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Pleural effusion is an accumulation of fluid in the pleural space. 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)

Nursing Care Plans

This is a post that contains 6 Pleural Effusion Nursing Care Plans.

1. Ineffective Breathing Pattern

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

Patient may manifest

  • Tachypnea
  • Presence of crackles on both lung fields upon auscultation
  • Use of accessory muscles
  • Cyanosis
  • Orthopnea
  • Diaphoresis

Nursing Diagnosis

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

Planning

  • Patient will demonstrate appropriate coping behaviors and methods to improve breathing pattern.
  • Patient would be able to apply techniques that would improve breathing pattern and be free from signs and symptoms of respiratory distress.
Nursing Interventions Rationale
Monitor and record vital signs. To obtain baseline data
Assess breath sounds, respiratory rate, depth and rhythm To note for respiratory abnormalities that may indicate early respiratory compromise and hypoxia.
Elevate head of the patient To promote lung expansion
Encourage patient to perform deep breathing exercises To promote lung expansion.
Provide relaxing environment To promote adequate rest periods to limit fatigue
Administer supplemental oxygen as ordered To maximize oxygen available for cellular uptake
Assist client in the use of relaxation technique To provide relief of causative factors
Administer prescribed medications as ordered For the pharmacological management of the patient’s condition
Maximize respiratory effort with good posture and effective use if accessory muscles. To promote wellness
Encourage adequate rest periods between activities To limit fatigue
Assist and prepare for thoracentesis: 
Explain thoracentesis to the pain. Tell the patient to expect a stinging sensation from the local anesthetic and feeling of pressure when the needle inserted. Knowing what to expect before the procedure can make the patient more apt to it.
Instruct patient to tell him to tell you immediately if he feels uncomfortable or has difficulty of breathing during procedure. If DOB occurs, it may require postponement of procedure.
Reassure the patient during thoracentesis. Remind to breath normally and avoid sudden movements (coughing, sighing). Reassure can relieve the anxiety that may occur during procedure.
Monitor vital signs during procedure. Watch out for signs of respiratory distress after thoracentesis. If fluid is removed too quickly, the patient may suffer bradycardia, hypotension, pain, pulmonary edema or even cardiac arrest.
Ensure tube patency by watching for fluctuations of fluid or air bubbling in the underwater seal chamber. Record the amount, color, and consistency of any tube drainage. Continuous bubbling may indicate an air leak.

2. Impaired Gas Exchange

Impaired gas exchange is a state in which there is excess or deficit oxygenation and carbon dioxide elimination. The compensatory mechanism of lungs is to lose effectiveness of its defense mechanisms and allow organisms to penetrate the sterile lower respiratory tract where inflammation develops. Disruption of mechanical defenses and ciliary motility leads to colonization of lungs and subsequent infection. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively. The release of endotoxins by the microbes can lodge in the brain, affecting the respiratory center in medulla resulting to altered oxygen supply.

Assessment

Patient may manifest

  • Several episodes of pallor
  • Tachypnea
  • Restlessness
  • nasal flaring
  • depth of breathing
  • Use of accessory muscles for breathing
  • Confusion
  • Cyanosis
  • Diaphoresis

Nursing Diagnosis

  • Impaired Gas Exchange R/T Alveolar –Capillary Membrane Changes  and respiratory fatigue Secondary to Pleural Effusion

Planning

Patient will demonstrate improved ventilation and adequate oxygenation of tissues AEB absence of symptoms of respiratory distress.

Nursing Interventions Rationale
Monitor and record vital signs To obtain baseline data
Monitor respiratory rate, depth and rhythm To assess for rapid or shallow respiration that occur because of hypoxemia and stress
Assess pt’s general condition To note for etiology precipitating factors that can lead to impaired gas exchange
Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus To evaluate degree of compromise
Elevate head of the pt. To enhance lung expansion
Note for presence of cyanosis To assess inadequate systemic oxygenation or hypoxemia
Encourage frequent position changes and deep-breathing exercises To promote optimum chest expansion
Provide supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/ situation To correct/ improve existing deficiencies
Review laboratory results To determine pt’s oxygenation status
Provide health teaching on how to alleviate pt’s condition To empower SO and pt
Administer prescribed medications as ordered For the pharmacological management of the patient’s condition

3. Activity Intolerance

Presence of a space-occupying liquid in the pleural space, the lung recoils, inward, the chest wall recoils outward, and the diaphragm is depressed inferiorly. This may lead to decrease lung volume and may result to significant hypoxemia and can only be relieved by thoracentesis. Due to inadequate ventilation there would be limitations in activity as tolerance to activity occur.

Assessment

Patient may manifest

  • Generalized weakness
  • Verbalization of lack of energy
  • Inability to perform activities of daily living

Nursing Diagnosis

  • Activity Intolerance

Planning

  • Patient will use identified techniques to improve activity intolerance
  • Patient will report measurable increase in activity intolerance.
Nursing Interventions Rationale
Establish Rapport To gain clients participation and cooperation in the nurse patient interaction
Monitor and record Vital Signs To obtain baseline data
Assess patient’s general condition To note for any abnormalities and deformities present within the body
Adjust client’s daily activities and reduce intensity of level. To prevent strain and overexertion
Discontinue  activities that cause undesired psychological changes To conserve energy and promote safety
Instruct client in unfamiliar activities and in alternate ways of conserve energy To relax the body
Encourage patient to have adequate bed rest and sleep To provide relaxation
Provide the patient with a calm and quiet environment To prevent risk for falls that could lead to injury
Assist the client in ambulation Fatigue affects both the client’s actual and perceived ability to participate in activities
Note presence of factors that could contribute to fatigue To determine current status and needs associated with participation in needed or desired activities
Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipment To sustain motivation of client
Give client information that provides evidence of daily or weekly progress To enhance sense of well being
Encourage the client to maintain a positive attitude To promote easy breathing
Assist the client in a semi-fowlers position To maintain an open airway
Elevate the head of the bed To prevent injuries
Assist the client in learning and demonstrating appropriate safety measures To avoid risk for falls
Instruct the SO not to leave the client unattended To help minimize frustration and rechannel energy
Provide client with a positive atmosphere To indicate need to alter activity level

4. Acute Pain

Pain may be considered as Pleuritic chest pain. Pleuritic chest pain derives from inflammation of the parietal pleura, the site of pleural pain fibers. Occasionally, this symptom is accompanied by an audible or palpable pleural rub, reflecting the movement of abnormal pleural tissues.

Assessment

Patient may manifest

  • Complains to chest pain on the thoracostomy site
  • Facial grimaces upon movement
  • Reports of pain
  • Restlessness
  • Confusion
  • Irritability

Nursing Diagnosis

  • Acute Pain

Planning

  • Patient will report pain is decreased or controlled.
Nursing Interventions Rationale
Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors. To identify intensity, precipitating factors and location to assist in accurate diagnosis.
Assess the response to medications every 5 minutes Assessing response determines effectiveness of medication and whether further interventions are required.
Provide comfort measures. To provide nonpharmacological pain management.
Establish a quiet environment. A quiet environment reduces the energy demands on the patient.
Elevate head of bed. Elevation improves chest expansion and oxygenation.
Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
Teach patient relaxation techniques and how to use them to reduce stress. Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.

Other Possible Nursing Care Plans

  • Impaired Skin Integrity RT Surgical Procedure [Thoracentesis]
  • Disturbed Body Image RT Insertion of Chest Thoracostomy Tube

See Also

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