1 Chest Tubes

B, C, D, E

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include a petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician. F. Place the patient is prone position after removal.

C

A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? A. The water in the chamber will increase during inspiration and decrease during expiration. B. There will be continuous bubbling noted in the chamber. C. The water in the chamber will decrease during inspiration and increase during expiration. D. The water in the chamber will not move.

A

A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? A. Intermittent bubbling may be noted in the water seal chamber. B. 200 cc of drainage per hour is expected during recovery of a pneumothorax. C. The chest tube is positioned at the patient's chest level to facilitate drainage. D. All of these options are appropriate findings

B

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.

D

A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side B. Use the incentive spirometer C. Cough at regular intervals D. Perform the valsalva maneuver

B

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x-ray B. Apply sterile gauze to the insertion site C. Place tape around the insertion site D. Assess respiratory status

a, b, e

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (SATA) A. encourage the client to cough q2h B. check for continuous bubbling in the suction chamber C. strip the drainage tubing q4h D. clamp the tube once a day E. obtain a chest x-ray

A, B, C, E

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (SATA) A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling catheter E. Occlusive dressing

Flutter (Heimlich) Valve

A ___ (also called the Heimlich valve after its inventor) is used to evacuate air from the pleural space; one-way rubber valve within a rigid plastic tube. The valve opens whenever the pressure is greater than atmospheric pressure, such as during expiration, and closes when intrathoracic pressure is less than atmospheric pressure, such as during inspiration. Drainage bags attached to the flutter valve must have a vent to the atmosphere in order to prevent a potential tension pneumothorax. This can be accomplished by simply cutting a small slit in the top of any drainage bag that does not have a built-in vent.

tension pneumothorax

A life-threatening collection of air within the pleural space; the volume and pressure have both collapsed the involved lung and caused a shift of the mediastinal structures to the opposite side.

B, C

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (SATA) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration D. Exposed sutures without dressing E. Drainage system upright at chest level

Tracheal deviation Absent breath sounds on one side Distended neck veins Respiratory distress Asymmetry of the chest Cyanosis

Assessment findings of tension pneumothorax:

Flutter (Heimlich) Valve

Allows for mobility of the patient, as the smaller drainage bag can be hidden under the clothes while the patient ambulates. Patients may go home with a Heimlich valve in place.

water

Amount of ___ in chamber controls suction to lungs.

Chest Tube

Are inserted to drain fluid, blood, or air; reestablish negative pressure; facilitate lung expansion; and restore normal intrapleural pressure.

Cardiac Tamponade

Blocked drains are a major concern for cardiac surgical patients due to the risk of __ __

tidaling

If no ___ is observed (rising with inspiration and falling with expiration in the spontaneously breathing patient), the drainage system is blocked, the lungs are reexpanded, or the system is attached to suction. If the chest tube is connected to suction, disconnect from wall suction to check for tidaling.

sucking chest wounds prolonged clamping of tubing kinks or obstruction of tubing mechanical ventilation with high PEEP

Causes of tension pneumothorax:

tidaling

Cessation of __ in the water seal chamber signals lung re-expansion or an obstruction within the system.

Emergency department (ED), at the patient's bedside, or in the operating room. Positioned with the arm raised above the head on the affected side to expose the midaxillary area, the standard site for insertion. Elevate the patient's head 30 to 60 degrees, when possible, to lower the diaphragm and reduce the risk of injury. A chest x-ray is used to confirm the affected side. The area is cleansed with an antiseptic solution. The chest wall is prepared with a local anesthetic, and a small incision is made over a rib. The area is first probed digitally to avoid injury with a sharp instrument. A clamp is used to hold the chest tube and guide it into place. The tube is advanced up and over the top of the rib to avoid the intercostal nerves and blood vessels that are behind the rib inferiorly. Once inserted, the tube is connected to a pleural drainage system. Two tubes may be connected to the same drainage unit with a Y-connector. The incision is closed with sutures, and the chest tube is secured. The wound is covered with an occlusive dressing. Some clinicians prefer to seal the wound around the chest tube with petroleum gauze. Proper tube placement is confirmed by chest x-ray.

Chest Tube Insertion Steps:

20

Chest Tubes and Pleural Drainage typically filled to __ cm of water.

Premedicate prior to removal. Valsalva maneuver during removal Apply occlusive dressing. Monitor for respiratory distress.

Chest tube removal nursing interventions:

Provide pain management 30 min before Assist the provider with tube/suture removal Instruct the client to take a deep breath, exhale, and bear down or to take a deep breath Apply airtight sterile petroleum jelly gauze dressing Obtain chest x-ray as prescribed Monitor for excessive wound drainage, infection, signs of pneumothorax

Chest tube removal nursing management:

bubbling

Continuous __ in the *water seal chamber* indicates an air leak in the system. Initially large air leak expected Eventually disappears

Water seals

Created by adding sterile fluid to a chamber up to the 2 cm line; allows air to exit from the pleural space on exhalation and stops air from entering with inhalation

Reexpansion pulmonary edema Vasovagal response Subcutaneous emphysema

chest tube complications:

Do not elevate system above chest. Change when full. Measure fluid level. Report > 100mL/hr. Dont clamp the tube without order, no matter what!! Reestablish water seal if disconnected MAY clamp 4-6 hours prior to removal

chest tube nursing management:

dry suction control

Dial in desired negative pressure, must vent when decreasing pressure

sterile water

Do NOT clamp—if break in system, place distal end in ___ to maintain water-seal.

20 inches long 12-40F

chest tube sizes:

below

Ensure the chest tube drainage system is __ the client's chest level

gravity drainage

Generally suction is discontinued, and the chest drain is on __ for 24 hours before the tube is removed.

suction control chamber

Gental constant bubbling in the __ __ __ is normal

Effected lung side up with arm above head. Good lung side down. Head of bed elevated 30-60 degrees to allow diaphragm to fall downward.

How would you position a pt. for insertion of chest tube?

Put water into water-seal compartment (middle compartment) to the 2 cm mark. Add water to the suction control chamber to the 20 cm level unless otherwise ordered. Attach suction tubing to drainage unit and to wall suction.

How would you set up a water- suction chest tube drainage system?

leak

If _____ persists, briefly clamp the chest tube at the patient's chest. If the leak stops, then the air is coming from the patient. If the air leak persists, briefly and methodically move the clamps down the tubing away from the patient until the air leak stops. The leak will then be present between the last two clamp points. If the air leak persists all the way to the drainage unit, replace the unit.

Disposable 3 chamber system

Is the most common chest tube system used. First chamber: drainage collection Second chamber: water seal Third chamber: suction control (wet or dry)

intermittent

It is normal to find __ (NOT CONTINUOUS) bubbling in the water seal chamber if the patient is recovery from a pneumothorax. Remember that a pneumothorax is an AIR leak between the lung and chest wall....therefore air will escape into the water seal chamber causing some bubbles.

36-40 24-36 12-24

Large (____F) tubes are used to drain blood, medium (____F) tubes are used to drain fluid, and small (____F) tubes are used to drain air.

Monitor for infection Keep dressing clean and intact Observe sutures remain intact and secure Never lift the drain above chest level The unit and all tubing should be below patients chest level to facilitate drainage Tubing should have no kinks or obstructions that may inhibit drainage Ensure all connections between chest tubes and drainage unit are tight and secure Connections should have cable ties in place Tubing should be anchored to the patients skin to prevent pulling of the drain Ensure the unit is securely positioned on its stand or hanging on the bed Ensure the water seal is maintained at 2cm at all times Milking of chest drains is only to be done with written orders from medical staff. Milking drains creates a high negative pressure that can cause pain, tissue trauma and bleeding Volume Color and Consistency

Management of Chest Tubes:

Dyspnea Distended neck veins Hemodynamic instability Pleuritic chest pain Cough Absent or reduced breath sounds on the affected side Hyperresonance on percussion of the affected side Dullness or flatness on percussion of the affected side Asymmetrical chest wall motion

Patient presentation (which may indicate need for chest tube):

Monitor vitals q4h Encourage coughing/deep breathing q2h Keep drainage system below chest level Monitor placement and function Check the water seal q2h, and add fluid as needed Document amt and color of drainage hourly for the first 24h and then q8h Report excessive drainage (>70ml/hr) or couldy/red drainage Monitor for tube occlusions Obtain chest x-ray to confirm placement Administer pain meds as prescribed Monitor for infection Keep 2 enclosed hemostats, sterile water, and an occlusive dressing nearby at all times Do not strip or milk tubing unless prescribed

Post chest tube insertion:

pneumothorax hemothorax post-op chest drainage pleural effusion pulmonary empyema

Potential indications for chest tube insertion:

milking, stripping

____ or ___ chest tubes is no longer recommended as these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. If ordered by physician to milk or strip tubes, do so GENTLY.

Stripping

____: squeeze drainage tube with thumb and forefinger and use gentle pulling motion down tube with other hand, then release the tubing.

dry

The ___ suction control chamber system contains no water. It has a visual alert that indicates if the suction is working.

water suction control

The ____ chamber uses a column of water with the top end vented to the atmosphere to control the amount of suction from the wall regulator. The chamber is typically filled with 20 cm of water. When the negative pressure generated by the suction source exceeds the set 20 cm, air from the atmosphere enters the chamber through the vent on top, and the air bubbles up through the water, causing a suction-breaker effect. As a result, excess pressure is relieved.

Milking

_______: alternately folding or squeezing and then releasing drainage tubing. Take 15-cm strips of the chest tube and squeeze and release starting close to the chest and repeating down the tube distally.

wall suction (active suction)

The addition of ___ to the chest drainage unit may actually promote the development of air leaks and thus prolong the number of days the chest tube needs to remain in place. Patients with just water-seal (passive) suction have a shorter duration of air leaks.

Wet suction

The height of the sterile fluid in the suction control chamber determines the amount of suction in the pleural space. A suction pressure of ‑20 cm H2O is standard. Should see bubbling continuously, monitor the fluid level and add fluid as needed to maintain the prescribed level of suctioning.

D

The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

−20

The suction pressure is usually ordered to be ____cm H2O, although higher pressures (−40 cm H2O) are sometimes necessary to evacuate the pleural space; lower pressure (-10 cm H2O) may be used for frail patients at risk for tissue damage with higher pressures. To initiate suction, the vacuum source is turned up until gentle bubbling is present in the chamber.

Tidaling

The water in the water seal chamber will rise and fall (swing) with respirations. *This will diminish as the pneumothorax resolves.*

water, dry

There are two types of suction control:

Pleural Drainage

chest drainage is larger and less portable and contains three basic compartments, each with a separate function-

Obtain vital signs and report these to the RN. Keep the drainage system and all tubing below chest level. Encourage patient deep breathing to prevent atelectasis. Assist with range-of-motion exercises if they are part of the plan of care. Measure chest tube output as a part of the intake and output and mark the drainage level on the drainage collection unit.

What could the receiving RN delegate to an unlicensed nursing personnel (UAP) in order to optimize time management?

If the tubing separates, instruct the patient to exhale as much as possible and to cough to remove as much air from the pleural space as possible If the chest tube drainage system is compromised, immerse the end of the chest tube in sterile water to restore the water seal If the chest tube is accidentally removed, cover the site with dry, sterile gauze

What to do if the tubing becomes disconnected, breaks, or is removed on accident?

B

What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. A. Mediastinal chest tube system B. Dry suction chest tube system C. Wet suction chest tube system D. Dry-Wet suction chest tube system

Dry suction

When a dry suction control device is used, the provider prescribes a level of suction for the device, typically ‑20 cm H2O. When connected to wall suction, the regulator on the chest tube drainage system is set to the manufacturer's recommendation

B

While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. B. Place a sterile dressing over the site and tape it on three sides and notify the physician. C. Attempt to re-insert the tube. D. Keep the site open to air and notify the physician.

Tidaling

With spontaneous respirations, the fluid will rise with inspiration (increase in the negative pressure in the lung) and fall with expiration. With positive pressure ventilation, the fluid will rise with expiration and fall with inspiration.

D

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops. D. Check the drainage system for an air leak.

A

You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes.

Mediastinal

__ tubes placed to drain the fluid after open-heart surgery are positioned directly under the sternum. Once the chest tube is in place, it is connected to a chest drainage unit.

Pigtail tubes

___ are very small (10F to 14F) tubes with a curly end designed to keep them in place. They are a safe and effective alternative to larger bore chest tubes for treatment of pneumothorax.

milking/stripping

intermittently compressing a chest tube in the area of a clot for 1 to 2 seconds

Wet suction: add sterile water to 2-cm mark in water-seal chamber and to 20-cm mark (or as ordered) in suction control chamber. Dry suction: add sterile water to the fill line of the air leak meter. Attach suction tubing and increase suction until the bellows-like float moves across the display window. Keep all tubing loosely coiled below chest level. Tubing should drop straight from bed or chair to drainage unit.

preparing the drainage unit: wet- dry-

To remove air or fluid from pleural and/or mediastinal space. Reestablishes negative pressure. Lung reexpands. They may also be inserted in the mediastinal space to drain air and fluid postoperatively.

purpose of chest tubes:

fluid and air from the pleural or mediastinal space contains 2 cm of water, which acts as a one-way valve and air from first chamber applies suction to the chest drainage system (water and dry)

three chambers of pleural drainage system function: