Causes

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)

NCPs

Ineffective Breathing Pattern

NDx: Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as evidenced by tachypnea, presence of crackles on both lung fields and dyspnea 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 Planning NursingInterventions Rationale To gain pt/ SOs trust and cooperation To obtain baseline data To note for respiratory abnormalities that may indicate early respiratory compromise and hypoxia 4. 5. 6. 7. 8. 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 patients condition 9. To promote wellness Expected Outcome

Subjective:Objectives:The patient manifested the following:

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.

1. 2. 3.

Establish rapport Monitor and record vital signs Assess breath sounds, respiratory rate, depth and rhythm

1. 2. 3.

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.

Tachypnea Presence of crackles on both lung fields upon auscultation

4. 5. 6. 7. 8. 9.

Elevate head of the pt. Provide relaxing environment Administer supplemental oxygen as ordered Assist client in the use of relaxation technique Administer prescribed medications as ordered Maximize respiratory effort with good posture and effective use if accessory muscles.

use of accessory muscles RR of 28 The patient may manifest the following: Cyanosis Orthopnea Diaphoresis

10. Encourage adequate rest periods between activities

10. To limit fatigue

Impaired Gas Exchange

NDx: Impaired Gas Exchange R/T Alveolar Capillary Membrane Changes and respiratory fatigue Secondary to Pleural Effusion 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 Planning Nursing Interventions Rationale To gain pt./SOs trust and cooperation To obtain baseline data 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. 6. 7. To evaluate degree of compromise To enhance lung expansion To assess inadequate systemic oxygenation or hypoxemia 8. 9. To promote optimum chest expansion To correct/ improve existing deficiencies Expected Outcome

Subjective:(none)Objective:The patient manifested:

Short term:After 1 hour of nursing interventions, the pt will verbalize understanding of the interventions given to improve patients condition.Long term:After 12 days of nursing interventions, the pt. will demonstrate improved ventilation and adequate oxygenation of tissues AEB absence of symptoms of respiratory distress.

1. 2. 3. 4. 5.

Establish rapport Monitor and record vital signs Monitor respiratory rate, depth and rhythm Assess pts general condition Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus

1. 2. 3.

Short term:The patient shall have verbalized understanding of the interventions given to improve patients condition.Long term:The patient shall manifest no signs of respiratory distress.

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

6. 7. 8.

Elevate head of the pt. Note for presence of cyanosis Encourage frequent position changes and deepbreathing exercises

The pt. may manifest the ff:

Confusion Cyanosis Diaphoresis

9.

Provide supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/ situation

10. To determine pts oxygenation status 11. To empower SO and pt 12. For the pharmacological management of the patients condition

10. Review laboratory results 11. Provide health teaching on how to alleviate pts condition 12. Administer prescribed medications as ordered

Activity Intolerance
NDx: Activity intolerance related to insufficient oxygen for activities of daily living

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 Planning Nursing Interventions Rationale Expected Outcome

Patient manifested:generalized weaknesslimited range of motion as observeduse of accessory muscles during breathing (+) DOB

Short Term:After 3-4 hours of nursing interventions, the patient will use identified techniques to improve activity intoleranceLong Term: After 2-3 days of nursing interventions, the patient will report measurable

1. 2. 3. 4. 5. 6.

Establish Rapport Monitor and record Vital Signs Assess patients general condition Adjust clients 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

1.

To gain clients participation and cooperation in the nurse patient interaction

Short Term:The patient shall have used identified techniques to improve activity intoleranceLong Term:The patient shall have reported measurable increase in activity intolerance.

2. 3.

To obtain baseline data To note for any abnormalities and deformities present within the body

4. 5. 6. 7. 8. 9.

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 clients actual and perceived ability to participate in activities

7. 8. 9.

Encourage patient to have adequate bed rest and sleep Provide the patient with a calm and quiet environment Assist the client in ambulation

10. Note presence of factors that could contribute to fatigue 11. Ascertain clients ability to stand and move about and degree of assistance needed or use of equipment

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

increase in activity 12. Give client information that provides evidence of daily or weekly intolerance. 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

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 Planning Nursing Interventions Rationale Expected Outcome

Subjective:(none)Objective:Patient manifested:

Short Term:After 3-4 1. hours of nursing interventions, the patients 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. 7. 3. 4. 5. 6.

Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.

1.

To identify intensity, precipitating factors and location to assist in accurate diagnosis.

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

(+) 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

2.

Assessing response determines effectiveness of medication and whether further interventions are required.

2.

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 subsides. Teach patient relaxation techniques and how to use them to reduce stress. 7. 5. 3. 4.

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.

blood pressure, every 5 minutes until pain 6.

Patient may manifest: Restlessness Confusion Irritability

Other Possible Nursing Care Plans

Impaired Skin Integrity RT Surgical Procedure [Thoracentesis] Disturbed Body Image RT Insertion of Chest Thoracostomy Tube