Pleural Effusion Nursing Diagnosis and Nursing Care Plan

Pleural Effusion Nursing Care Plans Diagnosis and Interventions

Pleural Effusion NCLEX Review and Nursing Care Plans

 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
• Fever
• Dry, non-productive cough
• Orthopnea – inability to breathe properly unless sitting up straight or standing

Causes and Risk factors of Pleural Effusion

The excess fluid in the pleural space can either be exudative (protein-rich) or transudative (protein-poor).

1. 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:

• Pneumonia
• Cancer
• Pulmonary embolism
• Kidney disease
• Inflammatory disease

2. 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
• Cirrhosis
• 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.

1. 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.
2. 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:

1. Chest Xray – may appear as white spots in the image
2. CT scan – will show a more detailed image, including lung structures
3. 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:

1. Treating the underlying cause. An example would be diuretics for congestive heart failure.
2. Thoracentesis. This involves puncturing and draining the excess fluid from the pleural space.
3. 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.
4. Pleural drain. This procedure involves long term drain for chronic pleural effusion.
5. 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.
6. Surgery. For effusions not relieved by drainage or pleural sclerosis, surgery may be warranted and they are divided into two:
7. 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
8. 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.

Pleural Effusion Nursing Diagnosis

Nursing Care Plan for Pleural Effusion 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

Pleural Effusion Nursing Interventions	Rationales
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 for Pleural Effusion 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 bpm

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.

Pleural Effusion Nursing Interventions	Rationales
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 for Pleural Effusion 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.

Pleural Effusion Nursing Interventions	Rationales
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.

Nursing Care Plan for Pleural Effusion 4

Impaired Gas Exchange

Nursing Diagnosis: Impaired Gas Exchange related to the altered supply of oxygen secondary to Pleural Effusion as evidenced by frequent coughing, difficulty of breathing, nasal flaring, restlessness, use of accessory muscles when breathing, and increased cardiac rate.

Desired Outcome:

The patient will be able to maintain optimal gas exchange as evidenced by unlabored breathing at 12 to 20 breaths per minute, normal range of oximetry results, and clear lung fields in the x-ray.

Pleural Effusion Nursing Interventions	Rationale
Check the patient’s breathing rate, characteristics, including the involvement of accessory muscles when breathing, and any other irregular breathing patterns. Auscultate the lungs and monitor for adventitious breath sounds.	To establish a baseline. Gas exchange is affected by rapid and shallow breathing patterns, as well as hypoventilation. Hypoxia, on the other hand, is characterized by an increased respiratory rate, the employment of accessory muscles, nasal flaring, diaphragm breathing, and a panicky appearance in the patient’s eyes.
Watch out for nail beds and skin cyanosis, as well as the color of the tongue and oral mucous membranes.	Central cyanosis of the tongue and oral mucosa signals severe hypoxia and requires immediate medical attention, whereas peripheral cyanosis of the extremities may or may not be significant.
Constantly monitor the patient’s oxygen saturation through a pulse oximeter.	Pulse oximetry is an effective method for detecting oxygenation abnormalities. Significant oxygenation concerns are indicated by an oxygen saturation of less than 90% or a partial pressure of oxygen of less than 80.
Constantly check the results of blood chemistry and arterial blood gases (ABG).	Elevated Carbon dioxide levels and diminishing levels of oxygen may indicate respiratory acidosis and hypoxemia (low level of blood oxygen, particularly in the arteries).
Place the patient in a high or semi-Fowler’s position with the head of the bed elevated. Also, encourage the patient to sit in an upright position if tolerated.	Improved thoracic capacity, complete diaphragm fall, and increased lung expansion prevent abdominal contents from crowding when placing the patient in the upright or semi-Fowler’s position.
Analyze the influence of shifting positions on ABGs and pulse oximetry readings.	Ventilation and perfusion imbalances are aggravated by positioning the patient’s most impaired lung regions in the dependent position, where perfusion is greatest.
Monitor the patient’s position at a regular interval to ensure that they do not slump in bed.	The patient’s abdomen compresses the diaphragm and inhibits adequate lung expansion while he or she is in slumped or slouched position.
Encourage the patient to cough and practice deep breathing techniques.	Gas exchange is hindered by excessive secretions that have accumulated in the lungs. Coughing and deep breathing exercises will help the patient evacuate secretions from his or her lungs.
Administer supplemental oxygen as directed by the attending physician, aiming for an oxygen saturation level of 90% or above.	Oxygen therapy may be necessary to maintain the adequate oxygen level of the patient.
Deliver humidified oxygen as ordered by the physician.	Humidified oxygen minimizes the risk of drying out the lungs of the patient.
Assist the patient in alleviating their anxiety level by providing reassurance.	Anxiety makes signs and symptoms including shortness of breath, respiratory rate, and effort in breathing worse.
Promote or assist ambulation in patients who are ambulatory, as recommended by the attending physician.	Chest expansion, secretion evacuation, and deep breathing are all improved by ambulation.
Prepare the patient for the procedure of thoracentesis.	Thoracentesis is a slightly invasive medical management in which a needle is inserted through the chest wall into the pleural space to extract fluid or air from around the lungs in order to diagnose and treat pleural effusions.
Start preparing the patient for pleurectomy or pleurodesis procedure as indicated by the attending physician if pleural effusion occurs repeatedly.	Pleurectomy, which involves surgically separating the parietal and visceral layers of the lungs, induces an inflammatory response that leads to adhesion formation between the two layers as they regenerate. Pleurodesis, on the other hand, is a procedure that includes infusing a sclerosing substance into the area between the lung and the chest wall to prevent fluid or air from accumulating between the layers.
Refer the patient to a chest physiotherapist as necessary.	To provide further knowledge and personalized treatment to the patient, resulting in enhanced gas exchange

