6 Pleural Effusion Nursing Care Plans

• 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

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

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.

The patient manifested:

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

The pt. may manifest the ff:

• Confusion
• Cyanosis
• Diaphoresis

Long term:

After 1-2 days of nursing interventions, the pt. will demonstrate improved ventilation and adequate oxygenation of tissues AEB absence of symptoms of respiratory distress.

1. Establish rapport
2. Monitor and record vital signs
3. Monitor respiratory rate, depth and rhythm
4. Assess pt’s general condition
5. Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus
6. Elevate head of the pt.
7. Note for presence of cyanosis
8. Encourage frequent position changes and deep-breathing exercises
9. Provide supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/ situation
10. Review laboratory results
11. Provide health teaching on how to alleviate pt’s condition
12. Administer prescribed medications as ordered

1. To gain pt./SO’s trust and cooperation
2. To obtain baseline data
3. To assess for rapid or shallow respiration that occur because of hypoxemia and stress
4. To note for etiology precipitating factors that can lead to impaired gas exchange
5. To evaluate degree of compromise
6. To enhance lung expansion
7. To assess inadequate systemic oxygenation or hypoxemia
8. To promote optimum chest expansion
9. To correct/ improve existing deficiencies
10. - To determine pt’s oxygenation status
11. To empower SO and pt
12. For the pharmacological management of the patient’s condition

Long term:

The patient shall manifest no signs of respiratory distress.

• generalized weakness
• limited range of motion as observed
• use of accessory muscles during breathing
• (+) DOB

Long Term:

After 2-3 days of nursing interventions, the patient will report measurable increase in activity intolerance.

1. Establish Rapport
2. Monitor and record Vital Signs
3. Assess patient’s general condition
4. Adjust client’s daily activities and reduce intensity of level.
5. Discontinue  activities that cause undesired psychological changes
6. Instruct client in unfamiliar activities and in alternate ways of conserve energy
7. Encourage patient to have adequate bed rest and sleep
8. Provide the patient with a calm and quiet environment
9. Assist the client in ambulation
10. Note presence of factors that could contribute to fatigue
11. Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipment
12. Give client information that provides evidence of daily or weekly progress
13. Encourage the client to maintain a positive attitude
14. Assist the client in a semi-fowlers position
15. Elevate the head of the bed
16. Assist the client in learning and demonstrating appropriate safety measures
17. Instruct the SO not to leave the client unattended
18. Provide client with a positive atmosphere
19. Instruct the SO to monitor response of patient to an activity and recognize the signs and symptoms

1. To gain clients participation and cooperation in the nurse patient interaction
2. To obtain baseline data
3. To note for any abnormalities and deformities present within the body
4. To prevent strain and overexertion
5. To conserve energy and promote safety
6. to relax the body
7. to provide relaxation
8. to prevent risk for falls that could lead to injury
9. fatigue affects both the client’s actual and perceived ability to participate in activities
10. to determine current status and needs associated with participation in needed or desired activities
11. to sustain motivation of client
12. to enhance sense of well being
13. to promote easy breathing
14. to maintain an open airway
15. to prevent injuries
16. to avoid risk for falls
17. to help minimize frustration and rechannel energy
18. to indicate need to alter activity level

Long Term:

The patient shall have reported measurable increase in activity intolerance.

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