NURSING CARE PLAN FOR PLEURAL EFFUSION
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PATIENT PROBLEM PLANNING & IMPLEMENTATION EVALUATION
DATE PATIENT OUTCOME
ACTUAL/POTENTIAL NURSING INTERVENTION DATE COMMENTS
Ineffective breathing pattern Client will be able to restore Assess client respiration 4 hourly e.g., rate, 14.1.2011 Client was able to restore 80% of
related to decreased lung effective lung expansion rhythm, depth and breath sound. Note lung expansion
expansion secondary to manifestation of ineffective breathing. Early
accumulation of fluid in the identification of respirations allow timely and
pleural cavity appropriate initiation of interventions
Client will be comfortable Client was comfortable
Monitoring vital signs 4 hourly. Tachypnea,
tachycardia, elevated blood pressure and
increasing hypoxemia and hypercapnia are signs
of compromised respiratory status.
Client will breath easily Client breathed easily
Assess client during self care activities. This
conserves energy and reduces fatigue.
Provide rest periods between scheduled activites
Client will be comfortable and treatments to prevent fatigue and reduce Client was comfortable
oxygen demands.
Positon client in semi fowlers or high fowlers
with head and arms supported on the cardiac
table to reduces pressure on the diaphragm and
permit optimal lung expansion.
Teach client to do deep breathing technique to
promote lung expansion
Provide oxygen theraphy e.g. 3L/min. nasal
prong or as ordered by physician to increase
oxygen saturation of the blood
Use pulse oximeter to monitor oxygen
saturation and pulse rate to detect oxygenation
level and effectiveness of treatment
NURSING CARE PLAN FOR PLEURAL EFFUSION
page 19
PATIENT PROBLEM PATIENT PLANNING & IMPLEMENTATION EVALUATION
DATE OUTCOME
ACTUAL/POTENTIAL NURSING INTERVENTION DATE COMMENTS
1/16/2011 Knowledge deficit Client will verbalize 14.1.2011 Client verbalized understanding on
regarding health condition, understanding of the Provide knowledge base for understanding the cause of his current condition,
treatment regimen and self cause of problem, dynamics of condition and significance of complications and identified signs
care related to lack of complications and therapeutic interventions to reduce fear of and symptoms requiring medical
exposure to information identify signs and unknown. attention
symptoms requiring
medical attention.
Encourage client to follow strict treatment
regimen to prevent complications like
pneumothorax, emyema, and collapsed lung
will develop if treatment is delayed.
Teach client that maintenance of general
well-being e.g., eat healthy heart food,
exercise, personal hygiene pomotes healing
and may prevent/limit recurrences
Teach client the signs and symptoms of all
his illness especially pleuritic pain, SOB,
dyspnea, hymoptysis, coughing of blood, etc.
that needs immediate medical attention to
prevent further damage and complications.
NURSING CARE PLAN FOR PLEURAL EFFUSION
page 20
PATIENT PROBLEM PATIENT PLANNING & IMPLEMENTATION EVALUATION
DATE OUTCOME
ACTUAL/POTENTIAL NURSING INTERVENTION DATE COMMENTS
09.1.11 Risk of injury related Client will not get Monitor client pulse, skin color, oxygen 14.1.2011 Client pleural tapping was
to pleural tapping pleural tapping saturation during thoracentesis for indicated successful and no complications
14.1.11 complications of physiologic tolerance of the procedure
Client will feel Apply client dressing over the puncture site Client felt less pain and
comfortable and less and position on the unaffected site for 1 hour comfortable
pain to allows the pleural puncture to heal
Administer client a cough suppressant as
ordered because movement and coughing
during the procedure may cause damage to
the lung or pleural
Position client to upright, learning forward
with arms and head supported on an
anchored overbed or cardiac table to
promote expansion of the rib enlarging
intercostal space for easy needle insertion
Inform client that local anesthesia will be
given to reduce pain/sensation pressure as
needle will be inserted to puncture the
parietal pleural to enter the pleural space
