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