Critical Care Nursing Theory Pleural Effusion

Critical Care Nursing Theory Pleural effusion

Pleural Effusion

-The pleural space is a potential space between the visceralpleuraethat lines the lungsand the parietal pleurae that lines the interior chestwall.

-There is a continuous flow of fluid from the parietalpleura of the chest wall to the visceral pleura, and the fluids eventually absorbed by the pulmonarylymphatics.

-The pleural cavity is only a potential space because in health the two layers of pleura are separated by only a thin film of serous fluid, sufficient to prevent friction between them during breathing. The serous fluid is secreted by epithelial cells of the membrane.

Pathophysiology

1- An increased rate of fluid formation,

2- A decreased rate offluid removal,

3- Both.

The causative mechanisms:-

1- Increased pressure in subpleural capillaries or lymphatics,

2- Increased capillary permeability,

3- Decreased colloid osmotic pressure of the blood,

4- Increased intrapleural negative pressure,

5- Impaired lymphatic drainage of the pleural space.

Types of pleural effusion:-

1- Transudative pleural effusion.

2- Exudative pleural effusion.

Pathophysiology and Etiology

• May be either transudative or exudative.
• Transudative effusions occur primarily in noninflammatory conditions; is an accumulation of low-protein, low cell count fluid.
• Exudative effusionsoccur in an area of inflammation; is an accumulation of high-protein fluid.
• Occurs as a complication of:
• Disseminated cancer (particularly lung and breast), lymphoma.
• Pleuropulmonary infections (pneumonia).
• Heart failure, cirrhosis, nephrosis.
• Other conditions: sarcoidosis, systemic lupus erythematosus (SLE), peritoneal dialysis.

- Mechanisms that produce these effusions include

1- Ischemia-induced increased pleural capillary permeability,

2- Imbalance in vascular and pleural space hydrostatic pressures,

3- Pleuropulmonary hemorrhage.

- A hemothorax is a bloody exudative pleural effusion and is diagnosed by a

pleural fluid-to-blood hematocrit ratio greater than 50%.

- Hemothorax canresult from

1- Trauma is the most commoncause of a hemothorax

2- Invasive procedures (placement of centralvenous catheter,

thoracentesis),

3- Pulmonary infarction,malignancies,

4- A ruptured aortic aneurysm.

5-As a rare complication of anticoagulation therapy.

Assessment

● Subjective findings:-

- Shortness of breath and pleuriticchest pain, depending on the amount of

fluid accumulation.

● Objective findings:-

1- Tachypnea and hypoxemia if ventilationis impaired,

2- Dullness to percussion,

3- Decreasedbreath sounds over the involved area.

Diagnostic Studies

- A lateral decubitus chest radiograph is the best demonstrationof free

pleural fluid.

- Diagnostic thoracentesis (aspiration of fluid from the pleural space) when

a pleural effusion issuspected on the basis of physical examination and is

confirmed radiologically, it is necessary to obtain a sampleof pleural

fluid for diagnosis.

- Thelaboratory tests performed on the pleural fluid obtainedby

thoracentesis (Evaluation ofthe pleural fluid is necessary to distinguish

transudativefrom exudative effusions.)

Test / Comment
Red blood cell count >100,000/mm3 / Trauma, malignancy, pulmonary embolism
Hematocrit >50% of peripheral blood / Hemothorax
White blood cell count (WBC)
>50,000–100,000/mm3 / Grossly visible pus, otherwise total WBC less useful than WBC differential
>50% Neutrophils / Acute inflammation or infection
>50% Lymphocytes / Tuberculosis, malignancy
>10% Eosinophils / Most common: hemothorax, pneumothorax; also benig
>5% Mesothelial cells / Asbestos effusions, drug reaction, paragonimiasis; tuberculosis less likely
Glucose <60 mg/dL / Infection, malignancy, tuberculosis, rheumatoid
Amylase >200 units/dL / Pleuritis, esophageal perforation, pancreatic disease, malignancy, ruptured ectopic pregnancy
Isoenzyme profile: salivary–esophageal disease, malignancy (especially lung)
pH <7.2 / Isoenzyme profile: pancreatic–pancreatic disease
Infection (complicated parapneumonic effusion and
empyema), malignancy, esophageal rupture, rheumatoid or lupus pleuritis, tuberculosis, systemic acidosis, urinothorax
Triglyceride >110 mg/dL / Chylothorax
Microbiological studies / Etiology of infection
Cytology / Diagnostic of malignancy

- When the distance betweenthe pleural fluid line to the inside of the chest

wall onlateral decubitus view is less than 1 cm:-

- It is difficult to obtain the pleural fluid by thoracentesis

- The pleural effusionis not likelyto be clinically significant.

- The associatedrisk of pneumothorax outweighs the benefit of

the thoracentesis.

Management

- Treatment of the underlying cause is necessary.

- Removalthe pleural effusion by thoracentesis or chest tubeplacement

may be indicated depending on the etiologyand size of effusion.

(The primary indication for therapeuticthoracentesis is relief of dyspnea.)

Thoracentesis

In thoracentesis, a needle is inserted into the pleural space

- To remove air, fluid, or both;

- To obtain specimens for diagnosticevaluation;

- To instill medications.

A chest radiograph,coagulation studies, and patient education are essentialbefore a thoracentesis.

Some patients may require medicationto reduce anxiety. Unlike bronchoscopy, thoracentesisrequires the cooperation of the patient;

Therefore, alocal anesthetic, rather than moderate sedation, is used tominimize the pain and discomfort that accompanies theprocedure.

During the procedure, the patient is placedeither in a chair or on the edge of the bed in an uprightposition with arms and shoulders raised so that the ribslift and separate, allowing easier needle insertion.

If apatient is unable to lift his or her arms, sitting on the bedwith the arms placed above the head on a table is an alternativeposition.

During thoracentesis, the nurse’s primary functions are:-

1- Provide comfort for the patient,

2- Perform ongoingassessment of the patient’s respiratory system,

3- Dress thewound with sterile dressings on completion of the procedure,

4- Send labeled laboratory specimens as ordered.

- Post-thoracentesis nursing care includes assessment forcomplications,

including pneumothorax, pain, hypotension,and pulmonary edema.

Positioning the patient for a thoracentesis. The nurse assists the patient to one of three positions and offers comfort and support throughout the procedure. (A) Sitting on the edge of the bed with head and arms on and over the bed table. (B) Straddling a chair with arms and head resting on the back of the chair. (C) Lying on unaffected side with the bed elevated 30-45 degrees.

Nursing Diagnosis

• Ineffective Breathing Pattern related to collection of fluid in pleural space

Nursing Interventions

Maintaining Normal Breathing Pattern

• Institute treatments to resolve the underlying cause as ordered.
• Assist with thoracentesis if indicated.
• Maintain chest drainage as needed.
• Provide care after pleurodesis.
• Monitor for excessive pain from the sclerosing agent, which may cause hypoventilation.
• Administer prescribed analgesic.
• Assist patient undergoing instillation of intrapleural lidocaine if pain relief is not forthcoming.
• Administer oxygen as indicated by dyspnea and hypoxemia.
• Observe patient's breathing pattern, oxygen saturation, and other vital signs, for evidence of improvement or deterioration.

Patient Education and Health Maintenance

• Instruct patient to seek early intervention for unusual shortness of breath, especially if he has underlying chronic lung disease.

Evaluation: Expected Outcomes

• Reports absence of shortness of breath

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Dr. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing