Nursing Care Plan for Pleura Effusion

Nursing Care Plan for Pleura Effusion

Pleural effusion


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.


* 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

Sometimes there are no symptoms.


Assessment

1. Anamnesis :
   In general, asymptomatic. The more fluid that buried more quickly and clearly the emergence of a complaint because it causes crowding, sub-febrile fever on the condition of tuberculosis.
2. Needs resting and activity
   • Clients complain weak, short of breath with effort might and main, difficulty sleeping, fever in the afternoon or evening accompanied by sweating a lot.
   • Found a tachicardia, tachypnea / dyspnea with effort to breathe with a vengeance, changes in consciousness (in the advanced stage), muscle weakness, pain and stiffness (rigidity).
3. Needs personal integrity
   • Clients reveal stress factors are long, and the need for help and hope
   • Can be found in the behavior of denial (especially in the early stages) and anxiety
4. Needs Convenience / Pain
   • Clients report any chest pain because of cough
   • Can be found to protect the part that pain behavior, distraction, and less resting or fatigue
5. Respiratory Needs
   • Clients reported cough, whether productive or non-productive, short of breath, chest pain
   • Can be found increased respiratory rate due to advanced disease and pulmonary fibrosis (parenchymal) and pleura, as well as an asymmetrical chest expansion, decreased vocal fremitus, deaf to percussion or decreased breath sounds on the side that suffered terdengan pleural effusion. Tubular breath sounds accompanied by soft pectoriloguy can be found in the lung lesions. Crackles can be found at the apex of short expiratory lung after coughing.
   • Sputum Characteristics: green or purulent, mucoid or yellow spots of blood
   • It can also be found in tracheal deviation
6. Security Needs
   • Clients reveal circumstances of immunosuppression such as cancer, AIDS, sub-febrile fever
   • Can be found in circumstances of acute sub-febrile fever.
7. Social interaction needs
   • The client expressed feelings of isolation due to illness, changes in role pattern.

Nursing Diagnosis

Ineffective airway clearance related to weakness and poor cough effort.


Nursing Intervention

NOC :

• Demonstrate effective airway clearance and proved with respiratory status, gas exchange and ventilation are not dangerous :
  • Having a patent airway
  • Removing the secretion effectively.
  • Having a rhythm and respiratory frequency in the normal range.
  • Having a lung function within normal limits.
• Show that adequate gas exchange is characterized by :
  • Easy to breathe
  • No anxiety, cyanosis and dyspnea.
  • Saturation of O2 in the normal range
  • Chest X-ray within the expected range.

NIC :

• Assess and document :
  • The effectiveness of oxygen and other treatments.
  • The effectiveness of treatment.
  • Trends in arterial blood gases.
• Anterior and posterior chest auscultated to determine the decrease or absence of ventilation and the presence of sound barriers.
• Suction airway
  • Determine the need for sucking oral / tracheal.
  • Monitor the status of oxygen and hemodynamic status and cardiac rhythm before, during and after exploitation.
• Maintain adequate hydration to reduce the viscosity of secretions.
• Explain the use of support equipment properly, such as oxygen, suction equipment lenders.
• Inform patients and families that smoking is an activity that is prohibited in the treatment room.
• Instruct patients about cough and deep breathing techniques to facilitate the release of secretion.
• Negotiate with respiratory therapists as needed.
• Tell your doctor about the results of an abnormal blood gas analysis.
• Assist in the provision of aerosols. Nebulizer and other pulmonary care according to institutional policies and protocols.
• Encourage physical activity to improve the movement of secretions.
• If the patient is unable to perform ambulation, the location of the patient sleeping position changed every 2 hours.
• Inform patients before starting the procedure to reduce anxiety and increase self-control.