Pleural Effusion Nursing Care Plan


Nursing Diagnosis
  • Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as evidenced by tachypnea, presence of crackles on both lung fields and dyspnea
  • Patient will demonstrate appropriate coping behaviors and methods to improve breathing pattern.
  • Patient would be able to apply techniques that would improve breathing pattern and be free from signs and symptoms of respiratory distress.
Nursing Interventions
  • Monitor and record vital signs.
    • Rationale: To obtain baseline data
  • Assess breath sounds, respiratory rate, depth and rhythm
    • Rationale: To note for respiratory abnormalities that may indicate early respiratory compromise and hypoxia.
  • Elevate head of the patient
    • Rationale: To promote lung expansion
  • Encourage patient to perform deep breathing exercises
    • Rationale: To promote lung expansion.
  • Provide relaxing environment
    • Rationale: To promote adequate rest periods to limit fatigue
  • Administer supplemental oxygen as ordered
    • Rationale: To maximize oxygen available for cellular uptake
  • Assist client in the use of relaxation technique
    • Rationale: To provide relief of causative factors
  • Administer prescribed medications as ordered
    • Rationale: For the pharmacological management of the patient’s condition
  • Maximize respiratory effort with good posture and effective use if accessory muscles.
    • Rationale: To promote wellness
  • Encourage adequate rest periods between activities
    • Rationale: To limit fatigue
Assist and prepare for thoracentesis:
  • Explain thoracentesis to the pain. Tell the patient to expect a stinging sensation from the local anesthetic and feeling of pressure when the needle inserted.
    • Rationale: Knowing what to expect before the procedure can make the patient more apt to it.
  • Instruct patient to tell him to tell you immediately if he feels uncomfortable or has difficulty of breathing during procedure.
    • Rationale: If DOB occurs, it may require postponement of procedure.
  • Reassure the patient during thoracentesis. Remind to breath normally and avoid sudden movements (coughing, sighing).
    • Rationale: Reassure can relieve the anxiety that may occur during procedure.
  • Monitor vital signs during procedure. Watch out for signs of respiratory distress after thoracentesis.
    • Rationale: If fluid is removed too quickly, the patient may suffer bradycardia, hypotension, pain, pulmonary edema or even cardiac arrest.
  • Ensure tube patency by watching for fluctuations of fluid or air bubbling in the underwater seal chamber. Record the amount, color, and consistency of any tube drainage.
    • Rationale: Continuous bubbling may indicate an air leak.

Nursing Diagnosis
  • Impaired Gas Exchange R/T Alveolar –Capillary Membrane Changes  and respiratory fatigue Secondary to Pleural Effusion

Patient will demonstrate improved ventilation and adequate oxygenation of tissues AEB absence of symptoms of respiratory distress.

Nursing Interventions
  • Monitor and record vital signs
    • Rationale: To obtain baseline data
  • Monitor respiratory rate, depth and rhythm
    • Rationale: To assess for rapid or shallow respiration that occur because of hypoxemia and stress
  • Assess pt’s general condition
    • Rationale: To note for etiology precipitating factors that can lead to impaired gas exchange
  • Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus
    • Rationale: To evaluate degree of compromise
  • Elevate head of the pt.
    • Rationale: To enhance lung expansion
  • Note for presence of cyanosis
    • Rationale: To assess inadequate systemic oxygenation or hypoxemia
  • Encourage frequent position changes and deep-breathing exercises
    • Rationale: To promote optimum chest expansion
  • Provide supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/ situation
    • Rationale: To correct/ improve existing deficiencies
  • Review laboratory results
    • Rationale: To determine pt’s oxygenation status
  • Provide health teaching on how to alleviate pt’s condition
    • Rationale: To empower SO and pt
  • Administer prescribed medications as ordered
    • Rationale: For the pharmacological management of the patient’s condition

Nursing Diagnosis
  • Activity Intolerance
  • Patient will use identified techniques to improve activity intolerance
  • Patient will report measurable increase in activity intolerance.
Nursing Interventions
  • Establish Rapport
    • Rationale: To gain clients participation and cooperation in the nurse patient interaction
  • Monitor and record Vital Signs
    • Rationale: To obtain baseline data
  • Assess patient’s general condition
    • Rationale: To note for any abnormalities and deformities present within the body
  • Adjust client’s daily activities and reduce intensity of level.
    • Rationale: To prevent strain and overexertion
  • Discontinue  activities that cause undesired psychological changes
    • Rationale: To conserve energy and promote safety
  • Instruct client in unfamiliar activities and in alternate ways of conserve energy
    • Rationale: To relax the body
  • Encourage patient to have adequate bed rest and sleep
    • Rationale: To provide relaxation
  • Provide the patient with a calm and quiet environment
    • Rationale: To prevent risk for falls that could lead to injury
  • Assist the client in ambulation
    • Rationale: Fatigue affects both the client’s actual and perceived ability to participate in activities
  • Note presence of factors that could contribute to fatigue
    • Rationale: To determine current status and needs associated with participation in needed or desired activities
  • Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipment
    • Rationale: To sustain motivation of client
  • Give client information that provides evidence of daily or weekly progress
    • Rationale: To enhance sense of well being
  • Encourage the client to maintain a positive attitude
    • Rationale: To promote easy breathing
  • Assist the client in a semi-fowlers position
    • Rationale: To maintain an open airway
  • Elevate the head of the bed
    • Rationale: To prevent injuries
  • Assist the client in learning and demonstrating appropriate safety measures
    • Rationale: To avoid risk for falls
  • Instruct the SO not to leave the client unattended
    • Rationale: To help minimize frustration and rechannel energy
  • Provide client with a positive atmosphere
    • Rationale: To indicate need to alter activity level

Nursing Diagnosis
  • Acute Pain
  • Patient will report pain is decreased or controlled.
Nursing Interventions
  • Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
    • Rationale: To identify intensity, precipitating factors and location to assist in accurate diagnosis.
  • Assess the response to medications every 5 minutes
    • Rationale: Assessing response determines effectiveness of medication and whether further interventions are required.
  • Provide comfort measures.
    • Rationale: To provide nonpharmacological pain management.
  • Establish a quiet environment.
    • Rationale: A quiet environment reduces the energy demands on the patient.
  • Elevate head of bed.
    • Rationale: Elevation improves chest expansion and oxygenation.
  • Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
    • Rationale: Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
  • Teach patient relaxation techniques and how to use them to reduce stress.
    • Rationale: Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation.