Pleural effusion is characterized by the accumulation of excess fluid between the lining of the chest wall and the lining of the lungs, known as the pleural space. Normally, there is a minimal amount of fluid in the pleural space that acts as lubrication to facilitate breathing.
The seriousness of the condition will depend on the cause and symptoms. Common causes of pleural effusion include infection, pneumonia, congestive heart failure, cancer, and diseases of the kidneys or liver.
A chest x-ray or CT scan can help diagnose pleural effusion and treatment depends on the underlying cause and the severity of symptoms.
The Nursing Process
Treatment may come in the form of antibiotics for infection or diuretics for congestive heart failure which the nurse will administer.
For more severe respiratory distress, procedures that help drain excess fluid may be indicated. Such procedures include thoracentesis, tube thoracostomy (chest tube), pleurodesis, or pleural drains. Nurses are responsible for the assessment and monitoring of the patient before and after these procedures.
Nurses can support patients through education by teaching infection prevention measures, how to manage chronic conditions, when to seek emergency support for symptoms, and how to take their medications.
Nursing Care Plans Related to Pleural Effusion
Ineffective Breathing Pattern Care Plan
An ineffective breathing pattern occurs when the lungs are not able to expand effectively during inspiration and/or expiration to provide adequate ventilation. This often happens to patients with pleural effusion as there is increased pressure in the lungs due to the excess fluid buildup in the pleural space, making breathing difficult. With an ineffective breathing pattern, the body will not get adequate oxygen.
Nursing Diagnosis: Ineffective Breathing Pattern
- Exudative pleural effusion
- Compromised lung expansion
- Excess fluid buildup in the pleura secondary to infection, inflammation, cardiac disease, or pulmonary disease
As evidenced by:
- Labored breathing
- Increased pain upon inhalation
- Oxygen saturation of less than 90%
- The patient will achieve an effective breathing pattern as evidenced by a respiratory rate of 12-20 bpm and oxygen saturation above 95%
- The patient will verbalize ease of breathing
Ineffective Breathing Pattern Assessment
1. Assess the patient’s respiration characteristics and vital signs.
Assessing the rate and depth of breathing along with O2 saturation, pulse, and blood pressure are necessary to monitor for changes or worsening in respiratory status.
2. Review the patient’s underlying condition.
Understanding the patient’s underlying condition is essential to providing appropriate interventions.
Ineffective Breathing Pattern Interventions
1. Administer medications as prescribed.
The patient may be prescribed antibiotics to treat pneumonia or diuretics for congestive heart failure.
2. Administer oxygen therapy as prescribed.
Providing supplemental oxygen is essential to prevent cellular hypoxia caused by low oxygen secondary to ineffective breathing patterns.
3. Elevate the patient’s HOB.
Elevating the head of the bed can improve lung expansion and help open up the airways enabling air to pass through with less obstruction making it easier to breathe.
4. Prepare for surgery/procedure as ordered.
Depending on the cause, pleural effusion may require placing a pleural drain or chest tube or performing procedures like pleurodesis. Nurses may perform some of these skills or may monitor the patient post-procedure for complications.
Acute Pain Care Plan
Acute pain in pleural effusion is caused by pleural inflammation of the parietal pleura which results from the movement-related friction between the two pleural surfaces. This type of pain is also referred to as pleuritic chest pain.
The pain is often characterized as sharp and is exacerbated by movement of the pleural spaces, as with coughing, sneezing, and deep inspiration.
Nursing Diagnosis: Acute Pain
- Inflammation and swelling of the pleura
As evidenced by:
- Reports of sharpness or burning in the chest
- Guarding the chest
- Worsening pain upon inhalation
- Shallow breathing
- The patient will report a decrease in pain when breathing as evidenced by a pain rating of 2 or less and a relaxed, unlabored respiratory rhythm.
- The patient will complete activities of daily living without complaints of respiratory discomfort.
Acute Pain Assessment
1. Assess the patient’s pain level, characteristics, and location.
Pleuritic pain must be differentiated from other types of chest pain to provide appropriate treatment. Assessing pain on a 0-10 numeric scale will provide information on the effectiveness of interventions.
