ATI Chapter 18 Chest Tube Insertion and Monitoring

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Chest tubes are inserted into the pleural space to:
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Drain fluid, blood, or air; reestablish a negative pressure; facilitate lung expansion; and restore normal intra-pleural pressure
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Chest tubes are removed when
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The lungs have re-expanded or there is no more fluid drainage
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First chamber of the disposable three chamber drainage system
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Drainage collection
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Second chamber of a disposable three chamber drainage system
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Water seal
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Third chamber of a disposable three chamber drainage system
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Suction control
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Purpose of the water seal
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Allows air to exit from the pleural space on exhalation and stops air from entering with inhalation
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Water seal in the chamber should be up to which line?
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2 cm line
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Tidaling
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Movement of the fluid level with respiration
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Cessation of tidaling in the water chamber signals
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Lung reexpansion or an obstruction within the system
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Indications for chest tube insertion
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Pneumothorax • hemothorax • post-operative chest drainage (thoracotomy or open-heart surgery) • pleural effusion (fluid and lung) • lung abscess (necrotic lung tissue)
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Client presentation
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Dyspnea • distended neck veins• poor circulation • cough • absent or reduced breath sounds
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Chest tube insertion preprocedure nursing actions
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Consent form • reinforce teaching: breathing will improve when the chest tube is in place • assess for allergies to local anesthetics • assist client and to supine or semi-Fowler’s • prepare the chest drainage system prior to the insertion • administer pain and sedation meds • prep the insertion site with povidone iodine
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Intraprocedure chest tube insertion nursing actions
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assist provider with insertion, application of dressing to the insertion sites and set up of the drainage system • chest tube sutured to chest wall and airtight dressing placed over the puncture wound • chest tube attached to drainage tubing that leads to the drainage system • drainage system below clients chest level • continually monitor vital signs
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Postprocedure nursing actions for chest tube insertion
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Assess vital signs, breath sounds, SaO2, color, respiratory effort at least every four hours • encourage coughing and deep breathing every two hours • keep drainage system below the clients chest level
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Monitoring the chest tube placement and function
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check water seal Q2 hours and at fluid as needed • document amount, color of drainage hourly for the first 24 hours and then at least every eight hours • excessive drainage greater than 70 mL per hour or drainage that is cloudy or red must be reported to the provider • monitor fluid in the suction control chamber • continuous bubbling should only be in the suction chamber
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Continuous bubbling from the water seal chamber indicates
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Air leak finding
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Nursing actions during an accidental disconnection, system breakage, or removal
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Instruct client to exhale as much as possible and to cost to remove as much air as possible from the pleural space. The nurse cleanses the tips and reconnects the tubing.
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If the chest tube drainage system is compromised
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Immerse the end of the tube in sterile water to restore the water seal
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If the chest tube is accidentally removed
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And occlusive dressing taped on only three sites should be immediately placed over the insertion site
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Tension pneumothorax assessment findings
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Tracheal deviation • absent breath sounds on one side • distended neck veins • respiratory distress • asymmetry of the chest • cyanosis
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Chest tube removal
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Pain meds 30 minutes before • assist provider with sutures • instruct client to take a deep breath, exhaled, they are down or to take a deep breath and hold it • apply airtight sterile petroleum jelly cause dressing, secure with a heavyweight stretch tape • obtained chest x-rays • monitor for excessive wounds drainage, signs of infection, recurrent pneumothorax

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