PLEURAL TAPPINGDefinition:- Thoracentesis or chest aspiration is the withdrawal of fluid from the pleural cavity by the introduction of a hallow needle into the pleural cavity through the chest wall. An excessive accumulation of fluid in the pleural cavity is due to some diseases of the lung, and in cardiac decomposition or renal inefficiency. When the effusion is purulent in nature it is said as empyema. Fluid may also collect in the pleural cavity as a result of malignant growth in the chest that pressing blood vessels.Purposes:- 1) For diagnostic purposes to find out the causative organism in a pleurisy 2) To remove the symptoms of pressure as pain, dyspnoea, cough and other symptoms.Aspiration can be done by some type of suction device such as a vacuum bottle or a large syringe. In empyema when the effusion is of a purulent in nature, it is difficult to be removed by means of a syringe and needle. So suction is done by means of an apparatus called Potain's apparatus.

Potains Apparatus:- It consists of a caliberated glass bottle having a rubber stopper in which there is a metal tube with branches each providing with stop corks. To each branch is fitted rubber tubing with adapter or metal ends. The sterile aspiration needle fits the metal end of one piece of tubing and through the other end air may be exhausted from the bottle by the exhaust pump leaving a vaccum inside the bottle into which the chest fluid will readily flow.

Position of the patient for the treatment:- may be sitting or lying down.Sitting Position:- The patient should sit on the side of the bed with his feet resting on a stool and his arms on a pillow laid over the back of a chair. Sometimes the patient leans over the bedside table.Lying position:- The patient lies on a semirecumbent position on the side of the bed most convenient to the doctor. He should lie with his affected side uppermost. A small pillow is placed under the thorax so as to arch the vertebrae and to widen the intercostal spaces. The arm of the affected side is held above head or forward with the hand on opposite shoulder. The patient should not be exposed unnecessarily. Nurse should remain with the patient.Preparation of the patient:- The patient should be dressed in loose jacket over the chest so as to expose the part easily during the procedure. He should be kept warm throughout. Skin area is washed and cleaned well and painted with iodine and sterile dressing applied over the part, and fix with binder or bandage.

Equipment1) Screen for privacy2) A tray containing:-a) Small rubber sheet and towel to protect the bed.b) Bottles of iodine, collodion or Tr. benzoin, Novocaine 2 percent.c) Transfer forceps in a jar of lotion,d) Kidney tray e) Binder or adhesive plaster and scissors.

Sterile tray containing: -a) Sponge holding forceps.b) Bowl of cotton swab.c) A small bowl for local anaesthetic.d) 2 cc syringe and needle for local anaesthetice) 20 cc syringe and aspiration needles (if aspiration is to be done with syringe)f) Aspiration apparatus with all its connections sterilized and tested for its efficiency in working.g) Aspiration needles of different sizes, three way adaptersh) Sterile test tubes for the collection of the specimens.i) Sterile dressings.j) Sterile gloves and mask for the surgeon.k) Sterile towels for draping the patient.

Procedure:- Explain the procedure to the patient to win his confidence and cooperation. Special instruction to be given that he should not cough or move during the treatment. If coughing is unavoidable he should inform the nurse or the doctor so that he may withdraw the needle to prevent it from entering the lungs. Screen for privacy.Assemble the equipment to the bedside convenient to the doctor. Keep the patient in position.Expose only the needed part by removing the jacket and the chest binder.Doctor gets ready. He prepares the skin area and discard the swab into the Kidney tray. The area is draped with sterile towel. Local anaesthetic is given if necessary at the site of introduction of the needle with the 2 cc syringe and the needle. Doctor may determine the site of puncture by examining the chest sounds depending upon the level of collection of fluid.

The aspiration bottle should be operated and made ready to connect with the needle before introducing the needle to the pleural cavity. Doctor introduces the aspiration needle between the ribs. A three-way adapter is attached to the needle and he closes the adapter before introducing, to prevent the entrance of air. As soon as the needle is in position he connects the needle to the rubber tubing of the bottle and open the stopcock on that side and the fluid will run into the bottle.

If an uncontaminated specimen is needed, it is collected from the needle itself or it may be collected into the syringe and then put into the test tube.

Watch the patient's condition during the treatment; colour, pulse, breathing or any difficulty, fainting or haemorrhage etc, When sufficient amount is taken the needle is withdrawn, the puncture is sealed, dressings applied and fixed with adhesive plaster' The patient rests for a prescribed period according to his condition. Sputum should be watched for the presence of blood, after aspiration. Specimen should be labelled and sent to the laboratory.

