Nursing Care Plan for Pleural Effusion

NCP 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. 2. 3. 4. 5.

6.

Activity / rest Symptoms: dyspnea with activity or rest Circulation Signs: Tachycardia, dysrhythmias, heart rhythm Gallop, hypertension / hypotension Ego integrity Signs: fear, anxiety Food / fluid The existence of the installation of central venous IV / infusion 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 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 Care Plan for Pleural Effusion

Definition A pleural effusion is an accumulation of fluid between the layers of tissue that line the lungs and chest cavity. Causes Your body produces pleural fluid in small amounts to lubricate the surfaces of the pleura, the thin tissue that lines the chest cavity and surrounds the lungs. A pleural effusion is an abnormal, excessive collection of this fluid. Two different types of effusions can develop : Transudative pleural effusions are caused by fluid leaking into the pleural space. This is caused by elevated pressure in, or low protein content in, the blood vessels. Congestive heart failure is the most common cause.

Exudative effusions usually result from leaky blood vessels caused by inflammation (irritation and swelling) of the pleura. This is often caused by lung disease. Examples include lung cancer, lung infections such as tuberculosis and pneumonia, drug reactions, and asbestosis.

Symptoms Chest pain, usually a sharp pain that is worse with cough or deep breaths Cough Fever Hiccups Rapid breathing Shortness of breath Source : http://www.nlm.nih.gov/medlineplus Assessment 1. Patient identity At this stage the nurse needs to know about the name, age, gender, home address, religion or belief, ethnicity, languages spoken, education and employment status of patients. 2. Main complaint The main complaint is the main factor that encourages patients to seek help or treatment to the hospital. Usually in patients with acquired pleural effusi complaint form shortness of breath, feeling the weight on the chest, pain due to irritation of the pleura Pleuritic that is sharp and localized, especially when coughing and breathing as well as non-productive cough. Disease History Now Patients with pleural effusi will usually preceded by signs such as cough, shortness of breath, pain Pleuritic, heavy feeling in chest, weight loss and so on. There should also be asked from any complaints that arise. What action has been taken to reduce or eliminate these complaints. Formerly Disease History To ask whether the patient had suffered from lung diseases such as tuberculosis, pneumoni, heart failure, trauma, ascites, and so on. This is needed to determine possible predisposing factors. Family Disease History To ask whether any family members who suffer from diseases that was allegedly the cause of pleural effusi like Ca lung, asthma, pulmonary tuberculosis and others. Psychosocial History Include feelings of illness of patients, how to handle it and how the patient's behavior toward action taken against him.

3.

4.

5.

6.

Nursing Diagnosis Ineffective breathing pattern related to decreased lung expansion secondary to accumulation of fluid in the pleural cavity Nursing Plan Objectives : Patients able to maintain normal lung function Criterion Results : Rhythm, frequency and depth of breathing in the normal range, the chest X-ray examinations did not find any accumulation of fluid, audible breath sounds. Plan of action : Identify the causative factor. Rational: By identifying the causes, we can determine which type of pleural effusi can take appropriate action.

Examine the quality, frequency and depth of breathing, report any changes that occur. Rational: By reviewing the quality, frequency and depth of breathing, we can determine how far the patient's condition changes. Lay the patient in a comfortable position, in a sitting position, with the head of the bed elevated 60 to 90 degrees. Rational: Decrease the diaphragm to expand the chest so the lungs can expand the maximum. Observation of vital signs (temperature, pulse, blood pressure, RR and response of patients). Rational: Improved tachcardi RR and an indication of decline in lung function. Perform auscultation of breath sounds every 2-4 hours. Rational: to determine abnormalities Auscultation of breath sounds in the lungs. Help and teach the patient to cough and breath in effective. Rational: Pressing the painful area when coughing or breathing deeply. Emphasis pectoral muscle and abdominal makes cough more effective. Collaboration with other medical teams to deliver O2 and medicines as well as thorax images. Rational: Giving oxygen may reduce the load and prevent the occurrence of respiratory cyanosis due hiponia. With the thorax images can be monitored the progress of the reduction in fluid and the return of flower power lung.

Nursing Care Plan for Diabetes Mellitus

NCP - Nursing Care Plan for Diabetes Mellitus

Diabetes Mellitus Diabetes mellitus, often simply referred to as diabetesis a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger). There are three main types of diabetes : Type 1 diabetes: results from the body's failure to produce insulin, and presently requires the person to inject insulin. (Also referred to as insulin-dependent diabetes mellitus, IDDM for short, and juvenile diabetes.) Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM. Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses of glucocorticoids, and several forms of monogenic diabetes. All forms of diabetes have been treatable since insulin became available in 1921, and type 2 diabetes may be controlled with medications. Both type 1 and 2 are chronic conditions that usually cannot be cured. Pancreas transplants have been tried with limited success in type 1 DM; gastric bypass surgery has been successful in many with morbid obesity and type 2 DM. Gestational diabetes usually resolves after delivery. Diabetes without proper treatments can cause many complications. Acute complications include hypoglycemia, diabetic ketoacidosis, or nonketotic hyperosmolar coma. Serious long-term complications include cardiovascular disease, chronic renal failure, retinal damage. Adequate treatment of diabetes is thus important, as well as blood pressure control and lifestyle factors such as smoking cessation and maintaining a healthy body weight.en.wikipedia.org

