A nurse is caring for a client who is scheduled for a thoracentesis. which of the following actions

Thoracentesis is a procedure to remove fluid or air from around the lungs. A needle is put through the chest wall into the pleural space. The pleural space is the thin gap between the pleura of the lung and of the inner chest wall. The pleura is a double layer of membranes that surrounds the lungs. Inside the space is a small amount of fluid. The fluid prevents the pleura from rubbing together when you breathe. Excess fluid in the pleural space is called pleural effusion. When this happens, it’s harder to breathe because the lungs can’t inflate fully. This can cause shortness of breath and pain. These symptoms may be worse with physical activity.

Why might I need thoracentesis?

Thoracentesis may be done to find the cause of pleural effusion. It can also be done to treat symptoms of pleural effusion by removing fluid. The fluid is then examined in a lab.

Thoracentesis can help diagnose health problems such as:

• Congestive heart failure (CHF), the most common cause of pleural effusion

• Viral, fungal, or bacterial infections

• Cancer

• Systemic lupus erythematosus (SLE) and other autoimmune disease

• Inflammation of the pancreas (pancreatitis)

• A blood clot in the lung (pulmonary embolism)

• An area of pus in the pleural space (empyema)

• Liver failure

• Tuberculosis (TB)

• Pneumonia

• Reactions to medicines

Your healthcare provider may have other reasons to advise thoracentesis.

What are the risks of thoracentesis?

All procedures have some risks. The risks of this procedure may include:

• Air in the space between the lung covering (pleural space) that causes the lung to collapse (pneumothorax)

• Bleeding

• Infection

• Liver or spleen injury (rare)

Your risks may vary depending on your general health and other factors. Ask your healthcare provider which risks apply most to you. Talk about any concerns you have.

Thoracentesis should not be done in people with certain bleeding conditions.

How do I get ready for thoracentesis?

Your healthcare provider will explain the procedure to you. Ask any questions you have. You may be asked to sign a consent form that gives permission to do the procedure. Read the form carefully. Ask questions if anything is not clear.

Tell your healthcare provider if you:

• Are pregnant or think you may be pregnant

• Are sensitive to or allergic to any medicines, latex, tape, or anesthetic medicines (local and general)

• Take any medicines, including prescriptions, over-the-counter medicines, vitamins, herbs, and other supplements

• Have had a bleeding disorder

• Take blood-thinning medicine (anticoagulant), aspirin, or other medicines that affect blood clotting

Make sure to:

• Stop taking certain medicines before the procedure, if instructed by your healthcare provider

• Plan to have someone drive you home from the hospital

• Follow any other instructions your healthcare provider gives you

You may have imaging tests before the procedure. These are done to find the location of the fluid to be removed. You may have any of the below:

• Chest X-ray

• Chest fluoroscopy

• Ultrasound

• CT scan

What happens during thoracentesis?

You may have your procedure as an outpatient. This means you go home the same day. Or it may be done as part of a longer stay in the hospital. The way the procedure is done may vary. It depends on your condition and your healthcare provider's methods. In most cases, a thoracentesis will follow this process:

1. You may be asked to remove your clothes. If so, you will be given a hospital gown to wear. You may be asked to remove jewelry or other objects.

2. You may be given oxygen through a nasal tube or face mask. Your heart rate, blood pressure, and breathing will be watched during the procedure.

3. You will be in a sitting position in a hospital bed. Your arms will be resting on an over-bed table. This position helps to spread out the spaces between the ribs, where the needle is inserted. If you are not able to sit, you may lie on your side on the edge of the bed.

4. The skin where the needle will be put in will be cleaned with an antiseptic solution.

5. A numbing medicine (local anesthetic) will be injected in the area.

6. When the area is numb, the healthcare provider will put a needle between the ribs in your back. You may feel some pressure where the needle goes in. Fluid will slowly be withdrawn into the needle.

7. You will be asked to hold still, breathe out deeply, or hold your breath at certain times during the procedure.

8. If there is a large amount of fluid, tubing may be attached to the needle. This will let the fluid drain more. The fluid will drain into a bottle or bag. In some cases, a flexible tube (catheter) will be put in place of the needle and the tubing will be attached for a day or two. You will stay in the hospital until the catheter is removed.

9. When enough fluid has been removed, the needle will be taken out. A bandage or dressing will be put on the area.

10. Fluid samples may be sent to a lab.

11. You may have a chest X-ray taken right after the procedure. This is to make sure your lungs are OK.

What happens after thoracentesis?

After the procedure, your blood pressure, pulse, and breathing will be watched. The dressing over the puncture site will be checked for bleeding or other fluid. If you had an outpatient procedure, you will go home when your healthcare provider says it’s OK. Someone will need to drive you home.

At home, you can go back to your normal diet and activities if instructed by your healthcare provider. You may need to not do strenuous physical activity for a few days.

Call your healthcare provider if you have any of the below:

• Fever of 100.4°F (38°C) or higher, or as advised by your healthcare provider

• Redness or swelling of the needle site

• Blood or other fluid leaking from the needle site

• Feeling short of breath

• Trouble breathing

• Chest pain

Your healthcare provider may give you other instructions after the procedure.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure

• The reason you are having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you are to have the test or procedure

• Who will do the test or procedure and what that person’s qualifications are

• What would happen if you did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how will you get the results

• Who to call after the test or procedure if you have questions or problems

• How much will you have to pay for the test or procedure

Thoracentesis, also known as pleural fluid analysis, is a procedure in which a needle is inserted through the back of the chest wall into the pleural space (a space that exists between the two lungs and the anterior chest wall) to remove fluid or air. Pleural fluid analysis is the microscopic and chemical lab analysis of the fluid obtained during thoracentesis.

Thoracentesis may be performed for diagnostic and/or therapeutic reasons. The diagnostic use of a thoracentesis involves pleural fluid analysis to distinguish between exudate, which may result from inflammatory or malignant conditions, and transudate, which may result from failure of organ systems that affect fluid balance in the body. This analysis aids in determining the cause of the abnormality.

Procedure

1. Position patient in the sitting position with arms and head resting supported on a bedside adjustable table.
If unable to sit, the patient should lie at the edge of the bed on the affected side with the ipsilateral (same side) arm over the head and the midaxillary line accessible for the insertion of the needle. Elevating the head of the bed to 30 degrees may help.

2. The usual site for insertion of the thoracentesis needle is the posterolateral aspect of the back over the diaphragm, but under the fluid level.
Confirm site by counting the ribs based on chest x-ray and percussing out the fluid level. Mark the top of the dullness by washable ink mark or indenting the skin.

3. Select the thoracentesis site in an interspace below the point of dullness to percussion in the mid posterior line (posterior insertion) or mid axillary line (lateral insertion).

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.Attach the three way stopcock and tubing, and aspirate the amount needed. Turn the stopcock and evacuate the fluid through the tubing.

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

Before the Procedure

• Check the doctor’s order.
• Identify the client.
• Asked patient to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.
• Explain and emphasize the importance of the procedure.
• Inform that she will be experiencing mild pain on the site where the needle was pricked
• Inform the client that the procedure takes only few minutes, depending primarily on the time it takes for fluid to drain from the pleural cavity.
• Inform the client not to cough while the needle is inserted in order to avoid puncturing the lung
• Explain when and where the procedure will occur and who will be present.
• Explain the procedure to the patient and SO, reinforcing what the physician has previously explained to the patient/SO

• 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.

During 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.

After the Procedure

• 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.

Possible Nursing Diagnoses: