NURSING CARE PLAN FOR A PATIENT WITH PLEURAL EFFUSION

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: • Ineffective • After 8 • Assess • Both rapid, • Goal met.

airway hours of respirations: shallow After 8
“Ubo ako ng ubo” clearance nursing note quality, breathing hours of
as verbalized by the related to intervention, rate, pattern, patterns and nursing
patient. retained the patient depth, and hypoventilat intervention,
secretions. will be able breathing ion affect the patient is
to maintain effort. gas able to
Objective: airway exchange. maintain
patency and airway
• Cough clear • With initial patency and
• Restlessness • Monitor
secretions vital signs. hypoxia and clear
• Pale readily. hypercapnia, secretions
• With left blood readily.
side CTT pressure,
connected to heart rate,
thorabottle. and
respiratory
rate all rise.
Vital signs taken: As the
hypoxia
• T: 36.9
and/or
• PR: 105
hypercapnia
bpm
become
(tachycardia
more severe,
)
BP may
• RR: 22 cpm
• BP: 110/80 drop, heart
mmHg rate tends to
continue to
be rapid
with
arrhythmias,
and
respiratory
failure may
ensue with
the patient
unable to
maintain the
rapid
respiratory
rate.

• Restlessness
is an early
sign of
hypoxia.
• Assess for
Chronic
changes in
hypoxemia
orientation
may result in
and
cognitive
behavior.
changes
such as
memory
changes.
 • Retained
• Assess secretions
patient’s impair gas
ability to exchange.
cough
effectively
to clear
secretions.
Note
quantity,
color, and
consistency
of sputum.

• This
• Maintain
oxygen provides for
administrati adequate
on device as oxygenation.
ordered,
attempting
to maintain
oxygen
saturation at
90% or
greater.

• Position
with proper
• This
body
promotes
alignment
 for optimal lung
respiratory expansion
excursion. and
improves air
exchange.
• Anticipate
need for
intubation
and
mechanical
ventilation if • Early
patient is intubation
unable to and
maintain mechanical
adequate gas ventilation
exchange. are
recommende
d to prevent
full
• Teach the decompensat
patient ion of the
appropriate patient.
deep
breathing
and • These
coughing facilitate
techniques. adequate air
exchange
and
secretion
clearance.