Nursing Care Plan for Empyema

Nursing Care Plan for Empyema

Empyema

Empyema is a collection of pus in the space between the lung and the inner surface of the chest wall (pleural space).

Symptoms

• Chest pain, which worsens when you breathe in deeply (pleurisy)
• Dry cough
• Excessive sweating, especially night sweats
• Fever and chills
• General discomfort, uneasiness, or ill feeling (malaise)
• Shortness of breath
• Weight loss (unintentional)

Nursing Diagnosis of Empyema 1:

Ineffective airway clearance related to bronchus spsame, increased production of secretions, weakness

Nursing Intervention and Rational:

Auscultation of breath sounds: note the presence of breath sounds, assess and monitor breathing sounds
R /: To determine the presence of airway obstruction, the degree yan tachipneu found the process of acute infection.

Assess the frequency of respiratory
R /: The process of acute infection (tachipnea)


Nursing diagnosis of empyema 2:

Impaired Gas Exchange related to airway obstruction secondary to the buildup of secretions, Bronchospasme

Nursing Intervention and Rational:

Assess the frequency and depth of breathing, note the use of auxiliary respiratory muscles and an inability to speak due to shortness
R /: Evaluation of the degree of respiratory distress or failure and chronic disease processes.

Help clients to find a position that facilitates breathing, with the head higher
R /: Supply of oxygen can be updated, in order to practice breathing lungs do not collapse.

Nursing diagnosis of empyema 3:

Imbalanced Nutrition, Less Than Body Requirements related to Shortness of breath, anorexia, nausea, vomiting, drug effects, weakness

Nursing Intervention and Rational:

Obserasi intake and output / 8 hours. The amount of food consumed each day and measuring body weight each day
R /: Identifying the lack of progress / storage of the expected goal

Create a fun atmosphere, an environment free of odor during meal times:

• Perform mouth care before and after meals
• Clean environment in which the presentation of food
• Avoid use of foul-smelling fragrances
• Perform chest physiotherapy and nebulizer at least one hour before meals
• Provide a place to dispose of tissues / secretions cough

R /: The smells and sights that are not pleasant during the meal can lead to anorexia. The drugs are given soon after a meal can trigger nausea and vomiting.