Exudative Pleural Effusion

Secondary to Pneumonia

Prepared by Alliah Mae A. Bandojo, Group 3, BSN 3C

 What is Pleural Effusion?
Pleural effusion, which some people call “water on the lungs,” is the buildup of
excess fluid between the layers of the pleura outside your lungs. The pleura are
thin membranes that line your lungs and the inside of your chest cavity. Normally,
everyone has a small amount of fluid in their pleura. This fluid acts as a natural
lubricant and makes it easier for your lungs to move when you breathe. But with
pleural effusion, you have too much fluid around your lungs. This means your body
is producing too much of the fluid or not absorbing enough of the fluid it makes
Types of Pleural Effusion
Healthcare providers split pleural effusion into two types,
depending on the kind of fluid around your lungs. Excess fluid
may be:

Protein-poor and watery (EXUDATIVE). Fluid of this kind

comes from cirrhosis or heart failure, for example. This
type of pleural effusion happens when there’s an increase
in pressure from the fluid.
Protein-rich (EXUDATIVE). Fluid of this kind comes from
cancer or an infection, for example. This type of pleural
effusion happens because too much fluid is getting through
your smallest blood vessels or your lymphatic system isn’t
draining enough.
PATHOPHYSIOLOGY
SAMPLE
 Predisposing Factors (Non-Modifiable) Precipitating Factors (Modifiable)
67 years old 35 yrs of smoking history
Male Lack of vaccination against pneumonia
COPD Exposure to respiratory irritants

inhalation of Streptococcus pneumoniae

Exudative Pleural Effusion

bacteria bypass upper respiratory defenses due to
the weakened barrier

pathogen adheres to alveolar epithelial cells in the

Amoxiclav Chest X-ray: Consolidation
lower respiratory tract using surface proteins

Secondary to Pneumonia
bacteria replicate and release virulence factors,
causing damage to the alveolar epithelial cells

PNEUMONIA

pattern recognition receptors (PRRs) on alveolar

cells and macrophages detect bacterial
components LEGEND:

Predisposing Factors
PRRs trigger the release of pro-inflammatory Precipitating Factors
cytokine
Disease Process
Signs/Symptoms
*IL-1 and TNF-α recruit neutrophils and Pharmacological/Medical Management
IL-6 affects the macrophages to the site of infection
Acetaminophen fever, chills, & fatigue hypothalamus and muscles Laboratory Results
*L-6 promotes systemic inflammation and fever
Disease

neutrophils migrate into alveoli, releasing enzymes

and reactive oxygen species to kill bacteria

inflammation increases vascular permeability,

causing leakage into alveoli
*pH: Decreased due to acidosis
*PaCO₂: Elevated
*PaO₂: Decreased Prednisone
productive cough with body attempts to clear the pathogens and alveoli fill with exudate (pus), containing dead compression worsens pre-existing COPD,
N-acetylcysteine shortness of breath, hypoxia, & cyanosis
purulent sputum exudate from the alveolar space neutrophils, bacteria, and cellular debris exacerbating symptoms
Supplemental Oxygen
Chest X-ray: Hyperinflation
fluid in alveoli impairs gas exchange and reduces fluid in the pleural space compresses the lung,
oxygenation. impairing ventilation and oxygenation

Thoracentesis
inflammation from the infected alveoli extends to
dullness to percussion, decreased tactile fremitus, & Chest X-ray: White-out
the adjacent pleural lining EXUDATIVE PLEURAL EFFUSION reduced breath sounds over the affected area appearance or opacification
Furosemide

Ibuprofen pleuritic chest pain PLEURITIS

*pleural fluid/serum protein ratio >0.5

increased vascular permeability in pleural pleural fluid becomes protein-rich due to leakage of
*pleural fluid/serum LDH ratio >0.6
capillaries leads to fluid leakage into the pleural plasma proteins and cellular components, fulfilling
*pleural fluid LDH > two-thirds of the
space Light's criteria for exudate
upper limit of normal serum LDH
NURSING CARE &
MANAGEMENT
 REVIEW OF HEALTH HISTORY
Nursing Assessment
1. Assess the patient’s general symptoms. 2. Track the medical history.
Not every patient will present with symptoms. Common causes of pleural effusion include:
Characteristics of pleural effusion include the Pulmonary infections
following: Congestive heart failure
Shortness of breath Cancer
Chest pain with coughing or breathing Liver disease
Dry cough Inflammatory disorders
Fever Pleuritis
Activity intolerance Pneumonia
Less common causes include:
Pulmonary embolism
Radiation
Certain medications
Esophageal rupture
 REVIEW OF HEALTH HISTORY
Nursing Assessment
3. Determine the patient’s occupational and social history.
Exposure to asbestos is a risk factor for pleural effusion. Inquire if the patient smokes or is exposed to
second-hand smoke as tobacco smoke is another risk factor.

4. Review the patient’s medications.

The following medications may cause drug-induced pleural effusion:
Methotrexate
Amiodarone
Phenytoin
Dasatinib (chemotherapy)

5. Inquire about chest pain characteristics.

Chest pain may result from pleural irritation, but as the pleural space fills with fluid and the pleural
surfaces are no longer in contact, pain may diminish, causing an incorrect belief that the condition has
improved.
 PHYSICAL ASSESSMENT
Nursing Assessment
1. Observe the patient’s breathing.
The patient may be asymptomatic or present with exertional dyspnea. They may complain or show signs of sharp, severe, localized pain when
breathing or coughing.

