Nursing Care Plan for Pleural Effusion
Nursing Care Plan for Pleural Effusion
Definition
Pleural effusion is buildup of fluid in the pleural space, the primary disease process are rare but usually occurs secondary to other diseases. Effusion may be a clear fluid, which may be a transudate, exudate, or may be blood or pus (Diane C. Baughman, 2000)
Pleural effusion is a collection of fluid in the pleural space that lies between the visceral and parietal surfaces, primary disease process is rare but the disease is usually secondary to other diseases. Normally, the pleural space contains a small amount of fluid (5 to 15ml) serves as a lubricant that allows the pleural surface to move without friction (Suzanne C. Smeltzer, 2002).
Etiology
Barriers resorption of fluid from the pleural cavity, because of the dam as in cardiac decompensation, renal disease, mediastinal tumors, Meigs syndrome (ovarian tumor) and superior vena cava syndrome.
The formation of excess fluid, due to inflammation (tuberculosis, pneumonia, viral), bronchiectasis, abscess subphrenic amoeba that penetrate into the pleural cavity, because the tumor where incoming fluid and bleed due to trauma.
Excess fluid pleural cavity, can be collected in the process neoplastic disease, thromboembolic, cardiovascular, and infection. It is caused by at least one of the four basic mechanisms:
Increased subpleural or lymphatic capillary pressure.
Decrease in colloid osmotic pressure of blood.
The increase in negative intrapleural pressure.
Inflammatory or neoplastic pleural.
Signs and Symptoms
The presence of liquid deposits due to friction resulting in feelings of pain, after quite a lot of liquid pain gone. If a lot of fluid, the patient will be short of breath.
The existence of the cause of disease symptoms such as fever, chills, and pleuritic chest pain (pneumonia), high heat (cocci), subfebril (tuberculosis), a lot of sweat, cough, lots of ripples.
Tracheal deviation away from the place of pain can occur if there is a significant accumulation of pleural fluid.
Physical examination in the state of lying and sitting would be different, because the liquid will move. Affected part will be less engaged in breathing, fremitus weakened (touch and vocals), the region was found dull percussion, sits in a state of liquid surface forming a curved line (Ellis-Damoiseau-line).
Found "Garland triangle", which is the area on the upper part of the tympanic percussion dim line-Damoiseau Ellis-line. Triangle Grocco-Rochfusz, namely the deaf because of fluid pushed to the other side of the mediastinum, the area was found to vesicular auscultation weakened with crackles.
At the beginning and end of audible crackles pleural disease.
Nursing Diagnosis
1. Ineffective breathing pattern related to a decrease in lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, inflammatory process.
2. Pain: Chest related to biological factors (tissue trauma) and physical factors (chest tube installation).
3. Risk for injury related to the injury, chest drainage system, lack of security education / prevention.
4. Knowledge Deficit: the conditions and rules of treatment.
Definition
Pleural effusion is buildup of fluid in the pleural space, the primary disease process are rare but usually occurs secondary to other diseases. Effusion may be a clear fluid, which may be a transudate, exudate, or may be blood or pus (Diane C. Baughman, 2000)
Pleural effusion is a collection of fluid in the pleural space that lies between the visceral and parietal surfaces, primary disease process is rare but the disease is usually secondary to other diseases. Normally, the pleural space contains a small amount of fluid (5 to 15ml) serves as a lubricant that allows the pleural surface to move without friction (Suzanne C. Smeltzer, 2002).
Etiology
Barriers resorption of fluid from the pleural cavity, because of the dam as in cardiac decompensation, renal disease, mediastinal tumors, Meigs syndrome (ovarian tumor) and superior vena cava syndrome.
The formation of excess fluid, due to inflammation (tuberculosis, pneumonia, viral), bronchiectasis, abscess subphrenic amoeba that penetrate into the pleural cavity, because the tumor where incoming fluid and bleed due to trauma.
Excess fluid pleural cavity, can be collected in the process neoplastic disease, thromboembolic, cardiovascular, and infection. It is caused by at least one of the four basic mechanisms:
Increased subpleural or lymphatic capillary pressure.
Decrease in colloid osmotic pressure of blood.
The increase in negative intrapleural pressure.
Inflammatory or neoplastic pleural.
Signs and Symptoms
The presence of liquid deposits due to friction resulting in feelings of pain, after quite a lot of liquid pain gone. If a lot of fluid, the patient will be short of breath.
The existence of the cause of disease symptoms such as fever, chills, and pleuritic chest pain (pneumonia), high heat (cocci), subfebril (tuberculosis), a lot of sweat, cough, lots of ripples.
Tracheal deviation away from the place of pain can occur if there is a significant accumulation of pleural fluid.
Physical examination in the state of lying and sitting would be different, because the liquid will move. Affected part will be less engaged in breathing, fremitus weakened (touch and vocals), the region was found dull percussion, sits in a state of liquid surface forming a curved line (Ellis-Damoiseau-line).
Found "Garland triangle", which is the area on the upper part of the tympanic percussion dim line-Damoiseau Ellis-line. Triangle Grocco-Rochfusz, namely the deaf because of fluid pushed to the other side of the mediastinum, the area was found to vesicular auscultation weakened with crackles.
At the beginning and end of audible crackles pleural disease.
Nursing Diagnosis
1. Ineffective breathing pattern related to a decrease in lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, inflammatory process.
2. Pain: Chest related to biological factors (tissue trauma) and physical factors (chest tube installation).
3. Risk for injury related to the injury, chest drainage system, lack of security education / prevention.
4. Knowledge Deficit: the conditions and rules of treatment.
