PROCEDURE (Perform) 27 Susan Yeager PURPOSE: Thoracentesis is performed to assist in the diagnosis and therapeutic management of patients with pleural effusions.

PREREQUISITE NURSING do not establish a diagnosis; instead the laboratory results KNOWLEDGE must be correlated with the clinical fi ndings and serum laboratory results. • Thoracentesis is performed with insertion of a needle or • Light ’ s criteria should be used to distinguish between a a catheter into the pleural space, which allows for removal pleural fl uid and . In order to apply of pleural fl uid. Light ’ s criteria, the total protein and lactate dehydroge- • Pleural effusions are defi ned as the accumulation of nase (LDH) should be measured in both and pleural fl uid in the pleural space that exceeds 10 mL and results fl uid ( Box 27-1 ). 2,3 from the overproduction of fl uid or disruption in fl uid • Exudative effusions indicate a local etiology (e.g., pulmo- reabsorption.1 nary embolus, ), whereas transudative effusions • Thoracentesis is not used to verify the presence of pleural usually are associated with systemic etiologies (e.g., heart effusion. Diagnosis of is made via clinical failure).3 examination, patient symptoms, and diagnostic tech- • Exudative pleural effusions meet one of the following niques. A number of techniques can demonstrate pleural criteria: effusion with varying levels of sensitivity. Percussion ❖ Pleural fl uid LDH/serum LDH ratio is greater than 0.6 requires a minimum of 300 to 400 mL for identifi cation international units/mL. of a pleural effusion, whereas a standard chest radiogra- ❖ Pleural fl uid LDH is more than two thirds of the upper phy requires 200 to 300 mL. Lateral decubitus radio- limit of normal for serum LDH. graphs can be used to recognize smaller fl uid amounts and ❖ Pleural fl uid protein/serum protein ratio is greater than highlight whether present fl uid is free fl owing. Ultrasound 0.5 g/dL. 3 scan, computed tomography (CT) scan, and magnetic • Relative contraindications for thoracentesis include the resonance imaging (MRI) technology can detect 100 mL following: 1 of fl uid with 100% sensitivity. Therefore, initial diagnosis ❖ Patient anatomy that hinders the practitioner from of pleural effusion may be optimized via imaging tech- clearly identifying the appropriate landmarks niques such as chest radiographs, ultrasound scans, CT ❖ Patients actively undergoing anticoagulation therapy or scans, or MRI combined with patient symptoms and clini- with an uncorrectable coagulation disorder cal examination fi ndings. ❖ Patients receiving positive end-expiratory pressure • Diagnostic thoracentesis is indicated for differential diag- therapy nosis for patients with pleural effusion of unknown etiol- ❖ Patients with splenomegaly, elevated left hemidia- ogy. A diagnostic thoracentesis may be repeated if initial phragm, or left-sided pleural effusion results fail to yield a diagnosis. ❖ Patients with only one as a result of a previous • Therapeutic thoracentesis is indicated to relieve the symp- toms (e.g., dyspnea, cough, hypoxemia, or chest pain) ❖ Patients with known lung disease caused by a pleural effusion. ❖ Patients with active skin infection at the point of needle • Pleural effusions are classifi ed as either transudative or insertion 4 exudative effusions. • Ultrasound scan–guided thoracentesis is thought to reduce • Samples of pleural fl uid are analyzed and assist in distin- complications. guishing between exudative and transudative etiologies of • Complications commonly associated with thoracentesis effusion. Results of laboratory tests on pleural fl uid alone include , , hemorrhage, hypotension, cough, pain, visceral injury, and reexpansion .4–6 • The most common complications from pleural aspiration are pneumothorax, pain, hemorrhage, and procedure This procedure should be performed only by physicians, advanced 5 practice nurses, and other healthcare professionals (including critical care failure. The most serious complication is visceral injury. nurses) with additional knowledge, skills, and demonstrated competence per • Hypotension can occur as part of the vasovagal reaction, professional licensure or institutional standard. causing bradycardia, during or hours after the procedure.

