Neurovascular bundle | Respiratory system diseases | NCLEX-RN | Khan Academy
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Neurovascular bundle | Respiratory system diseases | NCLEX-RN | Khan Academy

September 11, 2019

Voiceover: So, when an individual
has a pleural effusion, one of the more common
procedures that’ll we do to clear that effusion
is to do a thoracentesis, and a thoracentesis essentially is, we will go in with a needle,
right, and we’re going to inject the needle into that pleural space, and we’re going to withdraw
or aspirate all of that fluid. So, the image that you are looking at, I know it looks a little busy or crazy, but let me explain what
we’re looking at here. So, here’s a lung, okay? So, this is like we’re
doing a cross section view of a space, so we can see
this pleural effusion. So, here’s just part of the lung, and we’re looking at the base. This is a lung base. Here is the actual effusion, right? So, that’s the fluid. So, this means that this
is our pleural space here, and, of course, that
this darker pink color, that would be our visceral
membrane or visceral pleura, and then this yellow color
here, this in-between wall, that would be our parietal. I’m going to write that there. And then here, these little white dots, this is our ribs, right? So, we’re looking at our ribs like cut down through the cross section. In between our ribs, we
can see that we have our intercostal muscles, and then,
on the outside of our ribs, so, this would essentially
be our subcutaneous, right? So, I’m going to write SQ. That’s our subcutaneous tissue. That’s our fatty tissue. And then, outside of that,
well, this is just our skin. So, entry would be this, entry would be going in with the needle. Here’s my needle, going through the skin, through the fat, through the
muscle in between the ribs, into this pleural space, to get that fluid and drain it back out. So, that’s what we’re looking
at, just that same way. So, I’m going to take away
my needle, so we can talk a little bit more about
what we’re looking at. So, what’s important about
doing a thoracentesis is making sure that we’re
using the right technique so we don’t damage the tissues, and we don’t cause any
harm to the patients. Now, for this particular
image that we’re looking at, we want to make sure that we are careful with the VAN bundle, and this stands for our vein,
artery, and nerve bundle. Now, if you look here, and I’ll zoom in, you look here, right underneath, so this inferior portion of each rib, we have this bundle,
and I have them colored red, blue, and yellow. Our red is going to represent our artery, the blue is going to represent our vein, and the yellow will represent our nerve. So, we have a bundle of
all three of these things right underneath each rib. What does this mean? Well, when we’re doing a thoracentesis, again, when we’re going in with our needle into this space, we need
to be careful, boom, we need to be careful that
we don’t hit that VAN, and the reason for that is our
vein, artery, nerve bundle, it really is responsible
for a lot of things. So, imagine if we nicked an artery. We could be looking at severe bleeding, hemorrhaging, right? Right into this space, which
could lead to hypotension, so really dangerously low blood pressure, because we’re losing the fluid. We could go into shock. If by accident we injured that nerve, well, then we could lose
respiratory function, because that nerve, and I’m
abbreviating respiratory, that nerve actually controls
some of our muscle movement. So, just think about
all the terrible things that could happen if we
accidentally hit the VAN. We would really be putting this patient at a large potential of risk
and for some serious damage. So, when we are doing a thoracentesis, there is a proper way that
we should be doing it. First of all, always ultrasound-guided. So, I’ll put US, ultrasound,
always ultrasound-guided, because we want to make
sure that we’re visualizing where we’re going, so we
don’t cause any damage. Normally, when we’re
doing a thoracentesis, we go above the ninth rib. So, let’s just say that this
guy here, this is my ninth rib. So, I’m going to go
right above the ninth rib with my needle, right above it. My needle curved a little bit, but we’ll say we’re going straight, right into the pleural space, and I’m going to withdraw the fluid. The reason why I’m going
right above the ninth rib, one is because by going above the rib, I’m avoiding that nerve,
artery…vein, artery, nerve bundle, excuse me, and
the ninth is kind of like our landmark, and the reason is, is that it’s low enough
at the base of the lungs, because remember gravity,
this person is sitting up during the thoracentesis, so that means that all the fluid is
going to go to the bottom, so it’s low enough that
we can collect fluid at the base of the lung
but not too low that we hit the diaphragm by accident. So, this is going to be my ninth rib. Now, when we do that thoracentesis, we know that what we’re doing, we go in with the needle, and
essentially on the other side, what’s happening is that
we’re having the fluid drain out through the needle. Actually, let me change the color. So, we’re going to have
the fluid drain out through the needle, and
that’s going to go into some kind of collection container. So, that can be like a vial that we have, and that’s a pretty bad
vial, or it can go into a collection bag, and we
want to make sure that we collect this fluid,
that way we can test it, and what we’ll do is,
we’ll use Light’s criteria to test it to tell if
it’s a transudate fluid or it’s an exudate fluid, and this way, we know what caused it. So, it’s really important
that we’re careful not to hit that VAN bundle, or else
we can cause some damage. So, just by remembering the hallmarks, so here’s our ninth rib,
that’s really a good spot that we want to be going into, and ultrasound-guided, of
course, so we can make sure that we don’t cause any
harm to the patient.

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