Nursing Diagnosis and Nursing Intervention for Pleural Effusion

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Nursing Diagnosis and Nursing Intervention for Pleural Effusion

Nursing Diagnosis for Pleural Effusion

1. Ineffective breathing pattern related to decreased lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, the inflammatory process.
2. Chest pain related to biologic factors (tissue trauma) and physical factors (chest tube installation)

Nursing Intervention for Pleural Effusion

1. Ineffective breathing pattern related to decreased lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, the inflammatory process.
   
   Marked by :
   Dyspnea, Tachypnoea, changes in depth of breathing, accessory muscle use, impaired development of the chest, cyanosis.
   
   Goal :
   The pattern of effective breath
   
   Expected results :
   • Indicate the normal breathing pattern / effective
   • Free cyanosis and signs of hypoxic symptoms
   
   Intervention :
   • Identify the etiology or trigger factor
   • Evaluation of respiratory function (rapid breathing, cyanosis, changes in vital signs)
   • Auscultation for breath sounds
   • Note the position of the chest and trachea development, review fremitus.
   • Maintain a comfortable position is usually elevated headboard
   • Give oxygen through a cannula / mask
   • If the chest tube is installed :
     • Check the vacuum controller, liquid limit
     • Observations of air bubbles bottle container
     • Hose clamps on the bottom of the drainage unit if a leak
     • Watch the ebb and flow of water reservoir
     • Note the character / amount of chest tube drainage.



2. Chest pain related to biologic factors (tissue trauma) and physical factors (chest tube installation)
   
   Goal :
   Pain is reduced or lost
   
   Expected results :
   • The patient said the pain is reduced or can be controlled
   • Patients calm
   
   Intervention :
   • Assess for the presence of pain, the scale and intensity of pain
   • Teach the client about pain management and relaxation with distraction
   • Secure the chest tube to restrict movement and avoid irritation
   • Assess pain reduction measures
   • Provide analgesics as indicated

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