2. Inspect and palpate the chest.

Note decreased tactile fremitus and asymmetrical chest expansion with decreased expansion on the side of the effusion. Mediastinal shift and
tracheal deviation may suggest large pleural effusions.

3. Percuss the chest.

Percuss down the back by tapping with the fingers. Note for intercostal space fullness and dullness heard over the lung area where the effusion is.

4. Auscultate lung and heart sounds.

A pleural friction rub is present. Lung sounds may be diminished or absent. Egophony, or increased resonance of voice sounds, is heard when
auscultating the lungs.

5. Note extrapulmonary findings.

These additional physical and extrapulmonary signs may suggest the underlying cause of the pleural effusion, such as:
Congestive heart failure: Peripheral edema, distended neck veins, and S3 gallop
Nephrotic syndrome or pericardial disease: Edema
Liver disease: Cutaneous changes and ascites
Malignancy: Lymphadenopathy or a palpable mass
 DIAGNOSTIC PROCEDURES
Nursing Assessment
1. Obtain a chest X-ray. 4. Anticipate further imaging scans.
Chest radiographs (X-ray) determine the presence of Bedside ultrasound is the standard of care in many
effusion, mediastinal shift, and tracheal deviation. healthcare institutions. Ultrasound and CT scans are more

2. Determine transudates from exudates. accurate than chest X-rays at identifying the underlying

Identify if the fluid is exudative or transudative. The following cause.

are characteristics of exudates: 5. Assist with diagnostic thoracentesis.

High protein If the cause of the effusion is unknown or if it does not
High LDH respond to treatment, a diagnostic thoracentesis should be
Low glucose performed.

3. Perform further fluid testing. 6. Consider pleural biopsy.

These are frequently used tests to investigate the cause of A pleural biopsy is considered in cases of tuberculosis or
pleural effusion: cancer.
Fluid pH measurement Fluid triglyceride
Fluid protein Fluid cell count differential
Albumin Fluid gram stain and culture
LDH Fluid cytology
Fluid glucose
 MANAGE THE EFFUSION
Nursing Interventions
1. Treat the underlying cause. 5. Prepare for therapeutic thoracentesis.
When known, it is advised to treat the underlying cause of the This process removes large amounts of pleural fluid to reduce
pleural effusion. dyspnea and prevent further fibrosis and inflammation.
2. Assist with drainage. 6. Assist with chest tube insertion.
Regardless of transudative or exudative, large effusions causing A tube thoracostomy (chest tube) may be required for more
respiratory symptoms must be drained. complicated effusions or empyemas.
3. Administer antibiotics as ordered. 7. Discuss indwelling tunneled pleural catheters.
Administer antibiotics for effusions with an infectious etiology. Tunneled pleural catheters (TPC) are a reliable substitute for
4. Consider surgical treatment. pleurodesis in some benign and malignant effusions. TPC can be
Surgical intervention is necessary when a needle or small-bore implanted as an outpatient operation to be intermittently drained
catheter cannot adequately drain parapneumonic effusions. at home, reducing time spent in the hospital.
Consider the following surgical procedures: 8. Consider diet recommendations.
Pleurodesis: obliterating the pleural space Chylous effusions (lymph buildup) can cause fat, protein, and
Decortication: removal of the fibrous tissue restricting lung lymphocyte depletion from frequent drainage. Restricting fat
expansion intake may slow lymph accumulation in some patients.
Pleuroperitoneal shunts: for recurring symptomatic effusions Hyperalimentation or total parenteral nutrition (TPN) may be
Surgically closing the diaphragmatic defects: to prevent useful to limit chylous fluid accumulation and preserve nutritional
recurrent fluid accumulation such as in patients with ascites stores.
 CHEST TUBE AND DRAINAGE CARE
Nursing Interventions
1. Assess the drainage and monitor for air leaks.
Note the quantity and characteristics of fluid drained. Document findings each shift. Check for
an air leak (bubbling through the water seal). Significant air leaks (constant bubbling during
the respiratory cycle) could be signs of a leak in the tubing or disconnection from the patient.
2. Perform respiratory assessments.
Assess the patient’s respiratory status and perform a thorough respiratory assessment per
facility protocol.
3. Obtain follow-up chest X-rays.
A chest X-ray should be completed after pleural fluid aspiration. Obtain regular chest X-rays to
confirm the chest tube position. Once chest tube fluid begins to decrease, a chest X-ray can
evaluate for resolution of the effusion.
Thank you!
 REFERENCES
Pleural effusion. (2024c, November 12). Cleveland Clinic.
https://my.clevelandclinic.org/health/diseases/17373-pleural-effusion

Ccm, M. W. B. R. (2024, July 2). Pleural Effusion: Nursing Diagnoses, Care Plans,
Assessment & Interventions | NurseTogether. NurseTogether.
https://www.nursetogether.com/pleural-effusion-nursing-diagnosis-care-plan/