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Pleural Effusion - Assessment and Nursing Diagnosis

Pleural effusion is a medical condition where there is an excessive accumulation of fluid in the lungs, particularly in the pleural space. This fluid is responsible for lubricating the lungs so that they do not experience friction from rubbing against the ribs or other components of the thoracic cavity. Normally, the space around the lungs contains 10-15 milliliters of this fluid.

There are types of pleural effusion, depending on what is causing the issue. These include:

Hemothorax : This occurs when blood builds up in the chest cavity. It is most often due to injury
Hydrothorax : This is the general term for when any fluid accumulates in the chest cavity.
Pneumothorax : This condition arises when the entire lung collapses, which can be the result of pressure from fluid buildup.
Chylothorax : This happens when blood or pleural fluid remains in the thoracic cavity. While this can also be attributed to injury, it is most often related to lymphoma, or cancer of the lymph nodes.


Assessment for Pleural Effusion

1. Systemic Examination

a) Cardiovascular System
Hypotension, increased pulse, temperature sometimes rose.

b) Respiratory System
From this system, the assessment needs to be done related to pleural effusion is dyspnea, tachypnea, cough, fremitus focal weakness, chest wall is more convex on the side that contains fluid.

c) Digestive System
On the client with pleural effusion usually found loss of appetite, nausea, vomiting, hyperactive bowel sounds.

e) Musculoskeletal System
Physical weakness, prefer to lay on the direction that contains fluid.

f) Integumentary System
Dry skin, increased skin temperature, poor turgor.


2. Pattern of Daily Activities
That needs to be studied in daily activities are:
  • Personal hygiene: Due to a decrease in the ability or increased need help doing everyday activities.
  • Nutrition: There is a change and a problem in meeting the nutritional needs due to the tightness and lack of appetite.
  • Elimination: No problem.
  • Activities and sports: On the client with pleural effusion occurs fatigue, weakness, malaise, inability to perform daily activities because of difficulty breathing, fatigue or activity intolerance. Can not exercise because of pain due to tightness WSD installation actions.
  • Rest and sleep: There was difficulty sleeping at night due to coughing, tightness, pain, fever and sweating.


3. Psychological Data
  • Status of emotions: emotional instability can be found facing the disease.
  • The concept of self: changes in self-concept for fear of disease, negative views of themselves, due to the changing role of dependence.
  • Coping patterns: what is being done to overcome the problem client is maladaptive actions and to whom the client to ask for help or tell me if there is a problem.


4. Social Data
Behavior occurs withdraw from social interactions due to the inability to communicate.

5. Spirituality Data
Difficulty to perform the religious obligations because of illness and limited activity.


6. Diagnostic examination
According Doenges et al (2002) Diagnostic examination consists of:
  • Chest X-ray: to declare lung hyperinflation, flattening of the diaphragm, increased retrosternal air area.
  • Lung Function Tests: performed to determine the cause of dyspnea, to determine whether the abnormal function is obstruction or retraction.
  • Blood gas analysis: estimating progression of chronic disease processes.
  • Blood chemistry: to convince deficiency and emphysema primary diagnosis.
  • Sputum cultures to determine the presence of infection, identify the pathogen, sitolitik examination to determine malignancy or allergic disorders.
  • ECG right axis deviation, P wave elevation, atrial dysrhythmias, P wave elevation leads I, III, aVF, ventricular QRS axis.


7. Care and Treatment
Management of pulmonary tuberculosis disease is the provision of a high-calorie diet and high protein, WSD installation.


Nursing Diagnosis for Pleural Effusion

According Doenges et al (2002), nursing diagnoses that appear in patients with pleural effusion is:

1. Acute pain r / t surgical action (WSD).

2. Ineffective airway clearance r / t inflammatory process and secret accumulation in the respiratory tract.

3. Imbalanced Nutrition: Less Than Body Requirements r / t lack of food intake.

4. Activity intolerance r / t physical weakness

5. Knowledge Deficit: the conditions, rules and precautionary measures r / t the wrong interpretation of the cognitive limitations of the information, the information is inadequate / incomplete information.

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