Pleural Effusion NCLEX Review Care Plans
Nursing Study Guide on Pleural Effusion
The pleura are a pair of thin membranes that line the inside of the chest wall.
They compose a layer that envelops the entire surface of the lungs. Within this pleural space, a small amount of fluid is contained, aiding with respirations by allowing the lungs to glide through smoothly.
However, an unusual increase in the fluid in the pleural space will result to a condition called pleural effusion.
Pleural effusion, if left untreated, will hinder with normal respiration and thus, could be life threatening.
Drainage of this excess fluid is necessary yet treating the cause would also be prioritized to prevent future episodes of pleural effusion.
Signs and Symptoms of Pleural Effusion
The patient may not have signs and symptoms of pleural effusion. Sometimes, pleural effusion is discovered accidentally, sometimes through a random chest Xray for another disease.
But if the pleural effusion is moderate or massive, the following signs and symptoms can be observed:
- Dyspnea – shortness of breath or labored breathing
- Pleuritic pain or pleurisy – chest pain, especially when deep breathing
- Dry, non-productive cough
- Orthopnea – inability to breathe properly unless sitting up straight or standing
Causes and Risk factorsof Pleural Effusion
The excess fluid in the pleural space can either be exudative (protein-rich) or transudative (protein-poor).
- Exudative pleural effusions. These are characteristically the result of the inflammatory process of the pleura, and/or decreased in draining of lymph. Mechanisms of exudative formation include pleural swelling, migration of inflammatory fluid to peritoneal space, altered absorptivity of pleural tissues, and/or decreased capillary wall penetrability. The most common reasons for exudative pleural effusions are:
- Pulmonary embolism
- Kidney disease
- Inflammatory disease
- Transudative pleural effusions. These are commonly the result of an imbalance between oncotic and hydrostatic pressure, causing third space shifting of body fluids. Transudative effusions are usually ultrafiltrates of plasma squeezed out of the pleura because of these imbalances in thoracic pressure. However, other mechanisms of injury may include upward movement of fluid from the peritoneal cavity or iatrogenic in nature (e.g. misplaced central venous catheter). Pleural effusions that are transudative in nature is mostly caused by:
- Heart failure
- Pulmonary embolism
- Post-open heart surgery
- Autoimmune disease
- Bleeding (due to chest trauma)
- Tuberculosis and other rare infections
Since pleural effusions are indications of another condition, the risk factors are those of an underlying disease.
The seriousness of pleural effusion depends on its primary cause, as well as how severely the breathing is affected.
Two factors that must be considered are the treatment of underlying cause and probable mechanical problems of ventilation.
Complications of Pleural Effusion
Pleural effusion is a serious condition and may lead to developing certain complications.
- Lung dysfunction. Since the pleural space normally has a small amount of fluid, having these excesses can impede with the normal functioning of the lungs. This will make breathing difficult, restricting the natural expansion of the lungs, and thus causing dyspnea. Moreover, the accumulated air in the pleura may exert increased thoracic pressure, resulting to chest pain.
- Empyema. A localized infection called empyema may arise due to the pooling of excess fluid and will produce further complications.
All in all, these conditions may give rise to severe breathing problems and in turn give rise to life-threatening situation, prompting immediate and advanced airway and oxygenation management.
Diagnosis of Pleural Effusion
A pleural effusion diagnosis can only be determined initially through a physical examination (particularly auscultation) then confirmed through the following imaging procedures:
- Chest Xray – may appear as white spots in the image
- CT scan – will show a more detailed image, including lung structures
- Ultrasound – guided by sound waves, this procedure can approximate the amount and presence of excess fluid in the pleural space
Treatment of Pleural Effusion
Treatment for pleural effusion focuses on the underlying condition and the severity of respiratory complications. Management can be on a case-to-case basis, and may involve one or more of the following:
- Treating the underlying cause. An example would be diuretics for congestive heart failure.
- Thoracentesis. This involves puncturing and draining the excess fluid from the pleural space.
- Tube thoracostomy. This procedure includes thoracentesis and the placement of a draining tube to the pleural space to drain the excess fluid. It may take several days before the tube is removed.
- Pleural drain. This procedure involves long term drain for chronic pleural effusion.
- Pleurodesis. This procedure involves the application of an irritating substance into the pleural space, causing inflammation, thus binding the pleura and chest wall as they heal together.
- Surgery. For effusions not relieved by drainage or pleural sclerosis, surgery may be warranted and they are divided into two:
- Video assisted thorascopic surgery (VATS) – a minimally invasive procedure involving 1 to 3 small incisions under scope guidance and the introduction of sclerosing agent to prevent pleural effusion build-up
- Traditional thoracotomy (open thoracic surgery) – performed thru a 6-8 incision into the chest cavity to evacuate infected tissue and remove fibrous build-up causing pleural effusions.
Nursing Care Plans for Pleural Effusion
Nursing Care Plan 1
Nursing Diagnosis: Acute Pain related to inflammation and swelling of the pleura secondary to pleural effusion, as evidenced by sudden and severe chest pain, pain rating of 10 out of 10 on pain scale, guarding sign on the chest, irritability, worsening pain upon inhalation.
Desired Outcome: The patient will report a decrease of pain level to 0 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.|
|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.|
Nursing Care Plan 2
Nursing Diagnosis: Ineffective Breathing Pattern related to exudative pleural effusion, as evidenced by shortness of breath and cough, increased pain upon inhalation, labored breathing, oxygen saturation of 89%, and respiratory rate of 30 cpm
Desired Outcome: The patient will achieve effective breathing pattern as evidenced by respiratory rates between 12 to 20 breaths or cycles 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 if this is the underlying cause of the patient’s pleural effusion.|
|Administer oxygen therapy as prescribed.||To improve oxygenation in the body, aiming for a target level of oxygen saturation (usually above 96%).|
|Elevate the head of the bed.||Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.|
|Prepare the patient for surgery, as ordered.||Pleural effusion can be resolved by putting a pleural drain, performing pleurodesis, VATS, or thoracotomy.|
Nursing Care Plan 3
Nursing Diagnosis: Activity intolerance related to acute pain secondary to pleural effusion, as evidenced by pain score of 10 out of 10, fatigue, disinterest in ADLs due to pain, dyspnea and orthopnea, verbalization of tiredness and generalized weakness
Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.
|Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.||To create a baseline of activity levels and mental status related to acute pain, fatigue and activity intolerance.|
|Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with 60-90 minutes of undisturbed rest.||To gradually increase the patient’s tolerance to physical activity. To prevent triggering of acute pain by allowing the patient to pace activity versus rest.|
|Administer analgesics as prescribed prior to exercise/ physical activity. Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.||To provide pain relief before an exercise session. To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.|
|Refer the patient to physiotherapy / occupational therapy team as required.||To provide a more specialized care for the patient in terms of helping him/ her build confidence in increasing daily physical activity.|
Other possible nursing diagnosis:
- Anxiety related to pleuritic pain
- Deficient Knowledge
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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