Nursing Care Plan (NCP) for Thoracentesis (Procedure)

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Outline

Pathophysiology

The purpose of a thoracentesis is to remove fluid or blood from around the lungs in the pleural space.  This could be due to a pleural effusion (a collection of pleural fluid, sometimes infectious, sometimes not), or due to a hemothorax.  Removing this fluid allows for re-expansion of the lung and will help to alleviate symptoms for patients.

Etiology

Using ultrasound as a guide, the provider inserts a large needle through the space between the ribs into the pleural space to aspirate the fluid/blood. If this is only being done for sampling, a syringe of fluid will be collected and then the needle will be removed. If the goal is to drain a large volume of fluid (>100mL), then a catheter will be threaded over the needle and left in the pleural space. This will then be attached to a drainage bag or vacutainer bottle to allow slow drainage. 

Desired Outcome

Appropriate fluid will be collected and/or drained from the pleural space, allowing for full reexpansion of the lung and appropriate oxygenation.

Thoracentesis (Procedure) Nursing Care Plan

Subjective Data:

Indications

  • Dyspnea
  • Chest tightness

Complications

  • Sudden, severe shortness of breath
  • Anxiety/restlessness
  • Pain at insertion site

Objective Data:

  • Diminished/absent breath sounds over affected area 
  • Evidence of fluid or blood collection on chest-X-ray 

Note: COMPLICATIONS

  • Crepitus
  • Diminished/absent breath sounds
  • Bleeding from site
  • Fever/increased WBC
  • Redness/swelling at site

Nursing Interventions and Rationales

Nursing Intervention (ADPIE) Rationale
Ensure signed consent is obtained and patient is well educated on procedure  Informed consent should be obtained by the provider, including indications, risks, and possible complications of the procedure. You, the nurse, should simply ensure it is done and witness the patient’s signature.
Ensure emergency equipment available at bedside As with any procedure involving the airway, emergency equipment should be kept ready at the bedside, including suction, ambu bag, and artificial/advanced airways in case of respiratory distress.
Position patient on side of bed with arms and chest over bedside table This position helps to open the space between the ribs to allow for easier access to the location of the fluid or blood collection.
Monitor Vital Signs, LOC, Respiratory status before, during, and after procedure per facility policy. Obtaining a baseline assessment and set of vital signs helps to know if anything has changed during or after the procedure.  

Monitor VS during and after procedure per facility guidelines – being alert for possible respiratory distress.

Administer analgesic, anxiolytic, or cough suppressant as ordered Patients are not sedated during this procedure, however it is imperative that they are calm and still during – this will help to prevent complications. We don’t want them squirming or coughing or they could end up with a punctured lung.
Ensure strict sterile technique is maintained There is a high risk for infection, therefore it is imperative that you help keep the provider accountable to strict sterile technique. This also means that everyone in the room should have a mask and bonnet on.
After procedure, position patient with good lung down and provide O2 as needed Good lung down positioning helps promote perfusion to the good lung and reinflation of the ‘bad lung’. Patients may require O2 as their lung reinflates and they recover.
Monitor for possible complications:Pneumothorax

Subcutaneous Air

Bleeding

Infection

The needle could puncture the lung, causing a pneumothorax

If the pleural cavity is not closed properly, air can leak between the skin and the muscle – causing SubQ air

Bleeding at the site or bleeding internally (hemothorax) are both possible due to the invasiveness of the procedure

Strict sterile technique should be maintained – infection is possible as with any invasive procedure.

educate patient on signs and symptoms to report to the physician  Patients should report sudden shortness of breath, chest pain, or s/s infection like fever/chills, pain at the insertion site.

Writing a Nursing Care Plan (NCP) for Thoracentesis (Procedure)

A Nursing Care Plan (NCP) for Thoracentesis (Procedure) starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

  • https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/thoracentesis
  • https://www.nhlbi.nih.gov/health-topics/thoracentesis
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Transcript

Hey everyone, today, we’re going to be creating a nursing care plan for thoracentesis procedure. So, let’s get started. So first we’re going to go over the pathophysiology. So, the purpose of a thoracentesis is to remove fluid or blood from the pleural spaces around the lungs. This can be due to a pleural effusion, which is a collection of pleural fluid that can be infectious or due to a hemothorax. Removing this fluid will allow for re-expansion of the lung and will help to alleviate symptoms for patients. Nursing considerations: you want to make sure you have a sign consent for the procedure, monitor vital signs, respiratory status, administer medications, ensure sterile technique is done, monitor for complications, educate the patient on signs and symptoms to report to the provider. Desired outcome: an appropriate fluid will be collected and or drained from the pleural space, allowing for full re-expansion of the lung and appropriate oxygenation. 

