6 Nursing Diagnosis for Pleural Effusion

Pleural Effusion


Definition

Pleural effusion is a condition where there is a buildup of fluid in the pleural cavity between the parietal pleura and visceral pleura can be fluid transudate or exudate fluid.


Etiology

Based on the type of fluid that is formed, divided into the pleural fluid transudate, exudate and hemorrhagic.
  • Transudate can be caused by congestive heart failure (left heart failure), nephrotic syndrome, ascites (due to hepatic cirrhosis), superior vena cava syndrome, tumors, Meigs syndrome.
  • Exudate caused by infection, tuberculosis, etc., preumonia, tumors, lung infarct, radiation, collagen diseases.
  • Hemorrhagic effusion can be caused by tumors, trauma, pulmonary infarction, tuberculosis.
Based on the location of the liquid is formed, effusions were divided into unilateral and bilateral. Unilateral effusion have no specific connection with the cause of disease but bilateral effusion is found in the following diseases : congestive heart failure, nephrotic syndrome, ascites, pulmonary infarction, systemic lupus erythematosus, tumors and tuberculosis.

Pathophysiology

Under normal circumstances there is only 10-20 ml of fluid in the pleural cavity. The amount of fluid in the pleural cavity remains, due to the hydrostatic pressure of the parietal pleura by 9 cm H2O. Pleural fluid accumulation can occur if the colloid osmotic pressure decreases, for example in patients with hypoalbuminemia and increased capillary permeability due to any inflammatory process or a neoplasm, increased hydrostatic pressure due to heart failure and intra- pleural negative pressure in case of pulmonary atelectasis (Alsagaf, Mukti, 1995).

Pleural effusion occurs means of collecting a large amount of free fluid in the pleural cavity. Possible causes of effusion among others ; (1) the inhibition of lymphatic drainage of the pleural cavity, (2) heart failure that causes pulmonary capillary pressure and peripheral pressure becomes very high, giving rise to excessive transudation of fluid into the pleural cavity (3) Plasma colloid osmotic pressure greatly decreased, so also allows transudation fluid overload (4) infection or inflammation of any cause whatsoever on the pleural surface of the pleural cavity, which solves the capillary membrane and allows the flow of plasma proteins and fluid into the cavity rapidly (Guyton and Hall, 1997).


Assessment

The data were collected or studied include :

a. Patient identity
At this stage the nurse needs to know about the name, age, gender, home address, religion or belief, ethnic groups, language used, education and employment status of patients.

b. Main complaints
The main complaints are the main factors of patients to seek care or treatment to the hospital. Usually in patients with pleural effusion obtained complaints of shortness of breath, heaviness in the chest, pleuritic pain due to irritation of the pleura that is both sharp and localized primarily during coughing and breathing as well as non- productive cough.

c . History of present illness
Patients with pleural effusion will usually be preceded by signs such as cough, shortness of breath, pleuritic pain, heaviness in the chest, weight loss and so on. It should be also asked that began when a complaint arises. What action has been taken to reduce or eliminate these grievances.

d. Past medical history
It should be asked whether the patient had been suffering from lung diseases such as tuberculosis, pneumonia, heart failure, trauma, ascites, and so on. It is necessary to determine possible predisposing factors.

e. Family history of disease
Needs to be asked whether there are family members who suffer from diseases that are suspected as the cause of pleural effusion such as lung cancer, asthma, pulmonary tuberculosis, and so forth.

f. psychosocial history
Includes feelings of the patient against the disease, how to cope, and how the patient's behavior to the actions taken against themselves.


Some nursing diagnoses that may arise in patients with pleural effusion include:

1. Ineffective breathing pattern related to the decline in lung expansion secondary to the buildup of fluid in the pleural cavity (Tucleer Susan Martin, et al, 1998).

2. Imbalanced Nutrition Less Than Body Requirements related to an increase in metabolism, digestion appetite of respiratory failure secondary to suppression of abdominal structure (Barbara Engram, 1993).

3. Anxiety related to the threat of death imaginable (inability to breathe).

4. Disturbed Sleep Pattern related to persistent cough and shortness of breath as well as changes in the atmosphere (Barbara Engram).

5. Activity Intolerance related to fatigue (poor physical state) (Susan Martin Tucleer, et al, 1998).

6. Knowledge Deficit : about the condition , treatment rules related to lack of information displayed (Barbara Engram, 1993).

