Page 3 - Pleural Effusion Nursing care plan
P. 3
CikguOnline
CikguOnline
Ineffective Breathing Pattern
Ineffective breathing pattern related to abnormal accumulation of fluid in the pleural space
Assessment
• Dypnea noted upon assessment
• Nasal Flaring
• Shortness of breath
• Use of accessory muscles to breath
• Orthopnea
• Altered chest excursion
• Decreased minute ventilation
• Decreased vital capacity
• Respiratory rate of 35 cpm
Goals and outcomes
Short term goals:
• After 1 hour of health teaching, client will be able to:
❖ Identify lifestyle changes that may be required in assisting to prevent ineffective
breathing pattern.
❖ Participate in the treatment regimen.
Long term goal:
• After 72 hours of nursing intervention, client will be able to demonstrate normal and effective
respiratory pattern.
Nursing Interventions and Rationale
Nursing Interventions Rationale
Assessment
Monitor for signs and symptoms of Tachypnea, shallow respirations and asymmetric
respiratory distress: chest movement are frequently present because of
• Dypnea discomfort of moving chest wall and/or fluid in
• Decreased of absent breath lung due to a compensatory response to airway
sounds obstruction. Altered breathing pattern may occur
• Cyanosis together with use of accessory muscles to increase
• Shortness of breath chest excursion to facilitate effective breathing.
3
