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CHAPTER III

NURSING CARE PLAN PLEURAL EFFUSION

A ASSESMENT

DEMOGRAPHIC DATA

Name of Patient : Mrs. J

Age : 81Years Old

Sex : Female

Address : Jl.cancer no.5 rt/rw 05/09 Gumuruh, Batununggal Kota


Bandung.

Religion : Islam

Civil Status : Married

Occupation : Housewife
Informant : Mrs D and Client
Relationship to Patient : Grand daughter
Date of Admission : November,02, 2016

Time of Admission : 12.15 PM


Food Allergy : No known food allergies

Drug Allergy : No known drug allergies

Educational Attainment : Elementary Level

Chief Complaint : Shortness of Breath

Admitting Diagnosis : Right Pleural Effusion

Baseline Data

Height : 157 cm

Weight : 55 Kg

Body Mass Index : 22 (Within normal range)


HISTORY OF PAST AND PRESENT ILLNESS

HISTORY OF PAST ILLNESS

The patient on therapy irresa for lung cancer

HISTORY OF PRESENT ILLNESS

Dyspnea felt since 1 week before admission, vomitingfrom 3days ago anorexia, gets weaks,
all the body feel pain, headache, insomnia, sometime chestpain

Clinical Examination

VITAL SIGNS :
Temperature : 37, 0C1, Pulse : 112/mt., Respiration : 30/mt. Blood pressure : 120/80
mmhg
HEAD :
Scalp : No scar was seen but the scalp seems to be dry & having dandruff , Face :
Normal in shape , size and alignment ,a black mole was present on chin. Sinus area :
No tenderness present. Nodes : No nodes are enlarged
EYES :
Visual acuity : Normal , Visual field : Clear,6/6 , Ocular movement : Normal , moves
to both sides as well as towards the up and down . Lids : Eye Lides are normal no
edema or inflammation is being detected .
Lacrimal glands : The Lacrimal Glands are normal and secretes normally , Sclera :pale
Cornea : No Abnormality detected , Lens and media : Normal , the image forms
normally. Fundus : Normal
EARS :
External structure : Normal in alignment , Canal: Normal , no discharge is seen
Tympanic membrane : Normal. Hearing : Normal , checked by tunic fork.
NOSE :
External structure : normal in alignment , septum : No deviation seen, Mucus
membrane : Moist , no inflammation seen . Patency : Good , Olfactory sense : This
was normal , checked by using some dyspnea.
ORAL CAVITY :
Lips : Mildly cyanosed , cracked , dry . Buccal mucosa : Cyanosed and dry , Gums :
Pale Teeth : Unhygienic , yellow stain was present . Palates and uvula : Normal,
Tonsillar areas : No enlargement detected , Tongue : Cyanosed , dry . Floor :Normal .
Voice : No hoarseness was present . Breath : Dyspnoea present , the patient was on
oxygen .
NECK :
General structure : Normal in shape and size . Trachea : Present in central ,
Thyroid : Normal , no enlargement seen
CHEST AND RESPIRATORY SYSTEM :
Chest shape: Slightly heavy, Type of respiration : Thoraco- abdominal respiration was
present . Expansion : It was fast . General palpation : On palpation chest movement
wasnt present as well as apex impulse was felt on 5 th intercostals space. Percussion :
on percussion are fluid detected (Dulnnes). On Auscultation no detect sound of breath
in right chest. Breath sound : B/L +
CARDIOVASCULAR SYSTEM :
Dyspnoea : There was presence of marked yspnea on exertion ,even with mild
exertion . Expectoration : yes,expectoration was present .
Haemoptysis :There was no presence of haemoptysis , Palpitation :There was
presence of slightly palpitation, Build and nutrition :He was averagely nourished,
Nails and conjunctiva : Nails were cyanosed Thyroid : No enlargement detected,
Oedema : There was no presence of oedema,, Skin : The skin was
pallor & brittle .
ABDOMEN AND INGUINAL AREAS :
Contour and tone : Good contour and good muscle tone ., Scars marks : There is no
scar marks detected , Liver , Spleen, Kidneys and bladder: Normal ,Hernias :There is
no hardness or swelling over the groin Masses : No masses are felt on abdomen
Palpation : On palpation no mass or any kind of hardness is felt , abdomen was soft to
touch . Percussion : On percussion no fluid or gas collection detected . Auscultation :
On auscultation normal peristaltic movement heard .
MUSCULOSKELETAL SYSTEM :
Gait : Normal
Upper extremities : Both are in normal alignment no extra digits are present and
cyanosis were present on fingers .
Lower extremities: Both are in normal alignment .
Deformities : No such deformities detected .
Range of motion : He was so tired that could not perform the full ROM .
NERVOUS SYSTEM :
Mental status : He was well oriented to date , place and time , even he was
knowing the reasons for admission in hospital . .
Language : He has no problem in language , no sludge speech .
Motor co-ordination : Motor co-ordination was good .
Lower extremities : weakness of muscles , rigidity detected but well co- ordination
present , there is presence of cyanosis .
LABORATORY AND CHEST X-RAY
LABORATORY November,03, 2016

