Misamis University

College of Nursing & School of Midwifery

Ozamiz City

Nursing Procedures

ASSISTING WITH A THORACENTESIS

Purposes:
1. Assist the physician in removing fluid and/or air from the pleural space.
2. Assist the physician with a diagnostic aspiration of pleural fluid.

Equipments:
1. Thoracentesis tray including:
= aspirating needle = adhesive bandage
(16 gauge, 3 ½ inch with adjustable clamp) = 2 sterile gloves
= 5 cc and 50 cc syringes = gauze sponges
= 21 and 25 gauge needles = drape
= local anesthetic = antiseptic solution
= specimen tubes with caps – 3 = drain tune & collection bag

Procedure
1. Assemble all equipments.

2. Identify the patient

3. Reinforce the physician’s explanation of the procedure to the patient:

a. Reason for the procedure
b. Position required and importance of remaining immobile
c. Sensations of pressure and cold experienced during injection of local anesthetic

4. Obtain an informed consent for the procedure, if necessary.

5. Provide privacy.

6. Dress the patient in a clean hospital gown.

7. Obtain baseline vital signs and assess breath sounds.

8. Administer sedation if indicated.

9. Wash your hands.

10. Assist the physician by opening the thoracentesis tary and sterile gloves, using aseptic technique.

11. Position the patient comfortably with adequate support in one of the following positions:
a. Sitting upright supported by an overbed table with a pillow to lean on
b. Sitting on the side of the bed with the feet on a chair
c. Lying on the unaffected side with a small pillow placed under the chest.
12. Elevate the arm on the affected side by placing the patient’s hand on the opposite shoulder to expose
the puncture area.

13. Reassure and support the patient during the procedure.

14. Assist the physician as necessary.

15. Observe the patient for any changes in color, pulse and respirations throughout the procedure and
inform physician of any changes.

16. Assist the physician with applying an occlusive dressing following removal of aspirating needle.

17. Position the patient on the unaffected side for approximately 1 hour to permit the puncture site to
seal.

18. Assess vital signs every 30 minutes for 2 hours, then every hour for 4 hours, then every 4 hours for
24 hours, or as ordered.

19. Assess the patient at the same time intervals for signs and symptoms of pneumothorax.

20. Inspect dressing over the puncture site

21. And the surrounding skin area for drainage or inflammation when assessing other parameters.

22. Measure the amount of fluid if fluid was removed.

23. Send labeled specimen to the laboratory if diagnostic studies are ordered.

24. Discard remaining thoracentesis drainage according to your health care facility’s policy.

25. Discard equipment or return it to the appropriate location.

26. Document procedure and name of physician as well as nursing assessments of the patient during the
procedure.
 Misamis University
College of Nursing & School of Midwifery
Ozamiz City

Nursing Procedures

ASSISTING WITH A THORACENTESIS

(Performance Checklist)

Steps Weight Teacher’s Remarks

Rating
1. Assemble all equipments.

2. Identify & explain procedure to the patient.

3. Secure consent & provide privacy.

4. Dress the patient in a clean hospital gown.

5. Obtain baseline vital signs and assess breath sounds.

6. Wash hands.

7. Assist the physician by opening the thoracentesis tray and sterile gloves, using
aseptic technique.

8. Position the patient comfortably with adequate support

9. Elevate the arm on the affected side by placing the patient’s hand on the opposite
shoulder to expose the puncture area.

10. Reassure and support the patient during the procedure.

11. Observe & inform physician for any reaction by the patient.

12. Assist the physician in applying an occlusive dressing .

13. Position the patient on the unaffected side for approximately 1 hour to permit the
puncture site to seal.

14. Assess vital signs & observe for signs and symptoms of pnuemothorax.

15. Inspect dressing over the puncture site.

16. Send labeled specimen to the laboratory

17. Discard remaining thoracentesis drainage

18. After care of equipment.

19. Documentation

_______________________________ _______________________________
CI’s Signature Over Printed Name Date
 Misamis University
College of Nursing & School of Midwifery
Ozamiz City

Nursing Procedures

ASSISTING THE PATIENT UNDERGOING LUMBAR PUNCTURE

Definition:
Insertion of a needle into a lumbar subarachnoid space and withdrawal of cerebrospinal
fluid for diagnostic and therapeutic purposes.
Purposes:
1. To obtain cerebrospinal fluid for examination
2. To measure and relieve cerebrospinal pressure
3. To determine the presence or absence o blood in the spinal fluid
4. To detect spinal subarachnoid block
5. To administer medications entrathecally in certain cases.

Equipment: - Sterile lumbar puncture set - Skin Antiseptic

- Xylocaine 1%-2% - Band aid

Procedure Rationale

Preparatory Phase
1. Give a step-by-step summary of the procedure  Reassure the patient and gain his/her
cooperation.
2. Secure consent from client

For lying position

1. Position the patient on his/her side with a pillow  The patient is maintained in a horizontal
under his/her head and a pillow between legs. Patient position. The pillow between legs prevents the
should be lying in a firm surface upper leg from rolling forward.

2. Instruct the patient to arch the lumbar segment of  This posture offers maximal widening of the
his/her back and drew his/her knees up to his interspinous spaces and affords easier entry into
abdomen, clasping his/her knees with his /her hands. the subarachnoid space.

3. Assist the patient in maintaining this position by  Supporting the patient helps prevent sudden
supporting him/her behind the knees and neck. assist movements, which can prevent a traumatic
the patient to maintain the posture throughout the (bloody) tap and thus impede correct.
examination

For sitting position  In obese patients and those who have difficulty
1. Have the patient straddle a straight-back chain (facing in assuming an arch side-lying position, this
the back) and rest his head against his arms, which are posture may allow more accurate identification
folded on the back of the chair. of the spinous interspaces
 Misamis University
College of Nursing & School of Midwifery
Ozamiz City

Nursing Procedures

Performance Phase (by the physician)

1. The skin is prepared with antiseptic. Skin and
subcutaneous spaces are infiltrated with local
anesthetic

2. A spinal puncture needle is introduced at L3-L4  L3-L4 interspace is below the level of spinal
interspace. the needle id=s advanced until the cord
“give” of the legamentum flavum is felt and the
needle enters the subarachnoid space. Attached
manometer to spinal puncture needle.

3. After the needle enters the subarachnoid space, help

the patient to slowly straighten his leg.
 This maneuver prevents a false increase in
interspinal pressure. Muscle tension and
compression of the abdomen give falsely high
pressure.

4. Instruct the patient to breath quietly (not to hold his  Hyperventilation may lower a truly elevated
breath or strain). pressure. Talking can elevate CST pressure.

 With respiration there is normally some

5. The initial pressure reading is obtained by measuring fluctuation of CST in the amnometer. Normal
the level of the fluid column after it comes to rest. range of spinal fluid pressure with the patient in
lateral position is 70-180 mm H20

 Spinal fluid should be clear and colorless.

6. About 2-3 ml of spinal fluid is placed in each of 3 test Bloody spinal fluid may indicate cerebral
tubes for observation, comparison and laboratory contusion. Laceration subarachnoid hemorrhage
analysis. or traumatic top.

Follow –up Phase

1. Record
a. Procedure

b. Appearance of spinal fluid

c. Whether or not specimens were sent to

laboratory

d. Spinal pressure readings  Some patients suffer from post-puncture

headache, which is thought to be caused by the
e. Condition and reaction of the patient leakage of spinal fluid at the puncture site.
 Misamis University
College of Nursing & School of Midwifery
Ozamiz City

Nursing Procedures

ASSISTING THE PATIENT UNDERGOING LUMBAR PUNCTURE

(Performance Checklist)

Steps Weight Teacher’s Remarks

rating

Preparatory Phase
1. Give a step-by step summary of the procedure

2. Secure consent from the client

For lying position

3. Position the patient in his head and a pillow between his legs.
4. Instruct the patient to arch the lumbar segment of his back and draw his knees up
to his abdomen, clasping his knees with his hands.

5. Assist the patient in maintaining his position by supporting him behind the knees
and neck.

For sitting position

6. Have the patient straddle a straight back chain and rest his head against his
arms, which are folded on the back of the chair.

Performance Phase (by the physician)

4. Paint the skin with antiseptic solution

5. Offer gloves to the physician

6. Offer anesthetic solution to the physician

7. Help the patient to slowly straighten his leg after the needle enters the
subarachnoid space.

8. Instruct the patient to breath quietly and not to talk.

9. Place about 2-3 ml of spinal fluid in each of a test-tubes for laboratory

examination.

