Nursing Care of Patients with Chest Tubes and closed chest drainage

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*Keep all tubing as straight as possible or coiled loosely. -Do not let the patient lie on it. -Dependent loops allow fluid to collect in the tubing and impede the removal of air and fluid from the pleural space.
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#1. Keep tubing open
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*All connections between chest tubes, drainage tubes, and the drainage collector should be tight. -Taping at the connections will help prevent air from entering the system.
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#2. Only positive air leak
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*Keep the water seal and suction control chamber (wet systems) at the appropriate water levels by adding sterile water as needed.
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#3. Check level of H2O in both water seal chamber and suction control chamber
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*Mark the fluid level on the chest drainage system so that the amount of drainage can be determined. Marking intervals may vary from once an hour to every 8 hours. Any change in the quantity or characteristics of the drainage should be recorded and reported to the physician.
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#4. Check drainage unit collection chamber and mark the level on front of drain
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*Observe for air bubbles in the water seal chamber and fluctuations (tidaling) in the chest tube. If no fluctuations, (rising with inspiration and falling with expiration in spontaneously breathing clients; the opposite occurs with positive pressure mechanical ventilation) are observed, the drainage system is blocked or the lungs are re-expanded. If bubbling increases, there may be a leak in the system.
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#5. Check for bubbling in H2O seal chamber-bubbling means air is entering the system and vented out of the system. Look to see if the H2O level moves up & down with breathing (normal). No bubbling, check for tidaling in H2O seal.
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*Bubbling in the water seal can be continuous or intermittent (this indicates that there is still air left in the pleural space). this referred to as a positive air leak. In order to properly check for air leak, the suction, if present, needs to be momentarily turned off.
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#6. Bubbling indicates positive air leak
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*The area around the chest tube needs to be assessed for the presence of subcutaneous emphysema, or crepitus. Palpate the skin, assessing for a “Rice Krispies” or bubble wrap sensation. This can and should be done when the dressing is on, and a further assessment can be done when the dressing is removed for the daily sterile dressing change. -Subcutaneous emphysema can occur when the tube is inserted or when a large air leak is present (air leaks around, not through the chest tube). If present in small amounts that doesn’t increase, no treatment is usually required. If the subcutaneous air increases and involves the neck and face, it may compromise breathing and may necessitate surgical closure of the opening into the pleural space. Starting at pt. chest clamp tubing down tube to find the hole/leak. Positive Air leak is due to air leaving the pleural space.
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#7. Checking for SubC leaks
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*Keep 2 clamps at the bedside at all times. Never clamp a chest tube without a physician order. When chest tubes are clamped, air may be trapped in the pleural space and further collapse the lung.
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#8. Only clamp if there is a negative air leak to find hole.
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*If the drainage system cracks and loses its water seal, quickly submerge the chest tube in sterile water until the system can be reestablished.
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#9. Negative pressure; put end of chest tube right into sterile water that is already at bedside
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*Keep several petrolaum gauze (ie. Xeroform) at the client’s bedside at all times. If the chest tube is inadvertently pulled out, apply this gauze over the site immediately, taping three of four sides of the dressing (this allows escape of air from the chest, preventing a tension pneumothorax and possible mediastinal shift). Put the client in a High Fowler’s position, apply O2, monitor VS, and notify the physician. Observe for signs of a mediastinal shift (deviation of the trachea, muffled heart sounds, hypotension). Look for a trachea shift (mediastinal shift); vent up bottom piece.
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#10. Petrolatum gauze if tube comes out to keep air from rushing in. If subc crepitus, lift open flap to let air out.
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*Stripping and milking the tubes involves may cause tissue damage. It is not routinely done.
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#11. No stripping or milking chest tubes to enhance drainage; these maneuvers can expose the patient to dangerously high negative pressures in the chest that can damage lungs and heart-depending on location.
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*Never elevate the drainage system to the level of the client’s chest. Secure the drainage system so it does not tip over.
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#12. Gravity helps with drainage
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*The patient’s clinical status should be closely monitored. Vital signs should be taken frequently, lungs auscultated, and the chest wall observed for any abnormal chest movements or asymmetry.
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#13. Freq VS
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* When suction is discontinued, the nurse must make frequent respiratory assessments to see if the client can tolerate the increased workload of removing air and fluid from the pleural space. If the client becomes dyspneic or shows any sign of respiratory distress after the discontinuation of suction, it should be reinstated and the physician should be notified.
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#14. Discontinuation of suction
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*The client should be encouraged to cough and deep breathe periodically to facilitate lung re-expansion.
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#15. C & DB exercises
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*The client will have regular chest X-rays to determine if the lung is re-expanding. If the chest tube is to suction, these X-rays should be done at the client’s bedside. A physician order is needed to remove the client from suction (transport off the unit may be delayed until suction is no longer necessary).
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#16. Chest X-rays
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*If the drainage system is overturned and the water seal is disrupted, return the bottle to the upright position and encourage the client to take a few deep breaths and cough. If the water seal is not at the correct level (-2 cm mark), the system needs to be changed.
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#17. Correct water seal level of -2 cm
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* A Heimlich valve or Pleur-X catheter may be used for patients with persistent air leak (air remaining in the pleural space). The one-way valve that allows the escape of air from the pleural space, but prevents air from entering the pleural space. The Heimlich valve is usually attached to a drainage bag and allows a client with a small air leak to be discharged from the hospital. The Pleur-X catheter is usually not continually connected to a drainage device, but may intermittently be connected to a drainage bottle if a large pleural effusion is present and the patient is symptomatic.
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#18. Heimlich valve or Pleur-X catheter used for patients with persistent air leaks (air remaining in pleural space)

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