THORACENTESIS Purpose : therapeutically It is therapeutically done to relieve pain, dyspnea and other symptoms of the pleural pressure.

ure. to remove the excess fluid or air to ease breathing to introduce chemotherapeutic drugs to lubricate the pluera is present in the plueral cavity

Diagnostically: thoracentesis is performed to obtain and analyze fluid to determine the etiology of the plural effusion. Plueral fluid it is classified according to transudate or exudate. This is an important differentiation and is very helpful in determining the etiology of the effusion. Discussion: Thoracentesis is an invasive procedure that entails insertion of a needle into the pleural space of the removal of fluid (or rarely air). Transudate most frequently caused by congestive heart failure, cirrhosis, nephrotic syndrome.and hypoproteinemia. Exudates re most often found in inflammatory, infectious, neoplastic conditions

Equipments: Protective equipment: mask,goggles,gloves for all health personnel Test tubes, sterile specimen containers ,laboratory requisitions and labels

Analgesia if ordered, given 30 minutes before the procedure Antiseptic solution 4x4 inch gauze pads, tape, band aid Aspiration tray: most institution provide trays specific to the aspiration procedure. Standard equipment includes antiseptic solution (e.g. povidone iodine; chlorhexidine); gauze sponges (4x4 inch); sterile towels; local anesthesia solution; two 3ml syringes with 16- to 27- gauze needles. Additional equipment for thoracentesis: vacuum bottles stopcock with extension tubing

STEPS

RATIONALE

PERFORMED YES NO

REMARKS

PRE-TREATMENT EVALUATION Verify patients identity by using at least two forms of identifiers. Verify the type of the procedure scheduled, purpose and the procedure site with the patient and medical record RationaleThis ensure accurate patient identification and improves patients safety ASSESMENT ON SUBJECTIVE DATA: Assess the history of malignancy, pancytopenia, and anticoagulant use. Rationale:Factors can cause hemorrhage Asses for any signs and symptoms for pleural effusions Rationale:Small pleural effusions are usually asymptomatic. Large pleural effusions may cause dyspnea, pleuritic chest pain, and dry cough. ASSESSMENT ON OBJECTIVE DATA Patient evaluation: General appearance, vital signs, fever, pulse oximetry. Rationale:Provides baseline for comparison with post procedure vital signs Assess for pleural fluid present on its consistency, level. IRationale:f less than 200-300ml of pleural fluid is present. Findings consistent with the presence of a larger pleural effusion include dullness to percussion, and the decreased whisper or breath sounds. In large pleural effusions that compress the lung, accentuation of breath sounds and egophony may be noted just above the effusion. A pleural friction rub indicates pleuritis. A massive pleural effusion may cause contra-lateral shift of the trachea and bulging of the intercostal spaces. Check patient on chest X-ray, CBC with platelet and differentials, serum LDH, albumin, glucose, PT/PTT, as clinically indicated. Rationale:Chest x-ray films are used to localize the fluid and air in the pleural cavity and to aid in determining the puncture site. Laboratory test note the underlying contraindication for test such decreased in platelet and other components of the blood. PATIENT PREPARATION Explain to the purpose, risks/benefits, and steps of the procedure to be done. Risks: Pneumothorax, including tension pneumothorax Hemothorax

Hemorrhage Vasovagal episode Infection (empyema) Unilateral pulmonary edema Laceration of intra-abdominal viscera (puncture of liver or spleen). Subcutaneous emphysema Air embolism Pulmonary laceration Benefits Yield information which may be lifesaving or significantly alter treatment Relief of respiratory distress Rationale:An explanation helps to orient the patient to the procedure, assists the patient to mobilize resources and provides an opportunity to asks questions and verbalize anxiety Obtain consent from the patient or appropriate legal designee. Rationale:Federal regulations, many state laws require informed consent for procedure. Check platelet count and/or presence of coagulopathy.

Rationale:Consult with Hematology/Oncology attending physician if platelet count is < 20,000, or there is known coagulopathy as to whether platelet transfusion or other intervention is needed prior to thoracentesis. Tell to the patient that he needs not to restrict food or fluids. Rationale:Fasting or sedation is not necessary. Explain that he/she will receive a local anesthetic to minimize pain during the procedure. Rationale:It is right for the patient to know the procedure being done to him/her. The procedure is done on specific place of the body. Check patient history for hypersensitivity to the local anesthetic, and beta dine. Rationale:If the patient is allergic to the initially prescribed anesthetic, assessment findings provide an opportunity to use a safer anesthetic. Assess the patients level of understanding of procedures including concerns Rationale:This extent of instruction and level of support required.

