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Patient teaching
Indications
Potential diagnoses
o Transudates (heart failure, cirrhosis, nephritic syndrome)
o Exudates (inflammatory, infectious, neoplastic conditions)
o Empyema
o Pneumonia
o Blunt, crushin, or penetrating chest injuries/trauma, or
invasive thoracic procedures, such as lung and/or cardiac
surgery
Client presentation
o Large amount of fluid in the pleural space compress lung
tissue and can cause pain, shortness of breath, cough, and
other pleural symptoms of pleural pressure
o Assessment of effusion area may reveal decreased breath
sounds, dull percussion sounds, and decrease chest wall
expansion. Pain may occur due to inflammatory process
Interpretation of findings
Aspirated fluid is analyzed for general appearance, cell counts,
protein and glucose content, the presence of enzymes such as
lactate dehydrogenase (LDH) and amylase, abnormal cells, and
culture.
Preprocedure
Percussion, auscultation, radiography, or sonography is used to
locate the effusion and needle insertion site
Changes in fat deposit in many older client may make it difficult
for the provider to identify the landmarks for insertion of the
thoracentesis needle.
Nursing Actions
o Ensure the client has signed the informed consent form
o Gather all needed supplies
o Obtain preprocedure x-ray as prescribed to locate pleural
effusion and to determine needle insertion site
o Position the client sitting upright with his arms and
shoulders raised and supported on pillows and/or on an
overbed table and with his feet and legs well-supported
o Instruct the client to remain absolute still (risk of accidental
needle damage) during the procedure and not to cough or
talk unless instructed by the primary care provider
Intraprocedure
Nursing Actions
o Assist the provider with the procedure (strict surgical
aseptic technique)
o Prepare the client for a feeling of pressure with needle
insertion and fluid removal
o Monitor the clients vital signs, skin color, and oxygen
saturation throughout the procedure.
o Measure and record the amount of fluid removed from the
clients chest.
o Label specimens at the bedside, and promptly send them
to the laboratory
Note: the amount of fluid removed is limited to 1L at a time to
prevent cardiovascular collapse.
Postprocedure
Nursing Actions
o Apply a dressing over the puncture site, and assess
dressing for bleeding or drainage
o Monitor the clients vital signs and respiratory status
(respiratory rate and rhythm, breath sounds, oxygenation
status) hourly for the first several hours after the
thoracentesis.
o Auscultate the lungs for reduced breath sounds on side on
side of thoracentesis.
o Encourage the client to deep breathe to assist the lung
expansion
o Obtain a postprocedure chest-xray (check resolution of
effusions, rule out pneumothorax).
Complications
Mediastinal shift shift of thoracic structures to one side of the
body
o Monitor clients vital signs.
o Auscultate clients lungs for decrease in or absence of
breath sounds
Pneumothorax a collapsed of lung. It can occur due to injury to
the lung during the procedure.
o It can develop during the first 24 hr following a
thoracentesis
o Sign & symptom: diminished breath sounds
o Other indications: deviated trachea, pain on the affected
side that worsens upon exhalation, affected side does not
move in and out upon inhalation and exhalation, increased
heart rate, rapid shallow respirations, nagging cough, or
feeling of air hunger
o Monitor postprocedure chest-xray results.
Call
the physician:
o for any complications of thoracentesis noted as stated above
o nagging cough, elevated fever, fatigue, confusion
o Chest pain that does not relieved by SL medications
o Develop rash or has a decreased sense of taste or swelling of the face
if taking ACE inhibitors
o Report any signs of digoxin toxicity: fatigue, muscle weakness,
confusion and loss of appetite
Reminders:
o Take medications as prescribed.
a. Digoxin
- Take digoxin dose at the same time each day.
- Count pulse for 1 minute before taking digoxin. Hold if pulse
<60bpm & notify physician.
- Do not take digoxin at the same time as antacids. Separate the two
medications by at least 2 hr
- Regularly have digoxin and potassium levels checked.
b. Lasix diuretics
- Take diuretics in the early morning and early afternoon.
- Maintain fluid and sodium restriction a dietary consult can be
useful.
- Check weight daily at the same time, and notify the provider for a
weight gain of 2 lb in 24 hr or 5 lb in 1 week.
c. Nitroglycerine - vasodilator
- Regularly checked blood pressure.
- Vasodilators can cause orthostatic hypotension.
- Headache is common side effect of vasodilators. Sit & lie down
slowly.
References
Doenges, M., Moorhouse, M.F., & Murr, A. (2010). Nursing care plans: Guidelines for
individualizing client care across the life span. Philadelphia, PA: F.A. Davis Company.
Gulanick, M., & Myers, J.L. (2011). Nursing care plans: Nursing diagnoses, interventions and
outcomes, (7th ed.). St Louis: Mosby.