Chest Tubes PDF

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chest tubes...

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a) wet suction system i) Has 3 chambers-collection, water seal and suction ii) Sterile water added to water seal at 2cm line and suction control chamber at -20cm line. Sterile water is added to suction source as well. (want bubbling in suction control chamberindicates strength of the suction.) iii) Additional suction may be added to a suction source

1) Chest Drainage system a) Drain that removes air, fluid, or blood from the pleural space; restores negative pressure to the pleural space; re-expand a collapsed lung or partially collapsed lung; and prevent reflux of drainage back into the chest. b) The whole system is based on maintaining “negative intra-thoracic pressure”(water seal) c) Each time patient exhales- air is trapped in pleural space and it travels down the chest tube to water seal. The water seal allows air to escape but prevents air from getting back into the lungs. 2) Indications a) Pleural effusion b) Hemothorax c) Pneumothorax d) Empyema e) Tension pneumothorax f) Thoracic surgery

g) 3) Pleural Space a) Normally pleural space has some fluid in it. b) This fluid helps your lungs move smoothly when you breathe. c) Sometimes too much fluid builds up in pleural space which makes it difficult to expand lungs and patient may develop shortness of breath. 4) Mechanisms of breathing/physiology a) Principle of negative pressure b) Pressure in chest is lower than atmosphere c) When chest is opened there is a loss of negative pressure d) When air/fluid enter the space the pressure is disrupted 5) Chest tube a) Can be placed right and left pleural spaces and mediastinum b) Transparent tube with radiopaque markers c) Openings must be placed within chest tube d) Larger tubes 28-40 fr drain fluid e) Smaller tubes drain air 16-24fr f) After insertion sutured in place and connected to drainage system

i) 6) Chest tubes a) Suction source b) Collection chamber c) Mechanism to prevent air from reentering the chest(water seal) 7) Drainage system

8) 9) Drainage system a) Dry suction system i) Has three sections- collection, water seal and suction ii) Sterile water added to water seal chamber at 2cm line iii) Mechanical regulator used for suction controlfloat device iv) There should be no bubbling in water seal chamber

10) a) Water seal prevents air from moving back into chest b) Increase in water level during inspiration and back during expiration(tidaling) c) Tidaling- movement of water level with respiration.

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12) 13) Chest Drainage system 14) Collection chamber a) Any drainage from the chest flows into this chamber. 15) Water seal a) Allows air to exit the pleural space on exhalation and prevents air from entering the pleural space on inhalation 16) Chest drainage system a) Suction control chamber i) The setting of the suction control dial determines the approximate amount of suction imposed. ii) Wet suction- gentle bubbling in suction control indicates suction is working. iii) Dry suction- orange float shows in the indicator window.

17) 18) Chest tube placement a) May be done at bedside, ER or OR b) Air removal- 2nd intercostal space, mid-clavicular line c) Fluid removal- 4-6th intercostal space d) Explain procedure, consent and administer analgesics e) After procedure connect chest tube to drainage system f) Petroleum gauze and 4x 4 at insertion site g) Chest x-ray post insertion h) Make sure all connections are secure

19) 20) Nursing Management of chest tube a) Ensure drainage tube does not kink or loop. No dependent loops. b) Assess cardiopulmonary status, vital signs q 2hrs and as needed. c) Immediately report and respiratory distress and or change in vital signs. d) Check patency of chest tube. Monitor amount and color of drainage. Mark drainage level on drainage system each shift and record on I&O 21) Nursing Management of chest tubes a) Assess for continuous bubbling in the water seal chamber. b) If present check for air leaks c) Secure pluer-evac -if knocked over return to proper position and instruct patient to take deep breaths d) Collect specimen from leur lock on tubing e) Assess for tidaling in the water seal chamber with respirations f) Tidaling may stop… i) If lung has re-expanded ii) Tubing is obstructed iii) Dependent loops are present 22) Management of chest tubes a) Assess chest tube site for signs of infection b) Change dressing as needed and/or according to institution policy c) Keep pleur-evac below the level of the chest d) Keep clamp at bedside(controversial) e) Position pt in fowlers position and turn q 2 hrs 23) Management of chest tube a) Note a sudden increase/decrease in drainage and report to physician b) Serial chest x-rays are needed c) Note sudden decrease and trouble shoot i) Change patient’s position ii) Look for dependent loops iii) Gently milk chest tube 24) Report immediately a) Signs of rapid shallow breathing b) Pressure in the chest c) Hemorrhage- significant increase in drainage 25) Transport with chest tube a) Make sure drainage system is below level of the chest b) Suction is off and air is vented out c) Tubing is not clamped!!! d) Secure to stretcher or bed 26) Pleur-evac change a) Set up new pleura-evac b) Turn off suction(temporary) c) Clamp chest tube (seconds) the attach to new system

d) Reconnect suction if ordered 27) Documentation a) Breath sounds rate and pattern b) Amount of suction c) Type and amount of drainage d) Condition of dressing e) Presence of chest pain, temperature f) Presence of subcutaneous emphysema g) Patient education 28) Chest tube disconnected from closed system a) Provide a temporary water seal by immersing the end of the chest tube in a bottle of sterile water/saline 29) Clamp or not clamp? a) Clamp when…. i) Assessing for air leak ii) Clamping prevents the escape of air which could increase risk for pneumothorax iii) Never clamp during patient transport 30) Complications a) Infection b) Hemorrhage – note sudden fluctuations/increases in output c) Dislodged chest tube d) Air leak e) Subcutaneous emphysema 31) Removal of chest tube a) Decrease in drainage b) Air leak disappeared c) Normal breathing/no distress d) Chest x-ray pre-removal e) Have pt perform Valsalva Maneuver and tube is quickly removed. Pre medicate. f) Apply occlusive dressing g) Chest x-ray post removal 32) Pleurodesis a) Use of chemicals, powder, or pieces of cloth to irritate the walls of the pleural space b) Causes walls to swell and become attached to one another c) May help air/fluid from collecting in pleural space d) Surgical/chemical 33) PluerX drainage system a) Used to manage recurrent pleural effusions at home. b) Used instead of chest tube to deliver talc or bleomycin for chemical pleurodesis c) Placed in interventional radiology d) Usually drained daily- per doctors orders

34) 35) Practice a) Care for a patient with a chest tube includes which of the following? i) Milking or stripping the tubing aggressively to maintain patency

ii) Encouraging coughing or repositioning iii) Clamping the tube while transporting the patient iv) Keeping the pleuravac at or above the patients chest level 36) Practice a) The collection chamber is routinely assessed for which of the following? (choose all that apply) i) Fluid volume ii) Rate of volume increase iii) Drainage characteristics iv) Degree of bubbling 37) Practice a) The purpose of the water seal chamber in a threechamber chest drainage system is to: i) Facilitate drainage from the chest tube ii) Prevent airflow back into the patient iii) Facilitate control of negative suction iv) Prevent fluid from draining into the suction chamber 38) Case study summary of events a) C.S presents to the ER s/p fall on ice. Complaining of right sided rib pain, breast pain and chest pain b) Vitals: BP 168/78, HR 81,Pin 8/10 O2 98% c) Diminished breath sounds right side d) Pain upon inspiration e) Increasingly worse labored respirations f) Interventions include: i) Raise HOB ii) chest xray iii) Oxygen iv) suspect pneumothorax v) pain control vi) Prepare for chest tube insertion...