Severe Pneumonia: Building Anne’s Nursing Care Plan
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Anne’s story did not end when her deterioration was recognised.
In the original scenario, Anne Kaur was admitted with severe community-acquired pneumonia. She was hypoxaemic, tachypnoeic, febrile, hypotensive and newly confused. Her NEWS2 was 8 and her CURB-65 score was 4. The immediate priority was an A–E assessment, urgent escalation and treatment for severe pneumonia with suspected sepsis.
This continuation moves from recognising deterioration to planning, delivering and evaluating Anne’s nursing care. It is a worked educational example, not a care plan to copy into clinical documentation.
Read Anne’s original severe pneumonia scenario first
Anne after urgent review and initial treatment
Four hours later, Anne remains on the Acute Medical Unit. She has received oxygen to a prescribed target, intravenous antibiotics and carefully assessed intravenous fluid treatment. Blood cultures and other samples were obtained in line with the local sepsis and antimicrobial pathway. Her regular medicines are being reviewed by the prescriber because of her acute illness and risk of dehydration.
Her current observations are:
- Respiratory rate: 24 breaths/min
- SpO₂: 95% on 4 L/min oxygen
- Heart rate: 104 bpm
- Blood pressure: 108/66 mmHg
- Temperature: 38.0°C
- GCS: 15, although she remains intermittently disorientated to time
- Blood glucose: 10.8 mmol/L
Anne is still breathless when speaking or moving. She has a productive cough, feels exhausted and has taken only a few sips of water. She passed a small amount of concentrated urine after admission. Fluid balance monitoring is in place.
Anne says, “I want to get back to my own flat. Please keep my daughter involved, but ask me as well.” Her daughter confirms that Anne normally manages with a walking frame and twice-daily carer visits. Anne is usually orientated and makes her own decisions.
Before you see the worked plan
Which needs would you prioritise now?
- What remains an immediate threat to Anne’s safety?
- Which findings need continued monitoring and possible re-escalation?
- What matters to Anne personally?
- Which risks have developed because she is acutely unwell and less mobile?
- Which outcomes could you realistically evaluate during this shift?
A sensible care plan will not treat every problem as equally urgent. Anne’s breathing and circulation remain the first priorities, followed by acute confusion, hydration and nutrition, mobility, skin integrity and recovery planning.
Worked care plan
Priority 1: Impaired oxygenation and increased work of breathing
Assessed need or nursing problem
Anne has impaired gas exchange associated with right lower lobe pneumonia. Although her oxygen saturation has improved with supplemental oxygen, she remains tachypnoeic and breathless on minimal exertion.
Evidence
- Initial SpO₂ 90% on room air and PaO₂ 8.1 kPa while receiving oxygen
- Current SpO₂ 95% on 4 L/min oxygen
- Respiratory rate remains elevated at 24 breaths/min
- Productive cough, right-sided crackles and consolidation on chest X-ray
- Breathlessness when speaking and moving
Agreed outcome
Anne will remain within her prescribed oxygen saturation target, with no increase in oxygen requirement or work of breathing. Her respiratory rate, speech, comfort and overall clinical appearance will show an improving trend. Any deterioration will be recognised and escalated promptly.
Nursing actions and rationale
- Monitor Anne using the prescribed observation frequency and local NEWS2 escalation policy. Record oxygen delivery as well as SpO₂. A saturation value cannot be interpreted safely without knowing whether the patient is receiving oxygen.
- Continue regular A–E reassessment, paying attention to respiratory rate, work of breathing, ability to speak, chest movement, breath sounds within competence, fatigue and mental state. Deterioration may appear before the saturation falls.
- Administer and adjust oxygen only within the prescription, local policy and level of competence. For most acutely unwell adults who are not at risk of hypercapnic respiratory failure, the usual target is 94–98%. A different target must be clinically determined and documented.
- Position Anne in the way that best supports breathing, commonly upright if tolerated, while maintaining comfort and pressure-area care.
- Support sputum clearance through hydration, comfortable positioning, supported mobilisation and respiratory physiotherapy input when clinically appropriate. Do not introduce techniques that have not been assessed or recommended for her.
