Pleural Effusion
By:
Rawan, Hoor, Lamis, Abdullah
Table of contents
01 02 03
Demographic data History of present illness Physical examination
04 05 06
ICU management Patient medication Nursing care plan
07
Etiology and pathophysiology
Demographic data
Patient initial F.A Age 89 Y.O
Gender Female Nationality Saudi
Date of
Marital status Married addmetion
23/9/23
Chief Shortness of breath, Diagnosis Bilateral Pleural
complain lower limb edema
effusion
History of present illness
98 y.o Saudi female patient brought to ER by her family on 25/9/23 . Complained
of shortness of breath and lower limb edema. History of Alzheimer's disease and
inferior vena cava sarcoma. Patient was transferred from medical word on 9\10\23
to surgical ICU for plural tapping, decreased Spo2 70-80%.
Patient’s current medical condition
Patient in SICU 8th day, Bedridden on semi-fowler position, with
physical restraints, no signs of pain or distress, mechanical
ventilator attached via ETT, with peg tube for feeding, central line,
folly’s catheter, right pigtail and left chest drain for fluid removal.
Physical examination
Neurological assessment
● Bedridden
● Unconscious
● GCS: 6\15. E1V1M4
● Left pupils size 2mm and reactive to the light
● No eye ball on right eye
Head & Face & Neck
● Head was rounded in the midline with no lesions or lumps
● Symmetrical face with wrinkles
● Neck is symmetric, with head centered and without bulging masses.
● Jugular vein was distended
● Precense of Centeral line ( left subclabian ) , size #7
Respiratory assessment
Inspection
● Normal and symmetrical chest shape no kyphosis or Scoliosis.
● Patient on mechanical ventilator via ETT , size 7.5.
● Presence of Right pleural cathetar 1500ml.
● Left ICD with mild vaccum 800ml.
Palpation
● No masses, lesions or crepitus palpable.
● Tactile fremitus inapplicable due to ETT.
Percussion
● Dullness over the both sides of the lung due to fluid accumulation.
Ausultation
● Decreased breathing sounds (Bronchial, Broncho-vesicular, Vesicular), due to
presesnce of fluid in the plural space.
Cardiac assessment
Inspection
● Worm skin, No tenderness or lesions on the chest.
● No visible pulsations.
Palpation
● Pulses are palpable.
● Apical impulse is palpated in the mitral area.
Auscultation
● Norma S1-S2.
● Increased heart rate from 110-120 beat/min ( Tachycardia ).
Abdomen and GI assessment
Inspection
● Abdomen evenly rounded in shape free from lesions of rashes.
● Umbilicus is in the midline.
● No visible vines or peristaltic movement.
● Presence of intact peg tube #18.
Auscultation
● Presence of bowel sounds ( regular gurgles ) at rate of 25 per min.
● No Bruits ( whooshing sound ).
Palpation
● The abdomen is non tender and soft.
● No masses or lumps.
● No ascites.
Percussion
● Tympanic sounds over all abdomen quadrant.
● Dullness is heard over the liver and spleen.
Upper and lower limbs
● Muscle strength scale 3/5 ( Movement against gravity but not against added
resistance).
● Limited ROM of extremities.
● Weak pulses
● Prolonged Capillary refill (more than 3 seconds).
● Cold limbs
● Presence of pitting edema on both hands and right leg 4+ .
● Rebound between 2 to 3 minutes with an 8 mm pit.
Skin condition
● Skin was normal in color
● Decreased skin turgor ( less elastic )
● Ecchymosis noted on upper arms
● Redness & skin pealing noted on buttocks, perineal area, under axilla and
breasts.
● Redness on both heels
● SDTI under the left heel
Intake & Output
● Total intake = 4948.1
● Total output = 2305
● Balance : 49481.1 – 2305 = +2583.1 ( positive balance )
ICU management
● Monitoring and Assessment: Continuous monitoring of vital signs, including
oxygen saturation, respiratory rate, heart rate, and blood pressure
● Oxygen Therapy: Administer supplemental oxygen to maintain adequate
oxygenation levels.
● Drainage and Fluid Management: drainage procedures like thoracentesis or chest
tube insertion may be necessary to remove accumulated fluid and relieve
pressure on the lungs. Careful monitoring of fluid balance, electrolyte levels.
● Positioning and Respiratory Support: Optimize patient positioning to promote
lung expansion. Elevating the head of the bed and encouraging changes in
position can aid in improving ventilation.
Lines and tubes :
Centeral line: for medication admenistration and Blood sampling
Endotracheal tube: for airway and ventilation maintenance
peg tube: to provide adequate nutrition and administer oral medications
Right pleural cathetar: for the drainage of fluid from the pleural space
folly’s catheter: for urine collection and measure the output
Patient’s Vital signs
Temperature 36.6 C
Heart rate 118 beats/min
Blood pressure 92/70 mmHg
Respiratory rate 20 breaths/min
SPo2 100%
Mechanical ventilator sitting
Airway Endotracheal tube , size 7.5
Mode PRVC mode
Fio2 30%
Tidal volume 369
PEEP 5
I:E ratio 1:2
Arterial Blood Gas
FIO2 30 %
PH 7.20 ↓
PaCO2 48.6 ↑
PaO2 51 ↓
HCO3 23.2
Spo2 100%
interpretation Respiratory acidosis
Lab investigations
Test Patient results Normal values
RBC 3.76 million/mm3 4.2-5.4 million/mm3
WBC 20.000/mm3 5000-10.000mm/3
Hb 9.4 g/dl 12-16 g/dl
Hct 31.5 % 38-47%
BUN 5.6 mg/dl 6-20 mg/dl
Albumin 2.0 g/dl 4-6 g/dl
Chloride 110mEq/L 95-105 mEq/L
Creatinine 37 mg/dl 44-80 mg/dl
Potassium 3.30 mEq/L 3.5-5 mEq/L
Patient’s medications
Med name Dose/rout/ freq Used for
Used to treat infections caused by bacteria. It works by killing
meropenem 1 gm/ IV / BID
the bacteria or preventing their growth.
