Diagnostic and therapeutic procedures for lung disease (Nursing)

Thoracic puncture

• One-time stabbing of the pleural cavity in order to remove the pathological content.
• Diagnostic or therapeutic purpose.

Diagnostic purpose

• Determination of the character of the punctate.
  • Exudate – effusion of inflammatory origin.
  • Transudate – effusion of non-inflammatory origin.
  • Hemorrhagic effusion – suspected tumor, acute myocardial infarction.

Therapeutic purpose

• Remove air or effusion and allow lung expansion.
  • Fluidothorax – the presence of fluid in the pleural cavity.
  • Hemothorax – blood in the pleural cavity.
  • Chylothorax - means the presence of sap.
  • Empyema – means the presence of pus.
  • Pneumothorax – presence of air in the pleural cavity.

Injection site

• Pneumothorax – puncture the 2nd intercostal space in the medioclavicular line.
• Fluidothorax – we puncture the 8th intercostal space in the middle scapular line or in the posterior axillary line.

Patient preparation

1. Familiarizing the patient with the procedure.
   • The surgeon who will perform the chest puncture will explain everything to the patient and have him sign the informed consent.
   • Each puncture should be preceded by a chest X-ray.
2. Chest puncture aids:
   • Sterile: sterile squares and tampons, perforated drape, pean, puncture needle or disposable puncture set, connecting tube with three-way stopcock or pusher, injection needle, syringe, measuring container (to check the amount and nature of the puncture).
   • Non-sterile: disinfectant solution, plaster, local anesthetic (MESOCAIN 1%), sterile tubes for examination of punctate for microbiological, biochemical and cytological examination.

   *Tools may vary according to the requirements of individual doctors!!!

3. Patient position:
   • The patient sits cross-legged on the chair with his chest resting on the backrest.
   • Lies on the healthy side of the chest.

Workflow

1. The nurse will disinfect the chest, followed by local anesthesia and re-disinfection of the chest.
2. The doctor punctures the pleural cavity with a puncture needle with a connected connecting tube (with the pressure closed).
   • After correct impaling, a punctate will appear in the tube.
3. The doctor asks the nurse to release the pressure so that the fluid can be released.
4. The end of the puncture tube must always be below the level of the liquid in the container to prevent air from being sucked back in.
   • After draining the fluid from the chest cavity and taking the necessary sample, we close the connecting tube.
5. The doctor removes the puncture needle and the nurse covers the injection site with a sterile bandage.

Nursing care after the procedure

• The nurse observes the patient's behavior during and after the procedure.
• Measures physiological functions and evaluates his overall condition.
• According to the doctor's office, a control X-ray of the chest is performed on the patient.
• Place the patient in an elevated position.
• The nurse will record everything in the documentation (procedure, patient condition, procedure time, amount and nature of punctate, examination for which the punctate was sent, possible complications).
• He confirms the record with his signature.

Complications

• Hypotension.
• Lung damage.
• Liver damage.

Bronchoscopy

• Endoscopic examination method, which is used for the optical examination of the lower respiratory tract, i.e. trachea and bronchi.

Bronchoscopy

• It is performed in an endoscopy clinic or ward, in the department of intensive care and resuscitation - the necessity of monitoring physiological functions.
• The examination is usually performed on an empty stomach.
• Before the examination, the patient should have basic samples taken - biochemical blood test, or urine, blood count and coagulation.
• Bronchoscopy is performed by a doctor under topical or general anesthesia (less common).
• During the examination, it is possible to take samples for microbiological or histological examination.

Types of bronchoscopes

1. Rigid bronchoscope.
   • A thin, hollow, about 40 cm long metal tube, which is equipped with optics and a cold (non-burning) light source at the end.
   • It can be used when taking a large amount of tissue (biopsy) or when removing foreign bodies from the airways.
2. Flexible Bronchoscope.
   • More often used in practice, it is also suitable for small children.
   • Diameter 2-3 mm, optical fibers are arranged inside the bronchoscope, which are flexible and at the same time conduct light.
   • It is used to suck out secretions, blood, pus, remove foreign bodies, apply drugs to the desired places, and find sources of bleeding.

Indication

• Diagnostic.
  • Microscopic assessment of airways.
  • Checking the position of the ETK, TS cannula.
  • Decrease in SaO₂.
  • Clarification of airway narrowing.
  • Sampling of bronchial secretions.
  • Early diagnosis of cancer.
• Medicinal.
  • Removal of foreign bodies.
  • Building bleeding.
  • Cleansing the bronchi if the patient is unable to clear the cough by himself.

Utilities

• Bronchoscope, light source, aspirator.
• Sterile mask, gown.
• Physiological saline solution.
• Silicone spray.
• Tubes for collecting biological material.
• Sterile gloves.

Patient preparation

• The doctor explains everything to the patient and has him sign the informed consent → the exception is the patientt unconscious.
• Place the patient in a horizontal position.
• We will insert an anti-test insert into the mouth.
• We apply medicines according to the doctor's office.

Assistance of nurses to doctors

• The doctor puts on an empyrean, mouthpiece, gloves → the nurse connects the bronchoscope to the light source and the aspirator.
• Spray the bronchoscope with silicone spray.
• Holds the test insert, ETI or TS cannula during the examination.
• Monitors physiological functions, mainly SaO₂.
• Application of medicines to the respiratory tract according to the doctor's office.
• Collection of biological material.
• After the bronchoscopy, the nurse cleans the bronchoscope.

Patient care after the procedure

• The patient is taken to bed and his general state of health, especially BREATHING, is monitored for several hours.
• The patient has not eaten anything for at least two hours.
• If the patient will be discharged home, the rest regime must be observed throughout the day.

Nursing Diagnoses

• 'Fear and restlessness due to ignorance of bronchoscopic or puncture examination.
  • Goal: calm patient.
  • Intervention:
    • Empathetic approach, listening to the patient, answering questions.
    • Inform the patient about the entire examination, its course and subsequent steps after the examination.

• Risk of infection, sepsis, due to non-compliance with asepsis principles.
  • Goal: prevent sepsis.
  • Intervention:
    • Consistency in observing the principles of hand hygiene, consistent disinfection in the area of the procedure (puncture).
    • Adherence to procedures, nursing standards.
    • Monitor the area around the injection site, pain during puncture X monitor cough, mucus production after bronchoscopy.
    • Record the data found in the documentation.

• Risk of airway damage during bronchoscopic examination.
  • Goal: respiratory tract damage will not occur X early detection of respiratory tract damage.
  • Intervention:
    • Instructing the patient about the necessity of cooperation during the examination and warning of possible risks.
    • Administration of medicines according to the doctor's office.
    • Proper education of the patient during the procedure, timely response to his difficulties.
    • Ensuring a suitable position and maintaining it throughout the examination.
    • Striving for good psychological well-being of the patient.
    • Agree with the patient in advance the signals by which the patient can communicate with us during the examination.

Links

References

• MGR. ANDREA MILTNER,. Diagnostic and therapeutic procedures for lung diseases [lecture on the subject Module UPV, field Intensive care nurse - postgraduate study, Higher vocational school, secondary and higher medical school, Ústí nad Labem]. Usti nad Labem. 16.12. 2012.
• KAPOUNOVÁ, Gabriela. Ošetřovatelství v intenzivní péči. 1. edition. Prague : Grada, 2007. 350 pp. ISBN 978-80-247-1830-9.

• SAFRÁNKOVÁ, Alena – NEJEDLÁ, Marie, et al. Interní ošetřovatelství I. 1. edition. Prague : Grada, 2006. 280+4 pp. color appendices pp. ISBN 978-80-247-1148-5.

• DOENGES, Marilynn E – MOORHOUSE, Mary Frances. Kapesní průvodce zdravotní sestry. 2. edition. Prague : Grada, 2001. ISBN 80-247-0242-8.