- Escalate immediately if Anne becomes more breathless, cannot speak normally, becomes exhausted or less responsive, falls outside her prescribed target, needs increasing oxygen or develops other signs of deterioration.
Monitoring and evaluation
Trend observations rather than judging improvement from a single SpO₂ reading. Record the oxygen device and flow rate, Anne’s work of breathing, cough, sputum, comfort and response to movement. If she remains within target on less oxygen and her respiratory effort improves, the plan is progressing. Oxygen reduction should follow clinical review, prescription and local policy.
Priority 2: Ongoing risk from severe infection and impaired circulation
Assessed need or nursing problem
Anne has severe community-acquired pneumonia with physiological findings concerning for sepsis. Her blood pressure has improved after initial treatment, but tachycardia, fever and reduced urine output mean that close reassessment is still required.
Evidence
- Initial NEWS2 of 8
- Initial blood pressure 98/60 mmHg, heart rate 112 bpm and lactate 2.5 mmol/L
- Current heart rate 104 bpm and temperature 38.0°C
- Small volume of concentrated urine
- Raised white cell count and C-reactive protein
- Confirmed right lower lobe consolidation
Agreed outcome
Anne will show an improving physiological trend following treatment. Her perfusion, blood pressure, heart rate, mental state and urine output will be monitored, prescribed treatment will be given safely and on time, and any failure to improve will trigger urgent reassessment.
Nursing actions and rationale
- Continue observations and NEWS2 at the frequency set by the responsible clinical team and local escalation policy. Repeat A–E assessment whenever there is concern, even if the next scheduled observation is not yet due.
- Administer prescribed antibiotics at the correct time after checking identity, allergies, medicine, dose, route and relevant clinical information. Record administration and monitor for adverse reactions. Antibiotic choice follows local antimicrobial guidance and prescriber assessment.
- Monitor fluid balance accurately, including oral and intravenous intake and urine output. Report persistent oliguria, worsening concentration of urine, hypotension, increasing heart rate or signs of fluid overload.
- Support prescribed intravenous fluid treatment and reassessment within competence. Fluid decisions must take account of age, renal and cardiac function, response to treatment and risk of overload. Do not assume that every patient with infection needs the same volume or rate.
- Observe the cannula site and manage the vascular access device according to local policy.
- Support repeat blood tests, lactate measurement, cultures and clinical review as requested. Results must be considered alongside Anne’s condition rather than in isolation.
- Provide prescribed antipyretic or analgesic medicines safely and evaluate the effect on comfort. A falling temperature alone does not prove that the infection is resolving.
Monitoring and evaluation
Review trends in NEWS2, blood pressure, heart rate, temperature, capillary refill, cognition, urine output, fluid balance and relevant blood results. Improvement in one value does not cancel deterioration elsewhere. Re-escalate if Anne fails to improve, requires greater respiratory support, becomes hypotensive or develops worsening confusion, reduced urine output or other new concerns.
Priority 3: Acute confusion and risk of delirium
Assessed need or nursing problem
Anne has an acute and fluctuating change in cognition during severe infection. This is consistent with possible delirium and creates risks involving distress, falls, treatment disruption and reduced ability to communicate her needs.
Evidence
- Carers and her daughter report that confusion is not Anne’s normal baseline
- Initial GCS 14 with new confusion
- Current GCS 15 but intermittent disorientation to time
- Acute infection, hypoxaemia, fever, unfamiliar surroundings and reduced intake
Agreed outcome
Anne will remain safe and involved in her care. Reversible contributors to confusion will be assessed and treated, her cognition will be monitored against her usual baseline and staff will use communication that reduces distress and supports orientation.
Nursing actions and rationale
- Report and document the acute change from Anne’s baseline. Use the organisation’s approved delirium assessment process when requested and within competence.
- Continue to assess possible contributors such as hypoxaemia, infection, pain, dehydration, abnormal glucose, constipation, urinary retention, medicines and sleep disruption.
- Introduce yourself, explain care in short clear steps and gently reorientate Anne to place, time and situation. Ensure clocks, calendars, glasses and hearing aids are available if she uses them.
- Reduce avoidable ward moves and unnecessary overnight disruption where possible. Promote daytime activity and a normal sleep pattern as her condition allows.
- Involve Anne’s daughter with Anne’s agreement. Familiar information can help staff understand Anne’s baseline, preferences and communication.
- Do not assume that confusion means Anne lacks capacity for every decision. Capacity is specific to the particular decision and time. Give information and support in a form Anne can understand, seek senior guidance and follow the applicable legal framework and local policy if capacity is in doubt.
Monitoring and evaluation
Record fluctuations, behaviour, orientation, sleep, distress and ability to engage with care. Improvement means Anne is moving towards her usual cognition and can participate more consistently. Worsening confusion, agitation, drowsiness or reduced consciousness requires prompt reassessment and escalation.
Priority 4: Reduced oral intake and risk of fluid or nutritional deficit
Assessed need or nursing problem
Anne’s breathlessness, fever, fatigue and confusion are limiting her ability to drink and eat. She is at risk of dehydration and inadequate nutrition, but oral intake must be considered alongside her intravenous fluid plan and respiratory status.
Evidence
- Only a few sips taken since admission
- Small volume of concentrated urine
- Three days of acute illness before admission
- Fatigue and breathlessness during activity
- Type 2 diabetes and acute infection
Agreed outcome
Anne will receive safe, individualised support with hydration and nutrition. Her intake, urine output, swallowing safety, glucose and tolerance will be monitored, and concerns will be referred to the appropriate registered professional or multidisciplinary team.
Nursing actions and rationale
- Complete the locally approved nutrition and hydration screening and record weight when safe and appropriate.
- Ask Anne about food and drink preferences. Offer manageable amounts, support rest before meals and place drinks within reach when safe.
- Assess for coughing, choking, altered voice or difficulty coordinating breathing and swallowing. Stop and escalate concerns rather than encouraging oral intake that may be unsafe.
- Record oral and intravenous intake and output accurately. Avoid counting a drink as consumed simply because it was offered.
- Monitor blood glucose at the prescribed frequency and report results outside the agreed range. Acute infection, reduced intake and changes to diabetes medicines can all affect glucose.
- Refer or escalate for dietetic, speech and language therapy or medical review when screening or clinical findings indicate this is needed.
Monitoring and evaluation
Review what Anne actually manages, her urine output, fluid balance, mouth care, weight where relevant, glucose and any swallowing concerns. The plan should change if intake remains inadequate, her respiratory effort makes eating unsafe or signs of fluid overload or dehydration appear.
Priority 5: Reduced mobility, falls, skin damage and venous thromboembolism risk
Assessed need or nursing problem
Anne is normally mobile with a walking frame but is now weak, breathless and intermittently confused. Acute illness and immobility increase her risks of falling, pressure damage, deconditioning and venous thromboembolism.
Evidence
- Age 78 and acute severe infection
- Breathlessness and fatigue on minimal movement
- New fluctuating confusion
- Reduced oral intake
- Temporary reduction from her normal mobility
Agreed outcome
Anne will mobilise as safely as her clinical condition allows, maintain skin integrity and avoid preventable harm. Her usual ability and goal of returning home will remain central to planning.
Nursing actions and rationale
- Complete and update local falls, pressure-ulcer and venous thromboembolism risk assessments. Risk changes as Anne’s condition and mobility change.
- Ensure the call bell and essential items are accessible. Provide appropriate assistance with transfers and toileting and use Anne’s walking aid only after checking that mobilisation is clinically safe.
- Assess skin and pressure areas while preserving dignity. Support regular position changes based on her individual risk, comfort and ability rather than using a routine schedule without assessment.
- Encourage movement and mobilisation when clinically appropriate, with physiotherapy or occupational therapy input if needed. Balance recovery from immobility against oxygen requirement, fatigue and current physiological stability.
- Administer prescribed pharmacological venous thromboembolism prophylaxis after appropriate safety checks and monitor for bleeding or other concerns. Do not assume prophylaxis is suitable without the documented clinical assessment.
- Review what Anne will need to return to sheltered housing, including mobility, medicine management, carers and support from her daughter. Do not interpret temporary illness-related dependence as permanent loss of independence.
Monitoring and evaluation
Record mobility level, assistance required, symptoms during activity, skin condition, falls concerns and response to prophylaxis. As Anne improves, goals should progress from safe repositioning and transfers towards her usual walking-frame mobility.
How Anne remains part of the plan
Anne has already told the team what matters to her: returning to her own flat, remaining involved and having her daughter included without being spoken over.
Person-centred care therefore means:
- speaking to Anne directly and supporting her to understand decisions
- asking permission before sharing information with her daughter, unless another lawful basis applies
- checking her preferences rather than making assumptions from her age, surname, home circumstances or temporary confusion
- recognising her strengths, including her usual independence and established routines
- reviewing whether her existing carer visits will be sufficient after discharge
- planning recovery and discharge with Anne, not simply for her
What can the student nurse contribute?
Under appropriate supervision and within competence, a student nurse may contribute by:
- performing and reporting observations and elements of A–E assessment
- recognising trends and escalating deterioration promptly
- monitoring oxygen delivery, fluid balance, urine output, intake, skin and cognition
- supporting prescribed medicines and treatments in accordance with programme, placement and local requirements
- helping Anne with communication, orientation, comfort, nutrition and safe movement
- documenting care they have actually provided
- sharing Anne’s priorities during handover and multidisciplinary discussions
The registered nurse remains accountable for assessing Anne’s nursing needs, coordinating and evaluating care, delegating appropriately and responding to deterioration. Prescribing, diagnosing and independently changing treatment are not student-nurse responsibilities.
Evaluation later in the shift
Eight hours after admission, Anne’s SpO₂ remains within her prescribed target on a reduced oxygen flow following clinical review. Her respiratory rate is 21 breaths/min, heart rate 94 bpm, blood pressure 116/70 mmHg and temperature 37.7°C. She is orientated to person and place but still unsure of the date. She has passed more urine and managed a drink and a small amount of food with support.
This is an encouraging trend, but the care plan is not complete. Anne still needs:
- continued respiratory and physiological monitoring
- ongoing antimicrobial treatment and review
- repeat assessment of cognition and reversible delirium contributors
- continued fluid, nutrition and glucose monitoring
- supported mobilisation and reassessment of falls, skin and venous thromboembolism risk
- early discussion about her baseline function and discharge needs
The plan should be revised whenever Anne’s condition, response, priorities or level of independence changes.
Documentation example
“14:30. Care plan reviewed with Anne following initial treatment for severe community-acquired pneumonia and suspected sepsis. SpO₂ 95% on 4 L/min oxygen, RR 24, HR 104, BP 108/66, temperature 38.0°C, GCS 15 with intermittent disorientation to time. Remains breathless on movement with productive cough. Oral intake poor; fluid balance monitoring continued. Small volume concentrated urine reported to RN. Anne states that returning to her sheltered flat is important and agrees that her daughter may be involved in discussions. Ongoing respiratory, circulatory and cognitive monitoring planned. Mobility, falls, pressure-area, nutrition and VTE risks reviewed with supervising RN. Anne advised to use call bell before mobilising. Continue reassessment and escalate any deterioration.”
Documentation must describe what was assessed, agreed, provided and escalated. Do not record an intervention before it happens or copy a generic plan without checking that it applies to the patient.
Reflection questions
- Why does improved oxygen saturation not prove that Anne’s pneumonia has resolved?
- Which findings would make you re-escalate immediately?
- How would you know whether the hydration plan was helping or causing harm?
- How does Anne’s fluctuating confusion affect communication and decision-making?
- Which outcomes can be evaluated during one shift, and which require longer review?
- How has Anne’s wish to return home changed the plan?
References and further reading
Royal College of Physicians (2017). National Early Warning Score (NEWS) 2.