NURSING CARE PLAN FOR PLEURAL EFFUSION
page 18
PATIENT PROBLEM
DATE
ACTUAL/POTENTIAL
Ineffective breathing pattern
related to decreased lung
expansion secondary to
accumulation of fluid in the
pleural cavity
PATIENT OUTCOME
Client will be able to restore Assess client respiration 4 hourly e.g., rate,
effective lung expansion
Client will be comfortable
Client will breath easily
Client will be comfortable
PLANNING & IMPLEMENTATION EVALUATION
NURSING INTERVENTION DATE COMMENTS
14.1.2011 Client was able to restore 80% of
rhythm, depth and breath sound. Note lung expansion
manifestation of ineffective breathing. Early
identification of respirations allow timely and
appropriate initiation of interventions
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 breathed easily
Assess client during self care activities. This
conserves energy and reduces fatigue.
Provide rest periods between scheduled activites
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

PATIENT PROBLEM
DATE
ACTUAL/POTENTIAL
1/16/2011 Knowledge deficit
regarding health condition,
treatment regimen and self
care related to lack of
exposure to information
NURSING CARE PLAN FOR PLEURAL EFFUSION
page 19
PATIENT PLANNING & IMPLEMENTATION EVALUATION
OUTCOME
NURSING INTERVENTION DATE COMMENTS
Client will verbalize 14.1.2011 Client verbalized understanding on
understanding of the Provide knowledge base for understanding the cause of his current condition,
cause of problem, dynamics of condition and significance of complications and identified signs
complications and therapeutic interventions to reduce fear of and symptoms requiring medical
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
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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