Académique Documents
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By
Matt Vera, BSN, R.N
Procedure
3. Select the thoracentesis site in an interspace below the point of dullness to percussion in the mid posterior line (posterior
4. Sterile technique should be used including gloves, betadine prep and drapes.
5. 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. 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 to check for pleural fluid. Once fluid returns, note the depth of the
needle and mark it with a hemostat. This gives an approximate depth for insertion of the angiocatheter or thoracentesis needle. Remove
the anesthetizing needle.
6. Use a hemostat to measure the same depth on the thoracentesis needle or angiocath as the first needle. While exerting steady
pressure on the patient’s back with the nondominant hand, use a hemostat to measure the 15- to 18- gauge thoracentesis needle to the
same depth as the first needle. While exerting steady pressure on the patient’s 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 to avoid the neurovascular bundle that runs below the rib.
7.
the tubing.
Attach the three way stopcock and tubing, and aspirate the amount needed. Turn the stopcock and evacuate the fluid through
8. 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 because of 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.
9. When draining of fluid is completed, have the patient take a deep breath and hum, and gently remove the needle. This
maneuver increases intrathoracic pressure and decreases the chance of pneumothorax. Cover the insertion site with a sterile occlusive
dressing.
Thoracentesis Nursing Considerations
The patient may have a diagnostic procedure, such as a chest x-ray, chest fluoroscopy, ultrasound, or CT scan, performed prior
to the procedure to assist the physician in identifying the specific location of the fluid in the chest that is to be removed.
The patient may receive a sedative prior to the procedure to help the patient relax.
Asked the patient to remove any clothing, jewelry, or other objects that may interfere with the procedure.
The area around the puncture site may be shaved.
Vital signs (heart rate, blood pressure, breathing rate, and oxygen level) are to be monitored before the procedure.
Support the client verbally and describe the steps of the procedure as needed.
Vital signs (heart rate, blood pressure, breathing rate, and oxygen level) are to be monitored during the procedure.
The patient may receive supplemental oxygen as needed, through a face mask or nasal cannula (tube).
Observe the client for signs of distress, such as dyspnea, pallor, and coughing
Place the patient in a sitting position with arms raised and resting on an overbed table. This position aids in spreading out the
spaces between the ribs for needle insertion. If the patient is unable to sit, the patient may be placed in a side-lying position
on the edge of the bed on unaffected side.
The skin at the puncture site will be cleansed with an antiseptic solution.
The patient will receive a local anesthetic at the site where the thoracentesis is to be performed.
Don’t remove more than 1000 ml of fluid from the pleural cavity within first 30 minutes.
Place a small sterile dressing over the site of the puncture.
Observe changes in the client’s cough, sputum, respiratory depth, and breath sounds, and note complaints of chest pain.
Position the client appropriately
Some agency protocols recommend that the client lie on the unaffected side with the head of the bed elevated 30 degrees for
at least 30 minutes because this position facilitates expansion of the affected lung and eases respirations
Position the patient in a side-lying position with the unaffected side down for an hour or longer.
Include date and time performed; the primary care provider’s name; the amount, color, and clarity of fluid drained; and
nursing assessments and interventions provided.
Transport the specimens to the laboratory.
The dressing over the puncture site will be monitored for bleeding or other drainage.
Monitor patient’s blood pressure, pulse, and breathing until are stable.
Document all relevant information.
Here are some possible nursing diagnoses for a patient post-thoracentesis (you may also check on the nursing
care plans for Pleural Effusion)
References:
http://www.ucsfmedicalcenter.org/medstaffoffice/Standardized_Procedures/Thoracentesis.pdf
http://www.nhlbi.nih.gov/health/dci/images/thoracentesis.jpg