Approximately, 1.5 million pleural effusions are diagnosed in the United States each year. Pleural effusion is the most common manifestation of pleural disease, and its etiologies range in the spectrum from cardiopulmonary disorders and/or systemic inflammatory conditions to malignancy. Morbidity and mortality rates of pleural effusions are directly related to the cause of the underlying disease at the time of presentation, as well as biochemical findings in the pleural fluid.
A pleural effusion is a collection of fluid abnormally present in the pleural space, usually resulting from excess fluid production and/or decreased lymphatic absorption. It can occur by itself or can be the result of surrounding parenchymal diseases like infection, malignancy, or inflammatory condition. Pleural effusion is one of the major causes of pulmonary mortality and morbidity .
Pleural fluid is classified as a transudate or exudate based on modified Light criteria. Pleural fluid is considered an exudative effusion if at least one of the criteria is met.
- The pleural fluid protein/serum protein ratio is more than 0.5.
- The pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio is more than 0.6.
- Pleural fluid LDH is more than two-thirds of the upper limits of normal laboratory value for serum LDH.
Common causes of transudates include conditions that alter the hydrostatic or oncotic pressures in the pleural space like congestive left heart failure, nephrotic syndrome, liver cirrhosis, hypoalbuminemia leading to malnutrition, and the initiation of peritoneal dialysis. Common causes of exudates include pulmonary infections like pneumonia or tuberculosis, malignancy, inflammatory disorders like pancreatitis, lupus, rheumatoid arthritis, post-cardiac injury syndrome, chylothorax (due to lymphatic obstruction), hemothorax, and benign asbestos pleural effusion .
Pleural Effusion
Pleural fluid originates from the vasculature of parietal pleura surfaces and is absorbed back by lymphatics in the dependent diaphragmatic and mediastinal surfaces of the parietal pleura. Hydrostatic pressure from the systemic vessels that supply the parietal pleura is thought to drive the interstitial fluid into the pleural space and hence has a lower protein content than serum. Accumulation of excess fluid can occur if there is excessive production or decreased absorption or both overwhelming the normal homeostatic mechanism. If pleural effusion is mainly due to these mechanisms, then increased hydrostatic pressure usually causes transudative, leading to pleural effusion that has an altered balance between hydrostatic and oncotic pressures (usually transudates), increased mesothelial and capillary permeability (usually exudates), or impaired lymphatic drainage .
Nursing interventions for a client diagnosed with pleural effusion include determining the etiology of the pleural effusion and addressing the underlying cause. The following are nursing diagnoses associated with pleural effusion.
- Acute Pain
- Impaired Gas Exchange
- Ineffective Breathing Pattern
Pleural Effusion Nursing Care Plan
Below are sample nursing care plans for the problems identified above.
Acute Pain
The presence of chest pain, which results from pleural irritation, raises the likelihood of an exudative etiology, such as pleural infection, mesothelioma, or pulmonary infection. The pain may diminish in intensity as the pleural effusion increases in size and the inflamed pleural surfaces are no longer in contact with each other.
Nursing Diagnosis
- Acute Pain
Related Factors
- Pleural irritation/inflammation
- Coughing
- Malignant diseases
Evidenced by
- Verbalizations of pain aggravated by coughing or breathing
- Guarding behavior
- Facial mask of pain
- Distraction behaviors
Desired Outcomes
After the implementation of nursing interventions, the client is expected to:
- Verbalize reduced discomfort and pain.
- Report methods that provide relief.
- Demonstrate the use of therapeutic interventions to minimize pain.
Nursing Interventions
Assessment | Rationale |
Assess the client’s perceptions of pain and attitude toward pain. | The perception of pain can be influenced by age and developmental stage, underlying problems, and cognitive, behavioral, and sociocultural factors. The client may also have a high or low tolerance to pain and pain medications. |
Assess pain comprehensively, noting location, duration, precipitating and aggravating factors, and severity using a 0 to 10 scale. | Pain assessment helps determine the choice of interventions and provides a basis for comparison and evaluation of therapy. The pain can be mild or severe. It is typically described as sharp or stabbing and is exacerbated with deep inspiration. Pain may be localized to the chest wall or referred to the ipsilateral shoulder or upper abdomen because of diaphragmatic irritation. |
Note the presence of behaviors associated with pain- changes in vital signs, crying, grimacing, sleep disturbances, withdrawal, or narrowed focus | Nonverbal evidence of pain may or may not be congruent with verbal reports, thus indicating the need for further evaluation. For example, a stoic client 3 on a 10-point pain scale may also be restless, agitated, and sleepless. |
Monitor the client’s vital signs. | Changes in heart rate or blood pressure may indicate that the client is experiencing pain, especially when other reasons for changes in vital signs have been ruled out. |
Independent | |
Provide comfort measures, such as back rubs, change of position, and quiet music or conversation. Encourage the use of relaxation and breathing exercises. | Nonanalgesic measures administered with a gentle touch can lessen discomfort and augment the therapeutic effects of analgesics. Client involvement in pain control measures promotes independence and enhances a sense of well-being. |
Instruct and assist the client in chest-splinting techniques during coughing episodes. | Chest-splinting aids in the control of chest discomfort while enhancing the effectiveness of cough effort. |
