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Pleural Effusion

Concept Map

Yadira G

on 3 March 2015

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Transcript of Pleural Effusion

Pleural Effusion
Admission Data:

Patient: E.C.
Age: 56
Gender: Female
Ht: 5'4" Wt: 54.5 kg BMI: 20.6
Allergies: NKA, NKDA
Code Status: Full
Date of Admission: 01/19/2015
Assessment: 01/21/2015

Relevant Health History:
Subjective Data:
Nursing Diagnosis

1. Ineffective Breathing Pattern r/t pleural effusion
2. Impaired Gas Exchange r/t pleural effusion and pneumonia
3. Acute Pain r/t pleural effusion
4. Interrupted Family Processes r/t hospitalization
5. Deficient Knowledge r/t pleural effusion disease process, treatment, and prognosis.

Admitting Diagnosis: Pleural Effusion, Dyspnea
VS: BP: 154/83 P: 93 RR: 14 T: 98.5 F O2: 94% 2LPM thru cannula 86% Room Air
Head: No JVD bilaterally. PERRL. Vision impaired. Pt. is blind from left eye. Carotid pulses strong bilaterally. Face is symmetrical. Active pharyngeal reflexed.
Cardiovascular: S1 and S2 auscultated, HR 69, sinus rhythm. Fingers and toes Cap refill of <3 sec bilaterally. Radial, dorsal pedis, posterior tibial pulses equal and strong bilaterally. No edema noted on lower and upper extremities bilaterally. Left forearm AV Fistula, bruit and thrill auscultated.
Respiratory: Sputum is yellow. SatO2 is 94% at 2LPM thru cannula. RR 15. Breath sounds are clear in RUL,LUL, LLL, posterior and anterior. RML and RLL breath sounds are diminished. Respirations are even and unlabored.Pt. complains of chest pain with inspiration, pain level 8. Pt. asks "
Why do I have all that fluid in my lungs?"
Gastro-Active bowel sounds in all four quadrants. Abdomen is non-tender with palpitation.
Skin: Skin is dry and pale. Moist oral mucous membranes. Top and bottom dentures. Dentures were left at home. Braden scale of 21. Skin tugor assessed over sternum, is non-tenting. 20G IV noted on right forearm, NS, 10 mL/hour, skin is intact, no swelling. Long black hair, evenly distributed.
Neuro: Glascow Coma Scale 15.Awake, alert, and oriented x 3. Strong grips, shrugs, and push/pulls bilaterally. Speech is clear. Patient is calm and cooperative. Pt. expresses concern for grandchildren safety for they are home alone. Sensation in upper and lower extremities bilaterally.
Musculoskeletal: Weakness and unsteady gait. Fall precautions in place.

Objective Data:
Diagnostic Tests
WBC 7.75

RBC 2.95 L-Kidney Failure
Hgb 9.5 L-Kidney Failure
Hct 28.7 L-Kidney Failure
MVC 97
MCH 32
MCHC 33.1
RDW 14.6
PLT 216
Percent Neut 74-Current infection with pneumonia
Percent Lymph 14 L-Current infection with pneumonia
Sodium 138
Potassium 5.0
Chloride 100
Carbon Dioxide 30.0
Anion Gap 13
Glucose 179 H-Diabetes Mellitus
BLD Urea Nitrogen 21 H-Elevated due to Kidney Failure
Creatinine 3.4 H-Elevated due to Kidney Failure
Calcium 8.2 L-Low due to Kidney Failure
GFR 14.0
Desired Outcome:
Be free of symptoms of respiratory distress, cough,and yellow sputum, with clear lung sounds by discharge.

