Question

Case Scenario for Care Plan A 21 year female reported to the Accident and Emergency Department with severe respiratory distress and chest discomfort. Vital Signs- BP- 141/99 P-124 R-28 Temp-36.4 C, SPO2- 98% RBS- 93mg/dl, UA- Leukocytes +. Patient has nil known comorbidities and is alert and oriented by 3 spheres with a GCS of 15/15. The attending physician noted that the patient presented with decreased air entry to the right lung with creps at right lung base, left lung was clear. CT of Chest/ Abdomen Pelvis was done and it identified Right Pleural Effusion. Chest tube was inserted to the right lung and secured. Drainage of 500mls serous fluid noted. Oscillation noted. Patient was diagnosed with large right sided pleural effusion with chest tube insitu. Intravenous antibiotics, analgesics and intravenous fluids were prescribed for the patient. Patient was placed on 60% venticomponent at 15l/min, strict bed rest and vital sign monitoring q 3omins. Catheterization done and strict input and output charting requested. Upon arrival to ward patient verbalized she felt anxious and complained of breathlessness with and SPO2 of 93%. Patient verbalized to the nurse she also felt a stabbing pain at chest tube insertion site. The physicians’ assessment noted that the patient was breathless upon activity even when having meals and it was also noted that she has been constipated for 2 days.

Instructions

Construct a nursing care plan to manage three (3) actual and (1) potential problems.

Answer 1

A 21 year old female, reported to accident and emergency department with severe respiratory distress and chest discomfort.

Vital Signs-

BP- 141/99, P-124 R-28, Temp-36.4 C,

SPO2- 98%, RBS- 93mg/dl, UA- Leukocytes +
GCS - 15/15

The patient presented with decreased air entry to the right lung with creps at right lung base, left lung was clear.

CT scan revealed right Pleural effusion.

So, A chest tube is inserted and 500ml serous fluid is drained.

Patient was diagnosed with large right sided pleural effusion with chest tube insitu.
When arrived to ward, patient complained breathlessness and stabbing pain at the site of tube insertion. Patient was constipated from last 2 days.

## Pleural effusion is defined as the collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. When this recycling process is interrupted, a pleural effusion can result.

In this case, pleural effusion is could be due to increase in capillary permeability.

* Nursing care plans for problems -

Actual Problems - breathlessness because of pleural effusion, pain, constipation.

Potential problem could be infection at the site of tube insertion.

* Care plan -

Subjective cues - “It feels like one can’t get enough air when breathe.”

Objective cues -

• 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

Nursing Diagnosis with Rationale

Ineffective breathing pattern related to abnormal accumulation of fluid in the pleural space

Rationale

Normally, the pleural space is filled with fluid amounting 5-15 mL to provide lubrication of pleural surface and prevent friction. In pleural effusion, an abnormal volume of fluid collects in the pleural space, causing pain and shortness of breath. The ventilatory effort is insufficient to bring in enough oxygen or to get rid of sufficient amounts of carbon dioxide. Thus, potential nursing diagnosis for the client would be ineffective breathing pattern.

Objectives

Long term goal:

After 72 hours of nursing intervention, client will be able to demonstrate normal and effective respiratory pattern.

Short term goals:

After 1 hour of health teaching, client will be able to:

1. Identify lifestyle changes that may be required in assisting to prevent ineffective breathing pattern.
2. Participate in the treatment regimen.

Interventions

1. Monitor for signs and symptoms of respiratory distress:
   • Dypnea
   • Decreased of absent breath sounds
   • Cyanosis
   • Shortness of breath
2. Assess for pain and discomfort.

Independent:

Measures to improve breathing pattern

1. Raise head of bed 45 degrees or more if not contraindicated.
2. Instruct in diaphragmatic deep breathing and pursed-lip breathing.
3. Encourage ambulation and motility to the patient.
4. Promote rest and relaxation by scheduling treatments and activities with appropriate rest periods.

1. Conduct health teaching on the following:
   • Illness
   • Procedures and related nursing care

Assist the client in practicing pulmonary hygiene:

• • Clearing bronchial tree by controlled coughing
  • Decreasing viscosity of secretions via humidity and fluid balance

Dependent    

1. Administer supplemental oxygen.
2. Assist in performing thoracentesis.
3. Medicate with analgesics as appropriate

Rationale for Intervention

1. Pleural effusion can be a potential life-threatening condition. Careful assessment provides for early recognition and intervention for problem.
2. Pain may restrict or limit respiratory effort.
3. Allows gravity to assist in lowering the diaphragm, and provides greater chest expansion.
4. Promotes lung expansion and slightly increases pressure in the airways, allowing them to remain open longer.
5. Promotes tolerance for activities and helps with lung expansion and ventilation.
6. Avoids overexertion and worsening of condition.
7. Reduces anxiety; starts appropriate home care planning; assists the family in dealing with health-care system.
8. Provides basic information for the client and family that promotes necessary lifestyle changes.
9. Oxygen administration helps correct hypoxemia.
10. Evacuates fluid and as well as relieve dyspnea and respiratory distress.
11. Promotes deeper respiration and cough

For pain NSAIDs and antibacterial for infection.