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Pressure changes in the chest cavity (pleural space) can result from:

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Trauma ? Air, blood, effusions Infection ? pus Surgery

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Normally, pressure in the pleural space is:

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Negative all the time

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This may result in:

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-Atelectasis -Restriction of lung expansion due to trapped air/fluid

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Resolution

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A chest tube can be inserted into the pleural space to drain fluid, blood or air

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Indications for a Chest Tube

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• Closed Pneumothorax • Rib fracture • Hemothorax • Spontaneous Rupture Bleb • Pleural Effusion • Thoracic Surgery

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Patients at Risk for Pneumothorax

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•Men greater risk than women -tall & thin men •Smokers -blebs •History of chronic lung disease -again...blebs •History of previous pneumothorax •On mechanical ventilation

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"Chest Drain" or "Tube Thoracostomy"

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•Firm plastic tube with drainage holes -proximal end inserted into pleural space -usually inserted 5th intercostal space, mid-axilla •Placed using sterile procedure -bedside, OR & IR •Drains: Air, Pus, Blood, Bile •Restores negative pressure

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Chest Tube Placement

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•Air HIGH •Mediastinal Thoracic surgery •Fluid/Blood Low

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Insertion

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•Informed Consent/Time Out •Procedural sedation/analgesia •Positioning -Supine & 45 degree angle •Equipment- Chest Tube Tray or Cart •5th Intercoastal/Mid-axillary •Occlusive Dressing/ Xerofoam Gauze •Chest drainage system setup •Suction

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Documentation for Insertion

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•Time and date of procedure •Time and date chest drainage began •Amount Suction level applied •Amount and type (color) of drainage q shift •Patient's respiratory status

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Traditional Water-Seal (Wet Suction)

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suctioned determined by amount of water instilled into device

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Dry-Suction Water Seal (Dry Suction)

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dial on device controls suction

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Dry- Suction ( One-way valve)

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ideal for an emergency situation

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Traditional Water Seal Argyle, Pleur-Evac, Atrium (used at BH)

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Three Chambers: 1. Water seal chamber 2. Collection chamber 3. Suction chamber

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Water Seal Chamber

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•Prevents air from re-entering the chest -purpose of the water seal is to allow air to exit from the pleural space on exhalation and prevent air from entering the pleural during inhalation -Seal established by adding water 2cm •Middle chamber of system •Water level will fluctuate -Tidaling

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Water Seal (B)

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•Tidaling •Normal physiologic response •Noted in water seal chamber •Water level should rise and fall with the patient's respirations •Inhalation the water level should rise •Exhalation the water level should fall •If the patient is receiving positive pressure ventilation tidaling will be opposite direction

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Air Leak

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•Bubbling in water seal after initial insertion or when air is being removed are normal •Constant & vigorous bubbling in water seal may indicate an air leak •Gentle bubbling is ok • Check dressing, drainage setup, assess patient, NOTIFY MD

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Collection Chamber

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-Collects and measures drainage -If exceeds rate of 150mL/hr notify MD or refer to hospital protocol -Water level controls the amount of suction-Height of water controls amount of negative pressure ?Wet: Fill to 20 cm (usual amount) -Gentle bubbling prevent evaporation

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Dry-Suction Water Seal

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•One way valve connected to patient and chest tube •Valve allows air to exit chest cavity and prevents from re-entering •Increased mobility •Poor device for collecting drainage •Flutter Valve

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Nursing Responsibilities for Clients with A Chest Tube

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• Assessment • Perform a complete respiratory assessment - Include pain management • Palpate for Crepitus • Assess drainage • Continue review of labs e.g. H&H, ABG... • Skin Integrity ( dressing changes ) • Assess drainage setup e.g. Loops, Tidaling, air leak? • Assess effectiveness of Incentive Spirometer

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6 "Must's of Assessment

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• Dressing • Loops • Bubbles • Tidaling • Drainage • Water Level

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Evaluation (goals)

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• Respirations are within normal • Prescribed suction is maintained • Breath sounds are present in all lobes • Lung expansion is symmetrical-; RESTORE NEGATIVE PRESSURE • Drainage promotes improved cardiac output • Vital signs, O2 saturation, ABG and H;H levels are within normal range • Improved comfort level • Chest tubes remain in place , airtight and functioning properly • Chest able to be d/c'd in timely fashion

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Safety Measures

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• Connections taped • Rubber tipped clamps • Sterile water/saline bottle • Placement of unit and tubing • Petroleum gauze and gauze pads • Maintain patency • Maintain asepsis

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Air leak is present as indicated by vigorous bubbling in water-seal chamber

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o Ensure all connections secure o Change tubing if necessary o Apply sterile petroleum gauze *Check policy regarding clamping

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Accidental Disconnection (Between drainage system and chest tube)

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o Have the client exhale o Cleanse and reconnect tubing

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Chest tube becomes dislodged (From chest cavity

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o Instruct client to exhale, compress insertion site and apply 4X4 occlusive dressing o Assess patient o Notify MD immediately

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Client develops signs of mediastinal shift Signs:

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-Trachea shifts to unaffected side -Paradoxical pulse develops ? Decrease inspiration -Jugular vein distention -Decreased cardiac output

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To Do:

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o Observe for signs of respiratory distress o Notify physician immediately o Check drainage tube for patency o Prepare for possible pericardotomy

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Chest tube becomes obstructed -sudden lack of drainage

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o Observe for kinks and dependent loops o Lift tubing to drain pooled drainage into collection chamber o Assess tubing for signs of clotting o Report clotting to physician o No Milking

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Notice an absence of tidaling • May indicate:

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-Lung has re-expanded -Tubing is obstructed -A loop in tubing hangs below rest of tubing -Suction is not functioning

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Chest drainage system breaks

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Immerse end of tubing in sterile water to create seal

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To clamp OR not to clamp

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• ONLY when ordered or to exchange out systems (as per policy) • Determine air leak ( momentarily if policy) • Need MD order *NEVER TO TRANSPORT

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Chest Tube Removal

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-To facilitate the removal of chest tube(s) without the introduction of air into the pleural/mediastinal space -To facilitate the removal of chest tube(s) without contamination and development of infection -Discontinue an invasive intervention that is no longer necessary

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Chest Tube Removal (requires)

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1. Minimal drainage 2. Absence of air leak 3. Stable respiratory Status 4. Stable coagulation status 5. No bubbling in water seal

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Pleural chest tubes are removed one at a time

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Performed by MD, APRN, PA

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To Transport

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• Disconnect from suction -Verify with provider first • Do not clamp tube or tubing • Place drainage system below patient's chest level

Managing Nursing Care Of Patients With Respiratory Changes – Flashcards

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