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Nursing Care Plan for a Patient With Pleural Effusion

Nursing Care Plan for a Patient With Pleural Effusion

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Published by mac0422

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Published by: mac0422 on Mar 07, 2010
Copyright:Attribution Non-commercial

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08/03/2013

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NURSING CARE PLAN FOR A PATIENT WITH PLEURAL EFFUSIONASSESSMENTDIAGNOSISPLANNINGINTERVENTIONRATIONALEEVALUATION
Subjective:“Ubo ako ng ubo”as verbalized by the patient.Objective:
Cough
Restlessness
Pale
With leftside CTTconnected tothorabottle.Vital signs taken:
T: 36.9
PR: 105 bpm(tachycardia)
RR: 22 cpm
Ineffectiveairwayclearancerelated toretainedsecretions.
After 8hours of nursingintervention,the patientwill be ableto maintainairway patency andclear secretionsreadily.
Assessrespirations:note quality,rate, pattern,depth, and breathingeffort.
Monitor vital signs.
Both rapid,shallow breathing patterns andhypoventilation affectgasexchange.
With initialhypoxia andhypercapnia, blood pressure,heart rate,andrespiratoryrate all rise.As thehypoxiaand/or hypercapnia becomemore severe,BP may
Goal met.After 8hours of nursingintervention,the patient isable tomaintainairway patency andclear secretionsreadily.
 
BP: 110/80mmHg
Assess for changes inorientationand behavior.drop, heartrate tends tocontinue to be rapidwitharrhythmias,andrespiratoryfailure mayensue withthe patientunable tomaintain therapidrespiratoryrate.
Restlessnessis an earlysign of hypoxia.Chronichypoxemiamay result incognitivechangessuch asmemorychanges.
 
Assess patient’sability tocougheffectivelyto clear secretions. Notequantity,color, andconsistencyof sputum.
Maintainoxygenadministration device asordered,attemptingto maintainoxygensaturation at90% or greater.
Positionwith proper  bodyalignment
Retainedsecretionsimpair gasexchange.
This provides for adequateoxygenation.
This promotes

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