211 212 Unit I Pulmonary System

BOX 27-1 Light ’ s Criteria for Exudative • Three-way stopcock • Sterile 20-mL syringe Pleural Effusions (Applies If • Sterile 50-mL syringe One or More Criteria Are Met) • Two chemistry blood tubes EXUDATIVE CRITERIA • Hemostat or Kelly clamp Ratio of pleural fl uid protein to serum protein is > 0.5 • equipment Ratio of pleural fl uid lactate dehydrogenase (LDH) to serum LDH • Side table is > 0.6 • Pillow or blanket to be placed on side table 2 Pleural fl uid LDH level is > 3 of the upper limit of normal for • 14-gauge needle serum LDH • 16-gauge catheter • Vacutainers or evacuated bottles (1 to 2 L) with pressure Modifi ed from Porcel J, Light R: Diagnostic approach to pleural effusion in tubing adults, Am Fam Physician 73(7):1211–1220, 2006. Additional equipment, to have available as needed, includes the following: • Atropine, oxygen, supplies, advanced cardiac life-support equipment If it occurs during the procedure, cessation of the proce- • Ultrasound-scan equipment as available and with a cre- dure and intravenous (IV) atropine may be necessary. If dentialed provider hypotension occurs after the procedure, it is likely the • Two complete blood count tubes result of fl uid shifting from pleural effusion reaccumula- • One anaerobic and one aerobic media bottle for culture tion. In this situation, the patient is likely to respond to and sensitivity fl uid .7 • Sterile tubes for fungal and cultures specimen • Development of cough generally initiates toward the tubes end of the procedure and should result in procedure • Commercially prepackaged thoracentesis kits, which are cessation. available in some institutions • Reexpansion pulmonary edema is thought to occur from overdraining of fl uid too quickly. The incidence is less PATIENT AND FAMILY EDUCATION than 1% but asymptomatic radiologically apparent reper- fusion pulmonary edema may be slightly more frequent.5 • Assess patient ’ s and family ’ s level of understanding about The maximum volume of fl uid that can be safely removed the condition and rationale for the procedure. Rationale: is uncertain because the volume removed does not clearly This assessment identifi es the patient ’ s and family ’ s correlate with the onset of symptoms. Traditionally, to knowledge defi cits concerning the patient’ s condition, the avoid this complication, discontinuation of fl uid removal procedure, the expected benefi ts, and the potential risks. occurs with the onset of symptoms or when the total fl uid It also allows time for questions to clarify information and removed reaches 1000 to 1500 mL.5,6 voice concerns. Explanations decrease patient anxiety and • If using continuous positive airway pressure, caution enhance cooperation. should be taken to avoid potential pneumothorax follow- • Explain the procedure and the reason for the procedure, if ing aspiration if there is no pleural drain in place. 5 Patients the clinical situation permits. If not, explain the procedure receiving positive airway pressure can undergo thoracen- and reason for the intubation after it is completed. Ratio- tesis with an ultrasound-guided incidence of less than 7% nale: This explanation enhances patient and family under- pneumothorax noted. 4,8 standing and decreases anxiety. • Baseline diagnostic study results (i.e., lateral decubitus • Explain the patient ’ s role in thoracentesis. Rationale: , ultrasound imaging, CT scan, or MRI) This explanation increases patient compliance, facilitates should be reviewed before the procedure to identify the needle and catheter insertion, and enhances fl uid removal. location and extent of pleural fl uid accumulation. EQUIPMENT PATIENT ASSESSMENT AND PREPARATION • Indelible marker • Sterile gloves Patient Assessment • Sterile drapes • Assess medical history of symptoms, occupational expo- • Sterile towels sure, pleuritic chest pain, disease, heart • Adhesive bandage or adhesive strip failure, and medication usage. Rationale: Medical history • Antiseptic solution may provide valuable clues to the cause of a patient’ s • Sterile 4 × 4 gauze pads pleural effusion or presence of hypercoagulable states • Intervention medications (opioid, sedative, or hypnotic as a result of medications. Knowledge of medication agents, local anesthetic 1% or 2% lidocaine) usage can indicate the need for anticoagulation reversal. 5 • One small needle (25-gauge, 8 -inch long) In addition, an increasing number of medications are • 5-mL syringe for local anesthetic noted to contribute to exudative effusions. See http:// 1 9 • Three large needles (20- to 22-gauge, 1 2 to 2 inches long) www.pneumotox.com . 27 Thoracentesis (Perform) 213

• Assess for signs and symptoms of pleural effusion. or if initial tube drainage is unsuccessful and is to Rationale: Physical fi ndings may suggest a pleural be considered.2 effusion. • Assess baseline vital signs, including pulse oximetry. ❖ deviated away from the affected side Rationale: Baseline assessment data provide information ❖ Affected side dull to fl at with percussion about patient status and allow for comparison during and ❖ Absent or decreased breath sounds after the procedure. ❖ Tactile fremitus • Assess recent serum laboratory results, including the fol- ❖ Pleuritic chest pain lowing. Rationale: These studies help determine whether ❖ Hypoxemia the patient is at risk for bleeding. Although thoracentesis is ❖ Tachypnea considered to have a low risk of bleeding, an international ❖ Dyspnea normalized ratio of 1.5 or less is acceptable for invasive 5,11 ❖ Cough, weight loss, night sweats, anorexia, and malaise procedures. Platelet transfusion is recommended for may also occur with pleural infection or malignancy counts less than 50,000. No consensus/recommendations disease exist for partial thromboplastin time and hematocrit thresh- • Assess chest radiograph or other imaging fi ndings. olds. There is no evidence to support the use of bleeding Posterior-anterior chest radiographs should be performed times before minimally invasive procedures.11 2 in the assessment of all suspected pleural effusions. ❖ Hematocrit Rationale: If at least half the hemidiaphragm is obliter- ❖ Platelet count ated on erect anterior-posterior radiograph results, suffi - ❖ Prothrombin time/international normalized ratio cient fl uid is in the pleural space for a thoracentesis. ❖ Partial thromboplastin time Greater than 200 mL of fl uid is considered abnormal in • Assess timing of day that the procedure is to occur. Unless erect chest radiograph results. it is a patient emergency, pleural procedures should not • If a small amount of loculated fl uid is noted, a lateral take place out of hours. 5 Rationale: Avoiding out-of-hour decubitus radiograph should be obtained. Rationale: procedures when possible increases the likelihood of Lateral decubitus radiographs assist with distinguishing having additional staff and resources available to support between free-moving fl uid and pleural thickening. Lateral potential untoward sequelae. radiographs show blunting of the costophrenic angle with 50 mL. If the pleural effusion is measured to be greater Patient Preparation than 10 mm deep on a lateral decubitus radiograph, a • Verify that the patient is the correct patient using two diagnostic thoracentesis can be performed.10 identifi ers. Rationale: Before performing a procedure, the • Anterior-posterior chest radiographs completed in the nurse should ensure the correct identifi cation of the patient intensive-care setting are typically completed in the supine for the intended intervention. position and are less sensitive in the identifi cation of • Ensure that the patient understands preprocedural teach- pleural effusions. In this setting, hazy opacifi cation of one ings. Answer questions as they arise and reinforce lung fi eld or minor fi ssure thickening may be the only information. Rationale: This communication evaluates clues to the presence of a pleural effusion.10 Rationale: In and reinforces understanding of previously taught the supine position, pleural effusions tend to spread out information. across the posterior thoracic surface and are less evident • Obtain written informed consent for the procedure. Ratio- on supine radiographs. nale: Invasive procedures, unless performed with implied • Thoracic ultrasound guidance is strongly recommended consent in a life-threatening situation, require written for all pleural procedures for pleural fl uid acquisition.5 consent of the patient or signifi cant other. Marking of the site using thoracic ultrasound for subse- • Consider medications for pain, sedation, or chemical quent remote aspiration is not recommended except for paralysis, as indicated by the patient’ s condition. Ratio- large pleural effusions.5 Rationale: Ultrasound-guided nale: Pain and sedation medications or chemical paralysis pleural aspiration has been shown to increase the yield may be necessary to maximize positioning. If utilizing and reduce the risks of complications, particularly pneu- sedation or paralysis, ensure that airway adjuncts or defi n- mothoraces and inadvertent organ puncture. Ultrasound itive airways are secured before induction. detects pleural fl uid septations with greater sensitivity • Have atropine available. Rationale: Bradycardia, from a than computed tomography.2 However, it should be vasovagal refl ex, can occur during thoracentesis. noted that ultrasound may not impact the incidence of • Initiate pulse oximetry monitoring. Rationale: Pulse intercostal vessel laceration as vessels are not visualized oximetry provides a noninvasive means for monitoring on ultrasound.5 oxygenation and heart rate at the bedside, which allows • CT scans with contrast should be performed for pleural for prompt recognition and intervention should problems enhancement before complete drainage of the fl uid. Ratio- develop. nale: CT scans are useful in distinguishing malignant • Ensure patent intravenous access. Rationale: Provides IV from benign pleural thickening. CT scan results may also access for both procedural and emergency medications, as be helpful when complicated pleural infection is present necessary 214 Unit I Pulmonary System