Antibiotic that treat different types of infection caused by
Bactrim 2 Tap / Peg tube / BID
bacteria
Used to prevent clotting following hospital procedures or
cleaxan 70 mg / Sub / BID
illness.
Correct balance of fluid between blood vessels and the body
Albumin 100 Ml / IV / BID
tissues they supply
Fentanyl 50mcg/hr / IV infusion Opioid drugs for sedation and relieve pain
To reduce or avoid the need for red blood cell transfusions
Aranesp 60mcg / IV / QW
(stimulates bone marrow to make more red blood cells)
Nursing diagnosis
● Impaired gas exchange R/t excess fluid buildup in the pleura AEB respiratory acidosis,
decreased oxygen saturation 70-80%.
● Ineffective breathing patterns R/t compromised lung expansion secondary to pleural
effusion AEB dyspnea, tachypnea, low spo2 .
● Ineffective peripheral tissue perfusion R/t Interruption in blood flow to organs and
tissues secondary to anemia AEB low Hb 9.4 g/dl , delay capillary refile >3 sec, cold
extremities
● Excess fluid volume R/t loss of plasma proteins AEB positive fluid balance (+2583.1),
presence of pitting edema +4 , low Albumin level. (2.0 g/dl), increased BMI= 29.38.
Cont.
● Impaired physical mobility R/t decreased muscle strength and control AEB
patient bedridden , muscle strength scale= 3/5, limitation in ADLs.
● Impaired skin integrity R/t immobility AEB Redness & skin pealing on
buttocks, perineal area, under axilla and breasts.
● Risk for infection R/t fluid accumulation in the pleural cavity
Nursing diagnosis
Ineffective breathing patterns R/t compromised
lung expansion secondary to pleural effusion
AEB dyspnea, tachypnea, low spo2 ( 70-80%)
Goal
After 8 hour of nursing intervention patient breathing
patterns will be maintained and promote effective
lung expansion as evidenced by normal breathing
rate, depth and absence of dyspnea.
Nursing Interventions :
1- Monitor and record respiratory rate and depth and effort regularly.
2- Auscultate breath sounds at least every four hours.
3- Monitor for diaphragmatic muscle fatigue or weakness
4- Assist patient to Fowler’s position
5- Observe the presence of sputum for amount, color, and consistency
6- Suction airway as needed
7- Administer supplemental oxygen as prescribed
8- Provide pain relief measures as prescribed
Nursing diagnosis
Excess fluid volume R/t loss of plasma proteins AEB
positive fluid balance (+2583.1), presence of pitting
edema +4 , low Albumin level. (2.0 g/dl), increased
BMI= 29.38.
Goal
After nursing intervention during hospitalization,
the patient will demonstrate a reduction of edema
and demonstrate fluid volume
Nursing Interventions :
1- Monitor and record vital signs every 4hr
2- Mesure and record patint’s intake and output
3- Weight the patient at the same time each day
4- Place patient in fowlerl’s position
5- Reposition patient every 2 hr. inspect the skin and check the edema
6- Restrict fluid intake (....ml) as Dr order
7- Aplly antiembolism stocking
8- Admenister diuretics as prescribed
Nursing diagnosis
Impaired skin integrity R/t immobility AEB
Redness & skin pealing on buttocks, perineal
area, under axilla and breasts, SDTI under
the left heel, ecchymosis
Goal
To maintain patient’s skin integrity and show
no evidence of skin breakdowns and infection
Nursing Interventions :
1- Perform routine skin checks to detect any signs of redness, blanching, or skin breakdown
2- Turn or reposition the patient every 2 hours
3- Use pillows or specialized support surfaces to redistribute pressure.
4- Keep the skin clean and moisturized.
5- Utilize pressure-relieving devices such as foam or air mattresses, cushions, heel protectors.
6- Clean the wound and cover it with dressing to prevent infection
7- Administer pain medication as prescribed
Pleural effusion
What is Pleural effusion?
Pleural effusion is the accumulation of fluid in the
pleural cavity, the space between the layers of the
pleura surrounding the lungs. It can result from
various underlying conditions and may occur on
one or both sides of the chest.
Pathophysiology
Pleural effusion can develop due to increased production of
fluid, impaired drainage, or a combination of both. Conditions
such as heart failure, pneumonia, and liver disease can disrupt
the balance of pleural fluid dynamics.
Risk Factors:
1- congestive heart failure
2- infections like pneumonia
3- pulmonary embolism
4- liver disease
5- Autoimmune diseases
Etiology:
1- Infection
2- Congestive Heart Failure (CHF)
3- Pulmonary Embolism
4- Chest trauma or surgery
Signs and Symptoms:
Patients may experience:
1- dyspnea
2- chest pain
3- cough
4- decreased breath sounds on physical examination.
The specific symptoms depend on the underlying cause and the amount of
fluid present.
Treatment
Medical Treatment:
1. Diuretics
2. Antibiotics
[Link] or Radiation
Surgical Treatment:
[Link]
2. Pleurodesis
3. Thoracoscopy
Referance:
- Medical surgical- Nursing book
- Nursing diagnosis pocket
Thanks
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