Critical Care Nursing Theory
Pleural effusion
Pleural Effusion
- The pleural space is a potential space between the visceral pleurae that
lines the lungs and the parietal pleurae that lines the interior chest
wall.
- There is a continuous flow of fluid from the parietal pleura of the
chest wall to the visceral pleura, and the fluids eventually absorbed by
the pulmonary lymphatics.
- 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 of fluid 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
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May be either transudative or exudative.
Transudative effusions occur primarily in noninflammatory
conditions; is an accumulation of low-protein, low cell count fluid.
Dr. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing
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Critical Care Nursing Theory


Pleural effusion
Exudative effusions occur in an area of inflammation; is an
accumulation of high-protein fluid.
Occurs as a complication of:
o Disseminated cancer (particularly lung and breast), lymphoma.
o Pleuropulmonary infections (pneumonia).
o Heart failure, cirrhosis, nephrosis.
o 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 can result from
1- Trauma is the most common cause of a hemothorax
2- Invasive procedures (placement of central venous 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 pleuritic chest pain, depending on the amount of
fluid accumulation.
● Objective findings:1- Tachypnea and hypoxemia if ventilation is impaired,
2- Dullness to percussion,
Dr. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing
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Critical Care Nursing Theory
Pleural effusion
3- Decreased breath sounds over the involved area.
Diagnostic Studies
- A lateral decubitus chest radiograph is the best demonstration of free
pleural fluid.
- Diagnostic thoracentesis (aspiration of fluid from the pleural space) when
a pleural effusion is suspected on the basis of physical examination and is
confirmed radiologically, it is necessary to obtain a sample of pleural
fluid for diagnosis.
- The laboratory tests performed on the pleural fluid obtained by
thoracentesis (Evaluation of the pleural fluid is necessary to distinguish
transudative from exudative effusions.)
Test
Red blood cell count
>100,000/mm3
Hematocrit >50% of
peripheral blood
White blood cell count
(WBC)
>50,000–100,000/mm3
>50% Neutrophils
>50% Lymphocytes
>10% Eosinophils
>5% Mesothelial cells
Glucose <60 mg/dL
Amylase >200 units/dL
pH <7.2
Comment
Trauma, malignancy, pulmonary embolism
Hemothorax
Grossly visible pus, otherwise total WBC less useful than
WBC differential
Acute inflammation or infection
Tuberculosis, malignancy
Most common: hemothorax, pneumothorax; also benig
Asbestos effusions, drug reaction, paragonimiasis;
tuberculosis less likely
Infection, malignancy, tuberculosis, rheumatoid
Pleuritis, esophageal perforation, pancreatic disease,
malignancy, ruptured ectopic pregnancy
Isoenzyme profile: salivary–esophageal disease,
malignancy (especially lung)
Isoenzyme profile: pancreatic–pancreatic disease
Infection (complicated parapneumonic effusion and
empyema), malignancy, esophageal rupture, rheumatoid
Dr. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing
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Critical Care Nursing Theory
Triglyceride >110 mg/dL
Microbiological studies
Cytology
Pleural effusion
or lupus pleuritis, tuberculosis, systemic acidosis,
urinothorax
Chylothorax
Etiology of infection
Diagnostic of malignancy
- When the distance between the pleural fluid line to the inside of the chest
wall on lateral decubitus view is less than 1 cm:- It is difficult to obtain the pleural fluid by thoracentesis
- The pleural effusion is not likely to be clinically significant.
- The associated risk of pneumothorax outweighs the benefit of
the thoracentesis.
Management
- Treatment of the underlying cause is necessary.
- Removal the pleural effusion by thoracentesis or chest tube placement
may be indicated depending on the etiology and size of effusion.
(The primary indication for therapeutic thoracentesis 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 diagnostic evaluation;
- To instill medications.
A chest radiograph, coagulation studies, and patient education are essential
before a thoracentesis.
Some patients may require medication to reduce anxiety. Unlike
bronchoscopy, thoracentesis requires the cooperation of the patient;
Therefore, a local anesthetic, rather than moderate sedation, is used to
minimize the pain and discomfort that accompanies the procedure.
Dr. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing
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Critical Care Nursing Theory
Pleural effusion
During the procedure, the patient is placed either in a chair or on the edge of
the bed in an upright position with arms and shoulders raised so that the ribs
lift and separate, allowing easier needle insertion.
If a patient is unable to lift his or her arms, sitting on the bed with the arms
placed above the head on a table is an alternative position.
During thoracentesis, the nurse’s primary functions are:1- Provide comfort for the patient,
2- Perform ongoing assessment of the patient’s respiratory system,
3- Dress the wound with sterile dressings on completion of the procedure,
4- Send labeled laboratory specimens as ordered.
- Post-thoracentesis nursing care includes assessment for complications,
including pneumothorax, pain, hypotension, and pulmonary edema.
Dr. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing
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Critical Care Nursing Theory
Pleural effusion
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.
o Monitor for excessive pain from the sclerosing agent, which
may cause hypoventilation.
o Administer prescribed analgesic.
o Assist patient undergoing instillation of intrapleural lidocaine if
pain relief is not forthcoming.
o Administer oxygen as indicated by dyspnea and hypoxemia.
o Observe patient's breathing pattern, oxygen saturation, and
other vital signs, for evidence of improvement or deterioration.
Dr. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing
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Critical Care Nursing Theory
Pleural effusion
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
Dr. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing
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