Nursing Diagnosis and Interventions,
Pleural EffusionWhat is a Pleural Effusion?Pleural effusion is a condition in which there is fluid in the chest cavity that should not exist (there is normally very little fluid as a lubricant), where the fluid will suppress lung and heart that will cause shortness.Symptoms
Shortness of breath that is increasingly severe, usually felt on one side.
cough
Sometimes accompanied by chest pain
Stomach feel full / bloated
Some patients hear the sound of moving water when the whisk.How does this happen?Pleural effusion occurs because: An imbalance between the production and disposal of the lubricating fluid, so fluid accumulates.Some diseases that often cause complications pleural effusion is:
Pulmonary TB
Lung tumors
Hypo-albumin, a state in which the albumin / protein in blood is very low such as in cirrhosis of the liver disease, kidney failure, etc..
Heart failure
Breast tumor
Ovarian cysts
etc..What danger??
Although not including gravity, in most cases, the fluid should be removed because:
Polynomial, so that pressing the lungs, disrupting breathing and encourage the heart (cardiac pump is compromised, it can be fatal).
The fluid can harden / solidify (organization) that reduced lung volume, (tightness) and cause permanent disability which continues to appear on x-rays.
If infected, the liquid turns into pus. This became another disease that is empyema, different handling.
If the liquid is in the form of blood, for example due to an accident, his name: haemothorax, need immediate attention.Nursing Diagnosis for Pleural EffusionAnalysis can be expressions of the nursing diagnoses that include:
Ineffective airway clearance related to decreased lung expansion.
Fluid volume deficit related to diaphoresis.
Activity Intolerance related to dyspenia and fatigueNursing Interventions for Pleural Effusion1). Ineffective airway clearance related to decreased lung expansion.Goal: a patent airway / inadequateNursing Intervention:
Give oxygenation in accordance with the program.
Provide a comfortable sleeping position.
Monitor vital signs.
Teach effective cough.
Teach resistant chest when coughing.2). Fluid volume deficit related to diaphoresisGoal: balance of body fluidsNursing Intervention:
Vital signs every 6 hours.
Compress with warm water.
Record intake and output.
Collaboration with doctors for antibiotics.3). Activity Intolerance related to dyspnea and fatigueGoal: clients obtain energyNursing Intervention:
Assess the activity patterns.
Limit activity.
Aids to overcome weaknesses.
Schedule breaks.
