Nursing Care Plan for Pleural Effusion - Nursing Diagnosis : Ineffective Breathing Pattern
Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing. Normally, a small amount of fluid is present in the pleura.
Some of the more common causes are:
- Congestive heart failure
- Liver disease (cirrhosis)
- End-stage renal disease
- Nephrotic syndrome
- Pulmonary embolism
- Lupus and other autoimmune conditions
Other less common causes of pleural effusion include:
- Autoimmune disease
- Bleeding (due to chest trauma)
- Chylothorax (due to trauma)
- Rare chest and abdominal infections
- Asbestos pleural effusion (due to exposure to asbestos)
- Meig’s syndrome (due to a benign ovarian tumor)
- Ovarian hyperstimulation syndrome
Symptoms of pleural effusion include:
- Chest pain
- Dry, nonproductive cough
- Dyspnea (shortness of breath, or difficult, labored breathing)
- Orthopnea (the inability to breathe easily unless the person is sitting up straight or standing erect)
Ineffective Breathing Pattern
Definition : Inspiration and/or expiration that does not provide adequate ventilation
Defining Characteristics :
- Accessory muscle use
- Abnormal heart rate response to activity
- Altered respiratory rate or depth or both
- Assumption of 3-point position
- Decreased minute ventilation
- Decreased vital capacity
- Decreased tidal volume
- Nasal flaring
- Prolonged expiratory phase
- Pursed lip breathing
Nursing Diagnosis for Pleural Effusion : Ineffective Breathing Pattern related to decreased lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, inflammatory process.
Possibility evidenced by:
- respiratory depth changes,
- use of accessory muscles,
- impaired development of the chest,
- abnormal blood gas analysis.
Goal: Effective breathing pattern
- Showed normal breathing pattern / effective with normal blood gas analysis.
- Free cyanosis and signs of hypoxia symptoms.
- Identify the etiology or trigger factor.
- Evaluation of respiratory function (rapid breathing, cyanosis, changes in vital signs).
- Auscultation of breath sounds.
- Note the position of the trachea and chest development, review fremitus.
- Maintain a comfortable position is usually the head of the bed elevated.
- Give oxygen via cannula / mask
- When the chest tube is installed:
- check the vacuum controller, liquid limit.
- Observation of air bubbles bottle container.
- Hose clamp on the bottom of the drainage in the event of a leak.
- Keep an eye on the ebb and flow of water reservoir.
- Note the character / number of chest tube drainage.