About
Collection of fluid in the pleural space, usually secondary to another problem.
Assess
Decreased to absent breath sounds, pulmonary edema, crackles, underlying disease process such as pneumonia or congestive heart failure, dyspnea, decreased pulse-oximetry.
Complications
Pulmonary edema, end-stage heart failure, recurrent effusions may be indicative of cancerous process.
Diagnosis
- Impaired gas exchange related to decreased surface for air exchange at the alveoli-capillary membrane.
- Ineffective breathing pattern related to increased fluid accumulation in pleural cavity.
- Impaired comfort related to difficulty on breathing.
Goals
- The client will have a decrease in shortness of breath.
- The client will have clear breath sounds upon auscultation.
- The client will be free from infection.
Interventions
- Assess vital signs, pulse oximetry, lung sounds, and pain levels frequently.
- Prepare patient for a thoracentesis as indicated.
- Teach patient what to expect before, during, and after thoracentesis as indicated.
- Maintain chest tube drainage system, if indicated.
- Monitor drainage from chest tube drainage systems, if indicated.
- Assess for equal bilateral chest expansion.
- Administer pain medicine as ordered by a physician.
- Teach client measures to prevent infection or complication from injuries.
- Teach client to reposition frequently and to perform coughing and deep breathing exercises.
- Teach client signs and symptoms of infection or complications to report immediately to health care provider.
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