A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority?
A. Acute pain related to lung expansion secondary to lung infection.
B. Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to fever.
C. Anxiety related to dyspnea and chest pain.
D. Ineffective airway clearance related to retained secretions.
Correct Answer: D. Ineffective airway clearance related to retained secretions.
Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces, leading to an ineffective airway clearance related to retained secretions. This diagnosis is related to excessive secretions and ineffective cough or nonproductive coughing. Inflammation and increased secretions in pneumonia make it difficult to maintain a patent airway.
Option A: Increased sputum production in pneumonia comes with frequent coughing. Persistent coughing can be painful therefore the need for Acute Pain nursing diagnosis. Provide comfort measures: back rubs, position changes, quiet music, massage. Encourage use of relaxation and/or breathing exercises.
Option B: Risk for Deficient Fluid Volume may be related to the common risk factors manifested by patients with pneumonia: fever, diaphoresis, and mouth breathing. Monitor intake and output (I&O), noting color, character of urine. Calculate fluid balance. Be aware of insensible losses. Weigh as indicated.
Option C: Outline steps to enhance general health and well-being: balanced rest and activity, well-rounded diet, avoidance of crowds during cold/flu season, and persons with URIs. Reinforce the importance of continuing effective coughing and deep-breathing exercises.
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