6 Pleural Effusion Nursing Care Plans

Patient manifested:

• (+) DOB
• Complains to chest pain on the thoracostomy site
• Facial grimaces upon movement
• Reports of pain on the thoracostomy area, described as sharp provoked by breathing non-radiating, with a pain scale of 7 out of 10

Patient may manifest:

• Restlessness
• Confusion
• Irritability

Long Term:

After 2-3 days of nursing interventions, the patient will demonstrate activities and behaviors that will prevent the recurrence of pain.

1. Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
2. Assess the response to medications every 5 minutes
3. Provide comfort measures.
4. Establish a quiet environment.
5. Elevate head of bed.
6. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
7. Teach patient relaxation techniques and how to use them to reduce stress.

1. To identify intensity, precipitating factors and location to assist in accurate diagnosis.
2. Assessing response determines effectiveness of medication and whether further interventions are required.
3. To provide nonpharmacological pain management.
4. A quiet environment reduces the energy demands on the patient.
5. Elevation improves chest expansion and oxygenation.
6. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
7. Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.

Long Term:

The patient shall have demonstrated activities and behaviors that will prevent the recurrence of pain