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Signs/Symptoms: (Place * on current)  Shortness of Breath  Chest pain  Orthopnea  Dry nonproductive cough

Physical Assessment: Neuro: WNL Integumentary: Small lesions on legs from radiation therapy. Cardiovascular: +2 pitting edema Pulmonary: Lungs sound wet especially in the left base.

Diagnostics/Results:  CT Angio chest with contrast: Moderate left pleural effusion, mostly in basal/ subpulmonic region, and atelectasis in the left lower lobe

Pathophysiology: Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing. Normally, a small amount of fluid is present in the pleura (Cleveland Clinic).

Risk Factors: (Place * for patient)  Heart Failure *  Pulmonary embolism  Cancer *  Kidney disease  Inflammatory disease

GI: WNL

Medical History: PE, MS, Right mastectomy, Cardiomyopathy, Heart failure, Lymphoma, Hx of Chemo

Hematologic: WNL GU:WNL Musculoskeletal: Weak overall strength, needs assistance.

Home Medications: Did not get this information.

Patient Story: Name: P.E. Age/Gender: 64/Female Race/Ethnicity: White Admission Date: 10/21 Primary Dx: Pleural effusion

Hospital Medications:  Lasix  Enoxaparin  Protonix  Rocephin

Interventions/Rationales: (italicize rational) Nursing Diagnosis: 1. Ineffective breathing pattern related to decreased lung expansion (Fluid accumulation) as evidenced by diminished breath sounds. Measureable Goals:  



Be free of cyanosis and other signs/symptoms of hypoxia with an o2 sat of > 96% after thoracentesis Establish a normal/effective respiratory pattern with ABGs within patient’s normal range, following thoracentesis Reduce +2 pitting edema to no pitting edema by the end of the week.

1.

Maintain fluid restriction and administer proscribed diuretic (In order to decrease the edema in her legs and elevate the buildup of liquid in her lungs).

2.

Elevate head of bed (Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively). Administer oxygen therapy as prescribed (To improve oxygenation in the body).

3.

Evaluation: (evaluation each goal) Was not there to evaluate goals.

Provider Orders:  Thoracentesis  Fluid restriction of less than 1500 ml  Cardiac diet  Lasix...