Thoracentesis procedure for pleural fluid analysis by nursesnote

 Thoracentesis  procedure for pleural fluid analysis 

Pleural fluid analysis 

• Pleural fluid is continuously produced and reabsorbed with a thin layer normally in the pleural space. Abnormal pleural fluid accumulation (effusion ) occurs in disease of the pleura, heart, or lymphatics. The pleural fluid is studied, with other tests, to determine the underlying cause. 
• Obtained by aspiration (thoracentesis) or by tube thoracotomy ( chest tube insertion )
• The fluid examined for cancerous cells, cellular make up, chemical content, and microorganisms. 
• Pleural cavity usually contains less than 20 mL clear yellow (serous) fluid that lubricates the surface of the pleura, the thin membrane that lines the chest cavity and surrounds the lungs. A pleural effusion is an abnormal collection of this fluid. 
• The test performed to determine the cause of a pleural effusion, and to relieve associated shortness of breath. 

Nursing and patient care consideration 

• Observe and record total amount of fluid withdrawn, nature of fluid, and its color and viscosity. 
• Prepare sample of fluid and ensure transport to the laboratory. 
• A chest X-ray may be done before or after the fluid is withdrawn. 
• Patient should not cough, breath deeply, or move while fluid is being withdrawn. 

Assisting the patient undergoing Thoracentesis 

Equipment 

• Thoracentesis tray (if available ) or
• Syringe : 5-, 20-, 50-mL
• Needles : 22G, 26G, 16G
• Three-way stopcock and tubing 
• Hemostat
• Biopsy needle. 
• Germicide solution. 
• Local anesthetic ( lidocaine 1%)
• Sterile gauze pads (4×4 and 2×2)
• Sterile towels and drape
• Sterile specimen containers
• Sterile gloves

Procedure 

Preparatory phase

• Determine in advance if chest X-ray or other tests have been prescribed and completed. These should be available at the bedside. 
• Localization of pleural fluid is accomplished by physical examination, chest X-ray, ultrasound localization, or fluoroscopic localization. 
• Check if consent form has been explained and signed. 
• Invasive procedure require informed consent. 
• Inform the patient about the procedure and indicate how the patient can be helpful. Explain:
• The nature of the procedure.
• The importance of remaining immobile and of not talking or coughing.
• That no discomfort is anticipated after the procedure.
• An explanation helps orient the patient to the procedure, assists with coping, and provides an opportunity to ask questions and verbalize anxiety.
• Assist the patient to obtain comfortable position with adequate supports. If possible, place the patient upright and help the patient maintain this position during the procedure.
• The upright position ensures that the diaphragm is most dependent and facilitates the removal of fluid that usually localizes at the base of the chest. A comfortable position helps the patient to relax.
• Support and reassure the patient during the procedure.
• Sudden and unexpected movement by the patient can cause trauma to the visceral pleura with resultant trauma to the lung. A local anesthetic inhibits nerve conduction and is used to prevent pain during the procedure.

Performance phase

• Expose the site to be aspirated. If fluid is in the pleural cavity, the thoracentesis site is determined by study of the chest X-ray and physical findings, with attention to the site of maximal dullness on percussion. If air is in the pleural cavity , the thoracentesis site is usually in the second or third intercostal space in the midclavicular line.
• Fluid usually settle in the lower pleural cavity Air rises in the thorax because the density of air is much less than the density of liquid.
• Perform hand hygiene and put on personal protective equipment.
• To protect the patient and nurse.
• The procedure is done under aseptic conditions. After the skin is cleaned. the health care provider slowly injects a local anesthetic with a small-gauge needle into the intercostal space.
• An intradermal wheal is raised slowly; rapid intradermal injection causes pain. The pleura is very sensitive and should be well infiltrated with anesthetic before the thoracentesis needle is passed through it.
• Ultrasound or direct physical examination is used to guide needle placement.
• To prevent pneumothorax.
• The thoracentesis needle is advanced with the syringe attached. When the pleural space is reached, suction may be applied with the syringe.
• A 20-ml or 50-ml syringe with a three-way adapter (stop-cock) is attached to the needle. (One end of the adapter is attached to the needle and the other to the tubing leading to a receives the fluid being aspirated)
• When a larger quantity of fluid is withdrawn, a three-way adapter serves to keep air from entering the pleural cavity. The amount of fluid removed depends on clinical status of the patient and absence of complications during the procedure.
• If a considerable quantity of fluid id to removed, the needle is held in place on the chest wall with a small hemostat.
• The hemostat steadies the needle on the chest wall and prevents too deep a penetration of pleural space. Sudden pleuritic pain or shoulder pain may indicate that the visceral or diaphragmatic pleura are being irritated by the needle point.
• After the needle is withdrawn, pressure is applied over the puncture site and a small sterile dressing is fixed in place.
• This is done to prevent air entry into pleural space.

Follow-up phase

• Place the patient on bed rest. A chest X-ray is usually obtained after thoracentesis.
• Chest X-ray verifies that there is no pneumothorax.
• Record vital signs every 15 minutes for 1 hour.
• To assess for complications.
• Administer oxygen, as directed, if the patient has cardiorespiratory disease.
• Pulmonary gas exchange may worsen after thoracentesis in patients with cardiorespiratory disease.
• Record the total amount of fluid withdrawn and the nature of the fluid, its color, and viscosity. If prescribed, prepare samples of fluid for laboratory evaluation. 
• The fluid may be clear, serous, bloody, or purulent.
• Evaluate the patient at intervals for increasing respiration, faintness, vertigo, tightness in the chest, uncontrolled cough, blood-tinged mucus, and rapid pulse and signs of hypoxemia.
• Pneumothorax, tension pneumothorax, hemothorax, subcutaneous emphysema, or pyogenic infection may result from thoracentesis.