Page 4 - Pleural Effusion Nursing care plan

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Nursing Interventions Rationale

Interventions

Assess for pain and discomfort. Pain may restrict or limit respiratory effort.

Raise head of bed 45 degrees or more if Allows gravity to assist in lowering the diaphragm
not contraindicated. and provides greater chest expansion.

Promotes lung expansion and slightly increases
Instruct in diaphragmatic deep pressure in the airways, allowing them to remain
breathing and pursed-lip breathing.
open longer.

Encourage ambulation and motility to Promotes tolerance for activities and helps with
the patient. lung expansion and ventilation.

Promote rest and relaxation by
scheduling treatments and activities Avoids overexertion and worsening of condition.
with appropriate rest periods.

Conduct health teaching on the
following: Reduces anxiety; starts appropriate home care
• Illness planning; assists the family in dealing with health-
care system.
• Procedures and related nursing care

Assist the client in practicing
pulmonary hygiene:

• Clearing bronchial tree by Provides basic information for the client and
family that promotes necessary lifestyle changes.
controlled coughing
• Decreasing viscosity of secretions
via humidity and fluid balance

Administer supplemental oxygen. Oxygen administration helps correct hypoxemia.

Evacuates fluid and as well as relieve dyspnea and
Assist in performing thoracentesis.
respiratory distress.

Medicate with analgesics as appropriate Promotes deeper respiration and cough.

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