Activity Intolerance - Nursing Care Plan for Pleural Effusion

Nursing Diagnosis for for Pleural Effusion : Activity Intolerance related to fatigue ( poor physical state ) .

Goal : Patient is able to carry out activities as optimal as possible .

Outcomes :
Fulfillment optimal activity , the patient looks fresh and vibrant , personal hygiene patient enough .

Interventionas :

1 Evaluation of the patient's response during the move , record the complaint and the level of activity and a change in vital signs .
Raasional : Knowing the extent of the patient's ability to perform the activity .

2 Help the patient to meet their needs .
Rationale : Encourage the patient to practice actively and independently .

3 Monitor the patient while doing the activity .
Rationale : Provide education to patients and families in the subsequent treatment .

4 Involve the family in patient care .
Rationale : a sign of the patient's weakness has not been able to move fully .

5. Explain to patients about the need for a balance between activity and rest .
Rationale : Rest need to lower the metabolic requirements .

6 Motivation and monitor the patient to perform activities gradually.
Rational : regular activity and gradually will help restore the patient to normal conditions .

Disturbed Sleep Pattern - NCP for Pleural Effusion


Nursing Care Plan for Pleural Effusion

The gravity of the pleural effusion is determined by the amount of fluid, the rate of formation fluids and pressure levels in the lungs. If large effusion, lung expansion will be disrupted and the patient will experience shortness of breath, chest pain, non- productive cough even lung collapse will occur and there will consequently respiratory failure.

The conditions mentioned above are not uncommon cause of death in patients with pleural effusion. Various nursing problems arising in actual and potential problems due to pleural effusion include Disturbed Sleep Pattern, Impaired Gas Exchange, Fear / Anxiety and others .

Nursing Diagnosis : Disturbed Sleep Pattern

Goal : There was no disruption of sleep patterns and rest requirements are met.

Outomes : The patient will :
  • no shortness of breath,
  • can sleep comfortably without experiencing interference,
  • can easily fall asleep within 30-40 minutes and the patient rest or sleep within 3-8 hours per day.

Interventions and Rational :

1. Give the position as comfortable as possible for patients.
Rasonal : semi-Fowler's position or a pleasant position will facilitate the circulation of O2 and CO2.

2. Determine the motivation habits before bedtime in accordance with the habits of patients before treatment.
Rationale : Changing patterns of habitual bedtime will disrupt the sleep process.

3. Instruct the patient to relaxation exercises before bed.
Rationale : Relaxation can help overcome sleep disorders.

4. Observation cardinal symptoms and the patient's general condition.
Rationale : Observations cardinal symptoms in order to determine changes in the patient's condition.

Fear / Anxiety - Nursing Care Plan for Pleural Effusion

Pleural effusion is a clinical manifestation that can be found in approximately 50-60 % of patients with primary pleural malignancies. While 95 % of cases of mesothelioma ( pleural primary malignancies) can be accompanied by pleural effusion and approximately 50 % of breast cancer patients will eventually experience pleural effusion.

Incidence of pleural effusion is quite high especially in patients with malignancy if not administered properly it will reduce the quality of life of sufferers and increasingly burdensome condition of the patient. The lungs are part of the respiratory system is very important, in this organ disorders such as pleural effusion can cause respiratory problems and even can affect the cardiovascular system that can work ended in death.

Improving the condition of patients with pleural effusions requiring appropriate treatment by health workers, including nurses as providers of nursing care in hospitals. For that, the nurse needs to learn about the concept and management of pleural effusions and nursing care in patients with pleural effusion. So in this paper will discuss how the nursing care of patients with pleural effusion.

Nursing Diagnosis for Pleural Effusion : Fear / Anxiety related to the threat of death imaginable (inability to breathe).

Goal : Patient is able to understand and accept the situation so there is no anxiety.

Outcomes : The patient will :
  • Being able to breathe normally , able to adapt to the situation.
  • Non-verbal responses seem more relaxed and at ease, breath regularly with a frequency 16-24 times per minute, pulse 80-90 times per minute.


Interventions and Rationale :

1. Provide a pleasant position for the patient. Usually with a semi -Fowler. Explain about the disease and diagnosis.
Rationale: The patient is able to receive and understand the circumstances that might be used in the treatment of co-operation.

