Nursing Care Plan (NCP) for Thoracentesis (Procedure)
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Outline
Lesson Objectives for Thoracentesis Procedure
- Understanding Thoracentesis:
- Define thoracentesis as a medical procedure involving the aspiration of fluid or air from the pleural space using a needle or catheter.
- Indications and Purpose:
- Explore the clinical indications for performing thoracentesis, including the diagnostic and therapeutic purposes in conditions such as pleural effusion, pneumothorax, or hemothorax.
- Patient Preparation and Informed Consent:
- Discuss the importance of patient preparation before thoracentesis, including obtaining informed consent, explaining the procedure, and addressing patient concerns.
- Procedure Steps and Techniques:
- Outline the step-by-step procedure of thoracentesis, including patient positioning, site preparation, local anesthesia administration, and the insertion of the needle or catheter for fluid or air removal.
- Post-Procedure Monitoring and Complications:
- Highlight the post-procedure considerations, including monitoring for complications, assessing vital signs, and providing appropriate care to manage potential complications such as pneumothorax or bleeding.
Pathophysiology of Pleural Effusion (relevant to Thoracentesis)
- Accumulation of Fluid in the Pleural Space:
- Pleural effusion involves the abnormal accumulation of fluid in the pleural space, the thin fluid-filled space between the visceral and parietal pleura surrounding the lungs.
- Disruption of Pleural Equilibrium:
- Normally, there is a delicate balance between pleural fluid production and absorption. Disruption of this equilibrium can lead to an excessive accumulation of fluid, resulting in pleural effusion.
- Increased Pleural Permeability or Decreased Lymphatic Drainage:
- Various factors can contribute to pleural effusion, including increased permeability of the pleura, impaired lymphatic drainage, or increased production of pleural fluid due to inflammation, infection, or malignancy.
- Impaired Respiratory Function:
- As pleural effusion accumulates, it compresses the lung tissue, impairing lung expansion and reducing the functional capacity of the affected lung.
- This compression can lead to dyspnea, decreased lung compliance, and respiratory distress.
- Underlying Conditions and Causes:
- Pleural effusion is often a secondary manifestation of an underlying condition such as congestive heart failure, pneumonia, malignancy, liver disease, or pulmonary embolism. Identification of the underlying cause is crucial for targeted management.
Etiology of Pleural Effusion (Causes for Thoracentesis)
- Heart Failure (Congestive Heart Failure):
- Congestive heart failure can lead to increased hydrostatic pressure in the pulmonary vessels, causing fluid to leak into the pleural space.
- Infections (Pneumonia, Tuberculosis):
- Inflammatory processes, such as pneumonia or tuberculosis, can result in pleural effusion due to increased fluid production and impaired drainage.
- Malignancy:
- Cancer involving the lungs, pleura, or adjacent structures can lead to pleural effusion either by direct invasion or by producing inflammatory mediators that increase fluid accumulation.
- Liver Disease (Cirrhosis):
- Liver disease, particularly cirrhosis, can lead to the accumulation of ascitic fluid, which may migrate into the pleural space, causing pleural effusion.
- Pulmonary Embolism:
- Pulmonary embolism, a blockage in the pulmonary arteries, can result in increased pressure in the pulmonary vessels, contributing to pleural effusion.
Desired Outcome for Thoracentesis Procedure
- Safe and Successful Procedure:
- Ensure the thoracentesis procedure is conducted safely, with the successful removal of the targeted fluid or air from the pleural space.
- Relief of Respiratory Distress:
- Alleviate respiratory distress or symptoms associated with pleural effusion, improving the patient’s breathing and overall respiratory function.
- Minimal Discomfort and Pain:
- Minimize patient discomfort and pain during and after the procedure through appropriate pain management measures.
- Early Detection of Complications:
- Early identification and management of potential complications, including pneumothorax or bleeding, to prevent adverse outcomes.
- Patient Understanding and Satisfaction:
- Ensure the patient has a clear understanding of the procedure, feels informed and involved in decision-making, and expresses satisfaction with the care received.
Thoracentesis (Procedure) Nursing Care Plan
Subjective Data:
Indications
- Dyspnea
- Chest tightness
Complications
- Sudden, severe shortness of breath
- Anxiety/restlessness
- Pain at insertion site
Objective Data:
- Diminished/absent breath sounds over affected area
- Evidence of fluid or blood collection on chest-X-ray
Note: COMPLICATIONS
- Crepitus
- Diminished/absent breath sounds
- Bleeding from site
- Fever/increased WBC
- Redness/swelling at site
Nursing Assessment for Thoracentesis Procedure
- Pre-Procedure Assessment:
- Gather and document the patient’s medical history, focusing on respiratory conditions, bleeding disorders, and previous experiences with procedures.
- Assess vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation.
- Evaluate the patient’s understanding of the procedure, obtain informed consent, and address any concerns.
- Respiratory Status Assessment:
- Evaluate the patient’s respiratory status, including breath sounds, respiratory effort, and any signs of respiratory distress.
- Document baseline lung function and identify any pre-existing respiratory conditions.
