Thoracentesis medical surgical nursing

Seminar Presentation

1. THORACENTESIS M.PRADEEP M.S.C.NURSING 1 ST YEAR

2. INTRODUCTION: Thoracentesis is defined as introducing a hollow needle into plueral cavity and aspirating fluid or cu r, using aseptic technique Thoracentesis refer to the puncture by needle through the chest wall into the pleural space for the purpose of removing pleural fluid (blood, serous fluid, pus, etc.) and/or air ( pneumothorax )

3. DEFINITION: Thoracentesis or pleural aspiration or pleural lap is the insertion of needle into the pleural space through the chest wall to remove the pleural fluid or possibly air.

4. PURPOSES: To remove excessive pleural fluid (serous fluid , blood or pus ). To drain fluid /air from pleural cavity for diagnostic or therapeutic purposes. To introduce medications To aid in full expansion of lung To obtain specimen for biopsy To take pleural biopsy for diagnostic examination To relieve pain To relieve breathlessness caused by accumulation of fluid or air in the pleural space To aid in diagnosis and treatment (chemical, bacteriological , cellular, composition and malignancy)

5. INDICATIONS: Traumatic pneumothorax . Hemopneumothorax . Spontaneous pneumothorax . Bronchopleural fistula. Pleural effusion For diagnostic purpose Therapeutic purpose ( reduced dyspnea )

6. GENERAL INSTRUCTIONS: The patient should be prepared physically and psychologically for the procedure Thoracentesis is indicated in case of pleural effusion due to infection, traumatic injury, cancer or cardiac diseases . Etc Common site for thoracentesis is just below the scapula at the seventh or eighth intercostal space The patient should be warned that any sudden movements during the procedure may cause injury to the lungs, blood vessels, etc The level of the aspiration needle should be short to prevent prickling of the lungs Usually upright position is used during the procedure as it helps to collect the pleural cavity and hence facilitates to remove the fluid easily

7. Cont., Maintain strict aseptic technique to prevent introduction of Infection into the pleural space . The three way adaptor should be fitted with the needle before it is introduced into the chest cavity. The adaptor should be in a closed position to prevent the entry of air in to the pleural cavity . The nurse should check the syringes and needle for air-tightness . If these are not air-tight, then air will enter the pleural cavity, which causes the lung collapse . Remove the fluid slowly and not more than 1,000 ml at a time, if the tap is therapeutic, to prevent medi astinal shift.

8. Cont., Use water-seal drainage system, if pleural fluid is purulent and difficult to drain . The specimen should be sent to the laboratory soon after it is collected. The aspiration should be discontinued if any signs of complications are noted such as sharp pain, respiratory distress, excessive coughing, crepitushemoptysis , circulatory collapse, etc.

9. PRELIMINARY ASSESSMENT: Check The doctors order for any specific instructions. Written informed consent of the patient or relatives. General condition and diagnosis of the patient. Review fresh erect chest Xray . Confirm the diagnosis, location and extent of the pleural air/fluid/pus. Acute respiratory insufficiency (tension pneumothorax , rapidly developing effusion without dyspnea ) may demand thoracentesis without Xray .. Mental status of the patient to follow instructions. Articles available in the unit.

10. PREPARATION OF THE PATIENT AND THE ENVIRONMENT: Explain the sequence of the procedure Provide privacy. Chest Xray should be taken before thoracentesis to diagnose the location. Check the vital signs and record it on the nurse's record for reference. A mild sedative may be given of the patient before starting the procedure.

11. Cont., Maintain the desired position of the patient, during the procedure. The nurse should remain near the patient-to observe and to remind not to move during the procedure. Arrange the articles at the bed side or in the treatment room. 9. Premedication: injection atropine sulfate of 0.65mg is given intramuscularly or intravenously half an hour before the procedure.

12. EQUIPMENTS: A Sterile Tray Dissecting forceps-I . Sponge holding forceps-1. Syringe (5ml) and 2 needles for giving local anesthesia. Syringe (20ml) with 1 leur lock to aspirate the fluid. Aspiration needle number 16 (long and short). Three way stopcock. Small bowls-2, to take cleaning lotions Specimen bottles and slides. Cotton swabs, gauze pieces and cotton pads. Gown, masks and gloves for the doctor . Sterile dressing towels/slit.

13. Cont., An Unsterile/Clean Tray Mackintosh and towel. Kidney tray and paper bag. Spirit , tincture of iodine and benzoin Lignocaine 2 percent . Suction apparatus with water seal drainage system

14. PROCEDURES: Position the patient in Fowlers. Bring patient to one side of bed with feet supported, arms and head leaning forward on cardiac table with pillows . Untie gown to expose the site for aspiration . Instinct patient to avoid coughing and to remain immobile during procedure. Explain that a feeling of deep pressure will be experienced , while fluid is being aspirated from pleural space. P rovide sterile gloves to doctor . Open sterile set and assemble 20 ml, 50 ml syringes, 20-22 G needles and aspiration needle. Pour antiseptic solution to clean site.

15. Cont., After showing label to.doctor clean top of local anesthetic bottle and assist to withdraw mediation Reassure patient and instruct to hold breath during insertion of aspiration needle . As physician does procedure, observe for signs and symptoms of complications After fluid is withdrawn from pleural space,transfer to specimen container. After needle is withdrawn, apply pressure over puncture site. Assist in sealing the site with tincture of benzoin swab.

16. AFTER CARE: Instruct patient In lie on non-affected site for 1 hour, ensue bed rest for 6 to 8 hours Monitor vital signs every half hour until stable. Observe patient for signs Symptoms of hemothorax , tension pneumothorax , subcutaneous emphysema and air embolism. Administer analgesics and antibiotics are prescribed. Instruct patient Io carrv out deep breathing exercises. A chest Xrav may be taken to determine the effect of the procedure. The puncture site should be treated aseptically to prevent contamination of the wound. The container with aspirated fluid should be labeled and sent to the laboratory with requisition form. Replace the articles after cleaning. Wash hands thoroughly. Record the procedure in the nurse’s record sheet

17. COMPLICATIONS: Pneumothorax and hemothorax Tension pneumothorax Mediastinal shift Pulmonary edema