2. Teach relaxation techniques.
Rationale : Reduce muscle tension and anxiety.

3. Help in finding the source of the existing coping.
Rationale : The use of existing sources of coping constructively very helpful in dealing with stress.

4. Maintain a trusting relationship between the nurse and the patient.
Rationale : The relationship of mutual trust helps the therapeutic process.

5. Assess the factors that cause anxiety.
Rationale : Appropriate action is required to deal with the problems facing clients and build trust in reducing anxiety.

6. Help the patient recognize and acknowledge a sense of anxiety.
Rational : Anxiety is an emotion that effect when they are well identified, disturbing feelings be known.

Risk for Infection - NCP for Anemia

Nursing Care Plan for Anemia

Nursing Diagnosis : Risk for Infection

Definition : Increased risk of entry of pathogenic organisms.

Risk factors :
  • Invasive procedures.
  • Insufficient awareness to avoid exposure to pathogens.
  • Trauma.
  • Tissue damage and increased environmental exposure.
  • Rupture of amniotic membranes.
  • Pharmaceutical agents (immunosuppressants).
  • Malnutrition.
  • Increased exposure to environmental pathogens.
  • Imonusupresi.
  • Imum ketidakadekuatan made.
  • Inadequate secondary defenses (decreased hemoglobin , Leukopenia , suppression of inflammatory response).
  • Inadequate primary defenses (broken skin, traumatized tissue, decrease in ciliary, static body fluids, secretions changes in pH, changes in peristalsis).
  • Chronic disease.
Goal : increase the client 's immune status .

Outcomes :
  • Free from signs and symptoms of infection.
  • Demonstrated ability to prevent infection.
  • The number of leukocytes within normal limits.
  • Demonstrate healthy behavior.

NIC :

Infection Control
  • Clean up the environment after use for other patients.
  • Maintain isolation techniques.
  • Limit visitors when necessary.
  • Instruct visitors to wash their hands when leaving the visit and after visiting a patient.
  • Use antimicrobial soap for hand washing.
  • Wash hands before and after each nursing action.
  • Use suit , gloves as protective gear.
  • Maintain aseptic environment during the installation of equipment.
  • Change the location of the peripheral IV and central line and dressing in accordance with the general instructions.
  • Use intermittent catheters to decrease bladder infection.
  • Increase the intake of nutrients.
  • Provide antibiotic therapy if necessary.
Infection Protection
  • Monitor signs and symptoms of systemic and local infections.
  • Monitor granulocyte count, WBC.
  • Monitor susceptibility to infection.
  • Limit visitors.
  • Filter visitors to infectious diseases.
  • Partahankan aspesis technique in patients who are at risk.
  • Maintain isolation techniques if necessary.
  • Give the skin of the treatment area epidema.
  • Inspection of skin and mucous membranes of the redness, heat, drainage.
  • Inspection of the condition of the wound / incision surgery.
  • Encourage enter adequate nutrition.
  • Encourage fluid intake.
  • Instruct the break.
  • Instruct the patient to take antibiotics as prescribed.
  • Teach the patient and family the signs and symptoms of infection.
  • Teach how to avoid infection.
  • Report suspicion of infection.
  • Report positive cultures.

Anemia - Nursing Care Plan

Anemia Definition

Anemia is characterized by levels of hemoglobin (Hb) and red blood cells (erythrocytes) is lower than normal. If the hemoglobin level is less than 14 g / dl and erythrocyte less than 41 % in men, then a man is said to be anemic. Similarly in women, women with hemoglobin levels less than 12 g / dl and erythrocyte less than 37 %, then the woman was said to be anemic. Anemia is not a disease, but rather a reflection of the state of a disease or disorder caused by the body's functions. Physiologically anemia occurs when there is a shortage of hemoglobin to carry oxygen to the tissues.

Anemia was defined as a decrease in the volume of red blood cells or hemoglobin level to below the range of accepted values ​​for healthy people. Anemia is a symptom of an underlying condition, such as loss of blood components, elements inadequate or lack of nutrients needed for the formation of blood cells, resulting in decreased oxygen-carrying capacity of the blood, and there are many types of anemia with different causes.

Etiology
  1. Hemolysis (erythrocytes easily broken).
  2. Bleeding.
  3. Bone marrow suppression (eg by cancer).
  4. Nutrient deficiency (nutritional anemia), including iron deficiency, folic acid, pyridoxine, vitamin C and copper.

