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Czarlynn Goopio NCM 103, professor A. Definition Thoracentesis, also known as thoracocentesis or pleural tap, is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia. The lung is covered inside and out with a tissue called the pleura. The space between these two areas is called the pleural space. This space normally contains just a thin layer of fluid however some conditions such as pneumonia,cancer, or congestive heart failure may cause excessive fluid to develop (pleural effusion). The most common causes of pleural effusions are cancer, congestive heart failure, pneumonia, and recent surgery. In countries where tuberculosis is common, this is also a common cause of pleural effusions. When cardiopulmonary status is compromised (i.e. when the fluid or air has its repercussions on the function of heart and lungs), due to air (significant pneumothorax), fluid (pleural fluid) orblood (hemothorax) outside the lung, then this procedure is usually replaced with tube thoracostomy, the placement of a large tube in the pleural space. B. Purpose To provide pleural fluid specimens to determine the cause and nature of pleural effusion To provide symptomatic relief with large pleural effusion. The most common reasons for doing a thoracentesis are:
1. New Pleural Effusion - Thoracentesis may be done to figure out the cause of new fluid build-up in the chest. 2. Infection - When an infection is suspected to be the cause of fluid build-up in the chest, a thoracentesis may be done to help make a diagnosis. Fluid that is drained can be analyzed in the laboratory to identify the type of germ causing the infection and what medicines (antibiotics) might be effective. 3. Cancer—Some cancers spread to the lung or the pleura (the lining of the lung and chest wall). This can cause fluid to build up in the chest. A thoracentesis may be done to help make a diagnosis. Fluid that is drained can be examined in the laboratory to see if cancer cells are present. 4. Comfort—A large build up of fluid can be painful and make it hard to breathe. Removing some fluid may make the person more comfortable. C. Laboratory Values Studies of pleural fluid include Gram stain culture and sensitivity, acid-fast staining and culture, differential cell count, cytology, pH, specific gravity, total protein and lactic dehydrogenase. Transudate vs. Exudate A transudate is defined as pleural fluid to serum total protein ratio of less than 0.5, pleural fluid to serum LDH ratio < 0.6, and absolute pleural fluid LDH < 200 IU or < 2/3 of the normal . It has a low white blood cell (WBC)count, a low lactate dehydrogenase (LDH) enzyme level, and a low protein level. Congestive heart failure Nephrotic syndrome Hypoalbuminemia Cirrhosis Atelectasis trapped lung Peritoneal dialysis
Superior vena cava obstruction
An exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation. Its composition varies but generally includes water and the dissolved solutes of the main circulatory fluid such as blood. In the case of blood: it will contain some or all plasma proteins, white blood cells, platelets and (in the case of local vascular damage) red blood cells. hemorrhage Infection Inflammation Malignancy Iatrogenic Connective tissue disease Endocrine disorders Lymphatic disorders vs Constrictive pericarditis If an infection is present, the exudate will have a high WBC count, a high LDH enzyme level, a high protein level, and bacteria or other infectious organisms. If cancer is present, the exudate will have a high WBC count (often lymphocytes), a high LDH enzyme level, and a high protein level. Abnormal cells may also be present. If a pulmonary embolism is present, the exudate will have a low WBC count and large numbers of red blood cells. Amylase A high amylase level (twice the serum level or the absolute value is greater than 160 Somogy units) in the pleural fluid. acute or chronic pancreatitis pancreatic pseudocyst that has dissected or ruptured into the pleural space cancer or esophageal rupture. Glucose This is considered low if pleural fluid value is less than 50% of normal serum value. rheumatoid effusion.The levels are characteristically low (<15 mg/dL). lupus effusion bacterial empyema malignancy
This allows the pleural puncture to heal. Inform the patient about the nature of the procedure and a. Chest X-ray is ordered to detect possiblepneumothorax. oxygen saturation. Number of RBC – obvious sign of bleeding Culture and Stains If the effusion is caused by infection. blood cultures and sputum cultures) become positive. and the gag and cough reflexes remain intact. and other substances to determine the cause of the pleural effusion.The puncture wound of thoracentesis heals rapidly. Frequent assessment is important to detect possible complications of thoracentesis. a sensation of pressure may be felt. Straddling a chair with arms and head resting on the back of the chair. 5.g. c. These are indicators of physiologic tolerance of the procedure. the importance of remaining immobile b. provide additional information as needed. Cell Count and Differential Number of WBC – indication of infection. respiratory status.and other signs during thoracentesis. and puncture site for bleeding or crepitus. The appearance is generally milky but can be serous. . or hemoptysis. 4. Lying on the unaffected side with the head of the bed elevated 30 to 45 degrees if unable to assume a sitting position. most frequently as a result of trauma or malignancy (such aslymphoma). A pleural fluid pH below 7. frequently assess and document vital signs. An informed client will be less apprehensive and more able to cooperate during the thoracentesis. Position the client upright. Support and reassure the patient during procedure. Administer a cough suppressant if indicated. A triglyceride level over 110 mg/dl and the presence of chylomicrons indicate a chylous effusion. Sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Normal activities generally can be resumed after 1 hour if no evidence of pneumothorax or other complication is present.60. PostProcedure Care Monitor pulse. povidone-iodine. 