Pleural Effusion Nursing care plan

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Pleural





Effusion
























































Nursing Care Plan






Julie James Abdullah

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Contents


Ineffective Breathing Pattern .................................................................................................................... 3

Activity Intolerance ................................................................................................................................... 5
Pain Related to the Disease Process .......................................................................................................... 7





































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Ineffective Breathing Pattern



Ineffective breathing pattern related to abnormal accumulation of fluid in the pleural space

Assessment

• Dypnea noted upon assessment
• Nasal Flaring
• Shortness of breath
• Use of accessory muscles to breath
• Orthopnea
• Altered chest excursion
• Decreased minute ventilation
• Decreased vital capacity
• Respiratory rate of 35 cpm

Goals and outcomes

Short term goals:

• After 1 hour of health teaching, client will be able to:

❖ Identify lifestyle changes that may be required in assisting to prevent ineffective
breathing pattern.
❖ Participate in the treatment regimen.

Long term goal:
• After 72 hours of nursing intervention, client will be able to demonstrate normal and effective
respiratory pattern.


Nursing Interventions and Rationale

Nursing Interventions Rationale


Assessment

Monitor for signs and symptoms of Tachypnea, shallow respirations and asymmetric
respiratory distress: chest movement are frequently present because of
• Dypnea discomfort of moving chest wall and/or fluid in
• Decreased of absent breath lung due to a compensatory response to airway
sounds obstruction. Altered breathing pattern may occur
• Cyanosis together with use of accessory muscles to increase
• Shortness of breath chest excursion to facilitate effective breathing.




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Nursing Interventions Rationale

Interventions

Assess for pain and discomfort. Pain may restrict or limit respiratory effort.


Raise head of bed 45 degrees or more if Allows gravity to assist in lowering the diaphragm
not contraindicated. and provides greater chest expansion.

Promotes lung expansion and slightly increases
Instruct in diaphragmatic deep pressure in the airways, allowing them to remain
breathing and pursed-lip breathing.
open longer.

Encourage ambulation and motility to Promotes tolerance for activities and helps with
the patient. lung expansion and ventilation.

Promote rest and relaxation by
scheduling treatments and activities Avoids overexertion and worsening of condition.
with appropriate rest periods.

Conduct health teaching on the
following: Reduces anxiety; starts appropriate home care
• Illness planning; assists the family in dealing with health-
care system.
• Procedures and related nursing care

Assist the client in practicing
pulmonary hygiene:

• Clearing bronchial tree by Provides basic information for the client and
family that promotes necessary lifestyle changes.
controlled coughing
• Decreasing viscosity of secretions
via humidity and fluid balance


Administer supplemental oxygen. Oxygen administration helps correct hypoxemia.

Evacuates fluid and as well as relieve dyspnea and
Assist in performing thoracentesis.
respiratory distress.

Medicate with analgesics as appropriate Promotes deeper respiration and cough.












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Activity Intolerance




Activity intolerance related to oxygen impaired

Assessment

• Clients complain weak, short of breath with effort might and main, difficulty sleeping, fever in
the afternoon or evening accompanied by sweating a lot.
• Found a tachycardia, tachypnea / dyspnea with effort to breathe with a vengeance, changes in
consciousness (in the advanced stage), muscle weakness, pain and stiffness (rigidity).

Goals and outcomes

Client report and demonstrate a measurable increase in tolerance to activity with absence of dyspnea
and excessive fatigue, with vital signs within client’s acceptable range

Nursing Interventions and Rationale


Nursing Interventions Rationale

Assessment


Evaluate client’s response to activity.
Note reports of dyspnea, increased Establishes client’s capabilities and needs and
weakness and fatigue, and changes in facilitates choice of interventions.
vital signs during and after activities.

Interventions


Assist the client in practicing
pulmonary hygiene:

• Clearing bronchial tree by Clearance airway will reduce the oxygen
controlled coughing impairment
• Decreasing viscosity of secretions
via humidity and fluid balance
• Suctioning


Provide a quiet environment and limit Reduces stress and excess stimulation, promoting
visitors during acute phase, as rest
indicated.


Encourage use of stress management Reduces stress and excess stimulation, promoting
and diversional activities as rest
appropriate.



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Nursing Interventions Rationale

Bed and chair rest is maintained during acute
phase to decrease metabolic demands, thus
Explain importance of rest in treatment conserving energy for healing.
plan and necessity for balancing
activities with rest. Activity restrictions thereafter are determined by
individual client response to activity and
resolution of respiratory insufficiency.


Client may be comfortable with head of bed
Assist client to assume comfortable
position for rest and sleep. elevated, sleeping in a chair, or leaning forward on
over-bed table with pillow support.


Assist with self-care activities as
necessary. Provide for progressive Minimizes exhaustion and helps balance oxygen
increase in activities during recovery supply and demand.
phase

Encourage client to rest between Oxygen demand increase during movement /
activity activity.































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Pain Related to the Disease Process




Related To

Injuring agents (e.g., biological—inflammation of lung parenchyma, cellular reactions to circulating
toxins; physical—persistent coughing)

Assessment

• Verbal/coded report [pleuritic chest pain, headache, muscle or joint pain]
• Guarded behavior
• Expressive behavior—restlessness

Goals and outcomes

• Client will verbalize relief or control of pain.
• Client will demonstrate relaxed manner, resting, sleeping, and engaging in activity appropriately.

Nursing Interventions and Rationale


Nursing Interventions Rationale


Assessment

Chest pain, usually present to some degree with
Determine pain characteristics, such as
sharp, constant, and stabbing. pneumonia, may also herald the onset of
complications of pneumonia, such as pericarditis
Investigate changes in character, and endocarditis.
location, and intensity of pain.


Changes in heart rate or blood pressure (BP) may
indicate that client is experiencing pain, especially
Monitor vital signs.
when other reasons for changes in vital signs have
been ruled out.

Interventions

Provide comfort measures, such as back Non analgesic measures administered with a
rubs, change of position, and quiet gentle touch can lessen discomfort and augment
music or conversation. therapeutic effects of analgesics.

Client involvement in pain control measures
Encourage use of relaxation and promotes independence and enhances sense of
breathing exercises.
well-being








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Nursing Interventions Rationale

Mouth breathing and oxygen therapy can irritate
Offer frequent oral hygiene. and dry out mucous membranes, potentiating
general discomfort


Instruct and assist client in chest- Aids in control of chest discomfort while
splinting techniques during coughing enhancing effectiveness of cough effort.
episodes


These medications may be used to suppress
Administer analgesics and antitussives, nonproductive or paroxysmal cough or reduce
as indicated excess mucus, thereby enhancing general comfort
and rest.






























































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