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  1. Pleural Effusion Prepared by: Ali Refak lazeem Supervised by: Dr. Tahseen Assessment of respiratory status in acutely or critically ill Often, a patient is intubated and receiving mechanical ventilation 1. physical assessment , monitoring techniques and knowledgeable about possible ventilator-associated events. 2. The nurse analyzes findings from the health history and assessment while considering laboratory and diagnostic test results. 3.The nurse must assess for patient–ventilator synchrony and for agitation, restlessness, and other signs of respiratory distress (nasal flaring) . After checking the ventilator settings and that alarms are always in the “on” position 4. The nurse note changes in the patient’s vital signs and evidence of hemodynamic instability and report them to the physician
  2. 5.The patient’s position must be assessed to ensure that the head of the bed is elevated to prevent aspiration 6.The patient’s mental status should be assessed and compared to previous status. Lethargy and somnolence may be signs of increasing carbon dioxide levels 7.Chest auscultation, percussion, and palpation are essential and routine parts of the evaluation of the critically ill patient with or without mechanical ventilation. 8.Tests of the patient’s respiratory status are easily performed at the bedside by measuring the respiratory rate, tidal volume, minute ventilation, vital capacity, inspiratory force Indications For Tidal Volume, Minute Ventilation, Vital Capacity, Inspiratory Force 1- Risk for pulmonary complications, including those who have undergone chest or abdominal surgery 2-Prolonged anesthesia 3- Preexisting pulmonary disease 4-Older 5-Obese. These tests are also used routinely for mechanically ventilated patients
  3. Pleural Effusion  A collection of fluid in the pleural space,  rarely a primary disease process;  usually secondary to other diseases.  The pleural space contains a small amount of fluid (5 to 15 ml), which acts as a lubricant that allows the pleural surfaces to move without friction .  The effusion relatively clear fluid or bloody or purulent.  An effusion of clear fluid may be A transudate or an exudate. Pathophysiology  A transudate (filtrate of plasma that moves across intact capillary walls) occurs when factors influencing the formation and reabsorption of pleural fluid are altered, usually by imbalances in hydrostatic or oncotic pressures.  Most common from heart failure.  An exudate (extravasation of fluid into tissues or a cavity) results from inflammation by bacterial products or tumors involving the pleural surfaces
  4. Etiology 1-Heart Failure, 2-TB, Pneumonia 3-Pulmonary Infections (Particularly Viral Infections) 4-Nephrotic Syndrome, 5-Connective Tissue Disease, 6-Neoplastic Tumors. (Bronchogenic Carcinoma)
  5. CLINICAL MANIFESTATION Usually, the clinical manifestations are caused by the underlying disease. ➢ Pneumonia causes fever, chills, and pleuritic chest pain, ➢ A malignant effusion may result in dyspnea, difficulty lying flat, and coughing. ➢ A large pleural effusion causes dyspnea (shortness of breath). ➢ A small-to- moderate pleural effusion causes minimal or no dyspnea. Assessment of the area of the pleural effusion 1- decreased or absent breath sounds 2- decreased fremitus and a dull, flat sound on percussion. 3-Tracheal deviation away from the affected side may also be apparent. * In the an extremely large pleural effusion, the assessment reveals a patient in acute respiratory distress. Diagnosis 1-Chest x-ray 2-Computed tomography (CT) scan of the chest 3-Ultrasound of the chest 4-Thoracentesis (a needle is inserted between the ribs to remove a biopsy, or sample of fluid) 5-Pleural fluid analysis (an examination of the fluid removed from the pleura space) 6- Cytologic analysis for malignant cells
  6. Treatment The objectives of treatment 1-discover the underlying cause of the pleural effusion 2- prevent re-accumulation of fluid 3-relieve discomfort, dyspnea, and respiratory compromise. Specific treatment is directed at the underlying cause (e.g., heart failure, pneumonia, and cirrhosis) Treatment  Diuretics and other heart failure medications are used to treat pleural effusion caused by congestive heart failure.  A malignant effusion may also require treatment with chemotherapy, radiation therapy or a medication infusion within the chest.  Procedures for treating pleural effusions include:  Thoracentesis.  Tube thoracostomy (chest tube).  pleurectomy  if the underlying cause is a malignancy result re-accumulation of fluid,Repeated thoracenteses result in pain, depletion of protein and electrolytes, and pneumothorax.  A chemical pleurodesis performed to obliterate the pleural space and prevent re-accumulation of fluid . using thoracoscopic approach or chest tube.
  7.  A chemically irritating agent (e.g., talc or another) is instilled or aerosolized into the pleural space.  after instilled, the chest tube is clamped for 60 to 90 minutes and the patient is assisted to assume various positions to promote uniform distribution of the agent and to maximize its contact with the pleural surfaces  The tube is unclamped and chest drainage continued several days longer to prevent re-accumulation of fluid and to promote the formation of adhesions between the visceral and parietal pleurae
  8. Reference Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical- surgical nursing. Wolters kluwer india Pvt Ltd.