- Laboratory and Diagnostic Tests:
- Review relevant laboratory results, such as complete blood count (CBC), coagulation studies, and imaging studies, to assess bleeding risk and guide procedural planning.
- Psychosocial Assessment:
- Assess the patient’s anxiety levels, provide emotional support, and address any psychosocial factors that may impact the patient’s experience and cooperation during the procedure.
- Pain Assessment and Management:
- Assess the patient’s pain level, location, and type of pain.
- Implement appropriate pain management strategies, such as local anesthesia, to ensure patient comfort during the procedure.
- Intra-Procedure Monitoring:
- Monitor vital signs continuously during the procedure, particularly respiratory rate and oxygen saturation.
- Assess for any signs of distress, pain, or complications and communicate with the healthcare team as needed.
- Post-Procedure Assessment:
- Assess respiratory status and monitor for any immediate complications, such as pneumothorax or bleeding.
- Evaluate vital signs, oxygen saturation, and pain levels post-procedure.
- Patient Education and Follow-Up:
- Provide thorough post-procedure education, including potential side effects and signs of complications.
- Schedule follow-up appointments for ongoing assessment and management.
Implementation for Thoracentesis Procedure
- Pre-Procedure Preparation:
- Ensure the patient is in a comfortable position and educate them about the procedure, including its purpose, potential risks, and benefits.
- Witness informed consent and address any questions or concerns the patient may have.
- Sterile Technique:
- Follow strict sterile technique during the procedure to minimize the risk of infection.
- Prepare the insertion site using an antiseptic solution and use sterile drapes and gloves.
- Monitoring and Post-Procedure Care:
- Continuously monitor vital signs, respiratory status, and the patient’s overall condition during the procedure.
- Provide post-procedure care, including monitoring for immediate complications, managing pain, and ensuring the patient’s comfort.
Nursing Interventions and Rationales
| Nursing Intervention (ADPIE) | Rationale |
| Ensure signed consent is obtained and patient is well educated on procedure | Informed consent should be obtained by the provider, including indications, risks, and possible complications of the procedure. You, the nurse, should simply ensure it is done and witness the patient’s signature. |
| Ensure emergency equipment available at bedside | As with any procedure involving the airway, emergency equipment should be kept ready at the bedside, including suction, ambu bag, and artificial/advanced airways in case of respiratory distress. |
| Position patient on side of bed with arms and chest over bedside table | This position helps to open the space between the ribs to allow for easier access to the location of the fluid or blood collection. |
| Monitor Vital Signs, LOC, Respiratory status before, during, and after procedure per facility policy. | Obtaining a baseline assessment and set of vital signs helps to know if anything has changed during or after the procedure.
Monitor VS during and after procedure per facility guidelines – being alert for possible respiratory distress. |
| Administer analgesic, anxiolytic, or cough suppressant as ordered | Patients are not sedated during this procedure, however it is imperative that they are calm and still during – this will help to prevent complications. We don’t want them squirming or coughing or they could end up with a punctured lung. |
| Ensure strict sterile technique is maintained | There is a high risk for infection, therefore it is imperative that you help keep the provider accountable to strict sterile technique. This also means that everyone in the room should have a mask and bonnet on. |
| After procedure, position patient with good lung down and provide O2 as needed | Good lung down positioning helps promote perfusion to the good lung and reinflation of the ‘bad lung’. Patients may require O2 as their lung reinflates and they recover. |
| Monitor for possible complications: Pneumothorax
Subcutaneous Air Bleeding Infection |
The needle could puncture the lung, causing a pneumothorax
If the pleural cavity is not closed properly, air can leak between the skin and the muscle – causing SubQ air Bleeding at the site or bleeding internally (hemothorax) are both possible due to the invasiveness of the procedure Strict sterile technique should be maintained – infection is possible as with any invasive procedure. |
| educate patient on signs and symptoms to report to the physician | Patients should report sudden shortness of breath, chest pain, or s/s infection like fever/chills, pain at the insertion site. |
Evaluation for Thoracentesis Procedure
- Immediate Post-Procedure Assessment:
- Evaluate the patient’s respiratory status, pain level, and overall well-being immediately after the procedure.
- Monitor for signs of complications, such as pneumothorax or bleeding, and intervene promptly if necessary.
- Pleural Fluid Analysis:
- Ensure appropriate labeling and documentation of the collected specimens.
- Patient Comfort and Satisfaction:
- Assess the patient’s comfort level and satisfaction with the procedure.
- Address any post-procedure pain or discomfort promptly and provide necessary interventions.
- Monitoring for Delayed Complications:
- Monitor the patient for delayed complications, such as infection or recurrence of pleural effusion, during the recovery period.
- Implement appropriate interventions based on the assessment findings.
- Patient Education and Follow-Up:
- Provide comprehensive post-procedure education, including instructions for monitoring signs of infection or complications at home.
- Schedule follow-up appointments for ongoing evaluation and ensure the patient understands the importance of reporting any unusual symptoms.
