Pleural conditions are disorders that involve the membranes cov-ering the lungs (visceral pleura) and the surface of the chest wall (parietal pleura) or disorders affecting the pleural space.
Pleurisy (pleuritis) refers to inflammation of both layers of the pleurae (parietal and visceral). Pleurisy may develop in conjunc-tion with pneumonia or an upper respiratory tract infection, TB, or collagen disease; after trauma to the chest, pulmonary infarc-tion, or pulmonary embolism; in patients with primary and metastatic cancer; and after thoracotomy. The parietal pleura has nerve endings; the visceral pleura does not. When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain.
The key characteristic of pleuritic pain is its relationship to res-piratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is restricted in distribution rather than diffuse; it usually occurs only on one side. The pain may be-come minimal or absent when the breath is held, or it may be lo-calized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases.
In the early period, when little fluid has accumulated, a pleural friction rub can be heard with the stethoscope, only to disappear later as more fluid accumulates and separates the inflamed pleural surfaces. Diagnostic tests may include chest x-rays, sputum ex-aminations, thoracentesis to obtain a specimen of pleural fluid for examination, and less commonly a pleural biopsy.
The objectives of treatment are to discover the underlying con-dition causing the pleurisy and to relieve the pain. As the under-lying disease (pneumonia, infection) is treated, the pleuritic inflammation usually resolves. At the same time, it is necessary to monitor for signs and symptoms of pleural effusion, such as shortness of breath, pain, assumption of a position that decreases pain, and decreased chest wall excursion.
Prescribed analgesics and topical applications of heat or cold provide symptomatic relief. Indomethacin (Indocin), a non-steroidal anti-inflammatory drug (NSAID), may provide pain re-lief while allowing the patient to take deep breaths and cough more effectively. If the pain is severe, an intercostal nerve block may be required.
Because the patient has considerable pain on inspiration, the nurse can offer suggestions to enhance comfort, such as turning frequently onto the affected side to splint the chest wall and re-duce the stretching of the pleurae. The nurse also can teach the patient to use the hands or a pillow to splint the rib cage while coughing.
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