Page 5 - Pleural Effusion Nursing care plan
P. 5
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Activity Intolerance
Activity intolerance related to oxygen impaired
Assessment
• Clients complain weak, short of breath with effort might and main, difficulty sleeping, fever in
the afternoon or evening accompanied by sweating a lot.
• Found a tachycardia, tachypnea / dyspnea with effort to breathe with a vengeance, changes in
consciousness (in the advanced stage), muscle weakness, pain and stiffness (rigidity).
Goals and outcomes
Client report and demonstrate a measurable increase in tolerance to activity with absence of dyspnea
and excessive fatigue, with vital signs within client’s acceptable range
Nursing Interventions and Rationale
Nursing Interventions Rationale
Assessment
Evaluate client’s response to activity.
Note reports of dyspnea, increased Establishes client’s capabilities and needs and
weakness and fatigue, and changes in facilitates choice of interventions.
vital signs during and after activities.
Interventions
Assist the client in practicing
pulmonary hygiene:
• Clearing bronchial tree by Clearance airway will reduce the oxygen
controlled coughing impairment
• Decreasing viscosity of secretions
via humidity and fluid balance
• Suctioning
Provide a quiet environment and limit Reduces stress and excess stimulation, promoting
visitors during acute phase, as rest
indicated.
Encourage use of stress management Reduces stress and excess stimulation, promoting
and diversional activities as rest
appropriate.
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