Nursing Clinical Practice Guide
Clinical Scenario: You are a nurse on a medical-surgical unit. Mr. Johnson, a 68-year-old male with a recent history of upper respiratory infection, is admitted with a chief complaint of "sharp pain in my right side every time I take a deep breath." He is afebrile now but reports having had a fever a few days ago. He is guarding his right chest and taking shallow, rapid breaths to avoid pain.
Nursing Intervention Strategy:1. Assessment: Perform a focused respiratory assessment. Key Point! Auscultate lung sounds carefully. You might hear a distinctive pleural friction rub – a coarse, grating, leathery sound heard during both inspiration and expiration, localized over the area of pain. Assess pain using the PQRST mnemonic (Provocation/Palliation, Quality, Region/Radiation, Severity, Timing). Monitor for signs of developing effusion (increased dyspnea, decreased breath sounds, dullness to percussion).2. Nursing Diagnosis & Planning: A primary nursing diagnosis is Acute Pain related to inflammation of pleural membranes. The goal is for the patient to report reduced pain and demonstrate effective breathing techniques.3. Implementation:• Pain Management: Administer prescribed NSAIDs (e.g., ibuprofen) to reduce inflammation and pain. Assess effectiveness.• Positioning: Assist the patient to a position that minimizes pain, often lying on the affected side. This splints the chest wall and limits movement of the involved pleura.• Breathing/Coughing Techniques: Teach the patient to splint the chest with a pillow firmly against the painful area when coughing or doing deep-breathing exercises. This supports the chest wall and reduces stretching of the pleura.4. Patient Education & Evaluation: Educate the patient on the importance of deep breathing to prevent atelectasis despite the pain. Evaluate pain scores, respiratory rate, depth, and oxygen saturation. Report any increase in dyspnea or fever immediately.
Patient Safety and Precautions:• Critical: Never assume chest pain is pleuritic without a proper workup. Pulmonary embolism (PE) can also present with pleuritic pain. Sudden onset, tachycardia, hypoxemia, and risk factors (e.g., immobility) warrant immediate evaluation for PE.• Medication: NSAIDs can cause GI upset or renal impairment. Administer with food. Monitor for signs of bleeding if on anticoagulants.• Monitoring: Watch for the transition from pleuritic pain to effusion. Decreasing pain coupled with worsening dyspnea is a red flag.
Nursing Procedure & Medication Flow
Procedure: Assisting with Splinted Cough and Deep Breathing1. Explain the purpose: To clear secretions and expand lungs while minimizing pain.2. Help the patient sit upright or in a position of comfort.3. Place a pillow vertically against the patient's chest, centered over the area of pain.4. Instruct the patient to wrap their arms around the pillow and hug it firmly.5. For deep breathing: Instruct to take a slow, deep breath in through the nose, hold for 2-3 seconds, then exhale slowly through pursed lips.6. For coughing: After a deep breath, have the patient give two or three strong, sharp coughs while hugging the pillow.
Medication: Ibuprofen (NSAID) Administration• Action: Inhibits prostaglandin synthesis, reducing inflammation and pain at the pleural site.• Nursing Considerations: Administer with food/milk. Monitor for GI distress, black tarry stools (sign of GI bleed), and renal function (I&O, BUN/Cr). Avoid in patients with active peptic ulcer disease or severe renal impairment.
A Word from Your Senior Nurse
"In the real world, a patient with 'chest pain' will always get your full attention and a rapid ABC (Airway, Breathing, Circulation) assessment. Once life-threatening causes are ruled out, your keen assessment skills come into play. Hearing that classic pleural friction rub is like getting a direct answer from the body. Your job then is to be a coach and a comforter—teaching your patient how to breathe and cough effectively despite the pain. Remember, our goal isn't just to treat the pain, but to prevent complications like pneumonia and atelectasis. When you study, link that sharp, inspiration-worsened pain directly to the image of inflamed membranes rubbing. That clinical picture will stick with you for life, both on the NCLEX and at the bedside."