fluids and medications. Additional readiness indicators: conscious and oriented, able to communicate needs, able to mobilise safely (or safe home support arrangements in place for those with mobility limitations). Common discharge-too-early error in India: patients request early discharge before the physiological criteria are met — nursing's role is to communicate these objective thresholds clearly to the treating team and to families. Discharge education for patients and caregivers (TEACH-BACK every point): (1) Complete the full antibiotic course — typically 5–7 days for CAP; stopping early when feeling better is the commonest cause of relapse; (2) Return-to-ED warning signs: worsening breathlessness, SpO2 dropping below 92% on home pulse oximeter, temperature returning after resolution, confusion, inability to swallow medications; (3) Follow-up chest X-ray: a repeat CXR in 6–8 weeks confirms radiological clearance — this is especially important to rule out underlying malignancy in smokers over 40 where pneumonia can be the presenting event of a tumour; (4) Vaccination: pneumococcal vaccine (Pneumovax 23) and annual influenza vaccine — both free under Universal Immunisation Programme for high-risk groups; (5) Smoking cessation referral: give Quitline number 1800-112-356; (6) Hydration goal: 2–2.5 L/day to keep secretions thin during recovery.