Record the treatments, amount, colour, type of fluid withdrawn, the time of treatment, coughing any fainting gand any untoward symptoms accompanying or following the procedure, or any benfical effects observed should be recorded. Note the collection of specimen and the purpose of which they were sent to the laboratory. Wash the things properly, sterilize and keep in proper places.

Water seal Chest DrainageWater Seal Chest Drainage means that a column of water in a bottle seals off the atmospheric air preventing from entering the chest drainage tube and thereby in the pleural space. It is a closed drainage system by which the air and fluid in the pleural space is escaped through the drainage tube during exhalation and prevent their return flow to the pleural space during inhalation. It acts only on one way flow from into out and not from out to in, provided the apparatus is in proper working condition.

The normal breathing mechanism operates in the principle of negative pressure (the pressure in the chest cavity is lower than the pressure of the outside air, causing air to rush into the lungs). Whenever the chest is opened, for any cause, there is a loss of negative pressure which can result in the collapse of the lungs. The collection of air, fluid, or other substance in the chest can complicate cardiopulmonary function and even cause collapse or the fung, because these substances take up space. Three types of pathologic substance collect in the pleural space.1) Solids (fibrin or clotted blood)2) Liquids (serous fluids, blood, pus, chyle)3) Gas (air from the lung, tracheobronchial tree, or Oesophagus)Surgical incision of the chest wall almost always causes some degree of pneumothorax. Air and fluids collect in the intrapleural space, restricting lung expansion and reducing air exchange. It is necessary to restore pleural negative pressure and prevent this from happening. Therefore, during or immediately after thorasic surgery, chest catheters are positioned strategically in the pleural space, sutured to the skin and connected to some type of drainage apparatus in order to remove the residual air and drainage fluid from the pleural or mediastinal space. This assists in the re-expansion of remaining lung tissue.

A chest drainage system must be capable of removing whatever collects in the pleural space so that a normal pleural space and normal cardiopulmonary function may be restored and maintained. There are many types of commercial chest drainage systems in use and most of which work on water seal principle. The chest catheter is attached to a bottle, using a one-way valve principle. Water act as a seal and permits air and fluid to drain from the chest, but air cannot re enter the submerged tip, of the tube. The care of the patient with water-seal chest drainage* is discussed below.

Principles of Chest DrainageChest drainage can be categorized into three types of mechanical system. The Single bottle water-seal system.

The end of the drainage tube from the patient's chest is covered by a layer of water which permits drainage and prevents lung collapse by sealing out the atmosphere. Functionally, drainage depends on gravity, on the mechanics of respiration and, if desired, on suction by the addition of controlled vaccum.

The tube from the patient extends approximately 2.5cm (1 inch) below the level of the water in the container. There is a vent for the escape of any air that might be leaking from the lung. The water level fluctuates as the patient breathes. It goes up when the patient inhales and down when the patient exhales. At the end of the drainage tube bubbling may or maynot be visible. Bubbling can mean either persistent leakage of air from the lung or other tissues or a leak in the system.

The two-bottle systemThe two-bottle system consists of the same water-seal chamber puis a fluid collection bottle. Drainage is similar to that of a single unit, except that when pleural fluid drains, the underwater seal system is not effected by the volume of drainage.

Effective drainage depends on gravity or on the amount of a suction added to the system. When (suction) vacuum is added to the system from a vacuum source such as wall suction, the connection is made at the vent stem of the underwater seal bottle. The amount of suction applied to the system is regulated to the wall gauge.

The three bottle systemThis system is similar in all respects to the two-bottle system; except for the addition of a third bottle to control the amount of suction applied. The amount of suction is determined by the depth to which the tip of the venting glass tube is submerged. (For example, submersion to 10 cm below the surface of the water will equal 10 cm of water suction applied to the patient.)

In the three-bottle system (as in the other two) drainage depends on gravity or the amount of suction applied. The amount of suction in the system is controlled by the manometer bottle. The mechanical suction motor or wall suction creates and maintains a negative pressure through out the entire closed drainage system.

The manometer bottle regulates the amount of vacuum in the system. This bottle contains three tubes:1) A short tube above the water level comes from the water-seal bottle.2) Another short tube leads to the vacuum or suction motor or wall suction.3) The third tube is a long tube (stand pipe) which extends below the water-level in the bottle and which is open to the atmosphere outside the bottle. This is the tube that regulates the amount of vacuum in the system. This is regulated by the depth to which this tube is submerged-the usual depth is 20 cm (7.6 inches)

When the vacuum in the system becomes greater than the depth to which the tube is submerged, outside air is sucked into the system. This result in constant bubbling in the manometer (or pressure-regulator) bottle, which indicates that the systems is functioning properly. Management of the patient with water seal chest drainageProcedureSl.NoNursing Action Rationale Amplification

1) Attach the drainage tube from the pleural space to the tubing that leads to a long tube with end submerged in sterile normal saline.Water-seal drainage provides for the escape of air and fluid into a drainage bottle. The water acts as a seal and keeps the air from being drawn back into the pleural space.