Procedure for Diagnostic and Therapeutic Thoracentesis Steps Rationale Special Considerations Diagnostic Thoracentesis 1 . HH 2 . PE 3. Assemble equipment and review Ensures proper equipment is Ultrasound guidance reduces of available imaging. readily available throughout complications associated with procedure and in emergency pleural procedures in the critical situations. Review of imaging care setting and its routine use is ensures the proper side has been recommended.5 (Level C*) selected and provides anatomical guidance to the practitioner.6 4. Position patient for procedure with Positioning enhances ease of assistant standing in front of withdrawal of pleural fl uid. patient. Assuring patient is comfortable If the patient is alert and able, increases the chance that the position the patient on the edge of procedure will be successfully the bed with feet supported on a completed. Having the assistant stool and arms resting on a pillow in front of the patient ensures on an elevated bedside table ( Fig. visualization of facial cues and 27-1 A ). The patient may sit on a enables the cessation of chair backward and rest arms on a inadvertent patient movements pillow on the back of the chair. If that might interfere with the the patient is unable to sit, position procedure. the patient in the lateral recumbent position on the unaffected side, with the back near the edge of the bed and the arm on the affected side above the head. Elevate the head of the bed to 30 or 45 degrees, as tolerated.

Figure 27-1 Thoracentesis. A, Ideal patient position for thoracentesis.

A

*Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. 27 Thoracentesis (Perform) 215

Procedure for Diagnostic and Therapeutic Thoracentesis—Continued Steps Rationale Special Considerations 5. If not utilizing ultrasound, the Identifi es the superior border of the Use the posterior axillary line as the following physical examination pleural effusion and identifi es insertion point to avoid the spinal utilizing landmarks should be and validates the planned site for cord. completed. Percuss the affected thoracentesis. Palpation midway If the space identifi ed for insertion is side posteriorly to determine the between the spine and posterior below the eighth intercostal space highest point of the pleural axillary line is a location where (area is approximated at the effusion. Effusion is generally the ribs can generally be posterior edge of scapula), noted using the following: one to palpated. Accessing above the ultrasound scan should be done to two interspaces below the level at ninth rib minimizes potential mark the fl uid level and its which breath sounds disappear on injury to solid organs. Accessing relationship to the diaphragm, auscultation or become decreased, 9–10 cm lateral to the spine which helps identify a safe point of percussion becomes dull, or below the eighth rib was noted entry to avoid solid-organ damage. fremitus disappears. Identify the to be associated with decreased When able, ultrasound guidance intercostal space below this point canulation of tortuous vessels should be utilized to identify but above the ninth rib. Once the and has been deemed the “safe effusion location.2,5 (Level D*) level is noted, a mark should be zone.” 2,4,5 made 9–10 cm lateral to the spine moving toward the posterior axillary line. 6. Apply sterile personal protective Reduces the transmission of equipment, while an assistant microorganisms and body opens the necessary equipment secretions during an invasive onto a sterile fi eld or opens the procedure. appropriate sterile tray with the equipment. 7. Have an assistant provide Premedication with opioid, preprocedural medications. antianxiolytic, sedative, or hypnotic assures patient comfort throughout procedure. 8. Perform a preprocedure Ensures patient safety. verifi cation and time out, if nonemergent. 9. Sterilize a wide area surrounding Although the pleural space is the insertion site using 0.05% effi cient in clearing bacteria, chlorhexidine or 10% povidone- aseptic technique minimizes skin iodine solution. Use concentric contaminants, which reduces the circles from insertion site mark risk of infection.4 outward, and drape area with sterile drape. 10. Anesthetize the skin with 1%–2% Increases comfort for patient by 5 lidocaine (25-gauge, 8 -inch anesthetizing the skin. needle) in the typical wheal fashion around the insertion site.