Interventions & Rationales:
1. Note respiratory rate, depth, and ease of respirations. Observe for use of accessory muscles, pursed-lip breathing, changes in skin/mucous membranes color.
R: Respirations may be increased as a result of oxygen consumption and energy expenditure and/or respiratory reserve.
2. Auscultate lung sounds every 1-2 hours for air movement and abnormal breath sounds.
R: Lung sounds may be diminished or distant with air trapping.
3. Monitor the client’s behaviors and mental status for the onset of restlessness, agitation, confusion, and extreme lethargy.
R: Changes in behavior and mental status can be early signed of impaired gas exchange.
4. Monitor oxygen saturation continuously using pulse oximetry.
R: An oxygen saturation of <90% indicates significant oxygenation problems.
5.Teach the client relaxation techniques to help reduce stress responses and panic attacks increasing dyspnea.
R: Relaxation therapy can help reduce dyspnea and anxiety.
6. Help the client perform controlled coughing.
R: Controlled coughing makes the cough more forceful and effective.
Not Met. Continue to monitor patient's lung sounds, ABG's, and sputum.
Inpatient Medications
Acute Pain r/t pleural chest pain
AEB: Pt. reports a pain level of 8 with inspiration
Interventions & Rationals:
1. Assess patient pain for intensity using a 1-10 rating scale, for location and for precipitating factors.
R: To identify intensity, precipitating factors and location.
2. Question the client regarding the level of pain that is appropriate to achieve a effective breathing pattern.
R: The pain rating that allows the client to have comfort and appropriate function.
3. Elevate head of bed.
R: Elevation improves chest expansion and oxygenation.
4. Establish a quiet environment.
R: A quiet environment reduces the energy demands on the patient.
5. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
R: Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.
Knowledge Deficit r/t pleural effusion, prognosis, and treatment needs AEB: Pt. stated, " Why do I have all that fluid in my lungs?"
Interventions & Rationals:
1. Explain/ reinforce explanations of disease process.
R: Understanding disease process can lead to improved follow through of treatment plan.
2. Discuss the concept of energy conservation. Encourage resting as needed during activities.
R: Pt. needs to learn self-management skills to reduce dyspnea from fatigue.
3. Reinforce teaching of chest thoracentesis treatment.
R: Provides knowledge of treatment.
4. Discuss importance of regular medical follow-up care and when to notify healthcare professional of changes in condition.
R: Monitoring of the disease process allows for alteration in therapeutic regimen to meet changing needs.
5. Review / reinforce current therapeutic regimen, including use of medications
R: Following medication regimen is essential to progression of recovery and prevention of complications.

Interventions & Rationales:
1. Assess the patient's stress level and coping abilities during the initial nursing assessment and throughout hospitalization.
R: Assessing helps the nurse meet patient's varying needs.
2. Acknowledge the range of emotions and feelings that the patient might be experiencing due to change of health status and interruption in family process.
R: Establish Rapport.
3. Involve family members in the care of the patient.
R: Family focused activities can help families cope better with the hospital experience.
4. Assess for the influence of cultural beliefs,norms, and values on the family's perception of normal functioning.
R: What the family considers normal and abnormal family functioning may be based on cultural perceptions.
5. Assist patient in breaking down problems into manageable parts, to be able to identify support systems .
R: Assist with problem-solving process
Partially met. Patient's daughter is staying with children while mother is hospitalized.
Interventions & Rationales:
1. Note respiratory rate, depth, and ease of respirations. Observe for use of accessory muscles, pursed-lip breathing, changes in skin/mucous membranes color.
R: Respirations may be increased as a result of oxygen consumption and energy expenditure and/or respiratory reserve.
2. Auscultate lung sounds every 1-2 hours for air movement and abnormal breath sounds.
R: Lung sounds may be diminished or distant with air trapping.
3.Note pattern of respirations.
R: A normal respiratory pattern is regular in a healthy adult.
4. Observe color of tongue,oral mucosa,and skin.
R: Cyanosis of the tongue and oral mucosa is central cyanosis and represents a medical emergency.
5. Determine severity of dyspnea using a rating scale of 0-10.
R. Help patients measure their respiratory status.

Evaluation: Not Met. Continue to monitor patient's respiratory status.

Partially Met. Doctor provided an explanation of disease process but patient needs more teaching and repetition of disease process and treatment..

Met. Pt. reported a tolerable chest pain level of 4 by end of shift.
Discharge Planning:
Pt. to follow up with PCP after discharge. X-ray recommended in followup to confirm/deny existence of pleural effusion.
Follow up with cardiologist. Referral to cardiologist made.
Reinforce pt. education with written pamphlets/videos.
Refer patient to community resources (DES - food stamps and cash assistance) to help with childcare needs of grandchildren.

Ackley BJ., & Ladwig G.B. (2006). Nursing Diagnosis Handbook a Guide to Planning Care (7th ed.) St. Louise: Mosby Inc.

Doenges, Marilynn E., Mary Frances Moorhouse, and Alice C. Murr. Nursing Care Plans: Guidelines for Individualizing Client Care across the Life Span. Philadelphia: F.A. Davis, 2010. Print.

