Definition
Assisting with thoracentesis the removal of fluid or air from the pleural space is a critical nursing role that demands sterile technique, patient support, and vigilant monitoring.
Purposes
- To remove air and fluid from pleural cavity.
- To decrease pressure on the lung tissue.
- To aspirate pleural fluid for diagnostic studies.
- To instill medication into the pleural space.
- To perform pleural biopsy.
Articles
- A pleural aspiration set containing the following:
- Sponge holding forceps (1 No.)
- Syringe (5 mL) and needle.
- Syringe (20 mL) with Luer-lock.
- Aspiration needles (No. 16 g).
- Small bowls (2 Nos.).
- Dissecting forceps (1 No.).
- Artery forceps (1 No.).
- Specimen bottles and slides.
- Gown, mask, and gloves.
- Sterile dressing towels.
- Cotton swabs, gauze pieces, and pads.
- Scalpel blade.
- A clean tray containing the following:
- Mackintosh and towel.
- Kidney tray and paper bag.
- Spirit, povidone iodine.
- Lignocaine 2%.
- Adhesive plaster and scissors.
- Tincture benzoin.
- Other articles, such as:
- Cardiac table.
- Pillows.
Preparation
Preparing for a thoracentesis procedure involves several key steps to ensure safety and accuracy:
- Medical History Review:
- Inform your healthcare provider about any medications you are taking, especially blood thinners, as these may need to be adjusted.
- Disclose any medical conditions, such as bleeding disorders or respiratory issues.
- Dietary Instructions:
- In most cases, you can eat and drink as usual unless your doctor advises otherwise.
- Clothing and Accessories:
- Wear loose, comfortable clothing and avoid wearing jewelry or metallic items.
- Imaging Tests:
- A chest X-ray, ultrasound, or CT scan may be performed beforehand to locate the fluid and plan the procedure.
- Consent and Communication:
- Discuss the procedure with your healthcare provider, ask any questions, and sign the consent form.
- Medication Adjustments:
- If you are on anticoagulants or other medications, follow your doctor’s instructions regarding when to stop or adjust them.
Procedure
| Nursing action | Rationale | |
| Before procedure | ||
| 1. | Identify patient and explain the procedure to him and relatives. Explain that during procedure he may experience a sensation of deep pressure when fluid is aspirated. | Allays anxiety and wins cooperation. |
| 2. | Review the chest X-ray. | X-ray shows localization of fluid and air in pleural cavity for determining puncture site. |
| 3. | Obtain an informed consent from the patient. | Avoids risk of legal complications. |
| 4. | Instruct patient that he should not move during the procedure. | Any movement or coughing during the procedure can cause injury to vital organs or blood vessels. |
| 5. | Position the patient in any one position comfortably: Sitting on the edge of bed with the feet supported, arms and head on pillows over the cardiac table, orStraddling a chair with arms and head resting on the back of the chair, or Lying on the unaffected side, with the bed elevated 30-40° if patient is unable to assume sitting position. | An upright position facilitates localization of fluid at the base of the chest. |
| During procedure | ||
| 6. | Expose the chest. The physician determines the site for aspiration by visualizing chest X-ray and performing chest percussion. If air is to be removed, the site is usually in 2nd and 3rd intercostal space. If fluid is to be aspirated, then site is usually in the 8th and 9th intercostal space. | Fluid usually localizes at the base of the chest. |
| 7. | Clean the site with antiseptic solution and assist the physician in administering local anesthesia. | Reduces the risk of infection. |
| 8. | The physician introduces the thoracentesis needle. Instruct the patient to hold his breath when needle is inserted. | Respiratory movement can cause risk of puncture to vital organs. |
| 9. | When needle is in pleural space, physician aspirates pleural fluid with syringe. Assist in collecting specimen in sterile containers. A 20 ml syringe with a three-way adapter is attached to needle. The tubing which leads to the receptacle is attached to the third port of the three-way adapter.If a considerable quantity of fluid is to be removed, the needle is held in place on the chest wall. | The three-way adapter helps in preventing air from entering the pleural cavity when large volumes of fluid are removed. |
| 10. | For therapeutic purpose, usually 1,000-1,200 mL of fluid is removed and for diagnostic purpose, 30-60 mL of fluid is removed.Encourage patient to remain still during the procedure and monitor vital signs. | |
| 11. | After the needle is withdrawn, apply tincture benzoin seal and pressure dressing over the site. | Pressure dressing prevents risk of bleeding, leakage, and infection at site. |
| 12. | Position patient in bed with affected side up. He should remain in bed for 4-6 hours after the procedure. | This position minimizes the risk of possible fluid leakage. |
| 13. | Monitor vital signs every half an hour for 4-6 hours or till steady. Observe patient for complications, such as shock, fainting, low blood pressure, rapid pulse, rapid respiration, uncontrolled cough, and blood-tinged frothy sputum. Check breath sounds in all lung fields. | Complications may occur because of accidental puncture of vital organs or blood vessels. |
| After procedure | ||
| 14. | Record the procedure with total amount of fluid withdrawn, color, nature, and signs of complications. | |
| 15. | Send labeled specimen to laboratory. | |
| 16. | Instruct patient to do deep breathing and coughing exercises. Demonstrate and teach these exercises to patient. | Deep breathing and coughing promote lung expansion. |
| 17. | Have a chest X-ray if indicated. | |
| 18. | Wash articles used for thoracentesis in cold water and then in warm soapy water. Rinse, dry, and send for autoclaving. Wear gloves while washing. |
Special Precautions
- Position the patient upright and leaning slightly forward, with arms resting on a table. This maximizes access to the pleural space and reduces the risk of complications.
- Ensure the procedure is conducted under strict sterile conditions to minimize the risk of infection.
- Observe the patient for signs of discomfort, respiratory distress, or complications such as pneumothorax or bleeding.
- Use ultrasound to locate the optimal puncture site, especially in cases of small or loculated effusions.
- Monitor the patient for delayed complications, such as infection or fluid reaccumulation.
- Obtain a chest X-ray if necessary to rule out pneumothorax.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
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