NCP - Nursing Care Plan for Pleural Effusion

Thursday, February 25, 2010

Nursing Care Plan for Pleural Effusion

Definition A pleural effusion is an accumulation of fluid between the layers of tissue that line the lungs and chest cavity.

Causes Your body produces pleural fluid in small amounts to lubricate the surfaces of the pleura, the thin tissue that lines the chest cavity and surrounds the lungs. A pleural effusion is an abnormal, excessive collection of this fluid. Two different types of effusions can develop : Transudative pleural effusions are caused by fluid leaking into the pleural space. This is caused by elevated pressure in, or low protein content in, the blood vessels. Congestive heart failure is the most common cause. Exudative effusions usually result from leaky blood vessels caused by inflammation (irritation and swelling) of the pleura. This is often caused by lung disease. Examples include lung cancer, lung infections such as tuberculosis and pneumonia, drug reactions, and asbestosis. Symptoms Chest pain, usually a sharp pain that is worse with cough or deep breaths Cough Fever Hiccups Rapid breathing Shortness of breath Source : http://www.nlm.nih.gov/medlineplus

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Assessment 1. Patient identity At this stage the nurse needs to know about the name, age, gender, home address, religion or belief, ethnicity, languages spoken, education and employment status of patients. 2. Main complaint The main complaint is the main factor that encourages patients to seek help or treatment to the hospital. Usually in patients with acquired pleural effusi complaint form shortness of breath, feeling the weight on the chest, pain due to irritation of the pleura Pleuritic that is sharp and localized, especially when coughing and breathing as well as non-productive cough.

3. Disease History Now Patients with pleural effusi will usually preceded by signs such as cough, shortness of breath, pain Pleuritic, heavy feeling in chest, weight loss and so on. There should also be asked from any complaints that arise. What action has been taken to reduce or eliminate these complaints. 4. Formerly Disease History To ask whether the patient had suffered from lung diseases such as tuberculosis, pneumoni, heart failure, trauma, ascites, and so on. This is needed to determine possible predisposing factors. 5. Family Disease History To ask whether any family members who suffer from diseases that was allegedly the cause of pleural effusi like Ca lung, asthma, pulmonary tuberculosis and others. 6. Psychosocial History Include feelings of illness of patients, how to handle it and how the patient's behavior toward action taken against him. Nursing Diagnosis Ineffective breathing pattern related to decreased lung expansion secondary to accumulation of fluid in the pleural cavity Nursing Plan Objectives : Patients able to maintain normal lung function Criterion Results : Rhythm, frequency and depth of breathing in the normal range, the chest X-ray examinations did not find any accumulation of fluid, audible breath sounds. Plan of action : Identify the causative factor. Rational: By identifying the causes, we can determine which type of pleural effusi can take appropriate action. Examine the quality, frequency and depth of breathing, report any changes that occur. Rational: By reviewing the quality, frequency and depth of breathing, we can determine how far the patient's condition changes. Lay the patient in a comfortable position, in a sitting position, with the head of the bed elevated 60 to 90 degrees. Rational: Decrease the diaphragm to expand the chest so the lungs can expand the maximum. Observation of vital signs (temperature, pulse, blood pressure, RR and response of patients). Rational: Improved tachcardi RR and an indication of decline in lung function.

Perform auscultation of breath sounds every 2-4 hours. Rational: to determine abnormalities Auscultation of breath sounds in the lungs. Help and teach the patient to cough and breath in effective. Rational: Pressing the painful area when coughing or breathing deeply. Emphasis pectoral muscle and abdominal makes cough more effective. Collaboration with other medical teams to deliver O2 and medicines as well as thorax images. Rational: Giving oxygen may reduce the load and prevent the occurrence of respiratory cyanosis due hiponia. With the thorax images can be monitored the progress of the reduction in fluid and the return of flower power lung.

NCP: Risk for Impaired skin integrity r/t prolonged pressure at the dorsal portion of the body secondary to CTT
Written by adminNursing Care Plan'sFeb 13, 2011

Cues Objective: - Diaphoresis - CTT - Complete bed rest - Skin is warm to touch - Moist skin - HbA1c result: 8.1 (poor glucose control) - Albumin result: 15 (Low) - meds: Paracetamol VS taken: BP: 120/70 PR: 120 CR: 122 RR: 26 Temp.: 39.9 Need NUTRITIONAL-METABOLIC PATTERN Diagnosis Risk for Impaired Skin Integrity related to prolonged pressure at the dorsal portion of the body secondary to Chest Tube Thoracic CTT makes the patient unable to turn from sides to sides thus putting more pressure at the dorsal portion of the body and makes the patient at risk for skin being adversely altered. Objectives Within my days span of care, patient will be able to remain free from Impaired skin integrity as evidenced by: a.) Identify individual risk factors; b.) Verbalize understanding of treatment/therapy regimen c.) Demonstrate behaviors/techniques to prevent skin breakdown. Interventions 1. Assess skin routinely, noting moisture, color, and elasticity. May indicate particular vulnerability 2. Review pertinent laboratory results such as albumin. Low albumin levels correlates to decreased wound healing/ increasedpressure ulcers. 3. Observe for reddened/blanched areas or skin rashes, and institute treatment immediately. Reduces likelihood of progression to skin breakdown. 4. Massage bony prominences and use proper positioning, turning, lifting, and transferring techniques when moving client. To prevent friction or shear injury.

5. Provide adequate clothing/covers. To prevent vasoconstriction. 6. Keep bed linens dry and wrinkle free. To reduce chances of acquiring bedsores. 7. Provide protection by use of pads, pillows, foam mattress or water bed. to increase circulation and limit/eliminate excessive tissue pressure. 8. Emphasize importance of adequate nutritional/fluid intake. To maintain general good health and skin turgor. 9. Suggest use of lotion. To decrease irritable itching. 10. Recommend keeping nails short. To reduce risk of dermal injury when severe itching is present Evaluations After my days span of care my patient was able to remain free from impaired skin integrity as evidenced by: a. Was able to identify risk factors such as moisture or friction. b. Demonstrate behaviors/techniques to prevent skin breakdown such as by using lotion and by keeping bed linen and gown dry