Discharge Plan

Placement/type of dwelling: Discharge to home status post thoracentesis

in a single residential home.
Support system: Live with wife. Adult children are very involved with care.
Family comes to the hospital daily for support and care for the patient during
stay at the hospital

Assistance with ADLs: Minimal assistance with toileting and showering,

urinal or bedpan at bedside to accommodate fatigue and bedrest, walker
with ambulation as tolerated,

Equipment needs: walker, urinal, bedpan

Patient teaching

Patient prefers to learn: verbal & written information

Barriers to learning: none, patient is alert & oriented x4. Currently using
laptop while in
bed
Pleural effusion is excessive fluid in the pleural space.
Pleural space is the area between the parietal pleura (membrane lining
the chest cavity) and the visceral pleura, which surrounds the lungs.
Normally, this potential space holds about 50mL of lubricating fluid
that prevents friction between the pleurae as they move during
inhalation and exhalation.

Risk factors: atrial fibrillation, congestive heart failure, chronic coronary

artery disease, ischemic cardiomyopathy, DM2, family history of cardiac
disease, cardiac surgery (coronary artery by pass, graft mitral valve)

Procedure to treat Pleural effusion:

Thoracentesis is the surgical perforation of the chest wall and pleural
space with a large-bore needle. It is performed to obtain specimens for
diagnostics evaluation, instill medication inot the pleural space, and remove
fluid (effusion) or air from the pleural space for therapeutic relief of pleural
pressure.
Thoracentesis is performed under local anesthesia by a provider
at the clients bedside, in a procedure room, or in a providers
office
 Use of ultrasound for guidance decreases the risk of
complications

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.

Bleeding may occur during the procedure or at increased risk

for bleeding
o Monitor the client for coughing and/or hemoptysis
o Monitor the clients vital signs and laboratory results for
evidence of bleeding (hypotension, reduced Hgb level)
o Assess thoracentesis site for bleeding.

Infection can occur d/t the introduction of bacteria with the

needle puncture
o Ensure that sterile technique is maintained.
o Monitor the clients temperature following the procedure.

Follow up appointment: 2 weeks from discharge

Activity level: As tolerated

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.

d. Carvedilol beta-adrenergic blockers

- Check BP and HR regularly

e. Aspirin or coumadin anticoagulant

- Monitor for bruising & bleeding, increase risk while on this
medication
- Have blood monitored routinely to check bleeding times

o Schedule regular follow-up visits with the provider.

o Get vaccinations (pneumococcal and yearly influenza vaccines)

Health Promotion and Disease Prevention

o Maintain an exercise routine to remain physically active, and consult
with the provider before starting any exercise regimen.
o Consume a diet low in sodium along with fluid restrictions, and consult
with the provider regarding diet specifications.
o Refrain from smoking.
o Maintain heart healthy diet.

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.

Ignatavicius, D. & Workman, M. L. (2016). Medical-surgical nursing: Patient-centered

approach (8th ed.). St. Louis: Elsevier.