6 Pleural Effusion Nursing Care Plans
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)
See other nursing care plans here
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 | Nursing Diagnosis | Planning | Nursing
Interventions |
Rationale | Expected Outcome |
Subjective:
Objectives: The patient manifested the following:
The patient may manifest the following:
|
Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as evidenced by tachypnea, presence of crackles on both lung fields and dyspnea | 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. |
- Establish rapport
- Monitor and record vital signs - Assess breath sounds, respiratory rate, depth and rhythm - Elevate head of the pt. - Provide relaxing environment - Administer supplemental oxygen as ordered -Assisst client in the use of relaxation technique - Administer prescribed medications as ordered -Maximize respiratory effort with good posture and effective use if accessory muscles. -Encourage adequate rest periods between activities |
- To gain pt/ SO’s trust and cooperation
- To obtain baseline data - To note for respiratory abnormalities that may indicate early respiratory compromise and hypoxia - To promote lung expansion - To promote adequate rest periods to limit fatigue - To maximize oxygen available for cellular uptake -To provide relief of causative factors - For the pharmacological management of the patient’s condition -To promote wellness - 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. |
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 | Nursing Diagnosis | Planning | Nursing Interventions | Rationale | Expected Outcome |
| Subjective: (none)
Objective: 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 |
Impaired Gas Exchange R/T Alveolar –Capillary Membrane Changes and respiratory fatigue Secondary to Pleural Effusion | Short term:
After 1 hour of nursing interventions, the pt will verbalize understanding of the interventions given to improve patient’s condition. 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. |
- Establish rapport
- Monitor and record vital signs - Monitor respiratory rate, depth and rhythm - Assess pt’s general condition - Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus - Elevate head of the pt. - Note for presence of cyanosis -Encourage frequent position changes and deep-breathing exercises -Provide supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/ situation - Review laboratory results - Provide health teaching on how to alleviate pt’s condition Administer prescribed medications as ordered |
- To gain pt./SO’s trust and cooperation
- To obtain baseline data - To assess for rapid or shallow respiration that occur because of hypoxemia and stress - To note for etiology precipitating factors that can lead to impaired gas exchange -To evaluate degree of compromise - To enhance lung expansion - To assess inadequate systemic oxygenation or hypoxemia -To promote optimum chest expansion To correct/ improve existing deficiencies - To determine pt’s oxygenation status - To empower SO and pt For the pharmacological management of the patient’s condition |
Short term:
The patient shall have verbalized understanding of the interventions given to improve patient’s condition. Long term: The patient shall manifest no signs of respiratory distress. |
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 may occur.
| Assessment | Nursing Diagnosis | Planning | Nursing Interventions | Rationale | Expected Outcome |
| Subjective:
(none) Objective: Patient manifested: generalized weakness limited range of motion as observed use of accessory muscles during breathing (+) DOB |
Activity intolerance related to insufficient oxygen for activities of daily living | Short Term:
After 3-4 hours of nursing interventions, the patient will use identified techniques to improve activity intolerance Long Term: After 2-3 days of nursing interventions, the patient will report measurable increase in activity intolerance. |
Establish Rapport
Monitor and record Vital Signs Assess patient’s general condition Adjust client’s daily activities and reduce intensity of level. Discontinue activities that cause undesired psychological changes Instruct client in unfamiliar activities and in alternate ways of conserve energy Encourage patient to have adequate bed rest and sleep Provide the patient with a calm and quiet environment Assist the client in ambulation Note presence of factors that could contribute to fatigue Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipment Give client information that provides evidence of daily or weekly progress Encourage the client to maintain a positive attitude Assist the client in a semi-fowlers position Elevate the head of the bed Assist the client in learning and demonstrating appropriate safety measures Instruct the SO not to leave the client unattended Provide client with a positive atmosphere Instruct the SO to monitor response of patient to an activity and recognize the signs and symptoms |
To gain clients participation and cooperation in the nurse patient interaction
To obtain baseline data To note for any abnormalities and deformities present within the body To prevent strain and overexertion To conserve energy and promote safety to relax the body to provide relaxation to prevent risk for falls that could lead to injury fatigue affects both the client’s actual and perceived ability to participate in activities to determine current status and needs associated with participation in needed or desired activities to sustain motivation of client to enhance sense of well being to promote easy breathing to maintain an open airway to prevent injuries to avoid risk for falls to help minimize frustration and rechannel energy to indicate need to alter activity level |
Short Term:
The patient shall have used identified techniques to improve activity intolerance Long Term: The patient shall have reported measurable increase in activity intolerance. |
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 | Nursing Dx | Planning | Nursing Interventions | Rationale | Expected Outcome |
| Subjective:
(none) Objective: 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 |
Acute pain | Short Term:
After 3-4 hours of nursing interventions, the patient’s pain will decrease from 7 to 3 as verbalized by the patient. Long Term: After 2-3 days of nursing interventions, the patient will demonstrate activities and behaviors that will prevent the recurrence of pain. |
Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
Assess the response to medications every 5 minutes Provide comfort measures. Establish a quiet environment. Elevate head of bed. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides. Teach patient relaxation techniques and how to use them to reduce stress. |
To identify intensity, precipitating factors and location to assist in accurate diagnosis.
Assessing response determines effectiveness of medication and whether further interventions are required. To provide nonpharmacological pain management. A quiet environment reduces the energy demands on the patient. Elevation improves chest expansion and oxygenation. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation. Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation. |
Short Term:
Patient shall have verbalized a decrease in pain from a scale of 7 to 3. Long Term: The patient shall have demonstrated activities and behaviors that will prevent the recurrence of pain. |
Other nursing diagnoses:
- 5 Impaired Skin Integrity RT Surgical Procedure [Thoracentesis]
- 6 Disturbed Body Image RT Insertion of Chest Thoracostomy Tube
Source:
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