BARBA, ANNIKA Y.

BSN 4
SUBMITTED TO: ROY LABANON, RN
PLEURAL EFFUSION

ETIOLOGY
The normal pleural space contains approximately 10 mL of fluid, representing the balance
between (1) hydrostatic and oncotic forces in the visceral and parietal pleural capillaries and (2)
persistent sulcal lymphatic drainage. Pleural effusions may result from disruption of this natural
balance.
Presence of a pleural effusion heralds an underlying disease process that may be pulmonary or
non-pulmonary in origin and, furthermore, that may be acute or chronic. Although the etiologic
spectrum of pleural effusion can be extensive, most pleural effusions are caused by congestive
heart failure, pneumonia, malignancy, or pulmonary embolism.
The following mechanisms may play a role in the formation of pleural effusion:
Altered permeability of the pleural membranes (eg, inflammation, malignancy, pulmonary
embolism)
Reduction in intravascular oncotic pressure (eg, hypoalbuminemia due to nephrotic syndrome
or cirrhosis)
Increased capillary permeability or vascular disruption (eg, trauma, malignancy, inflammation,
infection, pulmonary infarction, drug hypersensitivity, uremia, pancreatitis)
Increased capillary hydrostatic pressure in the systemic and/or pulmonary circulation
(eg, congestive heart failure, superior vena cava syndrome)
Reduction of pressure in the pleural space (ie, due to an inability of the lung to fully expand
during inspiration); this is known as "trapped lung" (eg, extensive atelectasis due to an obstructed
bronchus or contraction from fibrosis leading to restrictive pulmonary physiology)
Decreased lymphatic drainage or complete lymphatic vessel blockage, including thoracic duct
obstruction or rupture (eg, malignancy, trauma)
Increased peritoneal fluid with microperforated extravasation across the diaphragm via
lymphatics or microstructural diaphragmatic defects (eg, hepatic hydrothorax, cirrhosis,
peritoneal dialysis)
Movement of fluid from pulmonary edema across the visceral pleura
Persistent increase in pleural fluid oncotic pressure from an existing pleural effusion, causing
further fluid accumulation
The net result of effusion formation is a flattening or inversion of the diaphragm, a mechanical
dissociation of the visceral and parietal pleura, and an eventual restrictive ventilatory defect as
measured by pulmonary function testing. [6]
Pleural effusions are generally classified as transudates or exudates, based on the mechanism of
fluid formation and pleural fluid chemistry. Transudates result from an imbalance of oncotic and
hydrostatic pressures, whereas exudates are the result of inflammatory processes of the pleura
and/or decreased lymphatic drainage. In some cases, it is not rare for pleural fluid to exhibit
mixed characteristics of transudate and exudate.
BARBA, ANNIKA Y.
BSN 4
SUBMITTED TO: ROY LABANON, RN

CLINICAL MANIFESTATION
1. Dyspnea
Dyspnea is the most common symptom associated with pleural effusion and is related more to
distortion of the diaphragm and chest wall during respiration than to hypoxemia.
2. Cough
Cough in patients with pleural effusion is often mild and nonproductive. More severe cough or
the production of purulent or bloody sputum suggests an underlying pneumonia or endobronchial
lesion.
3. Chest pain
The presence of chest pain, which results from pleural irritation, raises the likelihood of an
exudative etiology, such as pleural infection, mesothelioma, or pulmonary infarction
4. Extrapulmonary symptoms
Other symptoms in association with pleural effusions may suggest the underlying disease
process. Increasing lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea may
all occur with congestive heart failure.

MEDICAL MANAGEMENT
Large, infected, or inflamed pleural effusions often need to get drained to help you feel better
and prevent more problems.
Procedures for treating pleural effusions include:
1.Thoracentesis. If the effusion is large, your doctor may take more fluid than they need for
testing, just to ease your symptoms.
2.Tube thoracostomy (chest tube). Your doctor makes a small cut in your chest wall and puts a
plastic tube into your pleural space for several days.
3.Pleural drain. If your pleural effusions keep coming back, your doctor may put a long-term
catheter through your skin into the pleural space. You can then drain the pleural effusion at
home. Your doctor will tell you how and when to do that.
4.Pleurodesis. Your doctor injects an irritating substance (such as talc or doxycycline) through a
chest tube into the pleural space. The substance inflames the pleura and chest wall, which then
bind tightly to each other as they heal. Pleurodesis can prevent pleural effusions from coming
back in many cases.
5.Pleural decortication. Surgeons can operate inside the pleural space, removing potentially
dangerous inflammation and unhealthy tissue. To do this, your surgeon may make small cuts
(thoracoscopy) or a large one (thoracotomy).
BARBA, ANNIKA Y.
BSN 4
SUBMITTED TO: ROY LABANON, RN

NURSING MANAGEMENT AT EMERGENCY ROOM

As with any other life-threatening condition, initial nursing management is directed at ensuring:
1. Oxygen should be administered to all unstable patients, (Oxygen therapy).
2. The patient's circulatory status should be assessed and supported as indicated.
3. Clinical suspicion for pleural effusion should be confirmed with appropriate radiographic
evaluation. Chest radiography is the primary diagnostic tool.

NURSING MANAGEMENT in the WARD

1. Identify and treat the underlying cause
2. Monitor breath sounds
3. Place the client in a high Fowler’s position
4. Encourage coughing and deep breathing
5. Prepare the client for thoracentesis
6. If pleural effusion is recurrent, prepare the client for pleurectomy or pleurodesis as
prescribed