الفهرس 
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Abstract
Summary
The incidence of pleural disease in the general adult population is increasing, annually affecting over 3,000 people per million populations. Thoracentesis is a common diagnostic and therapeutic procedure for PE, in which a percutaneously introduced needle is used to remove fluid from the pleural space (Fysh et al., 2020).
Critical care nurse is playing a very important role in the care of the patient undergoing thoracentesis includes accurate and frequent assessment of arterial blood gases analysis, pulmonary care, coughing and incentive spirometry, early mobilization and control of pain and shivering for the prevention of Atelectasis which inhibits diffusion of oxygen and carbon dioxide across the alveolar capillary membrane and impairs effective gas exchange (Sole et al., 2020).
The aim of this study:
This study aimed to evaluate the effect of nursing guidelines regarding safe procedure of thoracentesis on patients’ outcomes.
Research hypotheses:
The current study hypothized that:
1- The nursing guidelines regarding safe procedure of thoracentesis will improve nurses’ level of knowledge and practice.
2- The nursing guidelines regarding safe procedure of thoracentesis will significantly improve patients’ outcomes.
Study design:
A quasi experimental design was utilized to test the study hypotheses.
Research setting:
This study was conducted in thoracic diseases department, intermediate chest ICU, and thoracic intensive care units affiliated to Ain Shams University Hospital.
Subjects:
The subject of this study was composed of 2 groups, patients (control & study groups) and nurses as follow:
1- Patients:
A purposive sample of 60 patients with pleural effusion and who were undergoing thoracentesis were recruited in this study according to the pre detected inclusion criteria.
2- The nurses:
The nurses’ group was composed of 30 nurses working at the previously mentioned selected settings were included in the study. They were willing to participate in the study. The same subject group was tested in pre and post nursing guidelines program.
Study tools:
Three tools were used in conducting this study as follow:
Tool (I): Patients’ Assessment Questionnaire: (Appendix I): This tool was developed by the researcher based on review of literature, it consists of five parts:
Part 1. Patients’ Demographic Data: It was concerned with data collection about demographic characteristics of the patients under study such as patients’ age, gender, and level of education. It was composed of (6) questions.
Part 2. Patients’ Clinical Data Assessment record: It was included (9) questions about patients’ past and present medical history such as; current diagnosis, cause of PE, site of thoracentesis, method of O2 administration, nature of tapped fluid, if the patient have thoracentesis previously, taking anticoagulant medications, and having a chronic disorder.
Part 3. Patients’ Physiological Parameters record: It was used to assess patient’s (study and control group) physiological condition that involves “vital signs (P, SBP, DBP, T, R), O2 saturation, dyspnea intensity, and chest pain intensity”.
Part 4. Expected Patients’ Complications record: it was concerned with the assessment of signs and symptoms of developing complications among the studied patients undergoing thoracentesis procedure in both groups (study & control groups) which can occur during or immediately after the procedure and included (18) questions. These complications may be hypotension, bradycardia, puncture site bleeding, hematoma, pleuritic pain, transient O2 desaturation, significant cough, gasping, hemoptysis, persistent bleeding, pneumothorax, heamothorax, visceral injury, re-expansion pulmonary edema, and death.
Part 5. Patient’s level of Satisfaction Scale: It was used to assess the effect of nursing guidelines on patient satisfaction in study group post nursing guidelines implementation through using standardized scale (patient satisfaction sheet).
Tool (II): Nurses’ Assessment Questionnaire (Appendix II):
It consists of five parts:
A. Nurses’ Demographic data: They include, age, gender, qualification, and years of experience in thoracic department.
B. Nurses’ knowledge regarding thoracentesis: It included 29 MCQ questions and 16 true or false questions with total 45 questions.
B.1. Nurses’ knowledge regarding safety measures of thoracentesis procedure: It was used to assess nurses’ level of knowledge regarding safety measures of thoracentesis procedure pre and post the designed guidelines implementation. It included 15 MCQ questions and 19 true or false questions with total 34 questions.
Tool (III): Nurses’ Observational checklist (Appendix III):
It was adopted from Wiegand, (2017) and Nettina, (2019) and used to assess nurses’ level of practice regarding thoracentesis procedure pre and post the designed guidelines implementation. It was included: assessing the care of the patient with thoracentesis before the procedure, during the procedure, and post the procedure.
Designed Nursing Guidelines Related Training Program (Appendix IV):
Guidelines developed by the researcher to the studied nurses caring for patients undergoing thoracentesis in the selected setting through review of related literature. Its main purpose is to ensure that each nurse has the capability to apply the designed nursing guidelines for such group of patients.
It included the following parts:
Theoretical part: which consists of information related to; anatomy and physiology of the respiratory system; pleural effusion definition, incidence rate, pathophysiology, classifications, causes, diagnosis, and management; thoracentesis definition, causes, indications and contraindications of the procedure, explanation of the procedure, and its complications; and finally information about safety measures for thoracentesis procedure. It was developed after reviewing related literature (Lu et al., 2020, Moorhead et al., 2018).
Practical part: regarding nursing care of patients undergoing thoracentesis before, during and after the procedure, it was adopted from (Wiegand, 2017, and Nettina, 2019).
A plan for training program sessions was developed to guide the researcher in the implementation and evaluation of its effectiveness on the nurses’ knowledge and practice, and patients’ outcomes.
Main results of this study showed that:
There was statistical significant difference between study and control groups post guidelines implementation as regards pulse rate, respiratory rate and O2 saturation and a highly statistical significant difference as regards diastolic BP, but there were no statistical significant differences as regards temperature, and systolic BP.
There was a statistical significant difference regarding dyspnea intensity level, and highly statistical significant difference as regards chest pain level between study and control group post guidelines implementations.
There was a highly statistical significant differences between study and control groups post guidelines implementation as regards suspected complications such as; bleeding at insertion site, wound at insertion site, change in deep of respiration, sever chest pain, increase in respiratory rate more than 1st reading, decrease in BP less than 1st reading, and irregular heartbeat. And a statistically significant differences as regards hematoma at insertion site, temporary decrease in O2 Sat, sever cough, decrease or absent breath sound in affected side, and subcutaneous emphysema.
There was (93.3%) of the study group post the designed guidelines implementation was satisfied regarding nurses performance during procedure, and psychological support nurses provided during procedure, and (86.7%) of them were satisfied regarding provided knowledge and explanation about thoracentesis pre procedure, and regarding patient satisfaction about the final effects and the result of the procedure there was (76.7%) of the studied patients were satisfied.
There was a highly statistical significance improvement in the satisfactory level of nurses’ knowledge as regards the care of patients undergoing thoracentesis post the designed guidelines implementation compared to pre (Mean ± SD 43.366±1.691 versus 23.155±4.56) respectively with statistically significant differences at P value (0.00). Also the studied nurses` total knowledge satisfactory level pre the designed nursing guidelines implementation was 3.3%, while it was 90% post the designed nursing guidelines implementation.
There was a highly statistical significance improvement in the satisfactory level of nurses’ knowledge as regards the care of patients undergoing safety measures of thoracentesis post the designed guidelines implementation compared to pre with (Mean ± SD 31.700±1.087 versus 17.800±4.334.56) respectively with statistically significant differences at P value (0.000). Also 6.7% of the studied nurses have satisfactory level of knowledge before implementing the designed guidelines implementation, while 83.3% of them have satisfactory level of knowledge after implementing the designed guidelines implementation.
There was a highly statistical significant improvement in the nurses’ satisfactory level of practice as regards the care of patients undergoing thoracentesis post the designed guidelines implementation compared to pre with (Mean ± SD= 83.801±1.584 versus 52.866±8.807 respectively) with statistically significant differences at P value (0.000). 6.7% of the studied nurses have total satisfactory practice level before implementing the designed nursing guidelines, while 76.7 of them have satisfactory practice level after implementing the designed nursing guidelines.
There is positive correlation between total knowledge post program and total practice post program.
There was statistical significant positive correlation between total nurses’ practice regarding caring of patients undergoing thoracentesis and patients’ physiological parameters post guidelines implementation, while there was non statistical significant negative correlation between total nurses’ practice and patients’ complications pre and post designed guidelines implementation.
There is significant positive corelation between total nurses’ knowledge regarding caring of patients undergoing thoracentesis and patients’ physiological parameters, while there was highly statistically significant negative correlation with patients’ complications post designed guidelines implementation.
According to the results of this study, it was concluded from this study that, the nursing guidelines regarding safe procedure of thoracentesis documented a positive impact on the patient outcomes, as there was positive correlation between total nurses’ practice and knowledge regarding caring of patients undergoing thoracentesis and patients’ physiological parameters post guidelines implementation.
Also, there was negative correlation between total nurses’ knowledge and practice regarding caring of patients undergoing thoracentesis and patients’ complications post designed guidelines implementation.
Also the nursing guidelines regarding safe procedure of thoracentesis had appositive effect on nurses’ level of knowledge and practice post the designed guidelines implementation, and there is positive correlation between total knowledge and total practice post implementing the guidelines.
On the light of the results of this study projected the following recommendations:
Finding out the factors that hinder the nurses in providing care for patients with thoracentesis among staff nurses should be maintained in an exploratory study to find out the difficulties experienced by the nurses in providing care to the patient undergoing thoracentesis.
The Planned teaching guidelines could be maintained periodically for nurses who provide care for patients undergoing thoracentesis.
Further researches are recommended periodically to be carrying out new approaches in the area of management of thoracentesis and evaluating its reflection on patients’ outcomes taking into consideration factors affecting nurses’ performance.