PLEURAL EFFUSION

Pleural effusion refers to a collection of fluid in the pleural space. It is almost always
secondary to other diseases.
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 effusions occur in an area of inflammation; is an accumulation of
hih-protein fluid.
!ccurs as a complication of"
o #isseminated cancer $particularly lun and breast%, lymphoma.
o Pleuropulmonary infections $pneumonia%.
o &eart failure, cirrhosis, nephrosis.
o !ther conditions'()sarcoidosis, systemic lupus erythematosus $*+E%,
peritoneal dialysis.
Clinical Manifestations
#yspnea, pleuritic chest pain, couh.
#ullness or flatness to percussion $over areas of fluid% with decreased or
absent breath sounds
Diagnostic Evalation
,hest --ray or ultrasound detects presence of fluid.
Thoracentesis'()biochemical, bacterioloic, and cytoloic studies of pleural
fluid indicates cause.
Manage!ent
.eneral
Treatment is aimed at underlyin cause $heart disease, infection%.
Thoracentesis is done to remove fluid, collect a specimen, and relieve
dyspnea.
/or Malinant Effusions
,hest tube drainae, radiation, chemotherapy, surical pleurectomy,
pleuroperitoneal shunt, or pleurodesis.
In malinant conditions, thoracentesis may provide only transient benefits,
because effusion may reaccumulate within a few days.
Pleurodesis'()production of adhesions between the parietal and visceral
pleura accomplished by tube thoracostomy, pleural space drainae, and
intrapleural instillation of a sclerosin aent $tetracycline, doxycycline, or
minocycline%.
o #ru introduced throuh tube into pleural space; tube clamped.
o Patient is assisted into various positions for 0 to 1 minutes each to
allow dru to spread to all pleural surfaces.
o Tube is unclamped as prescribed.
o ,hest drainae continued for 23 hours or loner.
o 4esultin pleural irritation, inflammation, and fibrosis cause adhesion
of the visceral and parietal surfaces when they are brouht toether by
the neative pressure caused by chest suction.
Co!plications
+are effusion could lead to respiratory failure.
N"sing Assess!ent
!btain history of previous pulmonary condition.
5ssess patient for dyspnea and tachypnea.
5uscultate and percuss luns for abnormalities.
N"sing Diagnosis
Ineffective 6reathin Pattern related to collection of fluid in pleural space
N"sing Inte"ventions
Maintainin 7ormal 6reathin Pattern
Institute treatments to resolve the underlyin cause as ordered.
5ssist with thoracentesis if indicated $see pae 289%.
Maintain chest drainae as needed $see pae 2:;%.
Provide care after pleurodesis.
o Monitor for excessive pain from the sclerosin aent, which may cause
hypoventilation.
o 5dminister prescribed analesic.
o 5ssist patient underoin instillation of intrapleural lidocaine if pain
relief is not forthcomin.
o 5dminister oxyen as indicated by dyspnea and hypoxemia.
o !bserve patient<s breathin pattern, oxyen saturation, and other vital
sins, for evidence of improvement or deterioration.
Patient Education and &ealth Maintenance
Instruct patient to see= early intervention for unusual shortness of breath,
especially if he has underlyin chronic lun disease.
Evalation# E$pected Otco!es
4eports absence of shortness of breath
%ERPES &OS'ER
&erpes >oster $shinles% is an inflammatory condition in which reactivation of the
chic=enpox virus produces a vesicular eruption alon the distribution of the nerves
from one or more dorsal root anlia. The prevalence increases with ae.
Pathophysiology and Etiology
,aused by a varicella->oster virus, which is a member of a roup of
deoxyribonucleic acid viruses.
?irus is identical to the causative aent of varicella $chic=enpox%. 5fter the
primary infection, the varicella->oster virus may persist in a dormant state in
the dorsal nerve root anlia. The virus may emere from this site in later
years, either spontaneously or in association with immunosuppression, to
cause herpes >oster.
Clinical Manifestations
Eruption may be accompanied or preceded by fever, malaise, headache, and
pain; pain may be burnin, lancinatin, stabbin, or achin.
