NIC NOC - Ineffective airway clearance related to Pleural effusion

Pleural effusion is an abnormal accumulation of fluids in the pleural space Between the parietal and visceral pleura of the Lungs. Breathlessness, chest pain and non-productive cough are the most common symptoms associated with pleural effusion.

Nursing Diagnosis and Interventions for Pleural effusion

Nursing Diagnosis: Ineffective airway clearance related to weakness and poor cough effort.

NOC:

• Demonstrate effective airway clearance and respiratory status evidenced by, gas exchange and ventilation are not dangerous:
- Having a patent airway
- Removing secretions effectively.
- Having a rhythm and respiratory frequency in the normal range.
- Having a pulmonary function within normal limits.

• Demonstrate adequate gas exchange, characterized by:
- Easy to breathe
- There is no anxiety, cyanosis and dyspnea.
- O2 saturation within normal limits
- Chest X-ray within the expected range.

NIC:
• Assess and document
- The effectiveness of the administration of oxygen and other treatments.
- The effectiveness of treatment.
- Trends in arterial blood gases.
• Auscultation of the anterior and posterior chest to find a decrease or absence of ventilation and the presence of noise barriers.
• Sucking airway
- Determine the need for oral suction / tracheal.
- Monitor the status of oxygen and hemodynamic status and cardiac rhythm before, during and after exploitation.
• Maintain adequacy of hydration to decrease viscosity of secretions.
• Explain the use of ancillary equipment properly, such as oxygen, suction equipment lenders.
• Inform the patient and family that smoking is an activity that is prohibited in the treatment room.
• Instruct the patient about the coughing and deep breathing techniques to facilitate the discharge of secretion.
• Negotiate with the respiratory therapist as needed.
• Give oxygen that has been humidified.
• Tell your doctor about the results of an abnormal blood gas analysis.
• Assist in the delivery of aerosol. Nebulizer and another lung treatment in accordance with institutional policies and protocols.
• Encourage physical activity to improve the movement of secretions.
• If the patient is unable to ambulate, the patient lies sleeping position changed every 2 hours.
• Inform the patient before beginning the procedure to reduce anxiety and increase self-control.

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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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