According to various sources the causes of anemia include:
  1. Less consumption of foods containing iron, vitamin B12, folic acid, vitamin C, and the elements necessary for the formation of red blood cells.
  2. Excessive menstrual blood. Women who are menstruating prone to iron deficiency anemia when much menstrual blood and not enough iron stores.
  3. Pregnancy. Pregnant women are prone to anemia because the fetus to absorb iron and vitamins for growth.
  4. Certain diseases. Diseases that cause continuous bleeding in the digestive tract such as gastritis and appendicitis can lead to anemia.
  5. Certain drugs. Several types of medications can cause stomach bleeding (aspirin, anti- inflammatory, etc.). Other drugs can cause problems in the absorption of iron and vitamins (antacids, birth control pills, antiarthritis, etc.).
  6. Retrieval operation of part or all of the stomach (gastrectomy). It can cause anemia because the body absorbs less iron and vitamin B12.
  7. Chronic inflammatory diseases such as lupus, rheumatoid arthritis, kidney disease, thyroid gland problems, some types of cancer and other diseases can cause anemia because they affect the process of the formation of red blood cells.
  8. In children, anemia can occur due to hookworm infection, malaria, or dysentery that caused a severe shortage of blood.

Pathophysiology

The presence of an anemia marrow reflects the existence of a failure or loss of red blood cells or both. Marrow failure (for example, reduced erythropoiesis) can occur as a result of nutritional deficiencies, toxic exposure , tumor invasion or other unknown causes.

Red blood cells can be lost through bleeding or hemolysis (destruction).
Red blood cell lysis (dissolution) occurs primarily in phagocytic cells or in the reticuloendothelial system, mainly in the liver and spleen. Byproducts of this process is bilirubin that would enter the bloodstream. Any increase in red blood cell destruction (hemolysis) immediately reflected by an increase in plasma bilirubin (normal concentration of ≤ 1 mg / dl, levels above 1.5 mg / dl result in jaundice in the sclera).

If the destruction of red blood cells in the circulation experience, (in hemolytic disorders) then it will appear in the plasma hemoglobin (hemoglobinemia). If the plasma concentration exceeds the capacity of plasma haptoglobin ( protein binding to free hemoglobin ) to bind everything, hemoglobin diffuses in the renal glomerulus and into the urine (hemoglobinuria).

Conclusions about whether an anemia in patients caused by destruction of red blood cells or red blood cell production is not sufficient usually be obtained on the basis of : 1 . reticulocyte count in the blood circulation ; 2 degree of the proliferation of young red blood cells in the bone marrow and maturation ways, as seen in the biopsy ; and presence or absence of hyperbilirubinemia and hemoglobinemia.


Signs and Symptoms
  1. Weak, tired, lethargic and tired.
  2. Often complain of headache and dizziness.
  3. Further symptoms such as eyelids, lips, tongue, skin and palms became pale. Pale because of lack of blood volume and hemoglobin, vasoconstriction.
  4. Tachycardia and heart murmur (an increase in blood flow velocity) Angina (chest pain).
  5. Dyspnea, shortness of breath, tired quickly when activity (reduced O2 delivery).
  6. Headache, weakness, tinnitus (ringing in the ears) illustrates the reduced oxygenation of the CNS
  7. Severe anemia GI disorders, and CHF (anorexia, nausea, constipation or diarrhea).

Complication 
  • Heart failure.
  • Seizures.
  • Poor muscle development (long-term).
  • Concentration decreases.
  • The ability to process information that is heard decrease.

Test
  • Hemoglobin concentration, hematocrit, red blood cell indices, white blood cell studies, the levels of Fe, iron binding capacity measurement, folate, vitamin B12, platelet count, bleeding time, prothrombin time, and partial thromboplastin time.
  • Bone marrow aspiration and biopsy. Unsaturated iron - binding capacity of serum.
  • Diagnostic assay to determine the presence of acute and chronic diseases as well as the source of chronic blood loss.

Nursing Care Plan for Anemia

Nursing Diagnosis for Anemia
  1. Ineffective Cerebral Tissue Perfusion related to changes in the oxygen bond with hemoglobin, decrease in hemoglobin concentration in the blood.
  2. Imbalance nutrition less than body requirements related to inadequate food intake .
  3. Self-care deficit related to weakness
  4. Risk for infection related to inadequate secondary defenses (decreased hemoglobin )
  5. Activity intolerance related to imbalance between supply and demand of oxygen .
  6. Impaired gas exchange related to ventilation perfusion .
  7. Ineffectivene breathing pattern related to fatigue .
  8. Fatigue related to anemia .

