Assisting with Aspirations: Bone Marrow Aspiration/Biopsy, Lumbar Puncture,

Paracentesis, and Thoracentesis

Procedure Rationale

ASSESSMENT

1. Identified patient using two identifiers, Ensures correct patient. Complies with The
compared identifiers with information on Joint Commission (2012) requirements and
MAR. improves procedure safety.

2. Verified type of procedure scheduled,

purpose, and procedure site with patient
and medical record.

3. Verified that informed consent was Federal regulations, many state laws, and
obtained at an appropriate time. accreditation agencies require informed
consent for procedures.

4. Determined patient’s ability to assume Movement during procedure can cause

position and stay still, discussed need for complications such as bleeding and injury
premedication with health care provider. to nerves or tissue. Required position
depends on site used for aspiration.

5. Obtained vital signs, SpO2/end-tidal CO2
value, and weight; obtained abdominal girth
measurement if necessary; assessed lower
extremity movement, sensation, and muscle
strength.
Provides baseline for comparison with vital
signs during and after procedure. Patients
will have decreased abdominal girth and
lose weight after paracentesis.

6. Instructed patient to empty bladder. Reduces risk for bladder trauma during
paracentesis. Promote Patient comfort.

7. Assessed patient's coagulation status. Invasive procedures are contraindicated in

patients with coagulation disorders because
of risk for bleeding.

8. Determined whether patient was allergic Precautions can be taken to decrease the
to antiseptic, latex, or anesthetic solutions. chance of allergic reactions.

9. Assessed patient's level of understanding Determines level of instruction and level of

of procedure, including any concerns. support required.

10. Assessed baseline pain level. Determines need to preprocedure

analgesia. Pain control helps patients
maintain proper position and tolerate
aspiration procedure.