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

Procedure continues on following page 216 Unit I Pulmonary System

Procedure for Diagnostic and Therapeutic Thoracentesis—Continued Steps Rationale Special Considerations 11. With lidocaine, insert a 20–22- Anesthetizes the work area for Always aspirate before injecting to 1 gauge, 1 2 –2-inch needle through optimal patient comfort. prevent lidocaine from entering a the wheal. Advance the needle Insertion above the rib minimizes blood vessel or the pleural space. toward the rib, injecting the manipulation or laceration of the A longer needle may be needed in lidocaine into the deep tissue. vascular bundle located beneath extremely obese patients. “Walk” the needle over the the rib and the intercostal arteries superior edge of the rib and ( Fig. 27-1 B ). 4,6 (Level C*) periosteum of the underlying rib superiorly and laterally. The exact puncture site should be immediately above the superior aspect of a rib and, when possible, 8–10 cm lateral from the spine. 6

Figure 27-1, cont’d B, Ideal placement of needle insertion.

B

12. After anesthetizing the periosteum In addition to anesthetizing the of the underlying rib, gently parietal pleura, utilizing this advance the needle and alternately technique the pleural space is aspirate and inject lidocaine until identifi ed by pleural fl uid pleural fl uid is obtained in the aspirate in the syringe. 4,12 If air syringe. bubbles are noted, the lung tissue may have been violated or air may have been introduced by the thoracentesis system. Withdraw syringe to tissue and redirect. Withdrawal of needle minimizes manipulation of lung tissue. 13. When pleural fl uid is obtained, Approximates the length of place a sterile gloved fi nger on the insertion for the thoracentesis needle at the point where the needle or catheter. needle exits the skin. Withdraw the needle and syringe. For therapeutic thoracentesis, proceed to step 21 . 14. Attach a three-way stopcock and The open stopcock valve allows for Longer needles may be necessary in 50-mL syringe to a 20–22-gauge, aspiration of pleural fl uid during the obese patient. 1 1 2 - or 2-inch needle. Open the needle insertion and minimizes stopcock valve between the atmospheric air introduction. syringe and the needle.

*Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. 27 Thoracentesis (Perform) 217

Procedure for Diagnostic and Therapeutic Thoracentesis—Continued Steps Rationale Special Considerations 15. Insert the selected needle via the Inserting the needle superior to the It is possible that no fl uid is accessed anesthetized tract, superior to the rib avoids disruption of the (dry tap). If a dry tap occurs, the rib, and continually aspirate until vascular and systems ( Fig. needle may be withdrawn and pleural fl uid is obtained, fi lling the 27-1B ). The pleural fl uid is used reinserted in a slightly different 50-mL syringe. Fluid should be for laboratory testing for the angle if the patient tolerated the separated into three sterile differential diagnosis. A sample initial “dry tap.” A second tap containers for microbiology, of 35–50 mL is needed for a warrants reevaluation with an biochemistry, and cytology diagnostic analysis of fl uid. A ultrasound if not initially analysis. change in patient position can be employed. 4 A larger gauge needle attempted to facilitate fl uid may be needed for thick or drainage. loculated fl uid, or the needle may have been inserted above or below the pleural fl uid. When pleural fl uid is aspirated, the needle may be stabilized with placing a hemostat or clamp on the needle at the skin site to keep the needle from advancing farther into the pleural space, preventing lung puncture. Note the appearance of the aspirated fl uid because this may provide clues to the underlying etiology of effusion. Straw-colored fl uid is common and typical of . Blood- stained fl uid is suggestive of , malignancy disease, pulmonary infarction, trauma, or postcoronary artery bypass surgery. Fluid turbidity suggests empyema or , and food particles indicates . 16. Fill the specimen tubes from the Analysis may aid in determining an To interpret pleural fl uid laboratory pleural fl uid–fi lled syringe by etiology of the pleural effusion. values utilizing Light ’ s criteria, turning the stopcock “off” to the serum and pleural fl uid chemistry patient and allowing the tubes to laboratory values must be obtained fi ll passively by vacuum or by (e.g., total protein and LDH). depressing the syringe plunger Initial laboratory testing may also ( Fig. 27-1 C ). Send the specimen include cytology, gram stain, tubes to the laboratory for culture, amylase, and .4 appropriate analysis.

