Let’s take a look at the concept map for our patient with pneumonia. The risk factors that lead to this diagnosis include the lack of hand hygiene and exposure to sick people. Becoming ill led this patient to be inactive and take less strong breaths, which lead to pneumonia.

We will educate our patient to practice good hand hygiene and avoid sick people.

The patient’s white blood cells are high because their body is trying to fight infection. The sputum culture is pending, but if a specific bacteria is grown, the doctor will be able to prescribe a specific antibiotic to treat it. The blood cultures were drawn before the patient started on the antibiotics, and they are currently pending. They will show us if the infection has spread into the blood, leading to sepsis.

The doctor ordered azithromycin 500 mg IV and ceftriaxone 1 gm IV. These are both antibiotics to fight the infection in the lungs.

Our first nursing diagnosis is risk of infection. Our nursing interventions include monitoring temperature for fevers, encouraging deep breathing, and assisting with oral hygiene. Our desired outcome for evaluation is that the patient will show no signs of worsening infection.

The next nursing diagnosis is an impaired gas exchange from the fluid in the alveoli. Our nursing interventions include monitoring pulse oximetry levels, administering oxygen as needed, and placing the patient in high fowler’s position to help with breathing. Our desired outcome for evaluation is that the patient’s gas exchange will improve as evidenced by normal pulse ox levels.

The last nursing diagnosis is ineffective airway clearance. Our patient has a lot of gunk in their lungs that they need to get out to improve that gas exchange and decrease the growth of infection in the lungs. The nursing interventions include encouraging coughing, auscultating lung sounds, administering decongestants as ordered, and assessing the patient’s need for nebulizer treatments. The desired outcome for evaluation is effective airway clearance evidenced by clear auscultation of lung sounds. 

Here is a clean picture of our pneumonia concept map. 

We love you guys! Go out and be your best self today! And as always, Happy Nursing!