There is a thin layer of fluid between the lung and the chest wall, in the human body. This liquid is very important because it acts as a lubricant between the chest wall and lungs when we breathe. Cavity or space between the chest wall and the lungs, where it accumulates fluid, called the pleura and the liquid is called pleural fluid. An abnormal increase in the number of pleural fluid causes the chest wall separate from the lungs. This condition is known as pleural effusion.
Possible signs of pleural effusion:
- The emphasis on the lungs
- Chest pain (does not occur in all patients)
- Difficulty breathing.
- Cough and fever with empyema (if the pneumonia was caused effusion)
- Dyspnea (shortness of breath)
Nursing Diagnosis for Pleural Effusion
1. Ineffective breathing pattern related to decreased lung expansion secondary to accumulation of fluid in the pleural cavity (Susan Martin Tucleer, et al, 1998).
2. Imbalanced Nutrition : Less Than Body Requirements related to an increased metabolism, decreased appetite due to shortness of breath secondary to suppression abdominal structures (Barbara Engram, 1993).
3. Anxiety related to the threat of death imaginable (inability to breathe).
4. Sleep pattern disturbance related to a persistent cough and shortness of breath and change of atmosphere.
5. Self-care deficit related to fatigue (physical state of the weak)
6. Deficient Knowledge about conditions, treatment of the rules related to less exposure to information.
Nursing Interventions for Pleural Effusion
1. Ineffective breathing pattern related to:
- Decrease in lung expansion (fluid accumulation)
- Musculuskeletal disorders
- Pain / anxiety
- Inflammatory process
- dyspnea, tachipnea
- changes in depth
- use of accessory muscles, nasal dilation
- impaired development of the chest and cyanosis, abnormal blood gas analysis
Expected outcomes / evaluation criteria, the client will:
- Showed a normal breathing pattern / blood gas analyzer effectively with the normal range
- There was no cyanosis
- No signs / symptoms of hypoxia.
1. Identifying the etiology / triggers factor
Rational: understanding the causes of lung collapse necessary for the proper installation of the chest tube and choose another teraupetik action.
2. Evaluation of respiratory function.
Rational: respiratory distress and changes in vital signs may occur due to physiological stress and may indicate the occurrence of pain or shock.
3. Auscultation of breath sounds
Rational: The sound of the breath can be decreased or no lobe, lung segment or the entire lung.
4. Assess fremitus
Rational: Sound and tactile fremitus (vibration) decreases in fluid-filled tissue / consolidation.
5. Collaboration in the assessment of radiographic series
Rational: hemathorak improvement and monitor progress of lung expansion.
6. Collaboration in the provision of supplemental oxygen through a cannula / mask as indicated.
Rational: A tool in reducing the work of breath, increased respiratory distress and cyanosis relief with respect to hypoxemia.
2. Ineffective airway clearance related to weakness and poor cough effort.
• Demonstrate effective airway clearance and respiratory status evidenced by, gas exchange and ventilation are not dangerous:
- Having a patent airway
- Removing secretions effectively.
- Having a rhythm and respiratory frequency in the normal range.
- Having a pulmonary function within normal limits.
• Demonstrate adequate gas exchange, characterized by:
- Easy to breathe
- There is no anxiety, cyanosis and dyspnea.
- O2 saturation within normal limits
- Chest X-ray within the expected range.
• Assess and document
- The effectiveness of the administration of oxygen and other treatments.
- The effectiveness of treatment.
- Trends in arterial blood gases.
• Auscultation of the anterior and posterior chest to find a decrease or absence of ventilation and the presence of noise barriers.
• Sucking airway
- Determine the need for oral suction / tracheal.
- Monitor the status of oxygen and hemodynamic status and cardiac rhythm before, during and after exploitation.
• Maintain adequacy of hydration to decrease viscosity of secretions.
• Explain the use of ancillary equipment properly, such as oxygen, suction equipment lenders.
• Inform the patient and family that smoking is an activity that is prohibited in the treatment room.
• Instruct the patient about the coughing and deep breathing techniques to facilitate the discharge of secretion.
• Negotiate with the respiratory therapist as needed.
• Give oxygen that has been humidified.
• Tell your doctor about the results of an abnormal blood gas analysis.
• Assist in the delivery of aerosol. Nebulizer and another lung treatment in accordance with institutional policies and protocols.
• Encourage physical activity to improve the movement of secretions.
• If the patient is unable to ambulate, the patient lies sleeping position changed every 2 hours.
• Inform the patient before beginning the procedure to reduce anxiety and increase self-control.
Nursing Diagnosis and Nursing Interventions for Nursing Diagnosis for Pleural Effusion