Thoracentesis

1. definition of terms 1.1. Thoracentesis- Involves the aspiration of fluid or air from the pleural space. - It relieves pulmonary compression and respiratory distress by removing accumulated air or fluid that results from injury or such conditions as tuberculosis, cancer, or heart failure.

Pleura: One of the two membranes around the lungs (parietal and visceral pleurae). There is normally a small quantity (about 3 to 4 teaspoons) of fluid that is spread thinly between the visceral and parietal pleurae. The pleural fluid acts as a lubricant between the two membranes. The pleural space is lubricated by fluid that is secreted and reabsorbed at relatively constant rates by the pleura. Because of the constant rate of secretion and reabsorption, there is generally only a small amount of fluid in the area at any time. The pleural fluid functions to prevent friction against the chest wall as the lungs inflate and deflate with breathing. 1.2. Aspirations the act of withdrawing fluid, such as mucus or serum, from a cavity of the body. 1.3. Centesis the act of puncturing a body cavity or organ with a hollow needle in order to draw out a fluid; a perforation or a puncture of a cavity

2. Identify the different sited and positions in thoracentesis 2.1. Sites Anteriorly 2nd and 3rd intercostal space in the midclavicular line

Posteriorly The ideal interspace is the 7th, 8th or 9th space, midway between the posterior axillary line and midline. The posterior approach is superior. The posterior gutter is deep and is the dependent site where the fluid tends to accumulate in the erect position. The interspaces are wider in the back as compared to the front. The neurovascular bundle is closer to the inferior margin of the rib posteriorly. Thus, there is a safer space to enter the chest. This site avoids possible accidental puncture of the liver, spleen, diaphragm and descending aorta.

2.2. Positions Sitting upright and leaning forward. If the patient is seated at the edge of the table, provide support for his legs such as a footstool. Support his arms on a padded on over-bed table.

Straddling a chair with arms and head resting on the back of the chair. He should lean forward on a pillow. A nurse can stand in front of the patient and hold the patient's hand.

Lying on the unaffected side The head of the bed is elevated 3045 degrees if unable to assume a sitting position.

3. discuss thoracentesis as to its: 3.1. purposes To remove fluid and air from the pleural cavity. Removal of air is often an emergency procedure to prevent suffocation from pressure on the lungs. Negative air pressure within the chest cavity allows normal respiration. The accumulation of air or fluid within the pleural space can eliminate these normal conditions and disrupt breathing and the movement of air within the chest cavity. Fluid removal is performed to reduce the pressure in the pleural space. To provide symptomatic relief with large pleural effusion. To provide pleural fluid specimens for analysis to determine the cause and nature of pleural effusion. For instillation of chemotherapeutic agents or other medications (sclerosing agents such as:) into pleural space. For patients with pleural effusions that are uncontrollable or recur due to a malignancy despite drainage, a sclerosing agent (a type of drug that deliberately induces scarring) occasionally may be instilled into the pleural cavity through a tube thoracostomy to inflame the pleural membranes and cause them to stick together, eliminating the pleural space and recurrent effusions. Done if the cause is malignancy or cancer-related

3.2. Indications Causes of fluid/air accumulation: A pleural effusion is an abnormal collection of fluid in the pleural space resulting from excess fluid production or decreased absorption. Other causes include trauma, infection, congestive heart failure, liver disease, and renal disease. In a disease process, the pleural space may fill with fluid, such as blood, pus (from infection), serum, or lymph. Alternately, the pleural fluid may be prevented from being reabsorbed, causing an accumulation of fluid in the pleural space. Pulmonary edema is an abnormal buildup of fluid in the air sacs of the lungs. It is usually caused by heart failure. As the heart fails, pressure in the veins going through the lungs starts to rise.

Pneumothorax - buildup of air or gas in the pleural space. Lung diseases, like chronic obstructive pulmonary disease (COPD), tuberculosis, and acute lung injury, cause pneumothorax. Hemothorax - buildup of blood in the pleural space. Injury to the chest is the most common cause of hemothorax. Pleurisy - inflammation of the pleura that causes sharp pain with breathing. Viral infection is the most common cause of pleurisy. Emphysema is a type of chronic obstructive pulmonary disease (COPD) involving damage to the air sacs (alveoli) in the lungs. As a result, your body does not get the oxygen it needs.