Here is a picture of a thoracentesis being done. You’ll notice in the picture, there is the lung here on this purple going to align here. You’re going to see how it’s being compressed, and here’s all this fluid down here, and there’s that catheter that the physician will put in. All of that fluid is going to be going into this bag right here and that is how they’re going to take all that out and be able to get this long to expand. 

All right, so we’re going to get to the care plan. So, we’re going to be writing down some subjective data and some objective data. So, what are we going to see with these patients that are having a thoracentesis? They could be complaining of having some chest tightness. They could be having some diminished or absent breath sounds. Depending on if it is hemothorax, or pneumothorax, or pleural effusion, other things you’re going to be seeing with these patients are evidence of fluid or blood collection on the X-ray. We also want to note complications from the procedure. Crepitus is one of the big things – a crackling rice krispies – is basically air that is surrounding the tissue. You may have bleeding at the site, fever, increased white blood cell count, some redness and swelling at the site, which can be indicative of an infection at the site.

So, interventions, what are we going to do for these patients? First thing we want to make sure is that they have a signed consent to have this procedure in their chart, and they need to make sure that the patient is very well educated on this procedure. Informed consent should be obtained by the provider, and include indications, risks, possible complications of the procedure. You, the nurse, should simply ensure that this is done and witness the patient’s signature. You also want to make sure that you have emergency equipment available at the bedside. So, with any procedure involving the airway emergency equipment should be kept ready at the bedside, including suction, O2, and an ambu bag, and any sort of artificial or advanced airway in case of respiratory distress. You also want to make sure that you’re positioning the patient on the side of the bed with the arms and chest over the bedside table, just as you saw in that picture. So, you want to make sure that they are positioned properly. It helps to open that space between the ribs to allow for easier access to the location of the fluid or the blood collection. Another intervention we’re going to be doing is we’re going to making sure we’re going to be monitoring the vital signs, level of consciousness, and their respiratory status – making sure we’re checking that before, during, and after the procedure per your facility policy. We want to make sure we’re obtaining a baseline assessment and set of vital signs, which will help to know if anything changed during or after the procedure. Another intervention we’re going to be doing is we’re going to be administering any sort of analgesic, mucolytic, or cough suppressant as ordered. So certain medications patients aren’t allowed to be sedated during this procedure; however, it’s very imperative that they’re very calm and still during this procedure and able to prevent any sort of complication. We don’t want them squirming around or coughing as that could end up with a punctured lung. We want to make sure we’re strict sterile technique is maintained because it’s a high risk for infection. So, it’s imperative that you help keep the provider accountable to strict sterile technique. Another intervention we’re going to be doing after the procedure is we want to make sure we’re positioning the patient with the good lung down and able to provide O2 as needed. It’s going to help promote perfusion to the good lung and reinflate the bad lung. Patients may be required to have O2 as that lung is reinflating as they recover. Another intervention we want to do is we want to make sure we’re monitoring for any sort of possible complication from that procedure. So, complications, well, what kind of complications are we going to be looking for? So, we’re going to be looking for a possible pneumothorax. We are also going to be looking for that crepitus, which is that air that’s escaping into surrounding tissues. That’s going to sound like that. Rice crispy, crackling sound. We’re also going to be looking for any sort of bleeding of infection. All these, you want to make sure you’re reporting back to the physician. And then lastly, we want to make sure we’re doing some education. We want to make sure the patient is aware of any signs and symptoms they want to report to the physician. They should report any sort of sudden shortness of breath, chest pain, any sort of sign symptoms of infection like fever, chills, pain at the insertion site, redness, swelling, all of these things are things that the physician needs to be aware of. 

All right, and now we’re going to get to the key points. So, thoracentesis is removing fluid or blood from around the lungs in the pleural space. This can be due to a pleural effusion, sometimes infectious, sometimes due to a hemothorax. Some subjective and objective data: we have dyspnea, chest tightness, diminished or absent breath sounds over the affected area, evidence of fluid and blood collection on a chest X-ray. We want to make sure that we have a signed consent form for the procedure, we are administering any sort of meds as needed, monitoring the respiratory status, and monitoring their vital signs. We also want to make sure we’re monitoring for those complications post procedure, making sure we’re positioning the patient in a good, lung-down position, and educating on signs and symptoms to be reported to the physician. And there you have it for thoracentesis. 

You guys did amazing. We love you guys. Go out, be your best self today and as always happy nursing. 

 

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