PLANNING

1. Identified expected outcomes.

● Patient describes purpose of ● Demonstrates understanding and

procedure. improves likelihood of cooperation.
 ● Patient assumes and maintains the
required position and remains still
throughout procedure.
● There is no bleeding at the needle
insertion site.
● Amount of aspirate is sufficient to
perform laboratory testing.
● Patient’s level of comfort equals a
score of 4 or less on a pain scale of
0 to 10.
● Vital signs, SpO2, and end-tidal
CO2, remain within normal limits
during and after aspiration
procedure.
● Patients undergoing paracentesis
has reduced abdominal girth and
improved respirations.
2. Explained steps of skin preparation,
anaesthetic injection, needle insertion, and
position required.
3. Premedicated for pain or anxiety if
ordered.
4. Verified recent chest x-ray examination.
IMPLEMENTATION
1. Perform hand hygien.
2. Set up sterile tray or open supplies to
make accessible for health care provider.
3. Take “Time-Out” to verify patient’s name,
type of procedure scheduled, and
procedure site with patient and health care
team.
4. Assisted patient in maintaining correct
position, reassured patient while explaining
procedure.
a Bone marrow:
• Adults: For sternal biopsy place in supine
position. For iliac crest biopsy place in
prone or lateral recumbent position.
• Children: For iliac crest biopsy place in
prone or lateral recumbent position
● Achieving a level of patient comfort
allows for the correct position which
facilitates safe and timely
completion of procedure.
● Precautions during procedure
prevent bleeding.
● Procedure performed with minimal
discomfort to patients.
● Removal of abdominal (ascites) or
pleural fluid increases lung
expansion and improves gas
exchange.
● Fluid successfully removed from
peritoneal space.
Explanation reduces anxiety.
Reduces pain and any anxiety associated
with the procedure.
Provides a pre-procedure baseline to
determine location of pleural fluid.
Reduces transmission of microorganisms.
Maintains integrity of sterile field and
promotes prompt completion of procedure.
“Time-Out” verification just before starting
procedure includes physician and all
personnel and is safety precaution to
prevent wrong patient, wrong site, and
wrong procedure errors (TJC, 2012).
Decreases chance of complications
occurring during procedure. Explanations
increase patient comfort and relaxation.
Provides best access to bone containing
marrow.
b LP: Position in lateral recumbent (fetal)
position with head and neck flexed (see
Table 44-3).
c Paracentesis: Position in bed in
semi-Fowler’s position or sitting upright on
side of bed or in chair with feet supported
(see Table 44-3).
d Thoracentesis: Place in orthopneic
position (upright position with arms and
shoulders raised and supported on padded
over-bed table) (see Table 44-3). If patient
is unable to tolerate, help to side-lying
position with affected lung positioned
upward.
5. Explain to patient that pain may occur
when lidocaine (local anesthetic) is injected
into tissues. Pressure may also occur when
tissue or fluid is aspirated.
6. Nurse assesses patient’s condition
during procedure, including respiratory
status, vital signs if indicated, and any
complaints of pain.
7. Note characteristics of aspirate:
a Bone marrow aspirate: Marrow may
appear red or yellow.
b LP: Record opening pressure; observe
fluid for color, cloudiness, or blood.
c Paracentesis: Fluid may appear yellow,
cloudy, bile-stained green, or blood tinged.
Peritoneal lavage fluid may appear bright
red.
8. Properly labeled specimen in presence of
patient, transported to laboratory in proper
container, labeled specimens in order of
collection.
9. Assisted with pressure over insertion site
and application of gauze after needle was
removed.
10. Removed PPE, discarded appropriately,
performed hand hygiene.
Provides full curvature and flexion of spinal
column to allow maximal space between
vertebrae.
Position uses gravity to cause fluid to
accumulate in lower abdominal cavity,
where it is drained more easily.
Expands intercostal space for needle
insertions.
Aspiration is painful but lasts for only a few
moments. If patient is having bone marrow
aspirate, deep pressure feeling is frequently
experienced as bone marrow is withdrawn.
Identifies any changes that indicate
complication.
Normal marrow.
Normal CSF is clear and colorless.
Cloudiness is result of protein, which
indicates an infection.
Blood-tinged fluid is caused by traumatic
tap. In patient with abdominal trauma
bloody lavage identifies active bleeding.
Ensures that correct laboratory results are
assigned to right patient. Test tubes are
numbered in sequence of collection.
Assists in homeostasis and secures
insertion site.
Reduces transmission of infection.
EVALUATION
1. Monitor LOC, vital signs, and
SPO2/end-tidal CO2 at appropriate
intervals.
2. Inspect dressing over puncture site for
signs of infection, inspect area under
patient for bleeding, avoid disrupting
healing clot at site.
3. Evaluated pain score.
4. Measured abdominal girth and
respirations following paracentesis,
compared with preprocedure assessments.
5. Asked patient to describe expectations
after the procedure.
6. Identified unexpected outcomes.
● Oversedation occurs.
● Site complications occur:
a. Bone marrow: Tenderness or
erythema at site
b. LP:
(1) Postprocedure headache
(PPHD) is evidenced by headache,
blurred vision, and tinnitus
(2) Excess loss of CSF is indicated
by decreased level of
consciousness, hearing loss, dilated
pupils, and decreased ICP.
c. Paracentesis: Leakage of fluid
from site and acute abdominal pain
occur.
d. Thoracentesis: Pneumothorax is
evidenced by sudden dyspnea,
tachypnea, and asymmetric chest
excursion.
RECORDING AND REPORTING
1. Recorded all pertinent information in the
Verifies patient’s physiologic status in
response to procedure or any potential
complications.
Determines further blood loss from the
puncture site. Infection is
Determines if patient is having increased
pain to warrant postprocedure analgesia.
Determines amount of change in abdominal
size and ability to ventilate.
● Notify health care provider and
obtain further orders.
● Administer analgesic as ordered.
● Continue to monitor site.
● Monitor fluid loss.
● Physician may inject blood patch
into epidural space.
● Medicate for pain as ordered.
● Maintain airway.
● Transfer to intensive care unit (ICU)
per physician order.
● Reinforce dressing; may also be
instructed to place sterile collection
bag over site.
● Monitor vital signs and SpO2.
● Assess abdomen for bowel sounds.
● Administer oxygen.
● Monitor vital signs and SpO2.
● Anticipate chest x-ray film
examination and possible chest tube
insertion.
appropriate log.

2. Reported changes in vital signs,

unexpected pain, or excessive drainage to
health care provider immediately.