NO Investigations Normal value Patients value

1. Haemoglobin 11.5-15.5 gm. 7,5gm

2. Lecosit 4000-10000/mm 14.300/mm

3. Haematocrit 37-45% 23,2%

4. Eritrosit L: 4,5- 6 P: 4- 5,5 2,86

5. Thombosit 150.000- 400./mm3 398.000

6. Albumin 3,5 5,0 g/L 2,1

7. Globulin 1,5 3,0 g/L 3,0

8. Total Bilirubin < 1,0 0,4

9. SGOT

10. SGPT

CHEST X-RAY :

Medial treatment : The medications which were being prescribed for him are listed
below :ciprofloxacin 2x200mg,cefotaxime 3 x 1gr, ranitidine 2 x 1amp, ondansentron
3 x 4mg, combivent 3 x pro Nebulizer,Vip Albumin 3x2, durogesic patch. Prosedur
therapy : punctie pleura, blood transfusion 3 lb 1lb/12 hours.

B ANALISIS DATA

DATA PATHWAY PROBLEM

Subjective : Pleural Effusion Ineffective Breathing


Patients complaining of Pattern
shortness of breath upon Exess fluid in cavum pleura
exertion Reduction of pressure in the pleural
space, preventing full lung expansion
Objective : Percussion :
on percussion are fluid Decrease Recoil and Comlience Lung
detected (Dulnnes). On
Auscultation no detect Ineffective Breathing Pattern
sound of breath in right
chest
RR 30x/m
Th/ Punctie Pleura

Subjective : Impaired Gas


Dyspnea Increase capillary hydrostatic pressure Exchange
in the systemic and/or pulmonary
Objective : circulation
RR 30x/m
Impaired Gas Exchange

Subjective : Difficulty breathing Activity Intolerance


Patient complain weak
Objective :
Psychological energy to endure or
Patient looks tired, the
patient is assisted by a complete required or desire daily
husban to do activities activity
such as to ambulate or
move, bathing and Activity intolerance
toileting
Muscles streanght
weakness in lower
extremitas.
Pleural Efusion
Subjective : Patient Acute Pain
complain Chest pain
Objective : Inflammatory processes in the lung
Pain scale 6 tissue

Pain stimuli

C INTERVENTION
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.

Outcome Nursing Interventions Rationale

1 Monitor and record vital signs 1 To gain pt/ SOs trust and
Short Term: After 3
cooperation - To obtain
hours of nursing
2 Assess breath sounds, baseline data
interventions the patient 2 To note for respiratory
respiratory rate, depth and
will demonstrate abnormalities that may
rhythm
appropriate coping indicate early respiratory
behaviors and methods compromise and hypoxia
3 Elevate head of the pt.
3 To promote lung expansion
to improve breathing 4 Provide relaxing environment
4 To promote adequate rest
pattern.
5 Administer supplemental periods to limit fatigue
5 To maximize oxygen
oxygen as ordered
Long term:
6 Assisst client in the use of available for cellular uptake
6 To provide relief of
relaxation technique
After 1 to 2 days of
7 Administer prescribed causative factors
nursing interventions, 7 For the pharmacological
medications as ordered
the patient would be 8 Maximize respiratory effort management of the patients
able to apply techniques with good posture and effective condition
8 To promote wellness
that would improve use if accessory muscles.
9 Encourage adequate rest
breathing pattern and be 9 To limit fatigue
periods between activities
free from signs and 10 To see the effectiveness of
10 Monitoring chest tube : fluid
symptoms of chest tube mounting
production
respiratory distress.

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.

