Nursing Care Plan for Pleural Effusion
Nursing Diagnosis for Pleural Effusion : Ineffective Breathing Pattern
related to:
decreased lung expansion secondary to accumulation of fluid in the pleural cavity.
Goal: Patient is able to maintain normal lung function.
Expected outcomes : rhythm, frequency and depth of breathing in the normal range, the chest X-ray examination did not reveal any accumulation of fluid, audible breath sounds.
Nursing Interventions Ineffective Breathing Pattern for Pleural Effusion:
1. Identification of the causative factors.
Rationale: By identifying the causes, we can determine the type of pleural effusion so it can take appropriate action.
2. Assess the quality, frequency and depth of breathing, report any changes that occur.
Rationale: By reviewing the quality, frequency and depth of breathing, we can determine the extent of changes in the patient's condition.
3. Give the patient in a comfortable position, in a sitting position, with the head of the bed elevated 60-90 degrees.
Rationale: Decreased diaphragm expands the chest area so it can be a maximum lung expansion.
4. Observation vital signs (temperature, pulse, blood pressure, respiration and patient response).
Rationale: Increased respiration and tachycardia is an indication of a decline in lung function.
5. Perform auscultation breath sounds every 2-4 hours.
Rational: Auscultation of breath sounds to determine abnormalities in the lungs.
6. Help and teach the patient to cough and breath in an effective manner.
Rational: Hitting the area of pain when coughing or breathing deeply. Emphasis chest muscles and abdomen made more effective cough.
7. Collaboration with the medical team for the delivery of oxygen and other drugs and thorax photo.
Rationale: Provision of oxygen can reduce the burden of respiratory and prevent cyanosis due hipoxia. Thorax with a photo of the progress can be monitored and the liquid reduced pulmonary return of power development.