Showing posts with label lungs. Show all posts

Jun 5, 2025

What is Thoracentesis.....

Thoracentesis: Understanding the Procedure and Its Importance

Thoracentesis, also known as pleural fluid aspiration, is a critical medical procedure. It involves puncturing the chest wall to collect a sample of pleural fluid for analysis or to relieve pulmonary compression causing respiratory distress. Effectively locating the fluid before the procedure significantly reduces the risk of puncturing vital organs like the lung, liver, or spleen.

Normally, the pleural cavity contains less than 20 ml of serous fluid. An abnormal accumulation or reabsorption of this fluid leads to pleural effusion. Based on specific characteristics, pleural fluid is classified as either a transudate or an exudate.

Purpose of Thoracentesis

Diagnostic Tool: To obtain pleural fluid specimens for analysis to determine the cause and nature of pleural effusion.
Therapeutic Relief: To provide symptomatic relief for patients suffering from large pleural effusions.

Procedure Overview

Preparation

Patient History Review: Check for bleeding disorders or anticoagulant therapy.
Imaging Studies: Explain that a chest X-ray or ultrasound study may precede the test to locate the fluid.
Patient Education: Thoroughly explain the procedure to the patient.
Patient Instructions: Instruct the patient not to cough, breathe deeply, or move during the test to minimize lung injury.
Baseline Vitals: Record the patient’s baseline vital signs.
Site Preparation: Shave the insertion site if necessary and properly position the patient.

Implementation

Patient Positioning: Position the patient to widen the intercostal spaces for easier access to the pleural cavity. If sitting is not possible, position on the unaffected side with the affected arm elevated.
Site Preparation: Prepare and drape the site once the patient is in position.
Needle Insertion: Inject a local anesthetic into the subcutaneous tissue, then insert the thoracentesis needle.
Fluid Aspiration: Once the needle reaches the fluid pocket, it's attached to a 50-ml syringe or a vacuum bottle to remove the fluid.
Patient Monitoring (During Aspiration): Continuously monitor the patient for signs of respiratory distress and hypotension.
Fluid Documentation: Note pleural fluid characteristics and total volume.
Post-Procedure: After needle withdrawal, apply pressure until hemostasis is achieved and apply a small dressing.
Specimen Handling: Place specimens in proper containers, label appropriately, and send to the laboratory immediately.
pH Specimen: Pleural fluid for pH determination must be collected anaerobically, heparinized, kept on ice, and analyzed promptly.

Nursing Interventions

Breathing Facilitation: Elevate the head of the bed to facilitate breathing.
Post-Procedure Imaging: Obtain a chest X-ray.
Patient Reporting: Instruct the patient to immediately report difficulty breathing.
Complication Reporting: Immediately report signs and symptoms of pneumothorax, tension pneumothorax, and pleural fluid reaccumulation.
Reexpansion Pulmonary Edema (RPE): Monitor the patient for reexpansion pulmonary edema (RPE), a rare but serious complication. Thoracentesis should be halted if the patient experiences sudden chest tightness or coughing.
Continuous Monitoring: Monitor vital signs, pulse oximetry, and breath sounds.
Site Observation: Observe the puncture site and dressings.
Subcutaneous Emphysema: Watch for subcutaneous emphysema.
Pleural Pressure: Monitor pleural pressure.

Interpretation of Results

Normal Results

Negative pressure in the pleural cavity with less than 50 ml serous fluid.

Abnormal Results

Bloody fluid: Suggests possible hemothorax, malignancy, or traumatic tap.
Milky fluid: Suggests chylothorax.
Fluid with pus: Suggests empyema.
Transudative effusion: Suggests heart failure, hepatic cirrhosis, or renal disease.
Exudative effusion: Suggests lymphatic drainage obstruction, infections, pulmonary infarctions, or neoplasms.
Positive cultures: Suggest infection.
Predominating lymphocytes: Suggest tuberculosis or fungal or viral effusions.
Pleural fluid glucose levels (30-40 mg/dl lower than blood glucose): May indicate cancer, bacterial infection, or metastasis.
Increased amylase: Suggests pleural effusions associated with pancreatitis.

Interfering Factors & Precautions

Interfering Factors

Failure to use sterile technique.
Antimicrobial therapy before fluid aspiration for culture (can decrease bacteria, making isolation difficult.

Precautions

Contraindicated in patients with a history of bleeding disorders or on anticoagulant therapy.
Strict sterile technique is paramount.