Nursing Care Plan for Pleural Effusion 5

Risk for Infection

Nursing Diagnosis: Risk for infection related to pooling of fluid in the pleural space secondary to Pleural Effusion.

Desired Outcome: The patient will stay infection-free, as shown through acceptable ranges of vital signs and the absence of infection signs and symptoms.

Pleural Effusion Nursing Interventions	Rationale
Keep an eye on the white blood cell count (WBC) of the patient.	The normal WBC count is between 4,500 and 11,000 cells per microliter. Although the infection may be present without an elevated WBC count in older people, a rising white blood cell count reflects the body’s attempts to fight infections. On the other hand, a very low WBC count could also suggest a high risk of infection.
Closely monitor the color and characteristics of the patient’s respiratory secretions.	Sputum that is thick, yellow, green, or tan-colored could suggest infection. It is possible that a sputum culture will be required by the attending physician.
Consider the patient’s dietary requirements. Weight and laboratory parameters, such as serum albumin, should be monitored.	Malnutrition has an impact on the development of immune cells, which are essential for fighting off infections.
Wash hands frequently or performs hand hygiene before making contact with the patient. Instruct also the patient and their family members on these responsibilities and let them be aware of when hand hygiene is required.	Microorganisms are effectively removed from hands using friction and running water. It is better to use antimicrobial soap than plain soap at reducing bacterial counts, while alcohol-based hand rubs are the most ideal. Between procedures, washing minimizes the chance of infections spreading from one part of the body to another. Handwashing frequently is intended to break the infection cycle. When handling a delicate site of entry, such as changing a central line dressing, catheter care, or incision care, maintaining clean hands and aseptic practices reduces the chance of transferring bacteria into the body. Hand hygiene is the most essential factor for avoiding infections.
Advise the patient to eat a well-balanced meal that is high in protein and calories.	Good nutrition and a well-balanced diet strengthen the immune system’s response and the functioning of all body systems.
Highly encourage coughing and deep breathing techniques every two hours, as well as frequent position changes.	These techniques contribute to the lowering of secretion stasis in the lungs.  When there are stagnant lung secretions, the respiratory tract becomes infected with bacteria, which can lead to another lung disease.
Encourage the patient to get adequate rest and sleep.	A good night’s sleep is a chief controller of immunological responses. Sleep deprivation can suppress immunity and make people more vulnerable to infection.
Place the patient in protective isolation if he or she is at greater risk of infection.	When the white blood cell count reveals neutropenia or a lack of neutrophils, protective isolation is enforced.
Administer antibiotics as directed by the physician. Also instruct the patient to complete the antibiotic course even if symptoms improve or subside.	Failure to complete the prescribed antibiotic therapy can result in drug resistance in the pathogen and recurrence of symptoms.
Frequently check vital signs, especially the patient’s temperature.	Temperature surges or persistently high temperatures could signify an infection somewhere in the body.
Monitor the patient’s insertion sites for signs of redness, edema, discharge, and discomfort.	These symptoms could suggest a localized infection.
Disinfect the incision sites and inspect the sites on a regular basis as directed by the attending physician.	Bacteria are more likely to be introduced into the body through incision sites and access locations. Incisions are kept clean and free of bacteria with the use of special wound treatments.
Examine whether the lines and drains of the patient are still appropriate. Consult the doctor about the potential of removing any lines or drains that are no longer needed.	The sooner the patient’s lines or drains can be eliminated, the better. Infection is less likely when there are less intrusive lines and equipment.
If not restricted, encourage sufficient fluid intake.	Hydration has several advantages when it comes to minimizing the risk of infection. Thins secretions and promotes mucus expectoration, which helps bacteria discharge down the esophagus instead of adhering to the respiratory tract. It also stimulates frequent bladder emptying and facilitates urine production to flush the urinary tract system.
Restrict the patient’s visitors as necessary.	Transmission of disease-causing microorganisms is reduced when visitors are limited.