Inflammation is usually unilateral, involvin the cranial, cervical, thoracic,
lumbar, or sacral nerves in a bandli=e confiuration.
?esicles appear in 0 to 3 days.
o ,haracteristic patches of rouped vesicles appear on erythematous,
edematous s=in.
o Early vesicles contain serum; they later rupture and form crusts;
scarrin usually does not occur unless the vesicles are deep and they
involve the dermis.
o If ophthalmic branch of the facial nerve is involved, patient may have a
painful eye. $This can be a medical emerency.%
o In healthy host, lesions resolve in 2 to 0 wee=s.
5 susceptible person can ac@uire chic=enpox if he or she comes in contact
with the infective vesicular fluid of a >oster patient. 5 person with a history of
chic=enpox or has received the immuni>ation is immune and thus is not at ris=
from infection after exposure to >oster patients.
7A4*I7. 5+E4T
?aricella->oster virus may be a life-threatenin condition to the patient who is
immunosuppressed, who is receivin cytotoxic chemotherapy, or who is a bone
marrow transplant recipient.
#ianostic Evaluation
Asually dianosed by clinical presentation.
,ulture of varicella->oster virus from lesions or detection by fluorescent
antibody techni@ues, includin viral detection that uses monoclonal antibodies
$MicroTra=% or by electron microscopy, to confirm dianosis.
Manage!ent
5ntiviral drus, such as acyclovir $Bovirax%, famciclovir $/amvir%, and
valacyclovir $?altrex%, interfere with viral replication; may be used in all
cases, but especially for treatment of immunosuppressed or debilitated
patients. Must be started within :2 hours of onset.
,orticosteroids early in illness'()iven for severe herpes >oster if
symptomatic measures fail; iven for anti-inflammatory effect and for relief of
pain. ,ontroversial.
Pain manaement; aspirin, acetaminophen, 7*5I#s, opioids'()useful durin
the acute stae, but not enerally effective for postherpetic neuralia. If treated
early $3; to :2 hours%, may decrease ris= of postherpetic neuralia.
Co!plications
,hronic pain syndrome $postherpetic neuralia%, characteri>ed by constant
achin and burnin pain or by intermittent lancinatin pain or hyperesthesia of
affected s=in after it has healed.
!phthalmic complications with involvement of ophthalmic branch of
trieminal nerve with =eratitis, uveitis, corneal ulceration, and possibly
blindness.
/acial and auditory nerve involvement, resultin in hearin deficits, vertio,
and facial wea=ness.
?isceral dissemination'()pneumonitis, esophaitis, enterocolitis, myocarditis,
pancreatitis.
N"sing Diagnoses
5cute or ,hronic Pain related to inflammation of cutaneous nerve endins
Impaired *=in Interity related to rupture of vesicles
N"sing Inte"ventions
,ontrollin Pain
5ssess patient<s level of discomfort and medicate as prescribed; monitor for
adverse effects of pain medications.
Teach patient to apply wet dressins for soothin effect.
Encourae distraction techni@ues such as music therapy.
Teach relaxation techni@ues, such as deep breathin, proressive muscle
relaxation, and imaery, to help control pain.
Improvin *=in Interity
5pply wet dressins to cool and dry inflamed areas by means of evaporation.
5dminister antiviral medication in dosae prescribed $usually hih dose%;
warn the patient of adverse effects such as nausea.
P.CC8D
5pply antibacterial ointments $after acute stae% as prescribed, to soften and
separate adherent crusts and prevent secondary infection.
Patient Education and &ealth Maintenance
Teach patient to use proper hand-washin techni@ue, to avoid spreadin
herpes >oster virus.
5dvise patient not to open the blisters, to avoid secondary infection and
scarrin.
4eassure that shinles is a viral infection of the nerves; nervousness does not
cause shinles.
5 careiver may be re@uired to assist with dressins and meals. In older
persons, the pain is more pronounced and incapacitatin. #ysesthesia and s=in
hypersensitivity are distressin.
Evalation# E$pected Otco!es
?erbali>es decreased pain
4eepitheliali>ation of s=in without scarrin