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Nursing Care Plan for Pleural Effusion

NCP for Pleural Effusion

Nursing Care Plan for Pleural Effusion

Pleural Effusion

A pleural effusion is an excess accumulation of fluid in the pleural space around the lungs. Medical ImageThe pleura are thin membranes that enclose the lungs and line the inside of the chest cavity. The 'pleural space' describes the small space between the inner and outer layers of pleura, which normally contains a small volume of lubricating pleural fluid to allow the lungs to expand without friction. This fluid is constantly being formed through leakage of fluid from nearby capillaries and then re-absorbed by the body's lymphatic system. With a pleural effusion, some imbalance between production and reabsorption of pleural fluid leads to excess fluid building up in the pleural space. There are two major types of pleural effusion :
  • Transudative effusions, where the excess pleural fluid is low in protein; and
  • Exudative effusions, where the excess pleural fluid is high in protein.

Causes

Anything that causes an imbalance between production and reabsorption of pleural fluid can lead to development of a pleural effusion. Medical Image Transudative pleural effusions (those low in protein) usually form as a result of excess capillary fluid leakage into the pleural space. Common causes of transudative effusions include :
  • Congestive heart failure;
  • Nephrotic syndrome;
  • Cirrhosis of the liver;
  • Pulmonary embolism; and
  • Hypothyroidism.
Exudative effusions, which are high in protein, are often more serious than transudative effusions. They are formed as a result of inflammation of the pleura, which might happen for example in lung disease. Common causes of exudative effusions include :
  • Pneumonia;
  • Lung cancer, or other cancers;
  • Connective tissue diseases, including rheumatoid arthritis and systemic lupus erythematosus;
  • Pulmonary embolism;
  • Asbestosis;
  • Tuberculosis; and
  • Radiotherapy.
Source : virtualmedicalcentre.com


Nursing Care Plan for Pleural Effusion

Nursing Assessment
  1. Activity / rest
    Symptoms: dyspnea with activity or rest
  2. Circulation
    Signs: Tachycardia, dysrhythmias, heart rhythm Gallop, hypertension / hypotension
  3. Ego integrity
    Signs: fear, anxiety
  4. Food / fluid
    The existence of the installation of central venous IV / infusion
  5. Pain / comfort
    Symptoms depend on the size / area involved: Pain is aggravated by breathing in, the possibility of spread to the neck, shoulders, abdomen
    Signs: Be careful on the area of pain, behavioral distraction
  6. Respiratory
    Symptoms: Difficulty breathing, cough, history of chest surgery / trauma,
    Signs: Tachypnoea, use of accessory respiratory muscles in the chest, intercostal retraction, decreased breath sounds and decreased fremitus (on the side involved),
    Chest percussion: hyper resonant in the area filled with air and noise deaf in fluid-filled area
    Observation and palpation of the chest: chest movement is not the same (paradoksik) when trauma. Skin: pale, cyanosis, sweating.

Nursing Diagnosis and Nursing Interventions for Pleural Effusion

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