3.3. contraindications Local skin infection over proposed site of thoracentesis Uncontrolled bleeding or clotting disorder Precaution o Pregnancy o Patients who are uncooperative, have uncontrolled coughing o Uncertain fluid location o Patients who have only one functional lung or who are on positive end-expiratory pressure ventilation 3.4. complications Vasovagal nerve stimulation may causes syncope (fainting) Pain Some discomfort may occur when the needle is inserted. Using a local anesthetic helps to reduce the pain. Pain generally resolves once the needle is removed. Bleeding- most especially due to low levels of coagulation factors. Hemothorax may occur if one of the intercostal blood vessels is punctured by the needle. Hemoptysis may occur if lung is punctured Subcutaneous Hematoma formation Infection- Pyogenic infection can result from contamination during procedure. Infection can occur if bacteria are introduced by the needle puncture. Pneumothorax or Occasionally, the needle used to obtain a fluid sample can puncture the lung. The hole created by the puncture usually seals quickly on its own. If it does not, air can build up around the lung, causing the lung to collapse. This is called a pneumothorax.

Tension Pneumothorax (Tension pneumothorax is the progressive build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return.) Drainage-related Pneumothorax (A pneumothorax may also occur if the lung fails to expand when fluid is withdrawn.) Liver or spleen puncture In very rare cases, the liver or spleen may be punctured during thoracentesis. Sitting upright and remaining still during the procedure helps to keep the liver and spleen away from the insertion area and minimizes the risk of this complication. 3.5. guidelines Ascertain that a chest x-ray, CT scan, or Ultrasound has been ordered and completed in order to pinpoint the location of the accumulation of fluid. Perform medical handwashing before preparation and after aftercare and maintain sterility throughout the procedure. Before undergoing this procedure, report any allergies, bleeding problems or use of anticoagulants, pregnancy, or possibility of pregnancy. Check the site of thoracentesis for signs of infection. If patient will receive sedation, restrict food and fluids. Administer local anesthetic, such as Lidocaine, if prescribed. Inform the patient about the nature of the procedure and: o The importance of remaining immobile o Pressure sensation to be experienced o To anticipate minimal discomfort after the procedure Instruct patient beforehand not to breathe too deeply or cough during procedure. Put on sterile gloves when assisting physician in specimen collecting, fluid drainage, and dressing. Monitor patient throughout the procedure. Notify physician of any abnormal changes such as pallor, difficulty in breathing or signs of hypovolemic shock or respiratory distress.

4. nursing responsibilities 4.1. Before Check physicians order, and the name, room, and identity of patient. Check the patients chart to confirm if an appropriate consent form has been signed. Prepare materials and all equipment at patients bedside or treatment area.

Check the expiration dates on the local anesthetics used and on each sterile package (thoracentesis set) and inspect package for tears. Check for the patency and for any damages in the equipment to be used. Prepare to access to supplemental oxygen should it be indicated by physician, such as in cases of respiratory emergency. Explain the procedure to the patient. Instruct patient to void before the procedure. Record baseline vital signs of patient to detect any deviations from what is expected during and after the procedure to avoid complications. Thoracentesis should be briefly halted and needle should be removed should patient cough to avoid puncturing the lung.

4.2. During Assist in positioning the client into any of the three positions for thoracentesis as desired or appropriate. Make sure the patient is comfortable with the position to avoid strain and instability. Make sure there is easy access to the intercostal spaces. Disinfect site prior to the procedure. Support and reassure patient during the procedure. Maintain sterility in assisting physician in handling materials to the physician, receiving specimen, and assisting in fluid drainage. Monitor for shoulder pain. Monitor patients vital signs at intervals for increasing respiratory rate to prevent development of complications 4.3. After Apply pressure on site for 15-30 minutes and air tight dressings and to avoid bleeding and possibility of introduction of air. Administer oxygen as indicated. Make sure that specimen collected has been adequately labeled and sent to the laboratory for testing. Do aftercare. Document date and time of procedure, patients response or objective cues after the procedure, specimen collected, such as the amount collected, time of collection and its characteristics. Monitor patient and his vital signs at regular intervals (e.g. every 15 minutes for 1 hour) to monitor any signs of complications.

Assisting in Thoracentesis

After 8 hours of varied teaching-learning activities, the level III students will be able to:

1. define the following terms: 1.1. thoracentesis 1.2. aspiration 1.3. centesis 2. identify the different sites and position in thoracentesis 3. discuss thoracentesis as to its: 3.1. puposes 3.2. indications and contraindications 3.3. complications 3.4. guidelines 4. state the nursing responsibilities before, during, and after a thoracentesis 5. show beginning skills in assisting a thoracentesis