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(PATIENT's CASE)
History of COPD; Chronic obstructive pulmonary
disease(COPD) is characterized by lunginflammationthat
persists after smoking cessation. Thisinflammationis
heterogeneous butthekeyinflammatorycell types involved are
macrophages, neutrophils and T cells.
(PATIENT's CASE)
Cigarette smoke promotes malignant pleural effusion by
enhancing timor-associated inflammation
PRE-DISPOSING
FACTORS
weak pump,
it backs up
pulmonary
vessels
Medical
Diagnosis
Heart
Failure
Cirrhosis
Nephrotic
Syndrome
Trauma
Malignancy
1st Mechanism;
Transudative
Inflammatory
Conditions
Infection
1st Mechanism;
Exudative
Pressure is
increased
Damage
during
surgery
Tumors in the
mediastinum
2nd Mechanism;
Lymphatic/Chylothorax
Pleural
Effusion
PATHOPHYSIOLOGY
TWO MECHANISMS
INCREASED
PLEURAL
FLUID
FORMATION
DIAGNOSTIC
CLINICAL
MANIFESTATIONS
NURSING
DIAGNOSIS
TRANSUDATIVE
INCREASED
HYDROSTATIC
PRESSURE
EXPECTED
OUTCOMES
Forces fluid
into pleural
space
NURSING
INTERVENTIONS
DECREASED
FLUID
CLEARANCE
Thoracic duct is
disrupted
EXUDATIVE
Inflammation
of the
pulmonary
capilliary
DECREASED
ONCOTIC
PRESSURE
Lymphatic fluid
accumulates
Larger spaces of the endothelial
cells allows more fluid, imunne
cells and large proteins like
Lactate-dehygrogenase to leak
Solutes like
albumin
cannot cross
capillary
by osmosis,
fluid moves
from low to
high solute
concentrations
FLUID
LEAKS INTO
PLEURAL
SPACE
PAIN RATING
SCALE
SMALL EFFUSIONS
may do unnoticed
PLEURAL
ASPIRATE
Identify the learner: the patient, family, significant other, or
caregiver.
Assess ability to learn or perform desired health-related care.
Assess motivation and willingness of patient to learn.
Determine priority of learning needs within the overall care
plan.
Allow the patient to open up about previous experience and
health teaching.
Observe and note existing misconceptions regarding material
to be taught.
Acknowledge racial/ethnic differences at the onset of care.
Include the patient in creating the teaching plan, beginning
with establishing objectives and goals for learning at the
beginning of the session.
Consider what is important to the patient.
Involve patient in writing specific outcomes for the teaching
session, such as identifying what is most important to learn
from their viewpoint and lifestyle.
Explore reactions and feelings about changes.
Give information with the use of media. Use visual aids like
diagrams, pictures, videotapes, audiotapes, and interactive
Internet websites
82%
RESPIRATORY
RATE
30 cpm
diminished breath sounds in
right side (infra axilary)
INTERVIEW
DEFICIENT KNOWLEDGE RELATED TO
POSSIBLE PROCEDURE
is performed fordiagnosisor treatment of a
disease and allows doctors to visualize,
biopsy or remove tissue as needed.
PERCUSSION
mild dullness over the (R)
chest (infra axillary)
PALPATION
asymmetrical chest expansion,
tenderness at the right side of
chest
CHEST X-RAY
IMAGING
(R) Fluid filled
BLOOD PRESSURE
90/60 mmHg
HEART RATE
120 bpm
THORACOTOMY (to
be done)
Not an active case
2. ACUTE PAIN RELATED TO PLEURISY
1. INEFFECTIVE BREATHING PATTERN
RELATED TO INCREASED FLUID IN THE
PLEURAL CAVITY
when assesed
10ml, straw colored fluid with
presence of protein 5.50mg/dl,
Pus cells - many
Goal:To understand thoracotomy
LTO:Patient will be able to identify
why he is going to have the procedure
STO:
Patient will be able to enumerate
specific risks and consequences in 15
mins
Patient willl show cooperation by
asking question after 20 minutes of
nursing Interventions
Sharp stabbing pain (R) Lung
(pleurisy), intensified by deep
inspiration and cough
OXYGEN
SATURATION
AUSCULTATION
LARGE EFFUSIONS
exhibits
scarring of the lining
of the lung
Pleural thickening
Sputum noted as white, with
blood-tinged sputum (one
episode 7 days ago)
GOAL:Patient will feel no pain
LTO:Patient displays improved well-being such as
baseline levels for pulse, BP, respirations, and
relaxed muscle tone
STO:
Patient describes satisfactory pain control at a level
less than 3 to 4 of his own rating scale before
nursing interventions, after 6 hours of nursing
interventions
Patient uses pharmacological and
nonpharmacological pain-relief strategies after 2
hours of nursing interventions
GOAL:Patient will show normalized breathing pattern
LTO:Patient maintains an effective breathing pattern, as
evidenced by relaxed breathing at normal rate and depth
and satisfactory breath sounds
STO:
Patient?s respiratory rate remains within established limits
after oxygenation in 20 minutes
Patient indicates, either verbally or through behavior,
feeling comfortable when breathing after 45 minutes of
nursing interventions
DECREASED CARDIAC OUTPUT RELATED
TO DECREASED OXYGENATION
Goal:To stabilize
cardiac output
LTO:Patient will be
able to exhibit gradual
normal ranges of
blood pressure
STO:
Patient will be able to
know normal ranges of
blood pressure and
heart rate after 15
minutes of nursing
interventions
Patient will be able to
position himself for
relief
Dx: Auscultate heart sounds; note
rate, rhythm, presence of S3, S4,
and lung sounds.Review results of
EKG and chest Xray.
Tx: Administer medications as
prescribed, noting side effects and
toxicity
Maintain adequate ventilation and
perfusion as in the following:
Position patient in semi-Fowler?s to
high-Fowler?s. Edx: Educate patient
about normal ranges of blood
pressure and heart rate.
Dx:Evaluate the appropriateness of inspiratory
muscle training.
Assess and record respiratory rate and depth
at least every 4 hours.
Observe for breathing patterns.
Auscultate breath sounds at least every 4
hours.
Utilize pulse oximetry to check oxygen
saturation and pulse rate.
Tx:Provide respiratory medications and
oxygen, per doctor?s orders.
Suction secretions, as necessary.This is to
clear blockage in airway.
Stay with the patient during acute episodes of
respiratory distress.Ambulate patient as
tolerated with doctor?s order three times daily.
Edx:Encourage frequent rest periods and
teach patient to pace activity.
Collaborative:Collaborate with physician
about possible chest- tube insertion
Dx:Foresee the need for pain relief.Preventing the pain is one thing that a patient experiencing it
can consider. Early intervention may decrease the total amount of analgesic required.
Acknowledge reports of pain immediately.
Get rid of additional stressors or sources of discomfort whenever possible.
Provide rest periods to promote relief, sleep, and relaxation.
Determine the appropriate pain relief method.
Tx:Pharmacological methods include the following:
Admister medications as ordered:
1.Nonopioids (acetaminophen), a nonselective NSAID, or a selective NSAID (e.g., cyclooxygenase
[COX]-2 inhibitor)
2.Opioid analgesics
3.Local anesthetic agents
Position patient as per comfort
Edx:Educate patient why he is experiencing pain
Collaborative:Collaborate with physisian with appropriate counter measures if pain is unbearable.