Encourage verbalization of feelings about pain. | Fears and concerns can increase muscle tension and lower the threshold of pain perception. |
Provide opportunities to talk and listen to client concerns. | The client’s verbalization of worries can help decrease stress factors associated with illness and hospitalization. Ongoing dialogue provides an opportunity to give information and correct misinformation. |
Schedule periods of rest and provide a quiet environment. | Rest periods decrease fatigue and conserve energy, enhancing the client’s coping abilities. |
Assist with self-care activities, breathing, arm exercises, and ambulation. | Assisting the client prevents undue fatigue and strain. Encouragement and physical assistance and support may be needed for some time before the client is able or confident enough to perform these activities because of pain or fear of pain. |
Dependent | |
Administer antitussives, as indicated. | These medications may be used to suppress nonproductive paroxysmal cough or reduce excess mucus, thereby enhancing general comfort and rest. |
Assist with patient-controlled analgesia (PCA) or analgesia through an epidural catheter. Administer analgesics routinely as indicated. | Maintaining a constant drug level avoids cyclic periods of pain, aids in muscle healing, and improves respiratory function and emotional comfort and coping. |
Prepare the client for pleurodesis, as indicated. | Pleurodesis or pleural sclerosis involves instilling an irritant into the pleural space to cause inflammatory changes that result in bridging fibrosis between the visceral and parietal pleural surfaces, effectively obliterating the potential pleural space. Pleurodesis is most often used for recurrent malignant effusions. Given the limited life expectancy of these clients, the goal of the therapy is to palliate symptoms while minimizing discomfort, hospital length of stay, and overall costs. |
Impaired Gas Exchange
Pleural effusion can cause gas exchange and relatively modest arterial hypoxemia. It appears to be most severe when the effusion is large, chest wall compliance is reduced, and/or diaphragm function is impaired. One primary mechanism may be an intrapulmonary shunt and ventilation-perfusion mismatch resulting from atelectasis of the underlying lung.
Nursing Diagnosis
- Impaired Gas Exchange
Related Factors
- Ventilation-perfusion mismatch
- Altered oxygen-carrying capacity of blood
- Altered delivery of oxygen
Evidenced by
- Dyspnea
- Cyanosis
- Tachycardia
- Restlessness and changes in mentation
- Hypoxia
Desired Outcomes
After the implementation of nursing interventions, the client is expected to:
- Demonstrate improved ventilation and oxygenation of tissues by ABGs within the normal range.
- Participate in actions to maximize oxygenation.
Nursing Interventions
Assessment | Rationale |
Assess respiratory rate, depth, and ease. | Manifestations of respiratory distress are dependent on and indicative of, the degree of lung involvement and underlying general health status . |
Observe the color of the skin, mucous membranes, and nailbeds, noting the presence of peripheral cyanosis (nailbeds) or central cyanosis (circumoral). | Cyanosis of nailbeds may represent vasoconstriction or the body’s response to the inflammatory process; however, cyanosis of earlobes, mucous membranes, and skin around the mouth is indicative of systemic hypoxia. |
Assess the client’s mental status. | Restlessness, irritation, confusion, and somnolence may reflect hypoxemia or decreased cerebral oxygenation. |
Monitor the client’s vital signs. | Tachycardia is usually present as a result of a fever. High fever, common in pleural effusion associated with pneumonia greatly increases metabolic demands and oxygen consumption. |
Independent | |
Assist with comfort measures to reduce fever and chills. | Help the client with adding or removing excess bedcovers, place the room at a comfortable temperature, and offer a tepid or cool water sponge bath to relieve the client’s fever and chills. |
Maintain bedrest and encourage the use of relaxation techniques and diversional activities. | This prevents exhaustion and reduces oxygen consumption and demands to facilitate the resolution of infection. |
Elevate the client’s head and encourage frequent position changes, deep breathing techniques, and effective coughing. | These measures promote maximal inspiration and enhance the expectoration of secretions to improve ventilation. |
Dependent/Collaborative | |
Monitor the client’s ABG levels and pulse oximetry. | These tests can identify problems, such as ventilatory failure; follows the progress of the disease process or improvement; and facilitates alterations in pulmonary therapy. |
Administer oxygen therapy. | The purpose of oxygen therapy is to maintain PaO2 above 60 mm Hg, or greater than 90% O2 saturation. Oxygen is administered by a method that provides appropriate delivery within the client’s tolerance. |
Prepare the client for a thoracentesis, as indicated. | Therapeutic drainage of pleural effusion improves gas exchange to a small but variable degree. Findings from a recent study suggested differences in oxygenation post-thoracentesis depending on the initial effusion size. Oxygenation improved at 48 hours post-thoracentesis with both small and large effusions; however, with large effusions, an initial worsening of oxygenation was also present. |
Ineffective Breathing Pattern
Dyspnea is the most common symptom associated with pleural effusion and is related more to distortion of the diaphragm and chest wall during respiration than to hypoxemia. In many clients, drainage of pleural fluid alleviates dyspnea despite limited alterations in gas exchange. Drainage of pleural fluid may also allow the underlying disease to be more easily recognized on repeat chest radiographs.
