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Introduction ⬇

Effusions are accumulations of fluids. They may be exudates, which generally accumulate as a result of inflammation (tuberculosis, abscess, pancreatitis), lung infarct or embolus, trauma, or systemic lupus erythematosus (SLE), or transudates, which are fluids not associated with inflammation (i.e., cirrhosis, heart failure, and nephrotic syndromes). Table 11.3 compares these two types of fluids.

Fluid contained in the pleural, pericardial, peritoneal, or abdominal cavity is a serous fluid. Accumulation of fluid in the peritoneal cavity is called ascites, or peritoneal effusion.

Cytologic studies of effusions (exudates or transudates) are helpful in determining the cause of these abnormal collections of fluids. Effusions are found in the pericardial sac, the pleural cavities, and the abdominal cavity. The chief problem in diagnosis is in differentiating malignant cells from reactive mesothelial cells.

Procedure ⬆ ⬇

  1. General procedure:

    1. Obtain material for cytologic examination of effusions by either thoracentesis or paracentesis.

    2. Remember that both of these procedures involve surgical puncture or a cavity aspiration of a fluid.

    3. Fluid may be obtained in syringes, vacuum bottles, or other containers, depending on the volume of accumulated fluid. Heparin may be added to prevent clotting. Check with your laboratory for specific instructions.

  2. Thoracentesis (lung) procedure:

    1. Ensure that ultrasound is available at the patient’s bedside so that the location of fluid may be determined.

    2. Give the patient a sedative if necessary.

    3. Expose the chest. The healthcare provider inserts a long thoracentesis needle with a syringe attached.

    4. Withdraw at least 40 mL of fluid. It is preferable to withdraw 300–1000 mL of fluid.

    5. Collect the specimen in a clean container and add heparin if necessary, particularly if the specimen is very bloody (5–10 U of heparin per milliliter of fluid). Do not add alcohol.

    6. Label the specimen with the patient’s name, date and time of collection, and test(s) ordered; the source of the fluid; and the diagnosis.

    7. Send the covered specimen immediately to the laboratory. (If the specimen cannot be sent at once, it may be refrigerated.)

  3. Paracentesis (abdominal) procedure:

    1. Ask the patient to void.

    2. Place the patient in Fowler position.

    3. Give a local anesthetic agent.

    4. Introduce a No. 20 needle into the patient’s abdomen and withdraw fluid, 50 mL at a time, until 300–1000 mL has been withdrawn.

    5. Follow the same procedure for collection and transport of the specimen as for thoracentesis.

    6. For all procedures, see Chapter 1 guidelines for intratest care.

Clinical Alert

Paracentesis can precipitate hepatic coma in a patient with chronic liver disease. The patient must be continually assessed for indications of shock: pallor, cyanosis, or dizziness. Emergency stimulants should be ready

Clinical Implications ⬆ ⬇

  1. All effusions contain some mesothelial cells. (Mesothelial cells make up the epithelial layer covering the surface of all serous membranes.) The more chronic and irritating the condition, the more numerous and atypical are the mesothelial cells. Histiocytes and lymphocytes are common.

  2. Evidence of abnormalities in serous fluids is characterized by:

    1. Degenerating red blood cells, granular red cell fragments, and histiocytes containing blood. Presence of these structures means that injury to a vessel or vessels is part of the condition causing fluid to accumulate

    2. Mucin, which is suggestive of adenocarcinoma

    3. Large numbers of polymorphonuclear leukocytes, which is indicative of an acute inflammatory process such as peritonitis

    4. Prevalence of plasma cells, which suggests parasitic infestation, Hodgkin disease, or hypersensitive state

    5. Presence of many reactive mesothelial cells together with hemosiderin histiocytes, which may indicate:

      1. Leaking aneurysm

      2. Rheumatoid arthritis

      3. Lupus erythematosus

    6. Malignant cells

  3. Abnormal cells may be indicative of:

    1. Malignancy

    2. Inflammatory conditions

Interventions ⬆ ⬇

Pretest Patient Care

  1. Explain the purpose of the test and the procedure. The procedure varies depending on the site of fluid accumulation. General patient preparation includes measuring blood pressure, temperature, pulse, and respiration; administering sedation as ordered; preparing local anesthetic agent as ordered; providing emotional support; and obtaining a signed consent form.

  2. Ensure that a signed consent is in the patient’s medical record.

  3. Be aware that local anesthetic agent and sedative may be ordered to achieve a state of conscious sedation.

  4. Follow guidelines in Chapter 1 for safe, effective, informed pretest care.

Clinical Alert

Contraindications for a thoracentesis and paracentesis include an uncooperative patient, active skin infection at site of needle insertion, and uncorrected coagulopathy. Additional contraindications for a paracentesis include pregnancy, distended urinary bladder, abdominal wall cellulitis, distended or obstructed bowel, and intra-abdominal adhesions

Posttest Patient Care

  1. Review test results; report and record findings. Modify the nursing care plan as needed. Monitor according to agency protocols.

  2. Check blood pressure, pulse, and respirations every 15 minutes for 1 hour, then every 2 hours for 4 hours, and as ordered. Check temperature every 4 hours for 24 hours. Apply adhesive bandage or dressing to site of puncture. Check dressing every 15–30 minutes.

  3. Turn patient onto the unaffected side for 1 hour and then to a position of comfort. Manage pain as indicated. Measure and record the total amount of fluid removed; note its color and character.

  4. See guidelines in Chapter 1 for safe, effective, informed posttest care.

Interfering Factors ⬆ ⬇

Vigorous shaking and stirring of specimens alters results.

Reference Values ⬆

Normal

Negative for abnormal cells