Nursing Care Plan For A Patient With Pleural Effusion

NURSING CARE PLAN FOR A PATIENT WITH PLEURAL EFFUSION ASSESSMENT

Subjective: “Ubo ako ng ubo” as verbalized by the  patient.

Objective: • • • •

Cough Restlessness Pale With left side CTT connected to thorabottle.

Vital signs taken: • •

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T: 36.9 PR: 105  bpm (tachycardia ) RR: 22 cpm

DIAGNOSIS

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Ineffective airway clearance related to retained secretions.

PLANNING

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After 8 hours of  nursing intervention, the patient will be able to maintain airway  patency and clear  secretions readily.

INTERVENTION

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Assess respirations: note quality, rate, pattern, depth, and  breathing effort.

Monitor  vital signs.

RATIONALE

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Both rapid, shallow  breathing  patterns and hypoventilat ion affect gas exchange. With initial hypoxia and hypercapnia,  blood  pressure, heart rate, and respiratory rate all rise. As the hypoxia and/or  hypercapnia  become more severe, BP may

EVALUATION

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Goal met. After 8 hours of  nursing intervention, the patient is able to maintain airway  patency and clear  secretions readily.

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BP: 110/80 mmHg

drop, heart rate tends to continue to  be rapid with arrhythmias, and respiratory failure may ensue with the patient unable to maintain the rapid respiratory rate.

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Assess for  changes in orientation and  behavior.

Restlessness is an early sign of  hypoxia. Chronic hypoxemia may result in cognitive changes such as memory changes.

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Assess  patient’s ability to cough effectively to clear  secretions.  Note quantity, color, and consistency of sputum. Maintain oxygen administrati on device as ordered, attempting to maintain oxygen saturation at 90% or  greater. Position with proper   body alignment

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Retained secretions impair gas exchange.

This  provides for  adequate oxygenation.

This  promotes

for optimal respiratory excursion.

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Anticipate need for  intubation and mechanical ventilation if   patient is unable to maintain adequate gas exchange.

Teach the  patient appropriate deep  breathing and coughing techniques.

lung expansion and improves air  exchange.

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Early intubation and mechanical ventilation are recommende d to prevent full decompensat ion of the  patient.

These facilitate adequate air  exchange and secretion

clearance.