Concept Mappleural Effusion Medical Diagnosis

CONCEPT MAP PLEURAL EFFUSION Medical Diagnosis Pleural effusion is the abnormal collection of fluid within the parietal and visceral space Clinical Manifestation Symptoms: dyspnea, cough, occasional sharp, non-radiating chest pain that is worse on inhalation Physical examination decreased movement of the chest on the affected side, dullness to percussion, decreased breath sounds over the affected area Empyema: include the manifestations of pleural effusion as well as fever, night sweats, cough, and weight loss. Nursing Diagnosis Ineffective Breathing pattern r/t pain Excess Fluid volume r/t compromised regulatory mechanisms; heart, liver, or kidney failure Acute Pain r/t inflammation, fluid accumulation Nursing Intervention Ongoing monitor: Vital signs, LOC, O2, cardiac rhythm, respiratory status, and urinary output Maintain patency of drainage system such as keep tubing loosely coiled, or tape connections Observe tidaling, air leak, anf fluid levels in water-seal chamber is chest tube drainage is using Patient education - Teaching about deep breathing, ROm, and using incentive spirometry -Teach patient to eat more protein because protein may leaks into fluids -Teach patient about signs that should be notify the HCP as soon as possible Collaborative care - Working collaboratively with the HCP team to provide the chest tube drainage as orders and maintain