diagnostic investigation

2. DIAGNOSTIC PROCEDURE OF
RESPIRATORY SYSTEM
Prepared by:
Roshna Adhikari
Roll No. : 1
BNS 2nd Year

3. Specific Objectives
• To define bronchoscopy, it’s purposes, types, and
complications
• To list the nursing management of bronchoscopy
• To introduce pulmonary angiography, it’s indication,
contraindication and complications
• To list about nursing intervention of pulmonary
angiography

4. Cont.…
• To introduce laryngoscopy and it’s indication
• To explain about nursing consideration of laryngoscopy
• To introduce thoracocentesis, it’s indication, purposes,
complications and contraindication

5. Cont....
• To explain about pre-procedure, intra procedure and post
procedure nursing management of thoracocentesis.
• To introduce thoracoscopy , it’s indication, procedure and
complication
• To state about nursing interventions of thoracoscopy.

6. Bronchoscopy

7. Introduction
• Bronchoscopy is the direct
inspection and examination of
larynx, trachea and bronchi
through either a flexible fiberoptic
bronchoscope or rigid
bronchoscope. The fiberoptic
bronchoscope is used more
frequently in current practice.

8. Therapeutic Uses
• Remove foreign bodies from the tracheobronchial tree.
• Remove secretions obstructing the tracheobronchial tree when
the patient cannot clear them.
• Treat postoperative atelectasis.

9. Diagnostic Uses
• To examine tissues or collect secretions
• To determine the location and extent of the pathologic process
and to obtain a tissue sample for diagnosis
• To determine if a tumor can be resected surgically.
• To diagnose bleeding sites diagnostic uses.

11. Types of bronchoscope
Fiber optic bronchoscope
• It is a thin, flexible bronchoscope that can be directed into
the segmental bronchi.
• Small size, flexible and excellent optical system increases
visualization which is ideal for pulmonary lesion

12. • Can be performed through endotracheal or tracheostomy
tubes on ventilators.
• Cytologic examinations can be performed without surgical
intervention.
• Can be performed at the bedside.

13. Cont…
Rigid bronchoscope
• It is a hollow metal tube with a light at its end.
• Used for removing foreign substances
• Used for investigating the source of massive hemoptysis,
or performing endobronchial surgical procedure.
• Performed at operating room not at bedside.

14. Complications
• Reaction to the local anesthetic.
• Infection
• Aspiration
• Bronchospasm
• Hypoxemia
• Pneumothorax , bleeding, and perforation

15. Nursing Considerations
• Before the procedure, a signed consent form is
obtained from the patient.
• Food and fluids are withheld for 6 hours before the
test to reduce the risk of aspiration when the cough
reflex is blocked by anesthesia.
• The patient must remove dentures and other oral
prostheses.

16. Cont…
• The nurse explains the procedure to the patient to reduce fear
and decrease anxiety and administers preoperative medications
(usually atropine and a sedative or opioid) as prescribed to inhibit
vagal stimulation (thereby guarding against bradycardia,
dysrhythmias, and hypotension), suppress the cough reflex,
sedate the patient, and relieve anxiety.

17. cont....
• The examination is usually performed under local anesthesia,
but general anesthesia may be needed for rigid bronchoscopy
• A topical anesthetic such as lidocaine (Xylocaine) may be
sprayed on the pharynx or dropped on the epiglottis and vocal
cords and into the trachea to suppress the cough reflex and
minimize discomfort

18. Cont…
• Sedatives or opioids are administered intravenously as
prescribed to provide moderate sedation.
• After the procedure, it is important that the patient takes
nothing by mouth until the cough reflex returns, because the
preoperative sedation and local anesthesia impair the
protective laryngeal reflex and swallowing for several hours

19. Cont…
• In the elderly patient assess for confusion and lethargy which may
be due to the large doses of lidocaine administered during
procedure .
• Once the patient demonstrates a cough reflex, the nurse may offer
ice chips and eventually fluids

20. Cont…
• Monitor the patient's respiratory status and observes for hypoxia,
hypotension, tachycardia, dysrhythmias, hemoptysis, and dyspnea.
Any abnormality is reported promptly.
• The patient is not discharged from the recovery area until
adequate cough reflex and respiratory status are present.

21. Cont…
• The patient is not discharged from the recovery area until
adequate cough reflex and respiratory status are present.
• Instruct the patient and family caregivers to report any
shortness of breath or bleeding immediately.

22. Pulmonary Angiography

23. Introduction
• Pulmonary angiography is most commonly used to investigate
thromboembolic disease of the lungs, such as pulmonary emboli
and congenital abnormalities of the pulmonary vascular tree.
• It involves the rapid injection of a radiopaque agent into the
vasculature of the lungs for radiographic study of the pulmonary.

24. catheter selection is done (pigtail catheter)

25. Cont…
• It can be performed by injecting the radiopaque agent into a vein
in one or both arms (simultaneously) or into the femoral vein, with
a needle or catheter
• The agent also can be injected into a catheter that has been
inserted in the main pulmonary artery or its branches or into the
great veins proximal to the pulmonary artery.

26. Indication

27. Indications
• Pulmonary embolism
• Retrieval of foreign objects ( embolized catheter fragments )
• Right heart failure
• Severe hypoxemia .
• Free floating right ventricular thrombus

28. Contraindications
• Allergy to the radiopaque dye,
• Pregnancy, and
• Bleeding abnormalities

29. Potential complications
• Acute renal failure,
• Acidosis,
• Cardiac dysrhythmias,
• Bleeding

30. Nursing Interventions
• The nurse should verify that informed consent
• Assess for known allergies that may suggest allergies to radio
opaque dye(e.g, iodine and shellfish)
• ensure that the patient has not eaten or had anything to drink pre
procedurally as prescribed(normally for 6 to 8 hours) and administer
preprocedure medications that may include antianxiety medications,
secretion-reducing agents, and antihistamines.

31. Cont…
• Assess anti coagulation status and renal function
• The nurse should instruct patients that they may experience a
warm flushing sensation or chest pain during the injection of
the dye

32. Cont…
• Monitor vital signs, level of consciousness, oxygen saturation, and
the vascular access site for bleeding or hematoma, and perform
frequent assessment of neuro vascular status.

34. Laryngoscopy

35. Introduction
• Laryngoscopy is visual examination of larynx using a
fiberoptic endoscope.
• It can be performed during bronchoscopy or as a separate
procedure used to diagnose laryngeal papilloma, nodule,
polyps or cancer.

36. Indication
• Any patient with symptoms referable to the throat such as:
• Dysphagia
• Globus sensation
• Hoarseness
• It is good choice for initial examination of hypo pharynx in all
patient presenting to the otolaryngologist

37. Direct laryngoscopy Indirect laryngoscopy

38. Nursing Consideration
• Make sure consent is taken.
• For the direct laryngoscopy the client is prepared as a surgical
procedure.
• Food and fluids are withheld for 4-6 hours to prevent regurgitation
and possible aspiration.

39. Cont…
• The client is given a pre-operative sedation.
• If the laryngoscopy is to be done under general anesthesia a
written consent is obtained.
• If the laryngoscopy is done under local anesthesia throat is spread
with topical anesthetic
• Explain that the study takes about 30 minutes,it takes longer if
minor surgery is performed as a part of procedure.

40. Cont…
• If biopsy or excision of tissue is expected the necessary articles are
kept ready. The procedure is done under strict aseptic technique.
• Following laryngoscopy the client who had general anaesthesia is
kept flat in bed without a pillow under the head. If it is done under
local anaesthesia the swallowing reflexes are absent in the client;
therefore the client is kept in a side-lying position to drain the saliva.

41. Post procedure
• Place the conscious patient in semi-Fowler’s position. Place the
unconscious patient on his side with his head slightly elevated to
prevent aspiration.
• If the procedure done under local anesthesia the swallowing
reflexes are absent ,therefore the client is kept in side-lying position
to drain the saliva.

42. Cont…
• Check the vital signs every 15 minute until patient is stable and then
ever 30 minutes for 2 hours and then 4 hourly for 24 hours.
• Listen the patient neck’s with stethoscope for the signs of stridor and
airway obstruction.
• The client is given nothing to oral intake until the gag reflex returns
• Before oral feeds are started ,provides sips of water to check client’s
ability to swallow

43. Cont…
• Watch for signs of complications. The following signs and
symptoms may be looked for, especially if a biopsy was done:
•Coughing and spitting of blood
•Pain in the throat and neck
•Swelling of the throat and neck
•Restlessness and breathing difficulty
•Impaired respiration

44. Cont…
• Record the procedure in the nurses record with date and time
• Note allergies, history of hypersensitivity to anesthetic
• Laryngoscope should be inserted through keeping patient in supine
position with the head extended ,for better visualization .
• After procedure keep client in semi-flowers position
• Assess for respiratory difficulty, rate, pattern (dyspnea may result
from laryngospasm. )

46. Contraindication of laryngoscopy
• Disease or injuries of cervical spine.
• Moderate or marked respiratory obstruction unless the air
way has been provided by tracheostomy.
• Recent coronary occlusion or cardiac decompensation.

47. complication of laryngoscopy
• Injury to lips and tongue if they are nipped between the
teeth and the laryngoscope.
• Injury to teeth .They might be dislodged and fall into
pharynx.
• Bleeding
• Laryngeal oedema.

48. Thoracocentesis

49. Introduction
• Thoracocentesis is an invasive procedure that involves insertion of
needle into the pleural space for removal of fluid or air. Pleural fluid
is removed to therapeutically relieve pain or shortness of breath
caused by excessive pleural pressure.

50. cont...

51. Purposes.
• To remove the air and fluid from pleural cavity
• To decrease pressure on the lung tissue
• To aspirate pleural fluid for diagnostic studies
• To instill the medication in the pleural space
• To perform pleural biopsy.

52. Indications
• Traumatic pneumothorax
• Hemopneumonthorax
• Spontaneous pneumothorax
• Broncho pleural fistula
• Pleural effusion

53. Contraindication
• Bleeding disorder
• Taking blood thinners
• With heart failure or enlargement of the trapped lung
• Uncooperative patient

54. Complications
• Pulmonary edema
• Pneumothorax,
• Tension pneumothorax,
• Subcutaneous emphysema,
• Pyrogenic infection
• Cardiac distress can occur after a sudden shift in mediastinal
contents when large amounts of fluid are aspirated.

55. Nursing management
Before the procedure
• Verify a signed informed consent for the procedure. This invasive
procedure requires informed consent.
• Assess knowledge and understanding of the procedure and its
purpose; provide additional information as needed.
• A person who is fully informed will be less apprehensive and more
able to cooperate during the thoracentesis.

56. Cont...
• Pre-procedure fasting or sedation is not required.
• Local anesthesia is used in this procedure and the gag and cough
reflexes remain intact.
• Administer a cough suppressant if indicated. Movement and
coughing during the procedure may cause inadvertent damage to
the lung or pleura.

57. Cont...
• Obtain a thoracentesis tray, sterile gloves, injectable lignocaine,
povidone-iodine, dressing supplies and an extra over-bed table or
Mayo stand. These supplies are used by the doctor performing the
procedure.
• Position the person upright, leaning forward with arms and head
supported on an anchored over-bed table. This position spreads the
ribs, enlarging the intercostal space for needle insertion.

58. Cont…
• Inform the person that, although local anesthesia prevents pain as
the needle is inserted, a sensation of pressure may be felt. A
pressure sensation occurs as the needle punctures the parietal .

59. Cont…
During And After Procedure
• Monitor pulse, colour, oxygen saturation and other signs during
thoracentesis. These are indicators of physiological tolerance of the
procedure.
• Apply a dressing over the puncture site and position on the
unaffected side for 1 hour. This allows the pleural puncture to heal.

60. Cont…
• Label obtained specimen with name, date, time, source; send specimen
to the laboratory for analysis. Fluid obtained during thoracentesis may
be examined for abnormal cells, bacteria and other substances to
determine the cause of the pleural effusion.
• During the first several hours after thoracentesis, frequently assess and
document vital signs; oxygen saturation; respiratory status, including
respiratory excursion, lung sounds, cough or haemoptysis; and
puncture site for bleeding or crepitus.

61. Cont…
Frequent assessment is important to detect possible
complications of thoracentesis, such as pneumothorax.
• Obtain a chest x-ray. Chest x-ray is ordered to detect possible
pneumothorax.
• Normal activities generally can be resumed after 1 hour if no
evidence of pneumothorax or other complication is present. The
puncture wound of thoracentesis heals rapidly.

62. Thoracoscopy

63. Introduction
• Thoracoscopy is a diagnostic procedure in which the pleural cavity
is examined with an endoscope fluid and tissue can be obtained for
analysis.
• Small incisions are made into the pleural cavity in an intercostal
space; the location of the incision depends on the clinical and
diagnostic findings.

64. Cont…
• After any fluids present in pleural cavity is aspirated ,the fiberoptic
mediastinoscope is insert into the pleural cavity, and its surface is
inspected through the instrument.
• After the procedure, a chest tube may being inserted, and the
pleural cavity is drained by negative-pressure water-seal drainage

65. chest tube

66. Indication
Diagnostic indication
• Pleural effusions, pleural
disease.
• Staging of tumors
• Biopsies of the lesions can
be performed under
visualization for diagnosis.
Therapeutic indication:
• Pleural effusion
• Pneumothorax.
• Empyema
• Pulmonary and pleural
masses

67. Procedure
• Thoracoscopy is performed in the operating room.
• Patient is given general anesthesia.
• Positioned in the lateral decubitus position with the involved side up.

68. Lateral decubitus position

69. Cont…
• Small incisions are made into the pleural cavity in an intercoastal
space, the location indicated by clinical and diagnostic findings.
• The fiberoptic mediastinoscpeis inserted into the pleural cavity, any
fluid present is aspirated, and the pleural cavity is inspected
through the instrument.
• After the procedure, chest tube may be inserted to facilitate re-
expansion of the lung

70. Cont…
• Chest tube is removed after chest x-ray confirms re-expansion.
• Thoracoscopic procedures have expanded with the availability of
video monitoring, which permits improved visualization of the lung

72. Pre-procedure
• Explain the patient about procedure.
• Ensuring that the informed consent is taken.
• Make sure that pulmonary function, coagulation tests,
electrocardiography and chest x-ray have been performed.
• Patient remains NPO for 10-12 hours prior to procedure.

73. Post-procedure:
• Monitor vital signs every 15 min for 1 hour, every hour for 2 hour
and then every 4 hour.
• Patient must remain NPO until gag reflex returns.
• Assess pain level of patient.
• Assess for respiratory status.

74. Cont…
• Look for the sign of bleeding and infection at the incisional site.
• Assess for shortness of breathe as it may indicate a pneumothorax
and should be reported immediately.
• If the chest tube is inserted during the procedure, monitoring of
chest drainage system and chest tube insertion site is essential

75. Complications:
Major complications:
• Empyema
• Hemorrhage
• Postoperative pneumothorax
and pneumonia
• Persistent air leak
Minor complications
• Subcutaneous emphysema
• Minor hemorrhage
• Operative site infection

77. Assignment:
Write down the nursing intervention of thoracoscopy before during
and after procedure.

78. References
• Joyce.M .Black: Medical Surgical Nursing.7th edition. Elsevier.
• Basavanthappa BT: Medical Surgical Nursing.1st edition. Jaypee
Brothers Medical Publishers Pvt.Ltd. (2003)
• Mandal.G.N: Text book of Medical Surgical Nursing. 5th
edition,Makalu Publication House, Dillibazar, Kathmandu.(2016)

79. Cont…
• Hinkle, J.L and Cheever K.H. Brunner and suddarth`s textbook of
medical-surgical nursing (12th edition). Philadelphia: Lippincott
Williams and Wilkins (2010)
• Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding,
M.M. (2017). Medical-Surgical Nursing: Assessment and
Management of Clinical Problems (10th ed.). St. Louis: Elsevier.
• Retrieved from: http://www.mayoclinic.com/health/respiratory
diagnostic procedure on 2023/01/23 at 11am