Pleural Effusion - Nursing Assessment, Diagnosis and Interventions

Monday, March 26, 2012 ·
Nursing Care Plan for Pleural Effusion

Pleural effusion is an abnormal accumulation of fluids in the pleural space Between the parietal and visceral pleura of the Lungs. Breathlessness, chest pain and non-productive cough are the most common symptoms associated with pleural effusion.

Nursing Assessment
  1. Activity / rest
    Symptoms: dyspnea with activity or rest
  2. Circulation
    Signs: Tachycardia, dysrhythmias, heart rhythm Gallop, hypertension / hypotension
  3. Ego integrity
    Signs: fear, anxiety
  4. Food / fluid
    The existence of the installation of central venous IV / infusion
  5. Pain / comfort
    Symptoms depend on the size / area involved: Pain is aggravated by breathing in, the possibility of spread to the neck, shoulders, abdomen
    Signs: Be careful on the area of pain, behavioral distraction
  6. Respiratory
    Symptoms: Difficulty breathing, cough, history of chest surgery / trauma,
    Signs: Tachypnoea, use of accessory respiratory muscles in the chest, intercostal retraction, decreased breath sounds and decreased fremitus (on the side involved),
    Chest percussion: hyper resonant in the area filled with air and noise deaf in fluid-filled area
    Observation and palpation of the chest: chest movement is not the same (paradoksik) when trauma. Skin: pale, cyanosis, sweating.
Source : nanda-nursing.blogspot.com

    Nursing Diagnosis and Interventions for Pleural effusion

    Nursing Diagnosis: Ineffective airway clearance related to weakness and poor cough effort.

    NOC:

    • Demonstrate effective airway clearance and respiratory status evidenced by, gas exchange and ventilation are not dangerous:

    - Having a patent airway

    - Removing secretions effectively.

    - Having a rhythm and respiratory frequency in the normal range.

    - Having a pulmonary function within normal limits.

    • Demonstrate adequate gas exchange, characterized by:

    - Easy to breathe

    - There is no anxiety, cyanosis and dyspnea.

    - O2 saturation within normal limits

    - Chest X-ray within the expected range.

    NIC:

    • Assess and document

    - The effectiveness of the administration of oxygen and other treatments.

    - The effectiveness of treatment.

    - Trends in arterial blood gases.

    • Auscultation of the anterior and posterior chest to find a decrease or absence of ventilation and the presence of noise barriers.

    • Sucking airway

    - Determine the need for oral suction / tracheal.

    - Monitor the status of oxygen and hemodynamic status and cardiac rhythm before, during and after exploitation.

    • Maintain adequacy of hydration to decrease viscosity of secretions.

    • Explain the use of ancillary equipment properly, such as oxygen, suction equipment lenders.

    • Inform the patient and family that smoking is an activity that is prohibited in the treatment room.

    • Instruct the patient about the coughing and deep breathing techniques to facilitate the discharge of secretion.

    • Negotiate with the respiratory therapist as needed.

    • Give oxygen that has been humidified.

    • Tell your doctor about the results of an abnormal blood gas analysis.

    • Assist in the delivery of aerosol. Nebulizer and another lung treatment in accordance with institutional policies and protocols.

    • Encourage physical activity to improve the movement of secretions.

    • If the patient is unable to ambulate, the patient lies sleeping position changed every 2 hours.

    • Inform the patient before beginning the procedure to reduce anxiety and increase self-control.

    Source : http://nursing-interventions.com