Chest tube - Ati templete PDF

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Summary

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Description

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Therapeutic Procedure

Yesenia Luna STUDENT NAME _____________________________________ Chest tube PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________

Description of Procedure Used to remove abnormal accumulations of air and fluid from the pleural space.

Indications Pneumothorax, hemothorax

CONSIDERATIONS

Nursing Interventions (pre, intra, post) Pre:Instruct the patient regarding the purpose of the procedure, what to expect, and sign and symptoms to report. Administer ordered analgesia as needed. Post:Assure chest x-ray is obtained after insertion and after removal Verify patient knows potential complications (dyspnea, hemoptysis, etc.) and what to do should they occur Position the drainage system in upright position, below level of the heart at all times. Place emergency equipment in patient's room (bottle of sterile NS, 4 x 4, Vaseline gauz tape & non-toothed padded clamps) Assure that extra drainage collection system is readily available on the unit Reposition patient q 2 hours Change dressing qd, or more frequently, if it becomes soiled, saturated, loose, or as otherwise instructed by prescriber Never clamp a chest tube, except momentarily, when: A. changing the chest tube system B. assessing for location of air leak C. assessing patient's tolerance of chest tube removal

Outcomes/Evaluation

drain air, blood, or fluid from the space surrounding pleural space

Potential Complications

Pain, vascular injury, improper positioning of the tube, inadvertent tube removal, postremoval complications, longer hospital stays.

Client Education Making sure not to lie on the chest tube and making sure it's not kinked or being pulled. Keeping the collection container upright and below chest level. Sitting position to help promote drainage into the collection device. Coughing and breathing exercises.

Nursing Interventions Pre:Assess patient's breath sounds, heart rate, blood pressure, temperature, respiratory rate and rhythm and O2 saturation. Assess patient allergies. Assure O2 and suction are available at bedside. Post:Immediately after insertion: A. insertion site, location and tube size Immediately after insertion and q 4 hours while chest tube is in place assess drainage collection system for: A. fluctuations in the air leak indicator B. air bubbles in the air leak indicator C. suction set at ordered level. Immediately after insertion, q 4 hours while chest tube is in place, and immediately after removal of chest tube assess: A. comfort level B. breath sounds, heart rate, blood pressure, temperature, respiratory rate and rhythm and O saturation C. drainage for amount, color and consistency D. dressing for occlusiveness and drainage from insertion site E. chest wall at insertion site for subcutaneous emphysema While chest tube is in place and drainage collection system is in use A. Mark volume of drainage (date, time and initial) qs

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