Saturday, March 10, 2012

Nursing Interventions for Ineffective Breathing Pattern - Pleural Effusion


Pleural effusion is a condition in which the lubrication lining the outside of the lungs builds up and eventually inhibits a person's breathing.

The pleural fluid remains in dynamic equilibrium with blood. Movements of the lung favour the movement of the fluid in and out of the pleural space. In most of the disease states, absorption of the fluid is reduced. The fluid may be contained in the general pleural space or it may be loculated in the interlobar fissure, infrapulmonary space or may remain adjacent to the mediastinum. The fluid progressively compresses the subjacent lung which undergoes collapse.

Although pleural effusion in itself is not a disorder, it is a symptom of several health issues, such as congestive heart failure and malignant cancers like mesothelioma.

Nursing Interventions for Ineffective Breathing Pattern - Pleural Effusion

Nursing Diagnosis: Ineffective breathing pattern related to:
  • Decrease in lung expansion (fluid accumulation)
  • Muskuluskeletal disorders
  • Pain / anxiety
  • inflammatory process
characterized by:
  • dyspnea, takhipnea
  • changes in depth / kesamaanpernapasan
  • use of accessory muscles, nasal dilation
  • impaired development of the chest and cyanosis, abnormal blood gas analysis

Expected outcomes / evaluation criteria, the client will:
  • Showed a normal breathing pattern / blood gas analyzer effectively with the normal range
  • There was no cyanosis
  • No signs / symptoms of hypoxia.


Nursing Interventions for ineffective breathing pattern - Pleural effusion:

1. Identifying the etiology / factor triggers
Rational: understanding the causes of lung collapse necessary for the proper installation of the chest tube and choose another teraupetik action.

2. Evaluation of respiratory function.
Rational: respiratory distress and changes in vital signs may occur due to physiological stress and may indicate the occurrence of pain or shock.

3. Auscultation of breath sounds
Rational: The sound of the breath can be decreased or no lobe, lung segment or the entire lung.

4. Assess fremitus
Rational: Sound and tactile fremitus (vibration) decreases in fluid-filled tissue / consolidation.

5. Collaboration in the assessment of radiographic series
Rational: hemathorak improvement and monitor progress of lung expansion.

6. Collaboration in the provision of supplemental oxygen through a cannula / mask as indicated.
Rational: A tool in reducing the work of breath, increased respiratory distress and cyanosis relief with respect to hypoxemia.

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