10. Documentation

11. Keep the patient horizontal (prone, supine or on his side) 6-12 hours. Encourage
a liberal fluid intake

12. Cleanse area with mild soap and water; pat dry.

13. Apply a karaya preparation or other peristomal preparation

14. Clean equipment with soap and water.

 _______________________
CI’s Signature Over Printed Name Date

Misamis University
College of Nursing & School of Midwifery
Ozamiz City

Nursing Procedures

POSTMORTEM CARE
Purposes:
1. Prepare the body for family viewing
2. Prepare the body for transfer to the morgue.

Equipments:
1. Bath supplies 3. Shroud 5. Identification tags
2. Linen 4. Bag for personal belongings 6. Waste receptacle

Procedure Rationale
1. Provide privacy for the patient and / or family. Assist
the roommate and visitors to leave the room
temporarily, if appropriate.

2. Verify that the patient has died and has been

pronounced dead by the physician.

3. Notify appropriate persons in the hospital as well as

the clergy if requested by the family.

4. Assemble all equipment.

5. Position the body supine in proper body alignment,

with the hands at the sides. Close the eyelids. Place a  Do not cross the hands because the
small pillow under the head. underlying hand will become discolored
and indented. The pillow will prevent
blood from pooling in the face, which can
6. Remove jewelry and eyeglasses and place with cause discoloration.
personal belongings.
 These items are often important as
mementos for the family and must be
returned to them. This will prevent the loss
7. Put on clean gloves. of valuables and protect you legally.

8. Replace dentures, if possible.  To protect yourself from body secretions.

 This gives the person’s face a more

familiar and natural appearance if the
patient is to be viewed by loved ones
9. Place a small towel under the chin. before being taken to the mortuary.

 To support the mouth in a closed position.

10. Remove and discard all tubes and lines and

change all dressings, if appropriate.

11. Bathe the body. Pat the body dry.  Brisk rubbing may cause undue discoloration of
the tissues.

12. Place disposable pads in the perineal area.  To absorb any stool or urine released as the
sphincter muscles relax.
13. Remove and discard gloves.

14. Apply a clean patient gown and clean bed

linen if the family will be viewing the body.
Leave the head uncovered and have the room
arranged neatly.

15. Prepare the family before viewing the body.

Offer support and your physical presence, if
desired, during their visit. Assist the family
 with funeral arrangements, if necessary.

16. Identify and assemble the patient’s personal

belongings for the family.

17. Attach at least two forms of identification to

the body. Place one tag on the patient’s body
(wrist, ankle, or big toe) and the other on the
outer covering or shroud, according to specific
policy. Leave the wrist identification band in
place.

18. Place the body within the shroud.

19. Arrange for transportation to the morgue.

20. Discard equipment or return to the appropriate

location.

21. Wash your hands.

Misamis University
College of Nursing & School of Midwifery
Ozamiz City

Nursing Procedures

POSTMORTEM CARE
(Performance Checklist)

Weight Teacher’s Remarks

Postmortem Care Rating

1. Provide privacy for the patient and / or family. 2

2. Verify that the patient has been pronounced dead by the physician 4
and Notify appropriate persons in the hospital.

3. Assemble all equipment. 3

4. Position the body supine in proper body alignment, with the hands at 5
the sides. Close the eyelids. Place a small pillow under the head.
5. Remove jewelry and eyeglasses and Put on clean gloves.
4
6. Replace dentures & place a small towel under the chin
2
7. Remove and discard all tubes and lines.
2
8. Bathe the body. Pat the body dry.
2
9. Place disposable pads in the perineal area.
2
10. Remove and discard gloves.
2
11. Apply a clean patient gown and clean bed linen.
2
12. Prepare the family before viewing the body.
4
13. Identify and assemble the patient’s personal belongings for the 4
family.

14. Attach at least two forms of identification to the body. 2

15. Place the body within the shroud. 4

16. Arrange for transportation to the morgue. 2

17. Discard equipment or return to the appropriate location. 2

18. Wash hands. 2

___________________________ __________________
CI’s Signature Over Printed Name Date