27950754 Nursing Care Plan for a Patient With Pleural Effusion
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NURSING CARE PLAN FOR A PATIENT WITH PLEURAL EFFUSION ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Subjective: “Ubo ako ng ubo” as verbalized by the patient. Objective: Cough Restlessne ss Pale With left side CTT connected to thorabottl e. Vital signs taken: T: 36.9 PR: 105 bpm (tachycard ia) Ineffective airway clearance related to retained secretions. After 8 hours of nursing intervention , the patient will be able to maintain airway patency and clear secretions readily. Assess respirations : note quality, rate, pattern, depth, and breathing effort. Monitor vital signs. Both rapid, shallow breathing patterns and hypoventilat ion affect gas exchange. With initial hypoxia and hypercapnia, blood pressure, heart rate, and respiratory rate all rise. As the hypoxia and/or hypercapnia become more severe, BP Goal met. After 8 hours of nursing intervention , the patient is able to maintain airway patency and clear secretions readily.
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Transcript of 27950754 Nursing Care Plan for a Patient With Pleural Effusion
NURSING CARE PLAN FOR A PATIENT WITH PLEURAL EFFUSION
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: “Ubo ako ng ubo” as verbalized by the patient.
Objective: Cough Restlessness Pale With left side
CTT connected to thorabottle.
Vital signs taken: T: 36.9 PR: 105 bpm
(tachycardia) RR: 22 cpm BP: 110/80
mmHg
Ineffective airway clearance related to retained secretions.
After 8 hours of nursing intervention, the patient will be able to maintain airway patency and clear secretions readily.
Assess respirations: note quality, rate, pattern, depth, and breathing effort.
Monitor vital signs.
Both rapid, shallow breathing patterns and hypoventilation affect gas exchange.
With initial hypoxia and hypercapnia, blood pressure, heart rate, and respiratory rate all rise. As the hypoxia and/or hypercapnia become more severe, BP may drop, heart rate tends to continue to be rapid with arrhythmias, and respiratory failure may ensue with the patient unable to maintain the rapid respiratory rate.
Goal met. After 8 hours of nursing intervention, the patient is able to maintain airway patency and clear secretions readily.
Assess for changes in orientation and behavior.
Assess patient’s ability to cough effectively to clear secretions. Note quantity, color, and consistency of sputum.
Maintain oxygen administration device as ordered, attempting to maintain oxygen saturation at 90% or greater.
Position with proper body alignment for optimal respiratory excursion.
Restlessness is an early sign of hypoxia. Chronic hypoxemia may result in cognitive changes such as memory changes.
Retained secretions impair gas exchange.
This provides for adequate oxygenation.
This promotes lung expansion and improves air exchange.
Anticipate need for intubation and mechanical ventilation if patient is unable to maintain adequate gas exchange.
Teach the patient appropriate deep breathing and coughing techniques.
Early intubation and mechanical ventilation are recommended to prevent full decompensation of the patient.
These facilitate adequate air exchange and secretion clearance.