Taber, Clarence Wilbur, and Donald Venes. Taber's Cyclopedic Medical Dictionary / Edited by Donald Venes. 21st ed. Philadelphia, Pa: F.A. Davis, 2009. Print.

Vallerand, April Hazard., Cynthia A. Sanoski, and Judith Hopfer Deglin. Davis's Drug Guide for Nurses. 13th ed. Philadelphia: F.A. Davis, 2013. Print.

Van, Leeuwen Anne M., Debra J. Poelhuis-Leth, and Mickey Lynn. Bladh. Davis's Comprehensive Handbook of Laboratory & Diagnostic Tests, with Nursing Implications. 5th ed. Philadelphia, PA: F.A. Davis, 2011. Print.

Ineffective Breathing Pattern r/t Pleural effusion
AEB: dyspnea, diminished lung sounds in RLL, ABG's P02 54.2, decreased vital capacity.
Impaired Gas Exchange r/t pleural effusion and pneumonia AEB: SatO2 86% Room Air, 2 LPM NC, Moderate thick yellow sputum, ABG'S pH 7.452 PO2 54.2 HCO3 28.10 Base Excess 3.80
Pleural effusion is an abnormal amount of fluid in the pleural space, between the visceral and pleural membranes. Normally only a small amount of pleural fluid is present in the pleural space. A buildup of excess pleural fluid (pleural effusion) may be caused by many conditions, such as infection, inflammation, heart failure, or cancer. The accumulation of fluid is due to imbalance in vascular hydrostatic forces in the chest or inflammatory conditions. Signs and symptoms include chest pain, dyspnea, dry or productive cough.
Past Health History:
-Diabetes Mellitus Type 2
-Chronic Renal Failure
-Pleural effusion requiring
3 Ultrasound Thoracentesis in the last year (2014).
Desired Outcome:
Demonstrate improved ventilation and adequate oxygenation of tissues by maintaining a SatO2 of 90% or higher in room air by discharge.
No Allergies to Drugs
B-complex Vitamin C Folic Acid qday
Calcium Acetate TID
Insulin Glargine 10 units qday
Insulin Lispro(Humalog) Slidding Scale
Lisinopril 40mg qday
Zosyn 2.25gm IV

Piggyback q12 hours
Hydralazine 20mg IV PRN
Hydrocodone-Acetaminophen 5/325mg q6hrs PRN
Morphine 4mg/1ml IV q2hours PRN
Lorazepam 1mg/0.5mg IV q4hours PRN
Chest X-ray
Bibasilar infil
Bilateral Pleural Effusions
US Guided Thoracentesis-Lt.Lung 1100ml yellowish fluid aspirated
Chest X-ray
Improved left pleural effusion.
Moderate to large right effusion.Bibasilar Pnuemonia
.Bibasilar atelectasis with consolidation.

pH 7.452 H
PCO2 41.1
PO2 54.2 L
Est SO2 89.6 L
HCO3 28.10 H
Base Excess 3.80 H
FI02 21
PO2/FI02 2.58 L

Pt. came in to ER complaining of SOB, chest pain with inspiration, and cough. Symptoms began one week prior. Pt. was also admitted for dialysis.
Pt. is worried about her 5 grandchildren that are home. She is the caregiver and guardian for all five children. Children are 12, 10, 8, 6, and 5 years old. Pt. wanted to call home to find out if the children went to school. Pt. became worried and concerned after speaking to her grandchildren for one of them wasn't going to school due to not having clean clothes.
Desired Outcome:
Patient will verbalized chest pain reduced to 3-5 by end of shift, using a pain rating scale of 1-10.
Patient's Presenting Signs/Symptoms
Chest Pain (Chief Complaint)
Difficulty Breathing/SOB
Painful Breathing
Dry Cough
Symptoms began 1 week prior to admission
Interrupted Family Processes r/t to hospitalization
AEB: Pt. expresses concern about her grandchildren, she stated "I need to talk to my grandchildren I need to find out if they went to school".Pt. is the only caregiver.
Desired Outcome:
Patient will identify ways to cope effectively and use appropriate support systems by end of shift.
Desired Outcome:

Pt. will be able to verbalize understanding of disease process and treatment by discharge.
56 yr old female -> kidney failure -> HTN -> heart failure -> pleural effusion
By: Yadira Garcia and Cameo Johnson
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