Nursing Care Plans | 01/05/2012, 3:40 pm

6 Pleural Effusion Nursing Care Plans


Pleural Effusion NCPPleural effusion is an accumulation of fluid in the pleural space. This is a post that contains 6 Pleural Effusion Nursing Care Plans.

Pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatic system. Any condition that interferes with either secretion or drainage of this fluid leads to pleural effusion.

Causes of pleural effusion can be grouped into four major categories:

  • Increased systemic hydrostatic pressure (e.g., heart failure)
  • Reduced capillary oncotic pressure (e.g., liver or renal failure)
  • Increased capillary permeability (e.g., infection or trauma)
  • Impaired lymphatic function (e.g., lymphatic obstruction caused by tumor)

1. Ineffective Breathing Pattern - Pleural Effusion Nursing Care Plans

NDx: Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as evidenced by tachypnea, presence of crackles on both lung fields and dyspnea

Ineffective breathing pattern occurs when inspiration and expiration does not provide adequate ventilation. Pleural inflammation causes sharp localized pain that increases deep of breathing, coughing and movement. This can result to shallow and rapid breathing pattern. Distal airways and alveoli may not expand optimally with each breath, increasing the possibility of atelectasis and impaired gas exchange.

Assessment Planning Nursing Interventions Rationale Expected Outcome
Subjective:

  • Dyspnea

Objectives:

The patient manifested the following:

  • Tachypnea
  • Presence of crackles on both lung fields upon auscultation
  • use of accessory muscles
  • RR of 28

The patient may manifest the following:

  • Cyanosis
  • Orthopnea
  • Diaphoresis
Short Term:After 3 hours of nursing interventions the patient will demonstrate appropriate coping behaviors and methods to improve breathing pattern.

Long term:

After 1 to 2 days of nursing interventions, the patient would be able to apply techniques that would improve breathing pattern and be free from signs and symptoms of respiratory distress.

  1. Establish rapport
  2. Monitor and record vital signs
  3. Assess breath sounds, respiratory rate, depth and rhythm
  4. Elevate head of the pt.
  5. Provide relaxing environment
  6. Administer supplemental oxygen as ordered
  7. Assisst client in the use of relaxation technique
  8. Administer prescribed medications as ordered
  9. Maximize respiratory effort with good posture and effective use if accessory muscles.
  10. Encourage adequate rest periods between activities
  1. To gain pt/ SO’s trust and cooperation
  2. To obtain baseline data
  3. To note for respiratory abnormalities that may indicate early respiratory compromise and hypoxia
  4. To promote lung expansion
  5. To promote adequate rest periods to limit fatigue
  6. To maximize oxygen available for cellular uptake
  7. To provide relief of causative factors
  8. For the pharmacological management of the patient’s condition
  9. To promote wellness
  10. To limit fatigue
Short Term:The patient shall have demonstrated appropriate coping behaviors and methods to improve breathing pattern.

Long term:

The patient shall have applied techniques that improved breathing pattern and be free from signs and symptoms of respiratory distress AEB respiratory rate within normal range, absence of cyanosis, effective breathing and minimal use of accessory muscles during breathing.

Navigation
  1. Ineffective Breathing Pattern
  2. Impaired Gas Exchange
  3. Activity Intolerance
  4. Acute Pain
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