References
- https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/thoracentesis
- https://www.nhlbi.nih.gov/health-topics/thoracentesis
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Transcript
Hey everyone, today, we’re going to be creating a nursing care plan for thoracentesis procedure. So, let’s get started. So first we’re going to go over the pathophysiology. So, the purpose of a thoracentesis is to remove fluid or blood from the pleural spaces around the lungs. This can be due to a pleural effusion, which is a collection of pleural fluid that can be infectious or due to a hemothorax. Removing this fluid will allow for re-expansion of the lung and will help to alleviate symptoms for patients. Nursing considerations: you want to make sure you have a sign consent for the procedure, monitor vital signs, respiratory status, administer medications, ensure sterile technique is done, monitor for complications, educate the patient on signs and symptoms to report to the provider. Desired outcome: an appropriate fluid will be collected and or drained from the pleural space, allowing for full re-expansion of the lung and appropriate oxygenation.
Here is a picture of a thoracentesis being done. You’ll notice in the picture, there is the lung here on this purple going to align here. You’re going to see how it’s being compressed, and here’s all this fluid down here, and there’s that catheter that the physician will put in. All of that fluid is going to be going into this bag right here and that is how they’re going to take all that out and be able to get this long to expand.
All right, so we’re going to get to the care plan. So, we’re going to be writing down some subjective data and some objective data. So, what are we going to see with these patients that are having a thoracentesis? They could be complaining of having some chest tightness. They could be having some diminished or absent breath sounds. Depending on if it is hemothorax, or pneumothorax, or pleural effusion, other things you’re going to be seeing with these patients are evidence of fluid or blood collection on the X-ray. We also want to note complications from the procedure. Crepitus is one of the big things – a crackling rice krispies – is basically air that is surrounding the tissue. You may have bleeding at the site, fever, increased white blood cell count, some redness and swelling at the site, which can be indicative of an infection at the site.
So, interventions, what are we going to do for these patients? First thing we want to make sure is that they have a signed consent to have this procedure in their chart, and they need to make sure that the patient is very well educated on this procedure. Informed consent should be obtained by the provider, and include indications, risks, possible complications of the procedure. You, the nurse, should simply ensure that this is done and witness the patient’s signature. You also want to make sure that you have emergency equipment available at the bedside. So, with any procedure involving the airway emergency equipment should be kept ready at the bedside, including suction, O2, and an ambu bag, and any sort of artificial or advanced airway in case of respiratory distress. You also want to make sure that you’re positioning the patient on the side of the bed with the arms and chest over the bedside table, just as you saw in that picture. So, you want to make sure that they are positioned properly. It helps to open that space between the ribs to allow for easier access to the location of the fluid or the blood collection. Another intervention we’re going to be doing is we’re going to making sure we’re going to be monitoring the vital signs, level of consciousness, and their respiratory status – making sure we’re checking that before, during, and after the procedure per your facility policy. We want to make sure we’re obtaining a baseline assessment and set of vital signs, which will help to know if anything changed during or after the procedure. Another intervention we’re going to be doing is we’re going to be administering any sort of analgesic, mucolytic, or cough suppressant as ordered. So certain medications patients aren’t allowed to be sedated during this procedure; however, it’s very imperative that they’re very calm and still during this procedure and able to prevent any sort of complication. We don’t want them squirming around or coughing as that could end up with a punctured lung. We want to make sure we’re strict sterile technique is maintained because it’s a high risk for infection. So, it’s imperative that you help keep the provider accountable to strict sterile technique. Another intervention we’re going to be doing after the procedure is we want to make sure we’re positioning the patient with the good lung down and able to provide O2 as needed. It’s going to help promote perfusion to the good lung and reinflate the bad lung. Patients may be required to have O2 as that lung is reinflating as they recover. Another intervention we want to do is we want to make sure we’re monitoring for any sort of possible complication from that procedure. So, complications, well, what kind of complications are we going to be looking for? So, we’re going to be looking for a possible pneumothorax. We are also going to be looking for that crepitus, which is that air that’s escaping into surrounding tissues. That’s going to sound like that. Rice crispy, crackling sound. We’re also going to be looking for any sort of bleeding of infection. All these, you want to make sure you’re reporting back to the physician. And then lastly, we want to make sure we’re doing some education. We want to make sure the patient is aware of any signs and symptoms they want to report to the physician. They should report any sort of sudden shortness of breath, chest pain, any sort of sign symptoms of infection like fever, chills, pain at the insertion site, redness, swelling, all of these things are things that the physician needs to be aware of.
All right, and now we’re going to get to the key points. So, thoracentesis is removing fluid or blood from around the lungs in the pleural space. This can be due to a pleural effusion, sometimes infectious, sometimes due to a hemothorax. Some subjective and objective data: we have dyspnea, chest tightness, diminished or absent breath sounds over the affected area, evidence of fluid and blood collection on a chest X-ray. We want to make sure that we have a signed consent form for the procedure, we are administering any sort of meds as needed, monitoring the respiratory status, and monitoring their vital signs. We also want to make sure we’re monitoring for those complications post procedure, making sure we’re positioning the patient in a good, lung-down position, and educating on signs and symptoms to be reported to the physician. And there you have it for thoracentesis.
You guys did amazing. We love you guys. Go out, be your best self today and as always happy nursing.
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