Thoracentesis

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Outline

Overview

Purpose is to drain pleural fluid (pleural effusion or hemothorax)

Nursing Points

General

  1. Indications
    1. Diagnose
      1. Sampling Pleural Fluid
      2. Biopsy
    2. Treat
      1. Remove Fluid
      2. Symptomatic Relief
  2. Contraindications
    1. Anticoagulant or Bleeding Disorder

Assessment

  1. Before Procedure
    1. Gather Supplies and Equipment
    2. Position patient over bedside table
      1. Alternative = good lung down
    3. Administer analgesic, sedative, and/or cough suppressant
    4. Baseline Respiratory Assessment
    5. Baseline Vitals
  2. Possible Complications
    1. Bleeding
    2. Infection
    3. Subcutaneous Emphysema
    4. Pneumothorax

Therapeutic Management

  1. During Procedure
    1. Stay with patient
    2. Monitor respirations
    3. Monitor vitals
    4. Continuous telemetry
    5. Promote comfort (patient shouldn’t move at all)
    6. Ensure sterile technique
  2. After Procedure
    1. Position with good lung down
    2. Post-procedure vital signs
    3. Monitor site and dressing
      1. Bleeding
      2. SubQ Air
    4. Monitor for infection
    5. Label & Send Specimens

Nursing Concepts

  1. Oxygenation/Gas Exchange
    1. Monitor for respiratory distress
    2. Give supplemental O2 if needed
  2. Infection Control
    1. Ensure sterile technique
    2. Monitor for s/s infection
  3. Comfort
    1. Keep patient still and calm
    2. Give pain meds

Patient Education

  1. Plan and purpose for procedure
  2. Required positioning during and after and why important
  3. s/s to report (dyspnea, sudden sob, chest pain)

Transcript

Let’s talk about Thoracentesis and what you need to do for these patients before, during, and after the procedure.

The purpose of a thoracentesis is to drain pleural fluid. This could be a large pleural effusion or even a hemothorax. We drain it for a number of reasons including sampling for testing or biopsies. We also remove the fluid to provide symptom relief, especially for someone with a large effusion that is making it difficult to breathe. The procedure involves inserting a needle through the rib cage into the pocket of fluid, then it’s connected to a bag or container and we allow it to drain very slowly. If we drain it too fast, that negative pressure could actually cause a tension pneumothorax. A key thing to note here is that if the patient is on an anticoagulant or has a bleeding disorder, we shouldn’t be sticking a large needle into their chest wall. Sometimes the benefits outweigh the risks, but that’s for the provider to determine.

Before any procedure we need to make sure informed consent is obtained – remember that is the provider’s job. We want to educate the patient on what to expect and what they need to be prepared for. We will gather the procedure supplies to the bedside including the tray with the needles, sterile gown, and sterile gloves for the doctor. Your facility may have different equipment, so if you aren’t sure, check with your charge nurse. We position the patient over a bedside table like you see here. That helps to open up the space between their ribs to allow for better access. We will usually give an analgesic and possibly a small dose of a sedative like lorazepam. This is NOT conscious sedation, the goal is simply to keep the patient comfortable and still during the procedure. Sometimes we’ll even give a cough suppressant because once that needle is in, we don’t want them moving or coughing. And then, as always, we’ll obtain a baseline assessment and set of vital signs.

Before any procedure we need to make sure informed consent is obtained – remember that is the provider’s job. We want to educate the patient on what to expect and what they need to be prepared for. We will gather the procedure supplies to the bedside including the tray with the needles, sterile gown, and sterile gloves for the doctor. Your facility may have different equipment, so if you aren’t sure, check with your charge nurse. We position the patient over a bedside table like you see here. That helps to open up the space between their ribs to allow for better access. We will usually give an analgesic and possibly a small dose of a sedative like lorazepam. This is NOT conscious sedation, the goal is simply to keep the patient comfortable and still during the procedure. Sometimes we’ll even give a cough suppressant because once that needle is in, we don’t want them moving or coughing. And then, as always, we’ll obtain a baseline assessment and set of vital signs.

During the procedure, you need to stay at bedside. You’ll monitor the patient’s respiratory status for signs of respiratory distress, and you’ll monitor their vitals frequently – usually every 5 minutes. They’ll typically be on continuous monitoring during the procedure – again, check your facility policy. As I mentioned before we want to keep them in this position and as still as possible, so we do what we need to to make them comfortable. Sometimes they need extra pillows under their arms to make it easier to sit there for a long. Lastly, this procedure carries a high risk of infection so we need to ensure strict sterile technique is maintained by the doctors. It also means you’ll be wearing a cap and mask when you’re in the room. Don’t be afraid to speak up if your doctor breaks sterile technique – we need to protect our patient.

As with any invasive procedure, there are risks associated like bleeding from the site and infection. thoracentesis can also cause subcutaneous emphysema or “subQ Air”. This is when air gets between the muscle and the skin. It feels like rice krispies. Usually this means the surgeon didn’t close the site well enough, so if you feel this, notify them to come assess it. And then of course we’re putting a hole in the chest wall so it’s possible the patient could develop a pneumothorax. So, after the procedure, we position the patient in a side-lying position with the good lung down. This helps to ensure good perfusion to the lung that’s working while the other one heals. It also limits swelling and bleeding at the site. We’ll perform post-procedure vital signs per facility policy and monitor the site and the dressing for signs of bleeding or SubQ Air. And then, if they did take samples of the fluid, we need to make sure they’re labeled appropriately and taken to the lab for processing.

Check out the careplan attached to this lesson for more specific nursing interventions, but let’s look at the priorities. Of course, since we’re dealing with the lungs and their ability to expand, we are concerned about oxygenation and gas exchange. Since this could be an infectious fluid and the procedure needs to be under strict sterile technique, we consider infection control a priority before, during, and after the procedure. And finally this patient may need analgesia during the procedure and will likely be uncomfortable afterwards, so we will manage those medications as needed and provide for comfort.

Some key takeaways are that thoracentesis is used to drain pleural fluid either to relieve symptoms or to send it for sampling. Before the procedure we need to ensure informed consent is obtained and provide for the patient’s comfort whether through sedatives or analgesics. During the procedure we will monitor the patient closely and make sure the provider maintains strict sterile technique. After the procedure, we monitor their vitals closely and assess the site for complications.

So those are the highlights of nursing care for thoracentesis. Don’t forget to check out the care plan to learn more. Happy Nursing!