PROCEDURAL GUIDELINES (to accompany Chapter 20)
Assisting the Patient Undergoing Thoracentesis
Equipment
•   Thoracentesis tray (should include standard supplies needed to  •  Local anesthetic
perform procedure)
•  Sterile gloves
Implementation
Nursing Actions
1. Ascertain in advance that a chest x-ray or ultrasound has
been ordered and completed and the consent form has
been signed.
2. Take “Time Out” with patient and healthcare providers.
Verify patient’s identity using at least two identifiers, not
including the patient’s room number. Verify purpose of
procedure and procedure site; assess patient for allergies to
latex, antiseptic, or local anesthetic; and review coagulation
status (prothrombin time/INR [international normalized ratio]
and platelet count).
3. Inform the patient about the nature of the procedure as
well as:
a. The importance of remaining immobile.
b. Pressure sensations to be experienced.
c. That minimal discomfort is anticipated after the
procedure.
4. Obtain baseline vital signs, oxygen saturation, pain level,
and respiratory status. Administer sedation if prescribed.
5. Position the patient comfortably with adequate supports. If
possible, place the patient upright or in one of the following
positions:
a. Sitting on the edge of the bed with the feet supported
and arms on a padded over-the-bed table.
b. Straddling a chair with arms and head resting on the
back of the chair.
c. Lying on the unaffected side with the head of the bed
elevated 30° to 45° if unable to assume a sitting position.
Pleural effusion
LWBK1592-CH20_online.indd 1
•  Antiseptic solution
•   Sterile collection bottles, laboratory requisition forms,  
and labels
Rationale
1. Chest x-ray films are used to localize fluid and air in the
pleural cavity and to aid in determining the puncture site.
When fluid is loculated (isolated in a pocket of pleural fluid),
ultrasound scans are performed to help select the best site
for needle aspiration.
2. Verification maintains patient safety and prevents potential
complications such as allergic reactions and bleeding.
3. An explanation helps to orient the patient to the procedure,
assists the patient to mobilize resources, and provides an
opportunity to ask questions and verbalize anxiety.
4. Provides preprocedure assessment data to guide sedation
administration and postprocedure assessment. Sedation
enables the patient to cooperate with the procedure and
promotes relaxation.
5. The upright position facilitates the removal of fluid that usu-
ally localizes at the base of the thorax. It expands the ribs
and widens the intercostal space to aid needle insertion.
A position of comfort helps the patient to relax and pre-
vents patient movement that could contribute to potential
complications.
7/25/17 5:50 PM
 PROCEDURAL GUIDELINES (to accompany Chapter 20)
Assisting the Patient Undergoing Thoracentesis (continued)
Nursing Actions
6. Support and reassure the patient during the procedure.
a. Prepare the patient for the cold sensation of skin antisep-
tic solution and for a pressure sensation from infiltration
of local anesthetic agent.
b. Encourage the patient to refrain from coughing.
7. Expose the entire chest. The site for aspiration is visualized
by chest x-ray and percussion. If fluid is in the pleural cav-
ity, the thoracentesis site is determined by the chest x-ray,
ultrasound scan, or fluoroscopy and physical findings, with
attention to the site of maximal dullness on percussion.
8. The procedure is performed under aseptic conditions. After
the skin is cleansed, the physician uses a small-caliber
needle to inject a local anesthetic slowly into the intercostal
space.
9. The physician advances the thoracentesis needle with the
syringe attached. When the pleural space is reached, suc-
tion may be applied with the syringe.
a. A 20-mL syringe with a three-way stopcock is attached
to the needle (one end of the adapter is attached to the
needle and the other to the tubing leading to a receptacle
that receives the fluid being aspirated).
b. If a considerable quantity of fluid is removed, the needle
is held in place on the chest wall with a small hemostat.
10. After the needle is withdrawn, pressure is applied over the
puncture site and a small, airtight, sterile dressing is fixed in
place.
11. Advise the patient that a chest x-ray will be obtained after
thoracentesis and activity will be limited for the first hour.
12. Record the total amount of fluid withdrawn from the proce-
dure and document the nature of the fluid, its color, and its
viscosity. If indicated, prepare samples of fluid for labora-
tory evaluation. A specimen container with formalin may be
needed for a pleural biopsy.
13. Monitor the patient at intervals for increasing respiratory
rate; asymmetry in respiratory movement; dyspnea; dimin-
ished breath sounds; anxiety or restlessness; tightness in
chest; uncontrollable cough; blood-tinged, frothy mucus; a
rapid pulse; pain; and signs of hypoxemia.
Adapted from: Caple, C. & Heering, H. (2016). Thoractentesis: Assisting with. In D. Pravikoff (Ed.). Nursing practice and skill. Glendale,
CA: CINAHL Information Systems.
LWBK1592-CH20_online.indd 2
Rationale
6. Sudden and unexpected movement, such as coughing, by
the patient can damage the visceral pleura and lung.
7. If air is in the pleural cavity, the thoracentesis site is usually
in the second or third intercostal space in the midclavicular
line, because air rises in the thorax.
8. An intradermal wheal is raised slowly; rapid injection causes
pain. The parietal pleura is very sensitive and should be well
infiltrated with anesthetic before the physician passes the
thoracentesis needle through it.
9. The use of a thoracentesis needle allows proper insertion.
a. When a large quantity of fluid is withdrawn, a three-way
stopcock serves to keep air from entering the pleural
cavity.
b. The hemostat steadies the needle on the chest wall.
Sudden pleuritic chest pain or shoulder pain may indicate
that the needle point is irritating the visceral or the dia-
phragmatic pleura.
10. Pressure helps to stop bleeding, and the airtight dressing
protects the site and prevents air from entering the pleural
cavity.
11. A chest x-ray verifies that there is no pneumothorax.
12. The fluid may be clear, serous, bloody, or purulent and
provides clues to the pathology. Bloody fluid may indicate
malignancy, whereas purulent fluid usually indicates an
infection.
13. Pneumothorax, tension pneumothorax, subcutaneous
emphysema, and pyogenic infection are complications of
a thoracentesis. Pulmonary edema or cardiac distress can
occur after a sudden shift in mediastinal contents when
large amounts of fluid are aspirated.
7/25/17 5:50 PM