Terms in this set (77)
What is the indication of a paracentesis?
- new onset
What are the relative contraindications for a paracentesis?
Overlying anatomical or infectious abnormalities
Distended abdominal organs (i.e. ileus, megacolon)
Surgical scars: May have attached bowel
T/F: using an US is the standard of care for a paracentesis?
What is the best approach for a paracentesis? Why?
Bc when the pt is supine, the fluid will pool to the posterior wall and avoiding bowel perforation is easier.
How should the pt be positioned for a paracentesis?
Pt supine and/or with head elevated to 10-30 degrees
(pic on lecture says 30-45 degrees)
What do you need to careful of when using the anterior approach for a paracentesis?
avoid the inferior epigastric arteries.
T/F: For a paracentesis, it is considered a complete sterile technique, when the practitioner must be gowned up as well?
FALSE- Sterile technique but do not have to fully scrub in (don't have to fully gown in)
When inserting the needle for a paracentesis, you want to pull the skin taught in what direction?
caudad (approx 1-2 cm)
How will fluid on an US appear?
This is where the needle will go to drain!
How can you recognize and locate the bowel in an US prior to performing a paracentesis?
Bowel will glisten (more than other tissue) and you will be able to see peristalsis.
While inserting the needle for a paracentesis, how can you tell you're in the peritoneal cavity?
loss of resistance will be felt
a. Hold syringe with (_) hand
b. Rest (_) surface of (_) hand on patient's abdomen, and use (_) of this hand to steady shaft of needle
c. Keep nondominant hand in this position during needle advancement and continue to hold the (_)
b. dorsal; nondominant; thumb and index finger
c. nondominant; shaft of needle
What type of drainage tubing is used for a paracentesis?
High-pressure drainage tubing
T/F: Want to insert the needle for a paracentesis into the wheal of the local anesthetic?
What should always be done after you advance the needle in for a paracentesis?
aspirate- want to do that after moving the needle every time until the fluid pocket is reached.
T/F: When performing a paracentesis, you want to make sure to push the catheter all the way flush with the skin to ensure all fluid will be drained?
Catheter does NOT have to be flush with skin, better to keep partially out than perforate the bowel or visceral organ
What should be done after removing the catheter of the abdomen when doing a paracentesis?
apply firm, direct pressure to the site for several minutes
What types of lab samples are commonly collected during a paracentesis?
Albumin, protein: exudative vs. transudative
Cell count, differential
Gram stain, cytology
Aerobic & anaerobic cultures: blood culture
What is the most common complication of a paracentesis? How can you fix this?
Ascitic fluid leak- apply dermabond or sutures
Dermabond= best bc it provides a perfect seal.
What types of circulatory dysfunction complications can occur with a paracentesis?
Increased RAAS and catecholamine activity
What is the indication for a thoracentesis?
Therapeutic (resp distress, CHF, cirrhosis, trauma, cancer)
What are the relative contraindications of a thoracentesis?
Overlying infection or anatomical abnormalities
What is the best XR view for detecting effusions?
lateral chest (can detect smaller effusions >50mL)
(upright PA chest- detect effusions >200 mL)
A lateral chest XR can detect effusions >_____
An upright PA chest XR can detect effusion >_____
What type of finding in a lateral chest XR supports the dx of a pleural effusion?
partial "blunting" of the CP angle
Pleural cavity extends to (_) posteriorly
What position does the pt need to be in for a thoracentesis?
Must be sitting up right
Where will the needle be inserted for a thoracentesis?
Mid-thoracic line (medial edge of scapula)
One interspace BELOW level of effusion detected with percussion/tactile fremitus
For a thoracentesis, where should the needle NEVER be inserted?
NEVER inferior to the 9th rib
The tip of the scapula is approx at what rib?
How would you perform a thoracentesis if you have a pt that is unable to sit up?
(need to use US assistance)
In relation to the rib, where should the needle need to be inserted for a thoracentesis? Why?
Just above the inferior rib of the two ribs- in order to avoid the neurovascular bundle.
How do you determine the level of effusion prior to performing a thoracentesis?
percuss- transition between dullness and resonance
tactile fremitus- transition from normal to absent
Per JCAHO, what needs to be done prior to any thoracentesis?
Verify the pt with 2 identifiers and review all relevant clinical data
mark the side of the effusion (must be visible after drape has been applied)
Take a "time-out" immediately before the procedure (verify the pt, the procedure, and the site are correct)
How do you anesthetize the area you are going to perform a thoracentesis or a tube thoracostomy?
Direct needle until it comes in contact with the superior border of ribs (so it contacts the bone)
Gently "walk" needle OVER rib (just superior to the rib in order to avoid the neurovascular bundle)
Alternate aspirating and injecting anesthetic as advancing needle
Sudden loss of resistance= in the cavity
For a thoracentesis, you need to IMMEDIATELY stop advancing needle once (_)
pleural fluid enters the syringe
After advancing catheter into place during a thoracentesis, you want to remove the needle and then what? Why?
Place finger over exposed catheter hub immediately after needle is removed to prevent air from entering pleural cavity
When performing a thoracentesis, the stopcock should be (_) to patient at all times, except when actively draining fluid. Failure to do so may result in (_)
When performing a thoracentesis, you want to time the removal of the catheter with patient (inhalation/exhalation)?
(to avoid the negative pressure pulling air into the area)
T/F: you always need to get a chest XR post- thoracentesis?
When would it be indicated to get a chest XR post-thoracentesis procedure?
If air was aspirated
Pt develops chest pain, dyspnea or hypoxemia
If it is a critically ill pt
If on a mechanical ventilation
What is re-expansion pulmonary edema?
Stretching and distention of pulmonary parenchyma (alveoli) during re-expansion leads to increased pulmonary blood flow and alveolar-capillary membrane disruption, leading to pulmonary edema
Why would a mini-catheter insertion (aka pleural pigtail catheter) be indicated over a tube thoracostomy?
When the pt has a constant pleural effusion (more of a permanent placement)
What are the absolute contraindications for a tube thoracostomy?
What is the most sensitive test for a pneumothorax?
CT (air will be pitch black)
What kind of clamp is used for a tube thoracostomy?
Kelly clamps (Large clamps)
What scissors are used for a tube thoracostomy?
Mayo scissors (large, curved)
What indications would you want to make sure to use a larger tube size (minimal 36 Fr) for a tube thoracostomy?
a HTX or empyema
T/F: For a tube thoracostomy, it is considered a complete sterile technique, when the practitioner must be gowned up as well?
TRUE- requires full scrub in!
What is the most common location for a tube thoracostomy?
5th intercostal space
, midaxillary line/nipple line (lateral to pectoralis muscle and breast tissue)
Go to the
4th intercostal space
if you failed the 5th or you got a recurrent PTX)
What is the other location that a tube thoracostomy can be place, but is only used if desperate!
second intercostal space, midclavicular line
How do you measure the tube prior to performing a tube thoracostomy?
Estimate the distance between
incision to apex
holes within pleural space.
Mark max insertion length with
T/F: tube location does not affect ability to drain?
How do you position the pt for a tube thoracostomy?
elevate head of bed to 30-60 degress
restrain ipsilateral arm over head
What do you ALWAYS want to ensure your pt has on before/during/after a tube thoracostomy?
Cardiac monitoring and pulse ox!
T/F: Most patients are sedated for a tube thoracostomy?
What medication do you want to give your pt prior to a tube thoracostomy since the pleura is VERY sensitive to pain?
Etomidate and a local anesthetic
Why is Etomidate the best drug to give for a pt getting a tube thoracostomy?
bc it has the LEAST cardiopulmonary risk
What are the steps for performing a tube thoracostomy?
Make incision over 4th or 5th rib (anterior axillary line)
Create tunnel with Kelly clamp
Penetrate pleural space with Kelly clamp
Finger sweep & maintain the tunnel with finger
Insert chest tube
Secure chest tube
What size scalpel is used to make the incision for the tube thoracostomy?
No. 10 scalpel
Where do you do the incision for a tube thoracostomy?
transverse incision 3-5 cm long (through skin and SQ tissue), over the 4th or 5th rib on the anterior axillary line (1-2 ribs below pleural entry point)
How do you create a tunnel for a tube thoracostomy?
By using a long kelly clamp, bluntly dissect over TOP of rib.
Separate the tissue (YOU ARE NOT CUTTING)
- Advance with clamp closed
- Pull back with clamp spread
When you are trying to do a tube thoracostomy, how will you know that you are in the pleural space?
"pop" will be felt when pleura is penetrated (may require significant force)
rush of air of fluid will signify penetration into the pleural space as well.
What do you use as a guide for the chest tube to ensure it's entry into pleural space?
** when preparing the tube to insert , make sure NOT to remove finger (bc hole can be easily lost)
How should the tube be inserted for a tube thoracostomy?
Direct posterior, medial and superior
should travel along the posterior thoracic wall
Once inserting the chest tube during a tube thoracostomy, what shoudl you do in order to reduce likelihood of kinking?
rotate tube 360 degrees
How far do you insert the chest tube?
up to the marker clamp OR when resistance felt
T/F: you always need to get a chest XR post- tube thoracostomy placement?
ALWAYS get a CHEST XR to confirm placement BEFORE securing tube!
How do you dress the tube/skin incision of a tube thoracostomy?
Wrap base of tube at skin incision with petroleum-impregnated dressing (Xeroform gauze)
Then, place two layers of gauze sponges (Y-shaped cut centered)- the second layer will be placed at a 90 degree from the first layer
The heimlich valve on the drainage system for a chest tube is only for (_)
You start to notice that there may be a complication after placing a chest tube when monitoring the patient. What should be the first thing to check?
check the equipement first, there could be a damaged collection system/ air leaks
What s/p tube thoracostomy complication typically occurs due to the surgical hole being made too large?
Before pulling out the chest tube, what do you want to make sure to do first?
discontinue the suction
maintain a water seal or clamp chest tube "clamping trail"
What monitoring needs to be done after removing the chest tube?
repeat chest XR after 6-12 hours (looking for resolution of PTX, lungs are fully expanded and no evidence of air leak)
When removing a chest tube, you want to have the pt do what?
Fully INHALE and do a valsalva maneuver
Once the chest tube is pulled out, what do you want to do?
suture the wound and place OCCLUSIVE dressing on the wound to prevent air from escaping back into the pleural space.
YOU MIGHT ALSO LIKE...
Chest Tubes Nursing Management
IV therapy accepted practice ATI
OTHER SETS BY THIS CREATOR
Genetics Lecture 2, Exam 2
Genetics Exam 2 Lecture 1
THIS SET IS OFTEN IN FOLDERS WITH...
CPSS- Lumbar Puncture