Pleural effusion is an accumulation of fluid in the pleural space.

Pleural fluid normally seeps

continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed
by the visceral pleural capillaries and lymphatic system. Any condition that interferes with either
secretion or drainage of this fluid leads to pleural effusion.

Causes of pleural effusion can be grouped into four major categories:

 Increased systemic hydrostatic pressure (e.g., heart failure)

 Reduced capillary oncotic pressure (e.g., liver or renal failure)
 Increased capillary permeability (e.g., infection or trauma)
 Impaired lymphatic function (e.g., lymphatic obstruction caused by tumor)

See other nursing care plans here

Nursing Care Plans

1 Ineffective Breathing Pattern
Ineffective breathing pattern occurs when inspiration and expiration does not provide adequate
ventilation. Pleural inflammation causes sharp localized pain that increases deep of breathing,
coughing and movement. This can result to shallow and rapid breathing pattern. Distal airways
and alveoli may not expand optimally with each breath, increasing the possibility of atelectasis
and impaired gas exchange.

Nursing Nursing Expected

Assessment Planning Rationale
Diagnosis Interventions Outcome
Subjective: Ineffectiv Short Term: - Establish - To gain pt/ Short
e After 3 hours rapport - SO’s trust and Term: The
 Dyspnea Breathing of nursing Monitor and cooperation - patient shall
Pattern interventions record vital To obtain have
Objectives: RT the patient signs baseline data demonstrate
Decreased will d appropriate
The patient Lung demonstrate - Assess breath - To note for coping
manifested the Volume appropriate sounds, respiratory behaviors
following: Capacity coping respiratory abnormalities and methods
as behaviors rate, depth and that may to improve
 Tachypnea evidenced and methods rhythm indicate early breathing
 Presence of by to improve respiratory pattern.
crackles on tachypnea breathing - Elevate head compromise
both lung , presence pattern. of the pt. and hypoxia Long term:
fields upon of
auscultation crackles Long term: - Provide - To promote The patient
 use of on both relaxing lung expansion shall have
accessory lung fields After 1 to 2 applied
 muscles and
 RR of 28 dyspnea days of environment - To promote techniques
nursing adequate rest that
The patient may interventions - Administer periods to limit improved
manifest the , the patient supplemental fatigue breathing
following: would be oxygen as pattern and
able to apply ordered - To maximize be free from
 Cyanosis techniques oxygen signs and
 Orthopnea that would -Assisst client available for symptoms of
 Diaphoresis improve in the use of cellular uptake respiratory
breathing relaxation distress AEB
pattern and technique -To provide respiratory
be free from relief of rate within
signs and - Administer causative normal
symptoms of prescribed factors range,
respiratory medications as absence of
distress. ordered - For the cyanosis,
pharmacologica effective
-Maximize l management breathing
respiratory of the patient’s and minimal
effort with condition use of
good posture accessory
and effective -To promote muscles
use if wellness during
accessory breathing.
muscles. - to limit fatigue

-Encourage
adequate rest
periods
between
activities

2 Impaired Gas Exchange

Impaired gas exchange is a state in which there is excess or deficit oxygenation and carbon
dioxide elimination. The compensatory mechanism of lungs is to lose effectiveness of its defense
mechanisms and allow organisms to penetrate the sterile lower respiratory tract where
inflammation develops. Disruption of mechanical defenses and ciliary motility leads to
colonization of lungs and subsequent infection. Inflamed and fluid-filled alveolar sacs cannot
exchange oxygen and carbon dioxide effectively. The release of endotoxins by the microbes can
lodge in the brain, affecting the respiratory center in medulla resulting to altered oxygen supply.

Nursing Nursing Inter- Expected

Assessment Planning Rationale
Diagnosis ventions Outcome
Subjective: Impaired Short term: - Establish rapport - - To gain Short term:
(none) Gas After 1 hour Monitor and record pt./SO’s trust The patient
Objective: Exchange of nursing vital signs and cooperation shall have
R/T Alveolar interventions, - To obtain verbalized
The patient –Capillary the pt will - Monitor respiratory baseline data understandin
manifested Membrane verbalize rate, depth and g of the
Changes understandin rhythm - To assess for interventions
Several and g of the rapid or shallow given to
episodes of respiratory interventions - Assess pt’s general respiration that improve
pallor fatigue given to condition occur because patient’s
Secondary to improve of hypoxemia condition.
Tachypnea Pleural patient’s - Auscultate breath and stress
Effusion condition. sounds, note areas of Long term:
Restlessnes decreased/adventitiou - To note for
s Long term: s breath sounds as etiology The patient
well as fremitus precipitating shall manifest
nasal After 1-2 factors that can no signs of
flaring days of - Elevate head of the lead to impaired respiratory
nursing pt. gas exchange distress.
depth of interventions,
breathing the pt. will - Note for presence of -To evaluate
demonstrate cyanosis degree of
Use of improved compromise
accessory ventilation -Encourage frequent
muscles for and adequate position changes and - To enhance
breathing oxygenation deep-breathing lung expansion
of tissues exercises
The pt. may AEB absence - To assess
manifest the of symptoms -Provide supplemental inadequate
ff: of respiratory oxygen at lowest systemic
distress. concentration oxygenation or
Confusion indicated by hypoxemia
laboratory results and
Cyanosis client symptoms/ -To promote
situation optimum chest
Diaphoresis expansion
- Review laboratory
results To correct/
improve
- Provide health existing
teaching on how to deficiencies
alleviate pt’s
condition - To determine
pt’s
Administer prescribed oxygenation
medications as
 ordered status

- To empower
SO and pt

For the
pharmacologica
l management
of the patient’s
condition

3 Activity Intolerance
Presence of a space-occupying liquid in the pleural space, the lung recoils, inward, the chest wall
recoils outward, and the diaphragm is depressed inferiorly. This may lead to decrease lung
volume and may result to significant hypoxemia and can only be relieved by thoracentesis. Due
to inadequate ventilation there would be limitations in activity as tolerance to activity may occur.

