NCP - Nursing Care Plan for Pleural Effusion

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


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.