Pleural Effusion
Nursing Interventions (Arber et al., 2014)(Malone, 2016)
Clinical Manifestations (Arber, et al., 2013)
Physical Assessment
Percussion: resonance becomes dull due to fluid replacing air space
Auscultation: Diminished/absent breath sounds over effusion with an increase in resonance (egophony)
Pathophysiology (Myatt, 2014) (Schumann, 2013)
Space between the visceral pleural and the parietal plural fill with an excessive amount of fluid/pus secondary to a disease or trauma (>250mL)
Exudative: accumulation of fluid/cells due to increase permeability of the lung capillaries leading to inflammation from cancer malignancies, infections, embolism, or GI disease
Dark yellow/amber colour due to an increase in protein in fluid
Palpation: increase in vocal fremitus about the effusion, but an absence of fremitus over the effusion
Client Centred Care (Arber et al., 2013)(Malone, 2016) (Myatt, 2014)
Treatment (Arber et al., 2013) (Norris, 2016)
Thoracentesis: a needle is inserted under localized anesthetic to drain fluid from the affected lung. Fluid sent for tests to determine possible cause for effusion
Indwelling Pleural Drain: long-term catheter inserted into pleural space to drain fluid allowing patient to go home during treatment. Common for recurrent effusions
Acknowledge Patients Lived Experience: Consider the patients past and current experiences that will influence the situation on hand
Open communication: helps to identify what the patients specific needs are and includes them in their care
Diagnosis (Myatt, 2014)
Ultrasound: amount of fluid is assessed and confirmed before a thorcentesis is performed
Radiograph (x-ray): confirms plural effusion as the fluid within the lung space shows white on an X-ray.
Thoracentesis: a needle is inserted under localized anesthetic to drain fluid from the affected lung. Fluid sent for tests to determine possible cause for effusion
Patient/Family Education: enables patient and family to become more engaged and participate in care and decision making
Tube Thoracostomy (chest tube): tube inserted into plural space to drain fluid over several days
Dry, nonproductive cough
Medications to treat Pleural Effusion (Skidmore-Roth, 2018)
Antibiotics: to treat infection based on causative agent
Diuretics: inhibits resorption of water, sodium, potassium and bicarbonate = increased urine volume
Etiology (Myatt, 2014)(Schumann, 2013)
Systemic
Local
Hydrothorax: non-inflammatory collection of fluid caused by chronic kidney disease, chronic liver disease, or congestive heart failure
Empyema: puss collection in pleural space caused by infection or cancer malignancies
Hemothorax: trauma to the lung causing blood collection in the pleural space
Chylothorax: lymphatic system leakage into pleural space from infections like pneumonia or tuberculosis
Transudative: caused by an increase in hydrostatic pressure within the capillaries of the lungs and a decrease in colloid osmotic pressure within the circulatory system
Congestive heart failure is the most common cause
Clear/pale yellow fluid
Increase fluid take up lung space leading to restriction of lung expansion and difficulty breathing
Fluid in pleural space restricts movement of lung expansion causing difficulty breathing
Orthopnea: shortness of breath when lying flat
Difficulty with physical activity
Difficulty taking deep breaths
Inspection: asymmetric chest wall expansion with tracheal tug and accessory muscle use when breathing
Vital Signs
Pain: present/increased due to inflammation
Temperature > 37.5 Celsius: fever will be present if effusion is caused by an infection
Respiratory rate >20 reaps/min: tachypnea to compensate for respiratory alkalosis
Oxygen saturation < 95%: due to compromised breathing ability
CT Scan: differentiate between malignancies, abscesses and pleural diseases
Antipyretics: inhibition of prostaglandins in the CNS (hypothalamic heat-regulating center)
Pain management: assess patients' level of pain. Use pharmacological/nonpharmacological interventions to relieve pain
Monitor: for signs of bleeding, increased shortness of breath, and infection
Anxiety Management: provide support during thoracentesis, pain management, explain procedures to patients so they know what to expect
Allows patient to feel like they are being treated like a human, not their disease
Chemical Pleurodesis: is when irritating, sclerosing agents are injected into the pleural space causing artificial synthesis of the parietal and visceral linings
which can prevent recurrence of effusions
Chest Tube: Ensure drainage system is in place and below patients' chest level; inspect insertion site for irritation/complications; ensure there are no kinks in the tubing; assess and record drainage levels; assess for leaks; report any signs of bleeding
Medications that can cause Effusion
Amiodarone
Beta blockers
Methotrexate
Nitrofurantoin
Phenytoin
Left ventricular failure
Liver cirrhosis: loss of liver cells and irreversible scarring of the liver
Hypoalbuminaemia: abnormally low levels of albumin in the blood
Peritoneal dialysis
Atelectasis: collapse or closure of a lung
Malignancy
Tuberculosis
Pulmonary embolism
Connective tissue disorders
Pancreatitis
Tetracycline, bleomycin, and sterile iodised talc
Relaxation techniques and diet to manage fatigue from dyspnea
Fluid accumulates between diaphragm and lower lobe of the affected lung
Heart Rate > 100 bpm
Pros: straight forward procedure
Cons: temporary fix if effusions are recurrent; distressing for patient
Pros: high success rates > 90%
Cons: inpatient procedure with risks of developing post-surgical pain, empyema (collection of puss), and respiratory failure
Pros: more time at home with family for patient; drainage can be continuous or intermittent
Cons: local cellulitis common problem
Pros: can be permanent fix
Cons: risk of infection and bleeding
Shortness of breath/dyspnea: deep breathing and coughing to promote lung expansion; position patient on unaffected side; smoking cessation; use of incentive spirometer
Can indicate reaccumulation of effusion and patient discomfort
Analgesics: Depresses pain impulse transmission at the spinal cord level by interacting with opioid receptors
Small, regular, high-calorie meals that are easy to swallow to meet nutritional needs
Use of fan on side of patients' face to reduce the feeling of breathlessness
Promote Lung Expansion: proper positioning and pursed lip breathing to reduce feeling of breathlessness and control breathing rate
Important to teach these techniques to care givers
Benzodiazepines: enhance the effect of GABA resulting in sedative, hypnotic, anxiolytic, anticonvulsant, and muscle relaxant properties
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Glucocorticoids, Macrolides, Cephalosporins, Fluoroquinolones, erythromycin
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Watch for superinfection and anaphylaxis
NSAIDS
ibuprofen, aspirin
assess hepatic and renal studies for toxicity
diazepam, lorazepam
furosemide, torsemide, bumetanide, and ethacrynic acid
treat congestive heart failure
opioids
morphine, codeine, oxycodone, hydrocodone
watch for respiratory depression, QT prolongation, hepatotoxicity, dependence
ANTIDOTE: Naloxone
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CONTROLLED SUBSTANCES
Collaborative Care (Bailey, 2013)
monitor patient closely for respiratory depression especially if used in combination with opioids
ANTIDOTE: flumazenil
What is Pleural Effusion?
Occurs when fluid collects in the pleural space of the lung (Lewis, Leitkemper, Dirksen, Bucher, Camera., 2014)
Water on the lungs
ANTIDOTE: epinephrine, aminophylline, IV corticosteroids
Treat the underlying cause
Specialists needed to diagnosis
Specialists creates the management plan to be implemented by the multidisciplinary team
Coordinate care
Inform the patient
Multidisciplinary team input and information sharing with patent
Patient is the focus for making decisions
Pleural space: is the space between the two types of pleura (Bailey, 2013).
The pleura: includes two thin layers of tissue that act as an elastic membrane, covering the lung, diaphragm and rib cage (Bailey, 2013).
Visceral Pleura: the inner layer which is wrapped very tightly around the lungs (Bailey, 2013).
Parietal Pleura: the outer layer, which lines the inside of the chest wall (Bailey, 2013).
fluid on the lung envelope
right, left or both lungs
Pleural biopsy
Bronchoscopy: Examining the airway
Megan Di Felice
Jenna Tuero
Eva VanBoekel