Assessmen Nursing Nursing Inter- Expected

Planning Rationale
t Diagnosis ventions Outcome
Subjective: Activity Short Term: Establish Rapport To gain Short
(none) intolerance After 3-4 Monitor and record clients Term: The
related to hours of Vital Signs participation patient
Objective: insufficien nursing and shall have
t oxygen interventions Assess patient’s cooperation used
Patient for , the patient general condition in the nurse identified
manifested: activities will use patient techniques
of daily identified Adjust client’s daily interaction to improve
generalized living techniques to activities and reduce To obtain activity
weakness improve intensity of level. baseline data intolerance
activity Discontinue 
limited intolerance activities that cause To note for Long
range of undesired any Term:
motion as Long Term: psychological abnormalitie
observed changes s and The patient
After 2-3 deformities shall have
use of days of Instruct client in present reported
accessory nursing unfamiliar activities within the measurable
muscles interventions and in alternate ways body increase in
during , the patient of conserve energy activity
breathing will report To prevent intolerance
measurable Encourage patient to strain and .
(+) DOB increase in have adequate bed overexertion
activity rest and sleep
intolerance. Provide the patient To conserve
with a calm and quiet energy and
environment promote
safety
Assist the client in
ambulation to relax the
body
Note presence of
factors that could to provide
contribute to fatigue relaxation

Ascertain client’s to prevent

ability to stand and risk for falls
move about and that could
degree of assistance lead to injury
needed or use of
equipment fatigue
affects both
Give client the client’s
information that actual and
provides evidence of perceived
daily or weekly ability to
progress participate in
activities
Encourage the client
to maintain a positive to determine
attitude current status
and needs
Assist the client in a associated
semi-fowlers position with
participation
Elevate the head of in needed or
the bed desired
activities
Assist the client in
learning and to sustain
demonstrating motivation
appropriate safety of client
measures
to enhance
Instruct the SO not to sense of well
leave the client being
unattended
to promote
Provide client with a easy
 positive atmosphere breathing

Instruct the SO to to maintain

monitor response of an open
patient to an activity airway
and recognize the
signs and symptoms to prevent
injuries

to avoid risk
for falls

to help
minimize
frustration
and
rechannel
energy

to indicate
need to alter
activity level

4 Acute Pain
Pain may be considered as Pleuritic chest pain. Pleuritic chest pain derives from inflammation of
the parietal pleura, the site of pleural pain fibers. Occasionally, this symptom is accompanied by
an audible or palpable pleural rub, reflecting the movement of abnormal pleural tissues.

Nursing Nursing Inter- Expected

Assessment Planning Rationale
Dx ventions Outcome
Subjective: Acute Short Term: Assess patient To identify Short Term:
(none) pain After 3-4 pain for intensity, Patient shall
hours of intensity using precipitating factors have
Objective: nursing a pain rating and location to verbalized a
interventions scale, for assist in accurate decrease in
Patient , the location and diagnosis. pain from a
manifested: patient’s for Assessing response scale of 7 to
pain will precipitating determines 3.
(+) DOB decrease factors. Assess effectiveness of
from 7 to 3 the response to medication and Long Term:
Complains to as verbalized medications whether further
chest pain on by the every 5 interventions are The patient
the shall have
 patient. minutes required.
thoracostom demonstrate
y site Long Term: Provide To provide d activities
comfort nonpharmacologica and
Facial After 2-3 measures. l pain management. behaviors
grimaces days of that will
upon nursing Establish a A quiet prevent the
movement interventions quiet environment recurrence of
, the patient environment. reduces the energy pain.
Reports of will demands on the
pain on the demonstrate Elevate head patient.
thoracostom activities and of bed.
y area, behaviors Elevation improves
described as that will Monitor vital chest expansion and
sharp prevent the signs, oxygenation.
provoked by recurrence of especially
breathing pain. pulse and Tachycardia and
non- blood pressure, elevated blood
radiating, every 5 pressure usually
with a pain minutes until occur with angina
scale of 7 out pain subsides. and reflect
of 10 compensatory
Teach patient mechanisms
Patient may relaxation secondary to
manifest: techniques and sympathetic
how to use nervous system
Restlessness them to reduce stimulation.
stress.
Confusion Anginal pain is
often precipitated
Irritability by emotional stress
that can be relieved
non-
pharmacological
measures such as
relaxation.

Other nursing diagnoses:

 5 Impaired Skin Integrity RT Surgical Procedure [Thoracentesis]

 6 Disturbed Body Image RT Insertion of Chest Thoracostomy Tube