Disturbed Sleep Pattern - NCP for Lower Back Pain

Nursing Care Plan for Lower Back Pain (LBP)


Low Back Pain is chronic pain in the lumbar, usually caused by a recessive the vertebral muscles, herniation and regeneration of the nucleus pulposus, osteoarthritis of the lumbar sacral spine (Brunner, 1999).

Causes
  • Changes in posture usually because primary and secondary trauma. Primary trauma such as : Trauma spontaneously, for example accidents. Secondary trauma such as : HNP, osteoporosis, spondylitis, spinal stenosis, spondylitis, osteoarthritis.
  • Lumbosacral ligament instability and muscle weakness.
  • Procedures degeneration in elderly patients.
  • The use of heels that are too high.
  • Obesity.
  • Lifting weights the wrong way.
  • Sprain.
  • Prolonged exposure to vibration.
  • Gait.
  • Smoking.
  • Sitting too long.
  • Less exercise (by sport).
  • Depression / stress.
  • Sports (golp, tennis, soccer).

Risk Factors of Low Back Pain

Physiological risk factors.
  • Age ( 20-50 years ).
  • Lack of physical exercise.
  • Less anatomical postures.
  • Obesity.
  • Severe scoliosis.
  • HNP.
  • Spondylitis.
  • Spinal stenosis (narrowing of the spine).
  • Osteoporosis.
  • Smoking.
Environment risk factors .
  • Sitting too long.
  • Prolonged exposure to vibration.
  • Sprains or twisted.
  • Sports ( golf, tennis, gymnastic, and football).
  • Vibration old.

Psychosocial risk factors.
  • Inconvenience of work.
  • Depression.
  • Stress.

Clinical Manifestations

Changes in gait.
  • Walking stiff.
  • No bias play back.
  • Lame.
Innervation
  • When tested with a light and a touch of the pin, the patient felt a sensation on both limbs, but having a stronger sensation in areas that are not stimulated.
  • Uncontrolled defecation and urination.

Pain.
  • Acute and chronic back pain for more than two months.
  • Pain when walking with the heel.
  • Pain in the muscles.
  • Lower back pain gets spread legs.
  • Painful heat on the back of the thigh or calf.
  • Severe pain in the feet increases.

Nursing Care Plan for Lower Back Pain

Nursing Diagnosis : Disturbed Sleep Pattern related to pain, discomfort

Defining characteristics :
  • Patients appear to endure pain ( moaning, grinning )
  • Patients express can not sleep because of pain .

Goal : sleep needs can be met.

Outcomes :

Sleep
  • The amount of time to sleep enough.
  • Normal sleep patterns.
  • Enough quality sleep.
  • Sleep on a regular basis.
  • Not often awakened.
  • Vital signs within normal limits.
Rest
  • Adequate rest.
  • The quality of a good rest.
  • Enough physical rest.
  • Enough psychic rest.
Anxiety control
  • Adequate sleep.
  • There is no physical manifestation.
  • No behavioral manifestations.
  • Seeking information to reduce anxiety.
  • Using relaxation techniques to reduce anxiety.
  • Interact socially.

Interventions for Lower Back Pain

Improved sleep / Sleep Enhancement
  1. Assess patterns of sleep / activity patterns.
  2. Encourage clients to sleep on a regular basis.
  3. Explain the importance of adequate sleep during illness and treatment.
  4. Monitor sleep patterns and note the physical, psychosocial disrupt sleep.
  5. Discuss on the client and family about the technical improvement of sleep patterns.

Environmental management
  1. Limit visitors.
  2. Take care of the noisy environment.
  3. No nursing action when clients sleep.

Anxiety Reduction
  1. Explain all procedures including the feelings that may be experienced while undergoing the procedure.
  2. Give the object that can provide a sense of security.
  3. Speaking slowly and calmly.
  4. Build a trusting relationship.
  5. Listen attentively clients.
  6. Create an atmosphere of mutual trust.
  7. Encourage parents to express feelings, perceptions and anxiety verbally.
  8. Provide equipment / entertaining activities to reduce tension.
  9. Suggest to use relaxation techniques.
  10. Provide a quiet environment.
  11. Limit visitors.

NANDA Nursing