B. SC NURSING
MEDICAL-SURGICAL NURSING- I
UNIT- III NURSING MANAGEMENT OF
PATIENTS WITH RESPIRATORY
PROBLEMS
PLEURAL EFFUSION
1

GENERAL OBJECTIVE
• At the end of the class students will gain in
depth knowledge regarding pleural effusion,
develops desirable attitude and able to apply
this knowledge whenever necessary.

Specific objective
• Explain the causes of pleural effusion
• Describe the pathophysiology of pleural effusion
• Explain the signs and symptoms of pleural
effusion
• Describe the diagnostic investigations for pleural
effusion
• Summarize the medical and nursing
management of pleural effusion
PLEURAL EFFUSION

PLEURAL EFFUSION
Introduction:
• Pleural effusions are accumulations of fluid
within the pleural space. They are classified as
transudates or exudates.
• TRANSUDATES-fluid buildup caused by systemic
conditions[ due to cardiac or renal problem]
• EXUDATES-fluid buildup caused by tissue leakage due
to inflammation or local cellular damage.
4

Definition:
• Pleural effusion is defined as abnormal accumulation
of fluid in the pleural space.
• Fluid can accumulate around the lungs due to poor
pumping by the heart or by inflammation.
• The excessive amounts of such fluid can impair
breathing by limiting the expansion of the lungs during
respiration.
PLEURAL EFFUSION
5

5
PLEURAL FLUID FORMATION
 Normally, 10 to 20 ml of pleural fluid is spread
thinly over visceral and parietal pleurae, facilitating
movement between the lungs and chest wall.
The fluid enters the pleural space from systemic
capillaries in the parietal pleurae and exits via
parietal pleural stomas and lymphatic's.

PLEURAL FLUID FORMATION
Pleural fluid accumulates when too much fluid
enters or too little exits the pleural space.
The fluid will be clear or pale yellow.

.Clear ultra filtrate of plasma
•Volume - 0.3 ml/kg[eg.50kg=12ml]
•Cells/ mm3 -1000 – 5000
•Mesothelial cells - 60%
•Monocytes - 30%
•Lymphocytes - 5%
•Protein - 1-2 g/dl
COMPOSITION OF PLEURAL FLUID

CLASSIFICATION
a)Based on site
Apical
Inter lobar
Sub-pulmonic-base[btw pleura and diaphragm]
Mediastinal-btw the lungs

B)Based on mechanism and type of pleural fluid
 Transudative
 Exudative
 Serous fluid[hydrothorax]-accumulation of serous fluid in
pleural cavity
 Blood[haemothorax]-blood accumulating in pleural cavity
 Pus [pyothorax or empyema]- accumulation of pus in
pleural cavity
 Chyle[chylothorax]-milky body fluid contains fatty cells

ETIOLOGY
• A viral infection such as the flu[influenza]
• A bacterial infection,such as pneumonia
• A fungal infection
• Autoimmune disorder eg.rheumatoid arthritis
• Certain medications
• Lung cancer near the pleural surface

PATHOPHYSIOLOGY
• Due to etiological factor
• Increased pressure in pulmonary capillaries
• Increased amount of fluid enter the interstitial
spaces of lung
• Increased interstitial pressure in interstitial
spaces

Fluid moves from the pulmonary interstitial spaces
into pleural space
Pleural effusion

Dyspnea-breathlessness
Pleuritic chest pain-a vague discomfort or sharp
pain that worsens during inspiration
Pain is usually felt over the inflamed site.
Dull percussion over area of effusion
Decreased breath sounds of area of effusion
Pleural rub,crackles sounds on auscultation
SYMPTOMS

DIAGNOSIS
• Chest x-ray

Pleural fluid cytology
•WBC count
•Predominant cell type(neutrophil,Lymphocytes,
•Eosinophils, red blood cells)
•Gram stain
•Acid fast for acid fast bacilli(AFB)
•Pleural fluid culture
•AFB culture
•Polymerase chain reaction for TB
DIAGNOSIS

• CT scan of chest
• Ultrasound of the chest
• Thoracentesis- a needle is inserted between
the ribs to remove a biopsy or to collect fluid]
• Pleural fluid analysis-examination of the fluid
removed from the pleural space.
• Thoracoscopy- minimally invasive technique
allows for a visual evaluation of the pleura
- It is also known as video assisted
thoracoscopic surgery[VATS]
- It is performed under general anesthesia

MANAGEMENT
 Treatment of pleural effusion is based on the
underlying condition and whether the effusion is causing
severe respiratory symptoms such as shortness of breath
or difficulty breathing.
Congestive heart failure- treat with diuretics
Thoracentesis [ tube thoracostomy ]- drained through a
chest tube.
Pleural sclerosis performed with sclerosing agents[such
as doxycycline , tetracycline]

SURGICAL MANAGEMENT :
1.VIDEO ASSISTED THORACOSCOPIC SURGERY
• 1-3 small incision Is made to remove fluids
• Very effective in managing effusion
• Antibiotics are inserted at the time of surgery to prevent
the recurrence of fluid build up.
2.THORACOTOMY-OPEN THORACIC SURGERY
• Performed through 6-8 inch incision in the chest
• Removes all the fibrous tissue- chest tube is maintained
for 2 weeks after surgery for drain collection

• Pleural shock
• Air embolism
• Introduction of infection
• Pneumothorax-lung collapse
• Pulmonary embolism
• Air embolism
• Acute pulmonary edema
• Injury to vascular bundles
• Hydropneumothorax-presence
of air and fluids
COMPLICATION

1.Impaired gas exchange related to fluid
collection in pleural spaces evidenced by
dullness on percussion, pleural friction rub
on auscultation.
Goal :demonstrates full lung expansion with normal
oxygen saturation intervention:
• Monitor respiratory rate and oxygenation status
• Initiate and maintain supplemental oxygen to
treat hypoxemia
NURSING MANAGEMENT

• Position the patient in fowlers to increase patient
comfort and to facilitate aeration in lungs.
• Chest tube care
• Monitor for bubbling of the suction chamber for
chest tube drainage system
• Ensure that tubing's are secured properly
• Keep drainage container below the chest level

2.Ineffective breathing pattern related to pain and
position as Evidenced by shortness of breath
,shallow respiration
Goal : demonstrates an effective respiratory rate ,
rhythm and depth of respiration
NURSING MANAGEMENT

• Intervention:
• Monitor respiratory rate, rhythm depth and effort of
respiration.
• Auscultate breath sounds, noting areas of decreased
ventilation
• Pain management
• Provide optimal pain relief with prescribed analgesics
• Ventilation assistance
• Position the patient will alleviate dyspnoea
• Assist with incentive spirometer.

REFERENCE
1.Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher,
L., & Harding, M.M. (2017). Medical-surgical nursing:
assessment and management of clinical problems
(10th ed.). St. Louis: elsevier.Pp.No-595-598.
2.Berthold Jany and Tobias Welte,.(2017) . pleural
effusion in adults—etiology, diagnosis, and treatment
3.Kamran boka, guy w .Soo hoo,(2017) . pleural
effusion : news perspective Drug and disease from
medscape.