Note that an X-ray film or ultrasound scan is often used Rationale:X-ray or ultrasound will assist in the location of the fluid. Fluoroscopy may also be used. Obtain baseline pain level Rationale:Determine the need for pre-procedure analgesia. Pain control helps patient maintain proper position and tolerance aspiration procedure PROCEDURE PERFORMED Assist the patient in the sitting position with arms and head resting supported on a bedside adjustable table. If unable to sit, the patient should lie at the edge of the bed on the affected side with the ipsilateral arm over the head and the midaxillary line accessible for the insertion of the needle Rationale:Elevating the head of the bed to 30 degrees may help. The upright position facilitates the removal of fluid that usually localizes at the base of the thorax. A position of comfort helps the patient to relax and it spreads the ribs and enlarges the intercostal space for the insertion of the needle. The procedure is performed under sterile technique. Rationale:To reduce the transmission of microorganism. Support and reassure the patient during the procedure. Prepare the client for the cold sensation of the skin germicide solution for a pressure sensation from the infiltration of local anesthetic agent. Remind the patient not to cough, not to breathe deeply, and not to move suddenly during the procedure. Rationale:Sudden and unexpected movement, such as coughing by the patient can traumatize the visceral pleura and the lungs Expose the entire chest. Rationale:To expose the area for the procedure Confirm site by counting the ribs based on chest xray and percussing out the fluid level. Mark the top of the dullness by washable ink mark or indenting the skin. Rationale:The usual site for insertion of the thoracentesis needle is the posteriolateral aspect of the back over the diaphragm, but under the fluid level. Select the thoracentesis site in an interspace below the point of dullness to percussion in the midposterior line (posterior insertion) or midaxillary line (lateral insertion). Rationale: To assess for an area for a better

insertion of the needle. Anesthetize the skin over the insertion site with 1% lidocaine using the 5 cc syringe with 25 or 27-gauge needle. Next anesthetize the superior surface of the rib and the pleura. Rationale:The needle is inserted over the top of rib (superior margin) to avoid the intercostals nerves and blood vessels that run on the underside of the rib (the intercostals nerve and the blood supply are located near the inferior margin). As the needle is inserted, aspirate back on the syringe Rationale:To check for pleural fluid. Once fluid returns note the depth of the needle and mark it with a hemostat. Rationale:This gives an approximate depth for insertion of the angiocatheter or thoracentesis needle. Remove the anesthetizing needle. Use a hemostat. Rationale:To measure the same depth on the thoracentesis needle or angiocath as the first needle. While exerting steady pressure on the patients back with the nondominant hand, use a hemostat. Rationale:To measure the 15- to 18- gauge thoracentesis needle to the same depth as the first needle. While exerting steady pressure on the patients back with the nondominant hand, insert the needle through the anesthetized area with the thoracentesis needle. Advance the needle until it encounters the superior aspect of the rib. Continue advancing the needle over the top of the rib and through the pleura, maintaining constant gentle suction on the syringe. Make sure you march over the top of the rib. Rationale:To avoid the neurovascular bundle that runs below the rib. Attach the three way stopcock and tubing, and aspirate the amount needed. Rationale:This is use to evacuate the fluid through the tubing. Remove the necessary amount of pleural fluid (usually 100 mL for diagnostic studies), but generally not remove more than 1500 mL of fluid at any one time. Rationale:There may be increased risk of pleural edema or hypotension. A pneumothorax from needle laceration of the visceral pleura is more likely to occur if an effusion is completely drained. When draining of fluid is completed, have the patient take a deep breath and hum, and gently remove the needle.

Rationale:This maneuver increases intrathoracic pressure and decreases the chance of pneumothorax. observe client for signs of distress,such dyspnea,pallor and coughing Rationale:to give emergency intervention and facilitate proper airway and oxygenation Cover the insertion site with a sterile occlusive dressing. Rationale:Prevent further bleeding and infection

POST PROCEDURE Obtain an upright portable (expiratory) chest x-ray To evaluate the fluid level and to rule out pneumothorax. For specimen handling, fill the tubes with the required amount of pleural fluid. Check that each tube is properly labeled by checking two patient identifiers- full name, date of birth and/or medical record number. Rationale:To ensure accurate specimen from the client Pleural fluid should be sent for appropriate laboratory tests Rationale:For diagnostic purposes for the client. Check the patients vital signs every 15 minutes for one hour, every 30 minutes for 2 hours, then every for four hours until the patient is stable. Rationale:Assess patients response on the procedure and note for the deviations from normal. Provide post-procedural analgesics as needed. Rationale:To address the pain of the patient. Monitor for the infection and further bleeding Rationale:To note for complication Position the patient properly by lying on the unaffected side with the head of bed elevated 30 degrees at least 30 minutes Rationale:To provide comfort and this position facilitates expansion of the affecred lung and eases respiration. Document the procedure, patients response, characteristics of fluid and amount, and patient response to follow-up. Rationale:For proper communication of treatment and collaboration of management of the patient. Performed by: Evaluated by: Eladio Martin Gumabay RN,MSN