2. Observe nonverbal cues and pain behaviors.
Pleuritic pain may cause patients to position themselves a certain way, decrease movement or ambulation, and restrict breathing, all of which cause deconditioning. The nurse should monitor for pain behaviors and intervene to prevent worsening complications.
Acute Pain Interventions
1. Administer prescribed pain medications.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen may decrease inflammation causing pleuritic chest pain.
2. Provide nonpharmacologic methods of pain relief.
Nonpharmacologic interventions like repositioning, guided imagery, and splinting the chest when coughing help manage pain and reduce stress. Also, this will help lower the dose of pain medication needed with decreased side effects.
3. Provide rest and simplify ADLs.
Pain may worsen when moving or performing tasks that take great effort. Rest frequently and do not overdo activities that will increase the work of breathing.
4. Educate the patient on deep breathing exercises.
Deep breathing exercises can help avoid ineffective shallow breathing, which is a natural response when experiencing pleuritic pain. Deep breathing can strengthen the lungs and improve oxygenation.
Impaired Gas Exchange Care Plan
The respiratory system is responsible for gas exchange – supplying oxygen to tissues and removing carbon dioxide. Pleural effusion affects the cardiorespiratory system and alters the ventilation-perfusion mechanism, causing reduced efficiency of the inspiratory muscles, restrictive ventilatory effect, and abnormal gas exchange.
Nursing Diagnosis: Impaired Gas Exchange
- Altered oxygen supply
- Decreased function of lung tissue
As evidenced by:
- Abnormal ABGs
- Changes in mental status
- The patient will exhibit improved gas exchange as evidenced by ABGs within normal limits.
- The patient will be able to maintain optimal gas exchange as evidenced by unlabored breathing and respiratory rate within normal limits.
Impaired Gas Exchange Assessment
1. Auscultate lung sounds.
An initial assessment will help provide baseline information and ongoing assessments will determine changes in the patient’s condition. Gas exchange is affected by shallow and rapid breathing patterns. Note areas of diminished breath sounds or fremitus.
2. Review laboratory values and imaging results.
Arterial blood gases (ABGs) measure oxygenation and acid-base balance in the blood which can help assess the patient’s respiratory status and prevent respiratory distress. Chest x-rays can help determine the size and location of the pleural effusion.
3. Assess and monitor the patient’s oxygen saturation.
A drop in oxygen saturation indicates respiratory insufficiency. For most individuals, oxygen saturation should be kept at 95% or greater.
Impaired Gas Exchange Interventions
1. Consider lateral positioning.
Elevating the head of the bed to 45 degrees and positioning the patient in a lateral position has been shown to increase O2 saturation and decrease respiratory rate in those with unilateral pleural effusions.
2. Provide supplemental oxygen as ordered.
Supplemental oxygen therapy may be necessary to maintain adequate oxygenation. Do not over-oxygenate.
3. Encourage ambulation.
Ambulation significantly improves chest expansion and the mobilization and drainage of secretions. Do not overexert to the point of dyspnea.
4. Provide support to reduce anxiety.
Dyspnea can cause anxiety and panic. These feelings can exacerbate shortness of breath. Provide a calming, supportive environment and reassure the patient.
5. Prepare the patient for indicated procedures.
Surgical interventions like thoracentesis, pleurodesis, or chest tube insertion may be indicated if the patient’s condition worsens. The nurse can educate the patient on what to expect with these treatments and how they alleviate symptoms.
References and Sources
- Fluid Around the Lungs (Pleural Effusion). Copyright 2022 Yale Medicine. From https://www.yalemedicine.org/conditions/fluid-around-the-lungs
- Fluid Around the Lungs or Malignant Pleural Effusion. Approved by the Cancer.Net Editorial Board, 09/2021. From https://www.cancer.net/coping-with-cancer/physical-emotional-and-social-effects-cancer/managing-physical-side-effects/fluid-around-lungs-or-malignant-pleural-effusion
- Jany, B., & Welte, T. (2019). Pleural Effusion in Adults-Etiology, Diagnosis, and Treatment. Deutsches Arzteblatt international, 116(21), 377–386. https://doi.org/10.3238/arztebl.2019.0377
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