Thoracentesis Procedure, Nursing Care Plans & Management

Thoracentesis drains fluid or air from the pleural space through a needle placed through the chest wall. You will see it both to diagnose an effusion (analyze the fluid) and to relieve a patient who cannot breathe under a large effusion or a tension pneumothorax. Ultrasound guidance makes it safer.

What is Thoracentesis?

Also called a pleural tap, thoracentesis inserts a needle or catheter into the pleural space to drain a fluid or air buildup. It is usually done under ultrasound guidance for accuracy and safety.

Indications

• Diagnostic. Work up pleural effusion, empyema, hemothorax, or chylothorax, and tell transudative from exudative effusions, by extracting and analyzing the pleural fluid.
• Therapeutic. Relieve dyspnea from a large effusion or pneumothorax, decompress a tension pneumothorax in an emergency, or optimize lung function before thoracic surgery.

Equipment

• Sterile gloves and drapes
• Local anesthetic (lidocaine)
• Syringes and needles (for anesthesia and specimen collection)
• Thoracentesis kit (sterile drape, antiseptic solution, skin marker, scalpel or needle, thoracentesis needle or catheter, collection bottles or vacuum containers, connecting tubing, dressing materials)
• Ultrasound machine (optional but strongly recommended)

Procedure

1. Position the patient sitting, arms and head resting on a bedside table. If they cannot sit, lie them on the affected side with that arm over the head. This opens the midaxillary line for insertion.
2. Plan the insertion site in the posterolateral back, below the fluid level. Confirm by counting ribs on x-ray and percussing for the fluid level. Mark the top of dullness with washable ink or a skin indentation.
3. Choose an interspace below the point of dullness in the mid-posterior line (posterior insertion) or mid-axillary line (lateral insertion), so the needle enters the pleural space without hitting lung tissue.
4. Use sterile technique: gloves, betadine prep, drapes.
5. Anesthetize the skin with 1% lidocaine using a 5 cc syringe and a 25 or 27-gauge needle, then anesthetize the superior surface of the rib and the pleura.
6. Insert over the top of the rib (superior margin) to avoid the intercostal nerves and blood vessels on the underside.
7. Aspirate to confirm pleural fluid. Once fluid returns, mark the depth with a hemostat and remove the anesthetizing needle.
8. Measure that depth on the thoracentesis needle with the hemostat. Apply steady pressure on the patient's back and insert through the anesthetized area to the same depth.
9. Advance over the top of the rib through the pleura with gentle suction on the syringe, staying above the rib to avoid the neurovascular bundle.
10. Attach the three-way stopcock and tubing and aspirate the amount needed; turn the stopcock and evacuate the fluid through the tubing.
11. Withdraw the required pleural fluid (typically 100 mL for diagnostics), but do not remove over 1500 mL at once. Controlled removal prevents re-expansion pulmonary edema and hypotension.
12. On completion, have the patient take a deep breath and hum before you gently withdraw the needle. This raises intrathoracic pressure and lowers the risk of pneumothorax. Cover the site with a sterile occlusive dressing.

Nursing Diagnoses

Possible diagnoses post-thoracentesis (see also the Pleural Effusion care plans):

1. Ineffective Breathing Pattern related to decreased lung volume capacity.
2. Impaired Gas Exchange related to alveolar-capillary membrane changes.
3. Impaired Skin Integrity related to the puncture and any chest tube insertion.
4. Acute Pain related to the puncture, chest tube sites, and immobility.
5. Impaired Physical Mobility.
6. Activity Intolerance.

Nursing Interventions

Before the procedure

1. Verify the physician's order.
2. Explain the procedure, risks, and benefits to the patient and guardian.
3. Obtain informed consent.
4. Tell the patient to expect mild pain at the needle site, managed with the local anesthetic.
5. Tell them it takes only a few minutes, depending mainly on how fast the fluid drains.
6. Tell them not to cough during insertion, since sudden movement risks injury to nearby structures.
7. Get imaging first (chest x-ray, fluoroscopy, ultrasound, or CT) to locate the effusion and guide safe placement.
8. Have them remove clothing, jewelry, and other objects; the area may be shaved.
9. Check baseline vital signs (heart rate, blood pressure, breathing rate, oxygen).

During the procedure

10. Monitor vital signs for early signs of complications.
11. Give supplemental oxygen as needed by face mask or nasal cannula.
12. Position the patient upright or on the unaffected side, with pillows for comfort and stability.
13. Hand instruments to the provider and maintain the sterile field.
14. Apply pressure and a sterile dressing over the puncture afterward to prevent air leak and infection.

After the procedure

15. Watch for distress: dyspnea, pallor, chest pain, which can signal pneumothorax or respiratory compromise.
16. Position on the unaffected side with the head of the bed elevated 30 degrees for at least 30 minutes to promote lung expansion and reduce fluid reaccumulation.
17. Document the amount of fluid or air drained, tolerance, complications, and instructions given.
18. Label the specimen (name, date, time, source) and send it to the lab.
19. Monitor blood pressure, pulse, and breathing until stable, and check the dressing for bleeding or drainage.
20. Tell the patient normal activities can resume after 1 hour if there is no pneumothorax or other complication.