V -THORACENTESIS

Thoracentesis

Definition: Puncturing the chest wall to remove excess fluid or air from the
pleural cavity.

Purpose: It is done for diagnostic purposes or to relieve breathing difficulties in

clients with:

1. TB
2. Cancer
3. Pleural effusion
4. Pulmonary edema
5. Chest injuries
6. Also performed to introduce chemotherapeutic drug intrapleu ral cavity
 Preparatory
Phase
Assemble
equipments
needed: use
aseptic
technique

1. Disinfectant according to hospital protocol (i.i. Betadine,

alcohol)
2. Sterile gauze, sterile cotton balls
1. Sterile kidney basin
2. Clean receptacle where to put gauze / cotton balls after use
3. Trocar large needle attached to a syringe or stop cork
4. Sterile container to collect specimen/s to send to laboratory

Actual Procedure:

1.Explaine procedure to patient and so will be done by physician who will do

the procedure.
1. Secure written consent.
2. The nurse assists the client to assume a position that allows easy access to
intercostals space. Two position commonly used.
a. Setting position with arms above the head, which spreads the ribs
and enlarges the intercostals space.
b. Setting on one side with arm held to the front and up
3.-Trocar is inserted
-A syringe is attach to the stopcock for aspiration
 -Dr will do percussion to chest and select exact site for insertion
- Fluid at the lower posterior chest
-Air at the lower anterior chest
-X-ray pior to procedure-for besat insertion site
3. The physician will insert the trocar/needle into the pleural cavity/ space.
The obturator will be removed and the fluid is withdrawn. If with syringe
the physician will aspirate the fluid to flow freely.
4. Collect specimen to be sent to laboratory and label. Fluid considered
infected caution should be observed.
5. If large container is used to receive fluid, the tubing is attached from stop
cork to the adaptor on the receiving bottle.
6. Assist patient throughout the procedure.
7. Record time started the procedure; time ended and physician who
performed.
8. Measure collected fluid and document amount, color of fluid collected.
9. Send specimen to lab.
10. Observe proper disposal technique according to hospital protocol.

Interpreting Results of Thoracentesis.

EXAMINING PLEURAL FLUID

Characteristic Possible Cause

Light, straw colored  Normal
Purulent  Empyema

Blood Tinged  Hemothorax

 Tuberculosis
 Pulmonary Infarction
 Neoplastic Disease
 Accidental tissue damage from
thoracentesis
Milky  Chylothorax
 Invasion of thoracic duct by a
tumor, or an inflammatory
process
 Traumatic rupture of thoracic
duct
 Cellular debris or cholesterol
crystals
 Low protein fluid  Cirrhosis
 Congestive Heart failure

Protein rich fluid  Infectious Disease

 Asbestosis
 Pulmonary Infarction
 Lymphatic drainage disorder

NURSING TIP
On the patient’s chart, document the color and amount of pleural
fluid obtained, and indicate which studies the doctor ordered, also note how
well the patient tolerated the procedure.

Significance of Pleural Fluid Analysis

Gram stain Culture and Sensitivity

Interpretation
Positive results may mean the early stages of bacterial infection. In
the later stages of bacterial infection, the fluid may look grossly purulent with a
positive gram stain, yet cultures may be negative from antibiotic therapy.

Acid Fast Stain and Culture

Interpretation:
Positive results may indicate tuberculosis

Red Blood Cell Count

Interpretation:
If count is about 10.000/mm3 and the specimen’s pink or light red,
may indicate tissue damage. If count is above 100,000/mm3 and the specimen’s
grossly bloody suggest intrapleural malignancy, pulmonary infarction,
tuberculosis, or closed chest trauma. If a hemothorax is present, the hematocrit
of the pleural fluid will be similar to that of capillary blood.

Leukocyte Count
Interpretation:
If count is above 1,000/mm3 or 50% neutrophils, may indicate
septic or non septic inflammation

Lymphocyte Count
Interpretation:
If count is over 50%, may indicate tuberculosis, lymphoma or
other form of cancer

Blood Clots
Interpretation:
May indicate neoplasm, tuberculosis or infection

Specific Gravity
Interpretation:
If measured exceeds 1.016, may indicate neoplasm , tuberculosis,
or infection, if less than 1.104 may indicate congestive heart failure

Total Protein
Interpretation:
Levels below 3g/dl suggest neoplasm, tuberculosis or infection

Lactic Dehydrogenase
Interpretation:
Levels rise in cancer and other conditions associated with
exudates; decrease heart failure and other conditions associated with transudates.

Glucose
Interpretation:
If less than serum glucose level, may suggest cancer, bacterial
infection, or nonseptic inflammation

Sediment
Interpretation:
May represent cancerous cells, cellular debris, or cholesterol
crystals.

Special Considerations

To prevent hypovolemic shock, fluid is removed slowly and no

more than 1,200 ml of fluid is removed at one time.
Pleuritic or shoulder pain may indicate pleural irritation by the
needle point.
A chest X-ray is usually ordered after the procedure to detect
pneumothorax and evaluate the results of the procedure
V. BIOPSY – tracheobronchial tissues are taken for cytologic assessment.

Pleural biopsy – small thracotomy incision using a COPE needle.

Lung biopsy – maybe done by surgical exposure- open lung biopsy.

COMPLICATIONS:
(1) Fever, pain from intercostals nerve injury (rare)
(2) Pneumothorax
S/S: dyspnea, pallor or cyanosis, diaphoresis, excessive pain.
(3) Hemothorax

III. SPUTUM EXAMS

When to collect:
(1) Before starting an antibiotic (unless it is to evaluate effectiveness of drug
therapy).
(2) Early morning (AFB and cytology)
(3) Before meals
(4) Before a routine oral hygiene procedures as brushing with toothpaste or
gargle with antiseptic solution
COLLECTING A SPUTUM CULTURE

Use these guidelines to help you collect a sputum specimen that can be
accurately analyzed by the laboratory:

(a) Collect the specimen first thing in the morning, if possible. Have the patient
brush his teeth and rinse his mouth before coughing into sputum cup.
(b) Make sure the patient coughs deeply enough. If you’re using a suction
catheter, make sure it extends all the way to the bronchus.
(c) Collect at least 5cc.
(d) If the patient has a contagious disease, collect the sputum specimen in a
nonporous container and label it “contaminated”.
(e) Take the specimen to the lab immediately.

ANALYZING A SPUTUM SPECIMEN

Four types of tests may be performed on a sputum specimen to identify the

infecting organism or abnormal cells.
(1) GRAM STAIN – . Gram staining often provides early presumptive diagnosis
of lower respiratory infection, such as bacterial pneumonia.
-Permits direct visualization ob bacterias
(2) ACID FAST STAINING – helps rapidly identify organisms.This test
provides early presumptive diagnosis of tuberculosis.

(3) CULTURE AND SENSITIVITY The tests helps d

-Allows growth and isolation of microbes
-Diagnose lower respiratory infection
(4) CYTOLOGIC (exfoliative) TESTING – is performed to identify cancer cells
and other abnormal cells to help diagnose and type malignant pulmonary lesions
and identify granulomas, inflammation, and other benign conditions.
-Identify cancer cells
-Help to diagnose the type of pulmonary lesion
-Identify granulomas, inflammation and benign conditons