Figure 27-1, cont’d C, Attach catheter to three-way stopcock syringe and vacu- tainer. Barton ED: Thoracentesis. In Rosen P, Chan TC, Vilke M, Sternbach G, editors: Atlas of emergency procedures, St. Louis, Mosby, 2001. pp. 36–37.

C Procedure continues on following page 218 Unit I Pulmonary System

Procedure for Diagnostic and Therapeutic Thoracentesis—Continued Steps Rationale Special Considerations 17. Evaluate patient response Monitoring patient heart rate, pulse throughout procedure. oximetry, and clinical response throughout the procedure enables prompt intervention or cessation of procedure should complications arise. 18. On completion of diagnostic If the patient is nonventilated and If air is aspirated during the thoracentesis, withdraw the needle. asymptomatic, only 1% of procedure, multiple needle passes Apply pressure to the puncture site patients were noted to have a are required, or the patient for a few minutes, then apply an pneumothorax on a develops signs of a pneumothorax, adhesive strip or adhesive bandage postthoracentesis chest imaging should be ordered. over the puncture site. Without radiograph. 4 Postthoracentesis chest radiograph concrete clinical indications, (i.e., in mechanically ventilated patients withdraw of air, multiple needle remains controversial.4 passes, or clinical changes), a chest radiograph is not necessary after a routine thoracentesis.2,4,6 (Level C*) 19. Discard used supplies and remove PE . 20. HH Therapeutic Thoracentesis 21. Insert a 14-gauge needle attached The 14-gauge needle is selected to a 20-mL syringe, bevel down, because it allows for insertion into the anesthetized tract until and passage of a 16-gauge pleural fl uid is returned. catheter; a smaller-sized catheter may be unstable and fold or kink on itself. 22. When pleural fl uid is obtained, Occluding the needle helps prevent remove the syringe from the the possible occurrence of a needle, occluding the needle with pneumothorax. an index fi nger. 23. Insert the 16-gauge catheter Advancing the catheter toward the In therapeutic thoracentesis, a through the 14-gauge needle. costodiaphragm allows for catheter is preferred over a needle Advance the catheter slowly optimal drainage of pleural fl uid. because the lung is expected to through the needle, angling the reexpand. catheter in a downward fashion A needle could puncture the lung toward the costodiaphragm until during reexpansion and cause a the catheter moves freely in the pneumothorax. pleural space. 24. While advancing the catheter Never pull the catheter back beyond the needle tip, remove the through the needle because the needle and leave the catheter in catheter may be cut or sheared the pleural space. Attach a by the needle tip. three-way stopcock with a 50-mL syringe to the end of the catheter.

*Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. 27 Thoracentesis (Perform) 219

Procedure for Diagnostic and Therapeutic Thoracentesis—Continued Steps Rationale Special Considerations 25. Fill the 50-mL syringe with When changing syringes, be certain To interpret pleural fl uid chemistry pleural fl uid. Fill the specimen the stopcock is positioned such laboratory values, serum chemistry tubes from the pleural fl uid–fi lled that air does not enter the pleural laboratory values also must be syringe by turning the stopcock space. Analysis may aid in obtained (see Diagnostic “Off” to the patient and allowing determining an etiology of the Thoracentesis section). Local the tubes to fi ll passively by pleural effusion. anesthetics (i.e., lidocaine) are vacuum or by depressing the acidic; therefore, care should be syringe plunger (Fig. 27-1 C ). Send taken during pleural to the specimen tubes to the avoid contamination of sample.4 laboratory for appropriate analysis. 26. Attach the vacutainer or evacuated The vacutainer or evacuated bottles The maximum volume of fl uid that bottles with tubing to the three- use negative pressure to can be safely reviewed is uncertain way stopcock. Open the valve to withdraw pleural fl uid from the because the volume removed does the vacutainer and fi ll the pleural space, providing not clearly correlate with the onset vacutainer. therapeutic relief. Reposition of symptoms. Traditionally, to catheter or patient, or both, if avoid this complication, drainage stops to determine discontinuation of fl uid removal whether fl uid is still present. occurs with the onset of symptoms or when the total fl uid removed reaches 1000–1500 mL.5,6 ( Level E * ) The patient may feel the need to cough as the lung reexpands. 27. On completion of thoracentesis, If the patient is nonventilated and If air is aspirated during the remove the catheter. Apply asymptomatic, only 1% of procedure, multiple needle passes pressure to the puncture site for a patients were noted to have a are required, or if the patient few minutes, then apply an pneumothorax on a develops signs of a pneumothorax, adhesive strip or adhesive bandage postthoracentesis chest imaging should be ordered. over the puncture site. (Level C * ) radiograph. 4 Postthoracentesis chest radiograph in mechanically ventilated patients remains controversial.4 28. Reposition the patient to optimize Patient may desire to lie down after comfort. procedure. Head of bed placement may vary if dyspnea, hypotension, or other symptoms re-present during procedure. 29. Dispose of equipment and remove PE . 30. HH

* Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. * Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

Expected Outcomes Unexpected Outcomes • Patient is comfortable and has decreased respiratory • Pneumothorax distress • Vasovagal response • Lung reexpansion occurs • Dyspnea • Site remains infection free • Hypovolemia • Procedure aids in diagnosis of etiology of pleural • Hematoma effusion • Hemothorax • Liver or splenic laceration • Reexpansion pulmonary edema Procedure continues on following page 220 Unit I Pulmonary System

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Monitor vital signs and Any change in vital signs may alert • Tachypnea cardiopulmonary status before the practitioner of possible • Decreased or absent breath sounds and after thoracentesis and as unexpected outcomes. Use of on the affected side needed. supplemental oxygen may be • , dyspnea necessary. • Asymmetrical chest excursion with respirations • Decreased oxygen saturation • • Sudden sharp chest pain • Anxiety, restlessness, apprehension • Tachycardia • Hypotension • Dysrhythmias • to the unaffected side • Neck vein distention • Muffl ed heart sounds 2. If indicated, obtain a A chest radiograph is used to evaluate • Pneumothorax postthoracentesis expiratory for lung reexpansion and evidence • Expanding pleural effusion chest radiograph.10 (Level D * ) of a possible pneumothorax or • Catheter migration hemothorax. If a pneumothorax or hemothorax is present, a may be necessary. Without concrete clinical indications, chest radiograph is not necessary after a routine thoracentesis 3. Follow institution standard for Identifi es need for pain interventions. • Continued pain despite pain assessing pain. Administer interventions analgesia as prescribed.

* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

Documentation Documentation should include the following: • Patient and family teaching • Total amount of pleural fl uid aspirated • Consent for procedure • Site assessment • Adherence to Universal Protocol • Intact catheter on withdrawal • Patient positioning and monitoring devices • Occurrence of unexpected outcomes • Medication administration and patient response • Postthoracentesis radiograph acquisition and results, • Patient tolerance, including procedural pain and as needed/available instillation and response to pain medications • Laboratory test ordered and results as available • Insertion of catheter or needle • Interpretation of laboratory results • Catheter or needle size used • Nursing interventions • Any diffi culties in insertion • Pain assessment, interventions, and effectiveness • Pleural fl uid aspirate characteristics 27 Thoracentesis (Perform) 221

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .