- Acute Pain related to Inflammation and swelling of the pleura as evidenced by Reports of sharpness or burning in the chest and Worsening pain upon inhalation
- Impaired Gas Exchange related to altered oxygen supply and decreased function of lung tissue as evidenced by Dyspnoea and Abnormal ABGs
- Impaired Spontaneous Ventilation related to Ventilatory compromise and excessive fluid in the pleural cavity as evidenced by Dyspnoea and Respiratory distress
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbal reports from the patient Expressions of pain, such as crying Unpleasant feeling (such as a prick, burn, or ache) Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns | Acute Pain related to Inflammation and swelling of the pleura as evidenced by Reports of sharpness or burning in the chest and Worsening pain upon inhalation | Patient will report a decrease in pain when breathing as evidenced by a pain rating of 2 or less and a relaxed, unlabored respiratory rhythm. Patient will complete activities of daily living without complaints of respiratory discomfort. | 1. Administer prescribed pain medications. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen may decrease inflammation causing pleuritic chest pain. 2. Provide nonpharmacologic methods of pain relief. Nonpharmacologic interventions like repositioning, guided imagery, and splinting the chest when coughing help manage pain and reduce stress. Also, this will help lower the dose of pain medication needed with decreased side effects. 3. Provide rest and simplify ADLs. Pain may worsen when moving or performing tasks that take great effort. Rest frequently and do not overdo activities that will increase the work of breathing. 4. Educate the patient on deep breathing exercises. Deep breathing exercises can help avoid ineffective shallow breathing, which is a natural response when experiencing pleuritic pain. Deep breathing can strengthen the lungs and improve oxygenation. | Patient reported a decrease in pain when breathing as evidenced by a pain rating of 2 or less and a relaxed, unlaboured respiratory rhythm. Patient completed activities of daily living without complaints of respiratory discomfort. |
Subjective data: Dyspnea Diaphoresis (excessive sweating) Visual disturbances Headaches Objective data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Abnormal arterial blood gas values or blood pH -Decreased oxygen saturation | Impaired Gas Exchange related to altered oxygen supply and decreased function of lung tissue as evidenced by Dyspnoea and Abnormal ABGs | Patient will exhibit improved gas exchange as evidenced by ABGs within normal limits. Patient will be able to maintain optimal gas exchange as evidenced by unlabored breathing and respiratory rate within normal limits. | 1. Consider lateral positioning. Elevating the head of the bed to 45 degrees and positioning the patient in a lateral position has been shown to increase O2 saturation and decrease respiratory rate in those with unilateral pleural effusions. 2. Provide supplemental oxygen as ordered. Supplemental oxygen therapy may be necessary to maintain adequate oxygenation. Do not over-oxygenate. 3. Encourage ambulation. Ambulation significantly improves chest expansion and the mobilization and drainage of secretions. Do not overexert to the point of dyspnea. 4. Provide support to reduce anxiety. Dyspnea can cause anxiety and panic. These feelings can exacerbate shortness of breath. Provide a calming, supportive environment and reassure the patient. 5. Prepare the patient for indicated procedures. Surgical interventions like thoracentesis, pleurodesis, or chest tube insertion may be indicated if the patient’s condition worsens. The nurse can educate the patient on what to expect with these treatments and how they alleviate symptoms. | Patient exhibited improved gas exchange as evidenced by ABGs within normal limits. Patient maintained optimal gas exchange as evidenced by unlabored breathing and respiratory rate within normal limits. |
Subjective data: Verbal reports of breathing difficulty Objective data: -Dyspnea -Restlessness -Hypoxia -Respiratory distress | Impaired Spontaneous Ventilation related to Ventilatory compromise and excessive fluid in the pleural cavity as evidenced by Dyspnoea and Respiratory distress | Patient will demonstrate ABGs within acceptable limits. Patient will remain free from dyspnoea or worsening respiratory distress. | 1. Prepare for drainage removal. Drainage of pleural effusion is safe for patients on mechanical ventilation and has been shown to improve ventilation. 2. Discuss surgical options. Surgical procedures such as pleurodesis, decortication, or shunts may be necessary if drainage proves ineffective at removing fluid. 3. Assist with positioning. Ensure the client is in a semi recumbent position with the head elevated 45 degrees. Reposition as needed to prevent atelectasis and pooling of secretions. 4. Closely monitor respiratory mechanics. In patients who are mechanically ventilated, catheter drainage or chest tube placement has been shown to significantly improve respiratory mechanics, including respiratory system compliance, end-expiratory lung volume, and PaO2/FiO2 ratio. | Patient demonstrated ABGs within acceptable limits. Patient remained free from dyspnoea or worsening respiratory distress. |