In this article, we will discuss pleurisy pathophysiology and careplan for nursing students.
Pleurisy is a medical condition affecting the two layers of tissue called “pleura”, which act as a separator between the lungs and the chest wall. One of the layers lines the exterior of the lungs, while the other wraps around the inner chest wall. There is a space between these two membranes, which has a thin sheet of liquid that acts as a lubricant.
The smooth gliding action between these two layers enables the two-way breathing process of lung expansion and contraction. Pleurisy, also known as “pleuritis”, occurs when there is swelling and inflammation of the pleura. In addition to this, the fluid in the pleural space may thicken, causing the pleura to rub together. These conditions manifest as a sharp chest pain called “pleuritic pain”, and can be worse during respirations.
Signs and Symptoms of Pleurisy
- Pleuritic pain – a sharp, stabbing chest pain that gets worse with breathing, coughing, or sneezing. This might also be worsened by moving the upper body and may radiate to the shoulders or back.
- Shortness of breath or difficulty of breathing – the patient tends to have less respirations or perform shallow breathing as a response to the pain
- Fever, in some cases, especially when infection is the cause of pleurisy
- Cough, in some cases
Causes of Pleurisy
- Infection: The most common cause of pleurisy is infection. Several viruses that cause pleurisy include influenza or flu virus, cytomegalovirus (CMV), parainfluenza virus, and Epstein-Barr virus. Bacterial infections resulting to pleurisy are less common and can be caused by streptococcus (related to pneumonia and throat infections), staphylococcus (related to skin infections and sepsis) or Mycobacterium tuberculosis. Fungal infection can also cause pleurisy.
- Trauma: Mechanical injury can result to pleurisy. The pleura can have swelling and inflammation when there is bruising or fracture of the ribs.
- Pulmonary embolism: A blood clot that blocks the lungs can cause reduced blood flow and oxygen levels in some parts of the lungs and eventually cause tissue death. This can also result to pleurisy.
- Pneumothorax: The buildup of air in the lungs following chest trauma or mechanical ventilation.
- Cancer: When a tumor grows in the pleural cavity, fluid buildup occurs, causing pleurisy and pleural effusion.
- Autoimmune disorders: Illnesses such as lupus or rheumatoid arthritis involve the immune system abnormally attacking healthy tissues.
- Certain medications with a side effect that manifests as a lupus-like condition, such as hydralazine, isoniazid, and procainamide.
- Chemotherapy and radiotherapy
Complications of Pleurisy
- Pleural Effusion: In cases when pleurisy is caused by a bacterial infection (such as tuberculosis) or a pulmonary embolism, an excessive buildup of fluid in the pleural cavity is evident. This is called pleural effusion, which is characterized by chest pain, shortness of breath, and cough. Treating the underlying cause of pleurisy usually resolves pleural effusion. If unresolved, surgical intervention such as putting a chest drain may be needed.
- Atelectasis: Pleurisy may eventually lead to the partial or total collapse of the lung due to fluid buildup in the alveoli.
- Empyema: Bacterial infections resulting to pleurisy may eventually develop pockets of pus in the pleural space known as empyema or purulent pleuritis.
- Imaging – chest X-ray, CT scan, or ultrasound
- Blood tests – to determine any bacterial, viral, or fungal pathogens, or any autoimmune disease
- Electrocardiogram (ECG) – to check if the chest pain is heart-related or pleurisy
- Thoracentesis – needle insertion to remove small amounts of pleural fluid from the lungs, and study a sample fluid to see the cause of pleurisy
- Thoracoscopy – the use of thoracoscope to view the thoracic cavity
Treatments for Pleurisy
- Antibiotics that are specific for bacteria-caused pleurisy
- Antifungals –for fungal-caused pleurisy
- If pleurisy is caused by a virus – antiviral may not be required as it can resolve on its own. The doctor may ask the patient to rest for a few days, with close monitoring.
- Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen are effective to relieve pleuritic pain
- In cases when NSAIDS are not helpful, paracetamol or codeine can be administered. Codeine can also help suppress cough.
- Chest drain –If pleurisy is associated with pleural effusion, a tube is inserted into the pleural space to drain excess fluid
- Smoking cessation – smoking causes irritation to the lungs
Nursing Care Plans ( nursing care plan sample pleurisy )
- Nursing Diagnosis: Acute Pain related to pleurisy as evidenced by chest pain rating of 8 out of 10 on pain scale
Desired Outcome: The patient will report a decrease of pain level to zero upon discharge
|Assess the patient using a 0-10 pain rating scale for intensity, as well as characteristics and location of pain (sharp, dull, crushing, etc.)||To assist in creating an accurate diagnosis and treating the underlying cause of pain.|
|Administer the prescribed pain medications and assess response at least 30 minutes after drug administration.||To alleviate the pain and to monitor the efficacy of pharmacological pain relief.|
|Educate patient on deep breathing exercises and relaxation techniques.||Deep breathing exercises can avoid ineffective shallow breathing which is common a response of a patient who has pleuritic pain. Relaxation techniques relieves stress and lowers energy demands.|
- Nursing Diagnosis: Ineffective Breathing Pattern related to bacteria-caused pleurisy as evidenced by shortness of breath and cough
Desired Outcome: The patient will achieve effective breathing pattern as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation of above 96%, and verbalizes ease of breathing.
|Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment.|
|Administer the prescribed antibiotic medications.||To treat bacterial infection, which is the underlying cause of the patient’s pleurisy.|
|Elevate the head of the bed.||Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.|
|Assist the patient to change positions as tolerated. Encourage the patient to lie on the affected side if possible.||According to Gate Control Theory of Pain, non-painful sensations such as putting pressure by lying on the affected side can reduce pain perception.|
Other possible nursing diagnosis:
- Ineffective Airway Clearance
- Anxiety related to pleuritic pain