Nursing Care Plan for Pleural Effusion 6

Anxiety

Nursing Diagnosis: Anxiety related to incapacity to take deep breaths secondary to Pleural effusion as evidenced by restlessness, shortness of breath, and verbalized feeling of fear.

Desired Outcome: The patient will be able to practice effective coping mechanisms as evidenced by diminished anxiety level.

Pleural Effusion Nursing Interventions	Rationale
Evaluate the coping skills of the patient.	Coping methods that formerly succeeded may no longer be viable in new and unexpected settings, necessitating a thorough evaluation.
Take note of the patient’s level of anxiety.	This data contributes to treatment planning. An individual suffering from severe anxiety episodes will demand different medical care than someone suffering from mild anxiety.
Do not leave the patient throughout anxiety occurrences. Remind patients that they are not alone through using presence, touch (with consent), verbal communication, and manner to encourage them to express or clarify their needs, worries, uncertainty, and inquiries.	Recognizing the anxiety of the patient demonstrates that the nurse understands the patient well and promotes trust.
Communicate with the patient in a confident and reassuring manner.	Signs of confidence and certainty aid in keeping the patient as comfortable as possible, which can help to lessen the anxiety.
Educate and encourage the patient to perform deep breathing exercises.	During an anxiety attack, rapid and shallow breathing might aggravate the patient’s respiratory condition.
Enable the patient to get enough rest and sleep.	Anxiety is usually linked to sleep disturbances. Excessive anxiety and worry make it difficult to fall asleep and stay asleep throughout the night. Sleep deprivation can exacerbate anxiety, resulting in insomnia and anxiety problems.
Support the patient in developing stress-relieving skills such as reading, guided imagery among others.	The capability of the mind is used in guided imagery to create soothing, serene images that are a combination of thoughts and senses. It can be an effective approach to reducing anxiety.
Keep a quiet and serene atmosphere to minimize sensory stimuli.	Prolonged discussion, noises, and equipment near the patient might cause anxiety to escalate into panic. Anxiety can become distressing for both the patient and others as it intensifies.
Use nonmedical words and a slow, calm voice to explain all procedures, treatments, and situations involving the patient. When possible, do this ahead of time and verify the patient’s comprehension.	Patients who receive pre-admission patient education experience lower anxiety and mental distress, as well as improved coping skills, because they are aware of what to expect. Anxiety is heightened by unpredictability and uncertainty.
Teach the patient how to take anti-anxiety drugs as prescribed by the attending physician.	Antianxiety drugs used for a short period of time can improve patient coping and diminish anxiety’s physiological manifestations.
Inform the patient and his or her family about the signs and symptoms of anxiety.	If the patient and family can recognize anxiety responses, they will be able to intervene sooner than they would be.
Remind the patient to restrict their use of central nervous system stimulants if applicable.	Caffeine and chocolate, among other central nervous system stimulants, can exacerbate physical anxiety symptoms.
Communicate with the patient in a calm manner, using simple language and short sentences.	The nurse’s anxiety can be passed on to the oversensitive patient. In a quiet and non-threatening atmosphere, the patient’s sense of stability improves. Patients suffering from moderate to severe anxiety may find it difficult to comprehend anything other than simple and direct, clear, and concise directions.

More Pleural Effusion Nursing Diagnosis

• Hyperthermia
• Fatigue
• Deficient Knowledge

Nursing References

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. (2022). 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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