Nursing Guide to Pleural Effusion: Nursing Diagnosis, Interventions, & Care Plans

Pleural Effusion Definition 

Pleural effusion is the excess accumulation of fluid in the pleural space, resulting from impaired drainage, increased production, or inflammation of the pleura (Cleveland Clinic, 2023; Rahman, 2024). 

Etiology and Epidemiology 

 Pleural effusion affects approximately 1.5 million people in the U.S. annually (Cleveland Clinic, 2023). 

Common causes include:  

• Heart failure
• Pneumonia
• Malignancies
• Pulmonary embolism
• Kidney failure
• Cirrhosis

Less common causes include: 

• Autoimmune diseases
• Tuberculosis
• Chest trauma
• Pancreatitis
• Certain medications
• Post-surgical complications
• Radiation therapy 

Diagnostic Criteria 

Imaging Studies 

• Chest X-ray: Identifies pleural fluid accumulation but may not detect small effusions
• Ultrasound: More sensitive for small effusions; helps guide thoracentesis
• Computed Tomography (CT): Detects underlying pathology such as malignancy, infection, or pulmonary embolism 

Pleural Fluid Analysis (via thoracentesis) 

• Differentiate transudative (low protein, systemic causes like heart failure) from exudative (high protein, local causes like infection or malignancy) effusions to determine the underlying cause (Rahman, 2024)
• Evaluate for infection using culture and Gram stain, assess for malignancy through cytology, and analyze biochemical markers such as lactate dehydrogenase, glucose, and pH (Cleveland Clinic, 2023) 

Additional Testing 

• Pleural Biopsy: Performed when malignancy or tuberculosis is suspected
• CT Angiography: Ordered if pulmonary embolism is a suspected cause 

Common Signs and Symptoms 

• Dyspnea
• Pleuritic chest pain
• Nonproductive cough
• Orthopnea
• Diminished breath sounds
• Decreased tactile fremitus
• Dullness to percussion 

Some individuals may be asymptomatic, with pleural effusion detected incidentally on imaging. 

Red Flags 

• Sudden or severe shortness of breath may mean fluid is building up quickly, or a pulmonary embolism is present. This requires immediate attention.
• A drop in oxygen levels, even with supplemental oxygen, is a serious sign that needs urgent evaluation.
• A high fever with chest pain could indicate an infection like pneumonia or empyema, which requires prompt antibiotic treatment.
• Low blood pressure and a fast heart rate may be signs of sepsis or bleeding in the pleural space, both of which need urgent medical care.
• If the trachea shifts to one side in a person with a large pleural effusion, it may mean the lung is being compressed, putting breathing at risk. This requires immediate intervention. 

Potential Complications 

Pleural effusion can lead to serious complications, including infection, respiratory distress, and hemodynamic instability (Cleveland Clinic, 2023; Rahman, 2024). 

• Empyema occurs when pleural fluid becomes infected and requires antibiotics and drainage.
• Fibrosis and lung entrapment develop from scarring, restricting lung expansion and sometimes requiring decortication.
• Re-expansion pulmonary edema happens when fluid is drained too quickly, causing alveolar flooding, hypoxia, and tachypnea.
• Hemothorax results from bleeding due to procedural injury and requires stabilization.
• Sepsis occurs when an infected effusion is left untreated, leading to systemic infection and urgent intervention. 

Treatments 

Pharmacological 

• Diuretics for heart failure-related effusions; monitor fluid balance
• Antibiotics for infectious causes; adjust based on culture results
• Corticosteroids and immunosuppressants for autoimmune-related effusions
• Chemotherapy or targeted therapy for malignant effusions 

Non-Pharmacological 

• Thoracentesis for symptom relief and diagnosis; monitor for pneumothorax
• Chest tube drainage for large or recurrent effusions; assess for obstruction or infection
• Pleurodesis for recurrent malignant effusions; educate on post-procedure discomfort
• Indwelling pleural catheters for long-term outpatient management; provide aseptic technique education 

Surgical 

• Video-assisted thoracoscopic surgery (VATS) is used for drainage and biopsy (Cleveland Clinic, 2023).
• Thoracotomy is performed for complex cases with fibrosis. 