Causes The cause of diabetes depends on the type. Type 2 diabetes is due primarily to lifestyle factors and genetics. Type 1 diabetes is also partly inherited and then triggered by certain infections, with some evidence pointing at Coxsackie B4 virus. There is a genetic element in individual susceptibility to some of these triggers which has been traced to particular HLA genotypes (i.e., the genetic "self" identifiers relied upon by the immune system). However, even in those who have inherited the susceptibility, type 1 diabetes mellitus seems to require an environmental trigger. Signs and Symptoms The classical symptoms of diabetes are polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger). Symptoms may develop rapidly (weeks or months) in type 1 diabetes while in type 2 diabetes they usually develop much more slowly and may be subtle or absent. Prolonged high blood glucose causes glucose absorption, which leads to changes in the shape of the lenses of the eyes, resulting in vision changes; sustained sensible glucose control usually returns the lens to its original shape. Blurred vision is a common complaint leading to a diabetes diagnosis; type 1 should always be suspected in cases of rapid vision change, whereas with type 2 change is generally more gradual, but should still be suspected. People (usually with type 1 diabetes) may also present with diabetic ketoacidosis, a state of metabolic dysregulation characterized by the smell of acetone; a rapid, deep breathing known as Kussmaul breathing; nausea; vomiting and abdominal pain; and an altered states of consciousness. A rarer but equally severe possibility is hyperosmolar nonketotic state, which is more common in type 2 diabetes and is mainly the result of dehydration. Often, the patient has been drinking extreme amounts of sugar-containing drinks, leading to a vicious circle in regard to the water loss. A number of skin rashes can occur in diabetes that are collectively known as diabetic dermadromes.

Nursing Care Plan for Diabetes Mellitus Assessment Family Health History Are there families who suffer from illnesses such as client ? Patient Health History and Previous Treatment How long suffered from DM client, how to handle, get what kind of insulin therapy, how to take the medicine whether regular or not, what is done to cope with illness clients. Activity / Rest: Tired, weak, hard Moves / walking, muscle cramps, decreased muscle tone. Circulation Is there a history of hypertension, AMI, claudication, numbness, tingling in the extremities, ulcers on the feet long healing time, tachycardia, changes in blood pressure Ego Integrity Stress, anxiety Elimination Changes in the pattern of urination (polyuria, nocturia, anuria), diarrhea Food / Fluids Anorexia, nausea, vomiting, do not follow the diet, weight loss, thirst, the use of diuretics. Neurosensori Dizziness, headache, numbness, muscle weakness numbness, paraesthesia, visual disturbances. Pain / Leisure Abdominal strain, pain (is / weight) Respiratory Cough with or without purulent sputum

Security Dry skin, itching, skin ulcer.

Nursing Diagnosis and Nursing Intervention Fluid volume deficient related to osmotic diuresis from hyperglycemia Planning After 8 hours of nursing interventions, the patient will demonstrate adequate hydration. Intervention Monitor orthostatic blood pressure changes. Rational : Hypovolemia may be manifested by hypotension and tachycardia. Assess peripheral pulses, capillary refill, skin turgor, and mucous membrane. Rational : Indicators of level of dehydration, adequacy of circulating volume. Monitor respiratory pattern like Kussmauls respirations and acetone breath. Rational : Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis. Monitor input and output. Note urine specific gravity. Rational : Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy. Promote comfortable environment. Cover patient with light sheets. Rational : Avoids overheating, which could promote further fluid loss. Monitor temperature, skin color and moisture. Rational : Fever, chills, and diaphoresis are common with infectious process; fever with flushed, dry skin may reflect dehydration.

1. Deficient Fluid Volume

Glucose appears in the urine (glycosuria) because the kidney excretes the excess glucose to make the blood glucose level normal. Glucose excreted in the urine acts as osmotic diuretic and causes excretion of increased amount of water, resulting in fluid volume deficit or polyuria.
Assessment Nursing Planning Diagnosi s Nursing Rationale Evaluation Interventio ns

Subjective: (none)

Objective:

elevated temperatur e of 38.4C/axill a increased urine output. sweating of the skin thirst exhaustion weight loss dry skin or mucous membrane

Deficient Short Establish Friendly Short Fluid Term:After 3 rapportTake relationship Term:After 3 Volume of NI, patient and record with patient of NI, patient r/t shall have vital and to be will have intracellu verbalized signsMonitor able to each verbalized lar DHN understanding the others understanding 2 the of causative temperature concernTo of causative DM II factors and obtain factors and purpose of baseline purpose of Assess skin turgor and individual dataTo individual mucous therapeutic monitor therapeutic membranes for changes in interventions interventions signs of and temperatur and dehydration e medications.Lo medications.L ng Term:After ong Encourage the 2 days of NI, Dry skin and Term:After 2 patient to mucous the patient days of NI, the increase fluid membranes patient will shall have intake are signs of have maintained dehydration maintained fluid volume at Administer a functional fluid volume at IVF as ordered To replace level as a functional by the Doctor fluid loss and level as evidenced by prevent individual good Administer evidenced by dehydration skin turgor, individual anti-pyretic as moist mucous prescribed by To replace good skin the Doctor. membrane and electrolytes turgor, moist stable vital and fluid loss mucous signs. membrane To decrease and stable vital signs body

temperature

and will have less occurrence of dehydration.