In order to allow movement of pleural surfaces and prevent friction, the pleural space contains 5 to 15 mL of fluid which acts as a lubricant. An increase in the collection of fluid without drainage will result to pleural effusion.

What is pleural effusion?

Pleural effusion is the abnormal accumulation of fluid in the pleural space. It is rarely a primary disease process but is usually secondary to other diseases (Smeltzer, et al., 2010). It may be a complication of underlying conditions such as heart failure, TB, pneumonia, nephritic syndrome, connective tissue disease, pulmonary embolism, and neoplastic tumors.

What are the types of effusion?

The effusion is usually composed of clear fluid or it can either be bloody or purulent. A transudative effusion is a condition where filtrates of plasma that move across intact capillary walls. Usually, there is an alteration in the reabsorption of the pleural fluid and the pleural membranes remain normal. On the other hand, exudative effusion results from inflammation by bacterial products or tumors involving the pleural surfaces (Smeltzer, et al., 2010).

Clinical Manifestations

  • Pleuritic pain that is sharp and increases with inspiration
  • Dry nonproductive cough
  • Dyspnea on exertion
  • Tachycardia
  • Decreased breath sounds
  • Elevated temperature

Assessment and Diagnostic Findings

  • Decreased or absent breath sounds and decreased fremitus upon physical examination
  • Chest x-ray reveals pleural effusion and a mediastinal shift away from the fluid
  • Bacterial culture of pleural fluid for presence of infection

Medical Management

  • Identify and treat underlying cause.
  • Thoracentesis is performed to evacuate fluid and as well as relieve dyspnea and respiratory distress.
  • Once the condition does not respond and recurrent pleural effusion results, pleurodesis is prescribed. Pleurodesis involves instillation of a sclerosing ingredient into the pleural space via a thoracotomy tube.

Pleural Effusion Nursing Care Plan

Nursing Problem with Cues

Subjective cues:

“It feels like I can’t get enough air when I breathe.”

Objective cues:

  • Dypnea noted upon assessment
  • Nasal Flaring
  • Shortness of breath
  • Use of accessory muscles to breath
  • Orthopnea
  • Altered chest excursion
  • Decreased minute ventilation
  • Decreased vital capacity
  • Respiratory rate of 35 cpm

Nursing Diagnosis with Rationale

Ineffective breathing pattern related to abnormal accumulation of fluid in the pleural space

Rationale

Normally, the pleural space is filled with fluid amounting 5-15 mL to provide lubrication of pleural surface and prevent friction. In pleural effusion, an abnormal volume of fluid collects in the pleural space, causing pain and shortness of breath. The ventilatory effort

is insufficient to bring in enough oxygen or to get rid of sufficient amounts of carbon dioxide. Thus, potential nursing diagnosis for the client would be ineffective breathing pattern.

Objectives

Long term goal:

After 72 hours of nursing intervention, client will be able to demonstrate normal and effective respiratory pattern.

Short term goals:

After 1 hour of health teaching, client will be able to:

  1. Identify lifestyle changes that may be required in assisting to prevent ineffective breathing pattern.
  2. Participate in the treatment regimen.

Interventions

  1. Monitor for signs and symptoms of respiratory distress:
    • Dypnea
    • Decreased of absent breath sounds
    • Cyanosis
    • Shortness of breath
  2. Assess for pain and discomfort.

Independent:

Measures to improve breathing pattern

  1. Raise head of bed 45 degrees or more if not contraindicated.
  2. Instruct in diaphragmatic deep breathing and pursed-lip breathing.
  3. Encourage ambulation and motility to the patient.
  4. Promote rest and relaxation by scheduling treatments and activities with appropriate rest periods.
  1. Conduct health teaching on the following:
    • Illness
    • Procedures and related nursing care

Assist the client in practicing pulmonary hygiene:

    • Clearing bronchial tree by controlled coughing
    • Decreasing viscosity of secretions via humidity and fluid balance

Dependent   

  1. Administer supplemental oxygen.
  2. Assist in performing thoracentesis.
  3. Medicate with analgesics as appropriate

Rationale for Intervention

  1. Pleural effusion can be a potential life-threatening condition. Careful assessment provides for early recognition and intervention for problem.
  2. Pain may restrict or limit respiratory effort.
  3. Allows gravity to assist in lowering the diaphragm, and provides greater chest expansion.
  4. Promotes lung expansion and slightly increases pressure in the airways, allowing them to remain open longer.
  5. Promotes tolerance for activities and helps with lung expansion and ventilation.
  6. Avoids overexertion and worsening of condition.
  7. Reduces anxiety; starts appropriate home care planning; assists the family in dealing with health-care system.
  8. Provides basic information for the client and family that promotes necessary lifestyle changes.
  9. Oxygen administration helps correct hypoxemia.
  10. Evacuates fluid and as well as relieve dyspnea and respiratory distress.
  11. Promotes deeper respiration and cough.

References


  1. Doenges, M.E., Moorhouse, M.F., and Murr, A.C. (2010). Nurse’s Pocket Guide. Philadelphia, Pennsylvania: F.A. Davis Company.
  2. Newfield S., Hinz, M., Tilley, D., Sridaromont, K., Maramba, P. (2007). Cox’s application of nursing diagnosis: Adult, child, women’s, mental health, gerontic, and home health considerations Philadelphia, Pennsylvania: F.A. Davis Company.
  3. Silvestri, L. A.(2005). Saunders Comprehensive review for the NCLEX-RN Examination.  St. Louis, Mo.: Saunders/Elsevier Inc.
  4. Smeltzer, S., Bare, B., Hinkle, J. Cheever, K. (2010). Brunner & Suddarth’s Textbook of Medical Surgical Nursing.Wolter Kluwer Health/ Lippincott Williams & Wilkins.

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