2. Only local anesthesia is used in this procedure. These supplies are used by the physician performing the procedure. enlarging the intercostal space for needle insertion. Normal cytology results do not reliably rule out malignancy. b. cough. bacteria. This invasive procedure requires informed consent. Fluid obtained during thoracentesis may be examined for abnormal Pleural Fluid pH Normal pleural fluid pH is approximately 7.color. Preprocedure fasting or sedation is not required. A Gram stain may give a rough indication of the causative organism. which are relatively high in lymph. respiratory excursion. This position spreads the ribs. pressure sensations to be experienced. During the first several hours after thoracentesis. sometimes before other cultures (e. The most common causes for pleural fluid are lung cancer. including. The latter often presents with an effusion. injectable lidocaine. such as pneumothorax. Triglyceride and Cholesterol Chylothorax (fluid from lymph vessels leaking into the pleural cavity) may be identified by determining triglyceride and cholesterol levels. c. lung sounds.oxygen saturation. Obtain a thoracentesis tray. 6.30 with normal arterial blood pH has the same differential diagnosis as low pleural fluid glucose. send specimen to the laboratory for analysis. Assess knowledge and understanding of the procedure and its purpose. Administer sedation if prescribed. Cytology Cytology is an important tool in identifying effusions due to malignancy. sterile gloves. microbiological culture may yield the infectious organism responsible for the infection. and position on the unaffected side for 1 hour. tuberculosis esophageal rupture (Boerhaave syndrome) D. Obtain a chest X-ray.metastasis from elsewhere and pleural mesothelioma. Assess the patient for allergy to the local anesthetic to be used. 3. source.leaning forward with arms and head supported on an anchored overbed table. Apply a dressing over the puncture site. but make the diagnosis more unlikely. Nursing Responsibilities PreProcedure Care Verify a signed informed consent for the procedure. that minimal discomfort is anticipated after the procedure. and diagnosis. and an extra overbed table or mayo stand. cells. Ascertain in advance that a chest x-ray has been ordered and completed and the consent form has been signed. Inform the client that although local anesthesia prevents pain as the needle is inserted. A pressure sensation occurs as the needle punctures the parietal pleura to enter the pleural space. Label obtained specimen with name. date. E. place the patient upright or in one of the following positions: a. A Ziehl-Neelsen stain may identify tuberculosis or other mycobacterial diseases. Movement and coughing during the procedure may cause inadvertent damage to the lung or pleura. Procedure 1. If possible. Position the patient comfortably with adequate supports. The main cause for chylothorax is rupture of the thoracic duct.dressing supplies.
Use of thoracentesis needle allows proper insertion. a rapid pulse. faintness. airtight. tightness in chest. 2. . 12. When fluid is loculated (isolated in a pocket of pleural fluid). Sedation enables the patient to cooperate with the procedure and promotes relaxation. subcutaneous emphysema. with attention to the site of maximal dullness on percussion. ultrasound scanning. the thoracentesis site is usually in the second or third intercostals space in the midclavicular line because air rises in the thorax. The parietal pleura is very sensitive and should be well infiltrated with anesthetic before the physician passes the thoracentesis needle through it. 8. An intradermal wheal is raised slowly. The physician advances the thoracentesis needle with the syringe attached. After the skin is cleansed. If a considerable quantity of fluid is removed the needle is held in space on the chest wall with a small hemostat. Pressure help to stop bleeding. b. 8. 9. 12. When a large quantity of fluid is withdrawn a three-way stopcock serves to keep air from entering pleural cavity. A 20-mL syringe with a three-way stopcock is attached to the needle( one end of the adater is attached to the needle and the other to the tubing leading to a receptacle that receives the fluid being aspirated. 4. If the patient is allergic to the initially prescribed anesthetic. After the needle is withdrawn. uncontrollable cough. Record the total amount of fluid withdrawn from the procedure and document the nature of the fluid. Posteroanterior and lateral chest x-ray films are used to localize fluid and air in the pleural cavity and to aid in determining the puncture site. If indicated. assists the patient to mobilize resources. Monitor the patient at intervals for increasing respiratory rate. such as coughing. by the patient can traumatize the visceral pleura and lung. A specimen container with formalin may be needed for a pleural biopsy. serous. prepare samples of fluid for laboratory evaluation. 7. b. tension pneumothorax. 13. When the pleural space is reached. pressure is applied over the puncture site and a small. 5. Expose the entire chest. and pyrogenic infection are complications of a thoracentesis. vertigo. 6. 11. a. its color and viscosity. The upright position facilitates the removal of fluid that usually localizes at the base of the thorax. b. 10. 9. assessment findings provide an opportunity to use a safer anesthetic. F. bloody. Sudden and unexpected movement. blood-tinged. etc. Pulmonary edema or cardiac distress ca occur after a sudden shift in mediastinal contents when large amounts of fluid are aspirated. asymmetry in respiratory movement. A chest x-ray verifies that there is no pneumothorax. frothy mucus. If air is in the pleural cavity.a. and physical findings. and the airtight dressing protects the site and prevents air from entering the pleural cavity. An explanation helps to orient the patient to the procedure. 11. 7. 13. Prepare the patient for the cold sensation of skin germicide solution and for a pressure sensation from infiltration of local anesthetic agent. Encourage the patient to refrain from coughing. the physician uses a smallcaliber needle to inject a local anesthetic slowly into the intercostal space. suction may applied with the syringe. purulent. the thoracentesis site is determined by the chest x-ray. The hemostat steadies the needle on the chest wall. Sudden pleuritic chest pain or shoulder pain may indicate that the needle point is irritating the visceral or the diaphragmatic pleura. and signs of hypoxemia. and provides an opportunity to ask questions and verbalize anxiety. The site for aspiration is visualized by chest x-ray and percussion. rapid injection causes pain. If fluid is in the pleural cavity. The procedure is performed under aseptic conditions. sterile dressing is fixed in place. ultrasound scans are performed to help select the best site for needle aspiration. 3. 10. Rationale for action 1. A position of comfort helps the patient to relax. a. Pneumothorax. Advise the patient that he or she will be on bed rest and a chest x-ray will be obtained after thoracentesis. The fluid may be clear.
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