Nursing Diagnosis
- Ineffective Breathing Pattern
Related Factors
- Decreased lung expansion due to fluid accumulation
- Musculoskeletal impairment
- Pain and anxiety
- Inflammatory process
Evidenced by
- Dyspnea
- Tachypnea
- Changes in depth and quality of respirations
- Use of accessory muscles when breathing
- Nasal flaring
- Cyanosis
Desired Outcomes
After the implementation of nursing interventions, the client is expected to:
- Establish a normal and effective respiratory pattern with ABGs within the client’s normal range.
- Be free of cyanosis and other signs and symptoms of hypoxia.
Nursing Interventions
Assessment | Rationale |
Auscultate the client’s breath sounds. | Breath sounds may be diminished or absent in a lobe, lung segment, or entire lung field (unilateral). Atelectatic areas will have no breath sounds, and partially collapsed areas have decreased sounds. A regularly scheduled evaluation also helps determine areas of good air exchange and provides a baseline to evaluate the resolution of pleural effusion. |
Evaluate respiratory function, noting rapid or shallow respirations, dyspnea, reports of “air hunger”, development of cyanosis, and changes in vital signs. | Respiratory distress and changes in vital signs occur because of physiological stress and pain or may indicate the development of shock due to hypoxia. |
Identify etiology or precipitating factors. | Understanding the cause is necessary for proper chest tube placement and the choice of other therapeutic measures. |
Assess fremitus. | Voice or tactile fremitus (vibration) is reduced in fluid-filled or consolidated tissue. |
Independent | |
For Chest Tube Care: | |
Check the suction control chamber for the correct amount of suction, as determined by water level, wall, or table regulator, at the correct setting. | This maintains prescribed intrapleural negativity, which promotes optimum lung expansion and fluid drainage. |
Monitor for air leaks and record the amount and quality of fluid drainage. | Record the amount and quality of fluid drained and monitor for an air leak (bubbling through the water seal) at each shift. Large air leaks (steady streams of air throughout the respiratory cycle) may be indications of loose connectors or of a drainage port on the catheter that has migrated out to the skin. |
Clamp the catheter briefly to check the origin of air leaks. | Briefly clamping the catheter at the skin helps to determine whether the air leak is originating from within the pleural cavity ( in which case, it stops when the tube is clamped) or from outside the chest (in which case, the leak persists). |
Place petrolatum gauze or other appropriate material around the insertion site. | This may usually correct an air leak from the insertion site. |
Evaluate for abnormal or continuous water-seal chamber bubbling. | With suction applied, this indicates a persistent air leak that may be from a large pneumothorax at the chest insertion site or chest drainage unit. |
Monitor water-seal chamber “tidaling” and whether it is transient or permanent. | The water-seal chamber serves as an intrapleural manometer (gauges intrapleural pressure); therefore, fluctuation, or tidaling, reflected pressure differences between inspiration and expiration. Tidaling of 2 to 6 cm during inspiration is normal and may increase briefly during coughing episodes. |
Position drainage system tubing for optimal function by shortening the tubing or coiling the extra tube on the bed. Drain accumulated fluid as necessary. | Improper position, kinking, or accumulation of clots and fluid in the tubing changes the desired negative pressure and impedes fluid evacuation. |
Note the character and amount of chest tube drainage, whether the tube is warm and full of blood and whether the blood fluid level in the water-seal bottle is rising. | This is useful in evaluating the development of hemorrhage requiring prompt intervention. |
Evaluate the need for gentle “milking” of the chest tube per protocol. | “Milking” may be indicated to maintain drainage in the presence of fresh bleeding, large blood clots, or purulent exudates. Caution is necessary to prevent undue discomfort or injury. |
Dependent/Collaborative | |
Repeat chest radiographs or CT scans as indicated. | Repeat the client’s radiographs when the drainage decreases to less than 100 ml/day to evaluate whether the effusion has been fully drained. If a large effusion persists radiographically, reevaluate the position of the chest catheter using a chest CT scan to ensure that the drainage ports are still positioned within the pleural collection. |
Assist in therapeutic thoracentesis as appropriate. | Therapeutic thoracentesis is used to remove larger amounts of pleural fluid to alleviate dyspnea and prevent ongoing inflammation and fibrosis in parapneumonic effusions . |
References
- Boka, K., & Soo, G. W. (2021, October 15). Pleural Effusion: Background, Anatomy, Etiology. Medscape Reference. Retrieved September 21, 2022, from https://emedicine.medscape.com/article/299959-overview#a10
- Krishna, R., & Rudrappa, M. (2021, August 11). Pleural Effusion – StatPearls. NCBI. Retrieved September 21, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK448189/
- Maskell, N. (2020). Pleural Disease. European Respiratory Society.
- Moorhouse, M. F., Doenges, M. E., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.