Outcome Nursing Interventions Rationale

1 Monitor and record vital signs 1 To gain pt./SOs trust and


Short term: After 1 2 Monitor respiratory rate, depth and
cooperation - To obtain
hour of nursing rhythm
baseline data
3 Assess pts general condition
interventions, the pt 2 To assess for rapid or
4 Auscultate breath sounds, note
will verbalize shallow respiration that
areas of decreased/adventitious
understanding of the occur because of hypoxemia
breath sounds as well as fremitus
interventions given 5 Elevate head of the pt. and stress
6 Note for presence of cyanosis 3 To note for etiology
to improve patients
7 Encourage frequent position
precipitating factors that can
condition.
changes and deep-breathing
lead to impaired gas
exercises
Long term: exchange
8 Provide supplemental oxygen at
4 To evaluate degree of
lowest concentration indicated by
After 1-2 days of compromise
laboratory results and client 5 To enhance lung expansion
nursing
6 To assess inadequate
symptoms/ situation
interventions, the pt.
9 Review laboratory results systemic oxygenation or
will demonstrate 10 Provide health teaching on how to
hypoxemia
improved ventilation alleviate pts condition 7 To promote optimum chest
11 Administer prescribed medications
and adequate expansion
as ordered 8 To correct/ improve existing
oxygenation of
deficiencies
tissues AEB absence
9 To determine pts
of symptoms of
oxygenation status
respiratory distress. 10 To empower SO and pt
11 For the pharmacological
management of the patients
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.

Outcome Nursing Interventions Rationale

1 Establish Rapport Monitor and 1 To gain clients participation


Short Term: After 3-
record Vital Signs and cooperation in the nurse
4 hours of nursing
patient interaction To obtain
interventions, the
2 Assess patients general condition baseline data
patient will use 3 Adjust clients daily activities and 2 To note for any abnormalities
identified techniques reduce intensity of level. and deformities present within
to improve activity Discontinue activities that cause the body
3 To prevent strain and
intolerance undesired psychological changes
4 Instruct client in unfamiliar overexertion
4 To conserve energy and
Long Term: activities and in alternate ways of
promote safety
conserve energy
After 2-3 days of 5 Encourage patient to have adequate
5 to relax the body
nursing bed rest and sleep
6 Provide the patient with a calm and
interventions, the
6 to provide relaxation
quiet environment
patient will report 7 to prevent risk for falls that
7 Assist the client in ambulation
measurable increase 8 Note presence of factors that could could lead to injury
8 fatigue affects both the
in activity contribute to fatigue
clients actual and perceived
intolerance.
ability to participate in
9 Ascertain clients ability to stand
activities
and move about and degree of
9 to determine current status
assistance needed or use of
and needs associated with
equipment
participation in needed or
10 Give client information that
desired activities
provides evidence of daily or
10 to sustain motivation of client
weekly progress
11 Encourage the client to maintain a
positive attitude 11 to enhance sense of well being
12 Assist the client in a semi-fowlers 12 to promote easy breathing
position
13 to maintain an open airway
13 Elevate the head of the bed
14 Assist the client in learning and
demonstrating appropriate safety 14 to prevent injuries
measures
15 to avoid risk for falls
15 Instruct the SO not to leave the
client unattended
16 Provide client with a positive 16 to help minimize frustration
atmosphere and rechannel energy
17 Instruct the SO to monitor response 17 to indicate need to alter
of patient to an activity and activity level
recognize the signs and symptoms

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.

Outcome Nursing Interventions Rationale

1 Assess patient pain for intensity 1 To identify intensity,


Short Term: After 3-
using a pain rating scale, for precipitating factors and
4 hours of nursing
location and for precipitating location to assist in accurate
interventions, the
factors. Assess the response to diagnosis.
patients pain will 2 To provide
medications every 5 minutes
decrease from 7 to 3 nonpharmacological pain
as verbalized by the management.
3 A quiet environment reduces
patient.
2 Provide comfort measures. the energy demands on the
Long Term: patient.
4 Elevation improves chest
After 2-3 days of expansion and oxygenation.
3 Establish a quiet environment. 5 Tachycardia and elevated
nursing
blood pressure usually occur
interventions, the 4 Elevate head of bed.
with angina and reflect
patient will
compensatory mechanisms
demonstrate 5 Monitor vital signs, especially pulse
secondary to sympathetic
activities and and blood pressure, every 5 minutes
nervous system stimulation.
behaviors that will until pain subsides. 6 Anginal pain is often
prevent the precipitated by emotional
6 Teach patient relaxation techniques
recurrence of pain. stress that can be relieved
and how to use them to reduce
non-pharmacological
stress.
measures such as relaxation.