Complications

Laceration of intercostal vessels
Pneumothorax
Mediastinal shift
Reexpansion pulmonary edema (RPE)
Bleeding
Infection

Thoracentesis: Introduction and Indications (Advanced Insights)

Dyspnea (shortness of breath) is a common presentation in the emergency department, and pleural effusion is a frequent cause – an abnormal collection of fluid in the pleural space. While X-rays are easily obtained, ultrasound has proven more sensitive for detecting smaller effusions and precisely identifying fluid location, allowing for accurate marking of the chest wall for thoracentesis. Ultrasound guidance significantly decreases the high complication rate associated with the procedure.

Indications:

Therapeutic intervention in symptomatic patients.
Diagnostic evaluation of pleural fluid.

Anatomy of the Pleural Space

The pleural space is bordered by the visceral and parietal pleura. Fluid in this space appears anechoic (black) on ultrasound and is easily detected above the brightly echogenic diaphragm when the patient is supine.

Scanning Technique and Pathology (Ultrasound-Guided Thoracentesis)

Procedure Technique:

The ideal patient position is sitting upright, leaning forward. A high-frequency linear transducer (7.5 to 10 MHz) is optimal, placed on the patient’s back in sagittal or transverse position. The lung appears as an echogenic structure moving with respiration. The goal is to find the deepest pocket of fluid superficial to the lung. Once found, the image is frozen, and a measurement is taken to approximate the needle insertion depth to reach the maximum fluid.

The ultrasound beam will penetrate the chest wall, showing ribs as echogenic structures with characteristic shadowing.
The area should be marked with a pen, then prepped and draped in standard surgical fashion before the procedure.

Complications (Ultrasound Considerations):

Complications can include pneumothorax, puncture of lung tissue, cystic masses, empyema, or mediastinal structures.

Pearls and Pitfalls (Ultrasound Guidance)

Failure to identify the deepest pocket of fluid.
Failure to identify the diaphragm, leading to potential intra-abdominal injury.
Failure to use this diagnostic tool for all thoracentesis procedures.
Not appreciating that the lung is a moving structure, which can change fluid depth with inspiration or expiration.

Keywords: Thoracentesis, Pleural Fluid, Pleural Effusion, Respiratory Distress, Lung Puncture, Ultrasound Guidance, Diagnostic, Therapeutic, Transudate, Exudate, Pneumothorax, Hemothorax, Empyema, Reexpansion Pulmonary Edema (RPE), Vital Signs, Sterile Technique, Anticoagulant Therapy, Chest X-ray, Intercostal Spaces, Pleural Cavity, Mediastinal Shift, Subcutaneous Emphysema, Patient Monitoring. Thoracentesis is a common procedure, with nearly 180,000 done each year in the U.S. alone.

Hashtags: #Thoracentesis #PleuralEffusion #RespiratoryHealth #MedicalProcedure #NursingCare #UltrasoundGuided #PulmonaryMedicine #PatientCare #DiagnosticProcedure #TherapeuticIntervention #MedicalEducation #Healthcare #NurseLife #EmergencyMedicine #CriticalCare #FluidAnalysis #LungHealth #ComplicationPrevention #MedicalSkills

Originating Source Credits-

https://my.clevelandclinic.org/health/treatments/24254-thoracentesis

https://www.webmd.com/lung-cancer/thoracentesis-procedure

Additional Resources-

https://www.ncbi.nlm.nih.gov/books/NBK441866/

Mar 7, 2015

ABG, Blood Gases, Alkalosis, Acidosis....

Question	Answer	Hint
normal pH	pH 7.35-7.45
most common buffer system	CO2 + H2O — H2CO3 — H+ + HCO3-
normal ratio of carbonic acid to bicarbonate	1:20
respiratory acidosis	Increased CO2 results in decrease in pH
respiratory alkalosis	Decreased CO2 results in increase in pH
respiratory component of acid-base balance	CO2 (carbon dioxide)
metabolic acidosis	Increased HCO3 results in increase in pH
metabolic alkalosis	Decreased HCO3 results in decrease in pH
metabolic component of acid-base balance	HCO3 (bicarbonate)
normal PaCO2	35-45 mmHg
normal PaO2	83-100 mmHg
normal HCO3	22-26 mEq/L
ABG analysis step 1	if pH is <7.35, acidosis if pH is >7.45, alkalosis
ABG analysis step 2	if CO2 is abnormal, respiratory if HCO3 is abnormal, metabolic
ABG analysis step 3	pH is normal: fully compensated pH & opposite number out of range: partially compensated pH out of normal range, opposite number in normal range: no compensation
oxyhemoglobin curve	changes in pH alter ease with hemoglobin releases O2 to plasma
values of metabolic acidosis	pH is low, HCO3 is low
values of metabolic alkalosis	pH is high, HCO3 is high
values of respiratory acidosis	pH is low, PaCO2 is high
values of respiratory alkalosis	pH is high, PaCO2 is low
causes of metabolic acidosis	diabetic ketoacidosis, starvation, lactic acidosis, excess ETOH or ASA, renal failure, diarrhea
s/s of metabolic acidosis	lethargy, confusion, stupor, coma, hyporeflexia, muscle weakness, bradycardia, thready pulses, low BP, Kussmaul resp, warm/flushed/dry skin, hyperkalemia
treatment of metabolic acidosis	treat the cause: insulin, hydration/electrolytes, antidiarrheals, sodium bicarbonate, dialysis
causes of metabolic alkalosis	antacid overuse, IV LR overuse, NaHCO3 overuse, vomiting, NG suctioning, thiazide diuretics
s/s of metabolic alkalosis	anxiety, irritability, hyperreflexia, muscle cramps/weakness, tachycardia, normal or low BP, shallow resps, hypokalemia, hypocalcemia
treatment of metabolic alkalosis	treat the cause: fluid/electrolyte replacement, NS IV, Ca++, K-sparing diuretics, antiemetics
causes of respiratory acidosis	head injury, Rx overdose, chest injury, electrolyte imbalance, severe obesity, ascites, hemothorax, COPD, aspiration, pneumonia, pulm edema, TB, PE
s/s of respiratory acidosis	skin pale to cyanotic & dry, increase PaCO2
treatment of respiratory acidosis	increase CO2 excretion: bronchodilators, steroids, Mucomyst, O2, pulmonary hygiene, PAP
causes of respiratory alkalosis	hyperventilation – anxiety, fear, mechanical ventilation; hypoxemia – asphyxiation, shock, high altitude
s/s of respiratory alkalosis	numbness & tingling around mouth, extremities, resp. effort normal or increase
treatment of respiratory alkalosis	treat underlying condition, support renal function w/ fluids, breath into bag or rebreather, sedatives

Cardiac System Oxygenation Help....

Cardio – Oxygen Questions Study Guide

Question	Answer	Hint
Normal functioning of the lungs depends on what three factors?	patent respiratory tree, functioning alveoli system, well functioning cardiovascular system
What is meant by a patent respiratory tree?	open, able to move air. If there is an occlusion or obstruction it is not patent and will have a negative impact on the respiratory sys.
What is the main function of the upper airway?	warms air, humidifies, filters air, and helps get microorganisms out
What are cilia and what are their main function?	hair like projections in the airway that help get contaminants out of the respiratory tree.
What are the functions of mucus and coughing?	Mucus helps to capture microbs while coughing helps move secretions out.
What helps to thin mucus in the lungs?	Hydration
What is the function of surfactant?	helps to keep the alveoli open/inflated and decreases surface tension
What is ventilation?	the movement of air in and out of the lungs
define/describe inhalation	active process, muscles contract, diaphragm moves down, pressure goes down and air rushes in
define/describe exhalation	passive process, muscles relax, diaphragm moves up, pressure goes up and air rushes out
What are 3 factors that affect respiration?	Accessory muscles, lung compiance, and airway resistance
What are the accessory muscles and what do they do?	They are the abdominal, intercostal, and sternocleidomastoid muscles which help the distressed pt. move air
What is lung compliance?	elasticity of lungs to expand; how easily the lungs expand. Decreased lung compliance means decreased elasticity
What factors affect lung compliance?	chest wall factors (position of the body-MS, obesity, lying in bed, etc.) and lung factors (problems in the lungs- pneumonia, fibrosis, pulmnary edema, etc.)
What is atelectasis?	decreased expansion of the lungs
What is pleural effusion?	collection of fluid between lung and chest wall. Fluid collapses the lungs.
What is pulmonary edema?	fluid inside the respiratory tree such as with lf. side heart failure- blood gets backed up into the lungs and dumped into the alveoli because heart can’t pump it out properly.
What is pulmonary fibrosis or pulmonary htn?	after an injury occurs fibrin and collagen are laid down to repair which toughens lung tissue and decreasing compliance
What is pneumothorax?	a collapse of a portion of lung with air in the pleural space
What is hemothorax?	blood in the pleural space
What can cause airway resistance?	any obstructions to airflow: narrowed tube, tumor, infection, secretions, edema, foreign objects, bronchial constriciton, etc.
define diffusion	movement of SOLUTES from an area of greater concentration to an area of lesser concentration
define osmosis	movement of SOLVENT from and area of lesser concentration to an area of greater concentration
define perfusion	movement of fluid (blood) through or into a system (blood entering vessels through walls)
Diffusion and perfusion are interrelated, therefore can you have one without the other?	Yes, it is possible to have diffusion but not perfusion however diffusion will not be effective. For example air is moving into the lungs, but there is a blocked area of tissue so perfusion is not happening
What things effect diffusion in the lungs?	surface area (less area = less diffusion), disease, and a decrease in environmental O2
What types of things can affect the amount of surface area in the lungs?	body position, tumor, lung collapse, lung removal, muscus plug, immobility, etc.
How is oxygen transported through the body?	97% is attached and transported via hemoglobin and 3% is dissolved into plasma
The amount of oxygen that binds to hgb depends on what?	PaO2 : more PaO2 the more oxygen that attached to Hgb
What is a normal PaO2?	between 80-100mmhg
At a PaO2 of 60mmhg how saturated are the Hbg with oxygen (SaO2)?	90%
What is hypoxemia?	decreased O2 in blood and causes hypoxia
What is hypoxia?	decreased O2 in the tissues
What are some sx/s of hypoxia?	cyanosis, pale coloration of skin, apprehensive, restless, confused, c/o dyspnea
What controls respirations in a healthy person?	CO2: CO2 crosses the bbb and mixes with H2O. H+ ions increase which causes faster breathing.
What controls respriation in a nonhealthy person?	O2 : since a nonhealthy person lives with high levels of CO2 because of the build up, O2 must therefor control the respiratory drive. Low levels of O2 increases breathing
Why is it important to monitor a pt. with COPD who is on oxygen?	Because if the O2 levels get too high then their respriatory drive is not triggered and the pt. can stop breathing
What are two ways of measuring O2 in the blood?	ABG (arterial blood gas) and Pulse oximeter (saturation of O2)
What are the normal ranges of PaO2 and PaCO2?	PaO2:80-100mmhg PaCO2:35-45mmhg
What does and ABG tell us?	How well diffusion is functioning in the lungs
What would a venus draw(VBG) tell us?	how much O2 is being used by the tissues; tells us the O2 demand in the peripheries
True or false?ABG will help us make critical decisions and tells us if the pt. needs O2 therapy.	True
What is a normal level on a pulse ox?	95-100% but anything over 90% is good
True or false? pulse ox will help us make critical decisions and tells us if the pt. needs O2 therapy.	False. It does not help make critical decisions, but may determine if a ABG is needed
How can a pulse ox give a misreading of O2 saturation?	If Hgb is low but still 90% saturated it could read 90%SaO2 when the pt. is actually hypoxic or hypoxemic because of the low Hbg levels
What types of pts need O2 therapy?	if they are hypoxic or hypoxemic, someone with a non-respiratory problem and demands more O2 to the tissues such as a febrile pt, someone with low levels of Hgb such as with blood loss or burn victims, someone with reduced O2 carrying ability such as a post-op pt, someone with decreased cardiac output
What is the % of O2 (fraction of inspired air FiO2) in room air?	21%
True or false? If over 2L/min of O2 is delivered then it needs to be humidified.	True
True or false? you need a dr. order to humidify but not to administer O2.	False. Oxygen is considered a drug and you need a dr.s order for it however you do not need an order to humidify
Up to how many L of O2 can be given with nasal prongs?	6L/min
simple face mask	delivers 5-8L/min O2, 40-60% FiO2, fits snugly, has vents to pull in room air and expel CO2
Partial rebreather	has reservoir bag and vents, needs humidity, delivers 5-11 L/min O2, 60-75% FiO2,
Non-rebreather	same as partial rebreather except it has vents, prevents outside air and exhaled CO2 from mixing with O2, needs to be monitored, delivers 6-15 L/min O2, 80-90% FiO2
Venti mask	only delivers up to 50% FiO2 but is more accurate than other masks because you can control the amount of O2 and room air that is given
What are 5 precautions when using oxygen?	1. no open flames 2. make sure electrical equ. is working properly 3. don’t use metallic tools 4. avoid oils 5. avoid static electricity

Respiratory Surgery Interventions and Questions....

Why should the nurse withhold food from a pt following a bronchoscopy? Aspiration – no gag reflex, to test for return of gag reflex, should touch pharynx with depressor.....

After a laryngectomy a pt can develop frequent coughing and copious secretions due to lack of warmed, moist air.
A good nursing intervention after surgery to promote adequate ventilatory exchange would be to? Position the client laterally with neck extended. The tongue will not obstruct the airway
Priority after a laryngectomy is? Keep the trach free of secretions – patent airway is priority
Can a pt with a total laryngectomy and radical neck dissection still chew and swallow? Yes
A pt has moderate edema of the neck tissues after a radical neck dissection. The nurse should assess for? Restlessness and dyspnea because this pt is at risk for airway obstruction, and these signs may indicate hypoxia

What are some interventions for pt with radical neck surgery? Chest tube to drain fluid, total Parenteral nutrition and bed rest. TPN provides nutrition, boosts immune defenses, and decreases thoracic duct flow, bed rest b/c lymphatic flow increases with activity

The reason to perform deep breathing exercises after surgery is to help with? Counteracts respiratory acidosis, retention of CO2 in the blood lowers the Ph, causing resp. acidosis; deep breathing maximizes gaseous exchange, ridding the body of excess CO2
A common early sign of laryngeal cancer for which the nurse should assess a client would be? Hoarseness –

What is the purpose of the third chamber in the 3 chamber underwater drainage system? It controls the amount of suction – 1^st collects drainage, 2^nd provides for the seal, 3^rd –controls amt of suction
What is the top priority when a client is unconscious? An obstructed airway, reduced O2 intake may lead to serious complications
A pt has an unresolved hemothorax and is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. He could be experiencing? Empyema, an accumulation of pus in a body cavity which is a result of bacterial infection. Turbid drainage is the hallmark sign
A client with supraglottic cancer undergoes a partial laryngectomy. Postop, a cuffed trach tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to? Cough as the cuff is being deflated, if cannot cough then the nurse should suction

Oxygenation of your Patient and Lung Function Interventions....

ARDS = Acute Respiratory Distress Syndrome
Pt w/intubation & PEEP = assess response Pt w/ heart failure and crackles = High Fowlers – promotes lung expansion & gas exchange, decreases venous return and cardiac workload Problem w/ pneumonectomy = ventilory exchange O2 & CO2 exchange is a priority Obese pt, smoker, major abdomen surgery. Postop what is priority? – O2 stats To monitor for s/sx of hyperventilation monitor for? – resp. alkalosis – increase rate and depth of breathing results in excessive elimination of CO2 Where do you hear stridor? Over the trachea or larynx Good breathing exercise is? Breathe from abdomen – improves lung expansion What to do with condensation collecting in the vent tubing? Empty the fluid from tubing – What to do in ER when trach is expelled? Hold open with tracheal dilator and call for help Pt is in pain on right side of chest, is dyspneic and coughs violently after abd surgery, nurse should? Elevate head of bed – may be pulmonary embolus and this promotes breathing by reducing the pressure of the abd. Organs on the diaphragm and increasing thoracic excrusion What can suctioning cause and what to do about it? Can cause dysrhythmias so hyperoxygenate prior to, during and after suctioning If nasogastric feedings are required in a pt with trach what should the nurse do with the cuff? Inflate the cuff before and for 30 min after ea feeding

A trach tube with high vol., low-pressure cuff is used to prevent? Mucosal necrosis – these cuffs do not compress the capillary beds and thus do not cause trach damage emphysema pt is using accessory muscles to breathe, his dyspnea is caused by? Difficulty expelling the air trapped in the alveoli – these pts use these muscles to breathe A pt with a PCO2 of 60 needs? Mechanical ventilation – this indicates progressive resp. failure, vent. Support is needed when the Pco2 is above 40 A lung cancer pt hooked to chest tube for drainage. Nurse should report what to physician? Subcutaneous emphysema on the 2nd day – evidence of a leak from the chest tube or the lung into the subq tissue A pt presents to ER after being hit in chest with a baseball. X-ray shows pneumothorax. What does nurse find on assessment? An absence of breath sounds on auscultation – collapsed lung

Notez On Nursing....