2) Tape the places where the tubing is connected if needed some connectors hold without taping.

(a) The tube should be approximately 2,5 cm (1 Inch) below the water level(b) The short tube is left open the atmosphereTaping the connecting points of the tubing will make certain that the tubing remains air tight to reestablish negative (intrapleural) pressure.(a) If the tube is submerged too deep below the water level a higher intrapleural pressure is required to expel air(b) Venting the short glass tube lets the air escape from the bottle

3) Mark the original fluid level with tape on the outside of the drainage bottle. Mark hourly/daily increments (date and time) at the drainage levelThis marking will show the amount of fluid loss and how fast fluid is collecting in the drainage bottle. It serves as a basis for blood replacement, if the fluid is blood. Grossly bloody drainage will appear in the bottle in the immediate post operative period and if excessive, may require re-operation. Drainage usually declines progressively in the first 24 hours.

4) Fasten tubing to the draw sheet with rubber bands and safety pin so that flow by gravity will occur. The tubing should not loop or interfere with the movements of the patients.Kinking, looping, or pressure on the drainage tubing can produce back pressure, and may thus possibly force drainage back into the pleural space or inpede drainage from the pleural space.

5) Encourage the patient to assume a position of comfort. Encourage good body alignment. When the patient is in the lateral position place a rolled towel under the tubing to protect it from the weight of the patient's body. Encourage the patient to change position frequently.The patient's position should be changed frequently to promote drainage and the body should be kept in good alignment to prevent postural deformities and contractures. Proper positioning helps breathing and promotes better air exchange. Medication maybe needed to enhance comfort and breathing.

6) Pool the arm and shoulder of the affected side through range of motion exercises several time daily. Some medication may be necessary.Exercise helps to avoid ankylosis of the shoulder and assists in lessening post operative pain and discomfort

7) "Milk" the tubing in the direction of the drainage bottle hourlyMilking the tubing prevents it from becoming plugged with clots and fibrin. Constant attention to maintaining the patency of the tube will faciliate prompt expansion of the lung and minimise complication

8) Make sure there is fluctuation (tidaling) of the fluid level in the long glass tubeFluctuation of the water level in the tube shows that there is effective communication between the pleural cavity and the drainage bottle, provides a valuable way of checking the drainage system, and is a gauge of intrapleural pressure.

9) Fluctuation of fluid in the tubing will stop when:(a) the lung has re-expanded(b) the tubing is obstructed by blood clots or fibrin.(c) dependent loop develops(d) suction motor or wall suction is not working properly.

10) Watch for leaks of air in the drainage system as indicated by constant bubbling in the water-seal bottle.a) Clamp tubing (Momentarily) close to the chest to look for air leak only, if so directed by the physician.b) Report excessive bubbling in the water- seal chamber immediately.c) Milking of chest tube in patients with air leak should only be done if requested by surgeon.Leaking and trapping of air in the pleural space can result in tension pneumothorax. If the leak is in the patient and the tube is clamped for more than few seconds' air-may back up in the pleural cavity and extend the patient's pneumothorax.

11) Observe and report immediately signs of rapid, shallow breathing cyanosis, pressure in the chest, subcutaneous, emphysema, or symptoms of haemorrhage.Many clincal conditions may cause these signs and symptoms, including tension pneumothoroax, mediastinal shift, haemorrhage, severe chest pain, pulmonary embolus, and cardiac tamponade. Surgical intervention may be necessary.

12) Encourage the patient to breath deeply and cough at frequent intervals. If there are signs of pain, adequate medication is indicated.Deep breathing and coughing help to raise the intrapleural pressure, which allows emptying of the accumulation, in the pleural space and removes secretion from the tracheobronchial tree, so that the lunges expands and atelectasis is prevented.

13) Stabilize the drainage bottle on the floor or in a special holder. Caution visitors and personnel against handling equipment or displacing the drainage bottle.If any part of the apparatus is damaged, the closed system of drainage will be destroyed and the patient will be endangered by atmospheric pressure in the pleural space and resultant collapse of the lung. The drainage system must be kept air tight to restablish negative intrapleural pressure.

14) If the patient has to be transported to another area, place the drainage bottle below the chest level (as close to the floor as possible). If he is lying on a stretcher. Hemostats (clamps) should be attached to the patients gown while he is transported.The drainage apparatus must be kept at a level lower than the patient's chest to prevent back flow of fluid into the pleural space.

15) When assisting the surgeon in removing the tube:a) Instruct tm patient to perform the valsalva's maneuver (forcible exhalation against a closed glottis, holding one's breath.b) Chest tube is clamped and quickly removed.c) Simultaneously a small bandage is applied and made air tight with vaseline gauze. Covered by 4" X 4" gauze and thoroughly covered and sealed with adhesive tape.

The chest tube is removed as directed when the lung is re-expanded (usually 24 hours to several days). During removal of the tube the chief priorities are prevention of entrance of air into the pleural cavity as the tube is withdrawn and prevention of infection.

Chest Physical Therapy:Postural Drainage:- Because of the patient is usually in an upright position, secretions are likely to accumulate in the lower part of the lung. When postural drainage-is used, the patient is positioned sequentially in different postures, so that the force of gravity helps to drain secretion from the smaller bronchial air ways to the main bronchi and trachea. The secretions are then removed by coughing. Inhalation of the prescribed bronchodilators before postural drainage assists in draining the bronchial tree.

Postural drainage exercises can be directed at any of the segments (bilateral) of the lungs. Usually the lower and middle lobe bronchi empty more effectively when the head is down. The upper lobebronchi empty more effectively when the head is up. Frequently the patient is placed in five positions.1 Position for drainage of each lobe.2 Head down, position.3 Prone position.4 Right and left lateral position.5 Sitting upright position.

Nursing Implication:- The nurse should be aware of the patient's diagnosis as well as the lung lobes or segments involved, the cardiac status, and any structural deformites of the chest wall and spine. To determine the area (s) needing treatment and the effectiveness of the treatment, the chest should be auscultated before and after the procedure.

Postural drainage is usually done four times daily, before meals and at bed time. If prescribed bronchodilator aerosol medtcations may be inhaled before postural drainage to reduce bronchospasm, decrease thickness of mucus and sputum and combat odema of the bronchial walls. The patient should be made as comfortable as possible in each position and an emesis basin or sputum cup and paper tissue should be available. The patient is instructed to remain 5-10 minutes in each position and to breath slowly through his nose and blow out through his mouth while assuming the posture. If he cannot tolerate the position, he should be helped to assume a modified posture.

When the patient changes positions, he should be instructed to cough as follow:-1) Assume a sitting position, and bend slightly forward.2) Keep the knee and hips flexed to promote relaxation and lessen the strain on the abdominal muscle while coughing.3) Inhale slowly through the nose and exhale through pursed lips several times.4) Cough twice during each inhalation while contracting (pulling in) abdomen sharply with each cough.It may be necessary to use chest percusion and vibration to loosen bronchial secretions and mucus plugs that adhere to the bronchioles and bronchi and to propel sputum in the direction of gravity drainage.

Following the procedure, the amount, colour, viscosity, and character of the ejceted sputum is noted; the patient's colour and pulse are evaluated in the first few times the exercise are performed. It may be necessary to administer oxygen during postural drainage.After postural drainage, the patient is made to brush his teeth, or given oral care before resting in bed.

BIBLIOGRAPHY1) Theresamma. CP., 2006 Fundamentals of Nursing Procedure manual for General nursing & Midwifery Course. 1st Edition, Jaypee Brothers, Medical Publishers (p) Ltd., New Delhi.p:192-198.2) Nancy Sr., 2002, Principles & Practice of Nursing & Nursing arts procedures, 5th edition published & Printed by N.R. Publishers, House, Indore.p:401-412.3) LC Gupta US, Sahu, Priya Gupta, 2007 Practical Nursing Procedure. 3rd Edition, Printed at Para Offset Pvt. Ltd. New Delhi; p: 422-427. 4) Sagunthala Sharma Birpuri 1997 Principles and Practice of Nursing 1st edition Printed at Lordson Publishers (P) ltd., New Delhi. p.156-160.5) Brunner & Siddarths, 2001, Text book of Medical- surgical Nursing- 12th edition, volume2, published by Wolters Kluwer (India) pvt. Ltd New Delhi, Page No: 741-7486) Lewis, collier, Heitkemper, 1996 Medicalsurgical Nursing, 4th Edition, Mosby year book- Inc USA, Page no: 443-448

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