Pleural Effusion Nursing Management Care Plan

Assessment and Interventions 

Respiratory Function and Oxygenation 

• Assess work of breathing, auscultate lung sounds, and monitor oxygen saturation for signs of worsening respiratory distress.
• Provide supplemental oxygen as needed, ensuring that delivery is titrated to maintain adequate oxygenation without causing carbon dioxide retention in individuals with underlying respiratory disorders.
• Encourage deep breathing exercises and the use of an incentive spirometer to prevent atelectasis and promote lung expansion. 

Fluid Drainage and Management 

• Monitor the amount, color, and consistency of pleural fluid from thoracentesis or chest tube drainage. Sudden cessation of drainage may indicate tube obstruction, requiring prompt intervention.
• Assess for signs of pneumothorax, including acute dyspnea, diminished breath sounds, and tracheal deviation, following any pleural drainage procedure.
• Position the individual appropriately to facilitate drainage and comfort, typically in a high Fowler’s position. 

Infection Control and Sepsis Prevention 

• Maintain strict aseptic technique when handling chest tubes or indwelling pleural catheters to reduce infection risk.
• Monitor for fever, increasing white blood cell count, or purulent drainage from the pleural space, which may indicate empyema.
• Ensure timely administration of prescribed antibiotics, particularly in cases of parapneumonic effusions or post-surgical infections. 

Pain Management 

• Administer prescribed analgesics, including nonsteroidal anti-inflammatory drugs or opioids, to manage pleuritic pain and discomfort from chest tubes.
• Encourage positioning adjustments to reduce pressure on the affected side and enhance comfort.
• Implement non-pharmacological pain relief strategies, such as guided breathing exercises or localized heat therapy, to reduce discomfort. 

Psychosocial and Cultural Considerations 

Psychosocial Support 

• Provide reassurance and clear explanations to reduce anxiety about breathing difficulties and procedures.
• Encourage energy conservation, pulmonary rehab, and support groups to prevent frustration and depression.
• Refer to palliative care for individuals with malignant effusions to address grief, fear, and symptom management.
• Educate caregivers on home drainage procedures and connect them with support resources. 

Cultural Considerations 

• Assess beliefs about invasive procedures and involve the family in discussions to improve acceptance.
• Use medical interpreters to ensure clear communication and prevent misunderstandings.
• Respect alternative medicine preferences while emphasizing evidence-based treatment.
• Recommend culturally appropriate dietary alternatives for individuals with fluid restrictions.
• Approach palliative care discussions with sensitivity to family roles and traditions. 

Home Management 

Self-Care 

• Educate on recognizing signs of fluid reaccumulation, including progressive shortness of breath and decreased exercise tolerance.
• Reinforce medication adherence, particularly for diuretics or corticosteroids, and monitor for adverse effects such as electrolyte imbalances or hyperglycemia.
• Provide guidance on pleural catheter care, if applicable, including aseptic drainage technique and frequency of monitoring for signs of infection. 

Safety Measures 

• Advise on positioning strategies to optimize breathing, such as maintaining an elevated head of the bed and avoiding restrictive clothing.
• Instruct on avoiding exposure to environmental lung irritants, including smoking and pollutants, which may exacerbate symptoms.
• Encourage gradual return to activity, balancing mobility with rest to prevent exertional dyspnea. 

Additional Information

Content Release Date

6/11/2024

Content Expiration

12/31/2028

Course Contributor

The content for this course was written by Sherry D. Haszto, M.S.N., R.N. Sherry is a nursing professional with over 22 years of experience. She has earned an Associate Degree in Nursing from Randolph Community College, a Bachelor of Science in Nursing from the University of North Carolina at Greensboro, and a Master of Science in Nursing from Walden University. Her background includes work in oncology and hematology, home healthcare, hospice and palliative care, healthcare education, nursing consultation, performance improvement, and quality assurance. Sherry is committed to supporting patient care and healthcare education, focusing on enhancing patient outcomes and maintaining quality standards in all aspects of her work. 

References

• Cleveland Clinic. (2023). Pleural effusion. https://my.clevelandclinic.org/health/diseases/17373-pleural-effusion  
• Rahman, N. M. (2023). Pleural effusion. Merck Manual Professional Edition. https://www.merckmanuals.com/professional/pulmonary-disorders/mediastinal-and-pleural-disorders/pleural-effusion?query=pleural%20effusion