Module 15: Closed Chest Drainage Systems

A patient has returned from the operating room with a chest tube in his sixth intercostal space with orders to connect the patient to wall suction. The patient has a three-chamber water-seal system. Eight hours later the nurse finds the patient complaining of increased chest pain, a respiratory rate of 40, and a pulse of 110. The water-seal chamber is dry. The patient is in obvious distress. What should the nurse suspect as the primary cause for the respiratory distress? A. There is no water in the water-seal chamber. B. The patient's chest tube has become dislodged. C. The wall suction needs to be increased. D. The patient is breathing shallowly and avoiding coughing.

A The water seal is dry, allowing air to enter the chest and preventing the lung from expanding. The level of water in the suction control chamber maintains the level of suction.

A patient suddenly becomes short of breath, is complaining of chest pain, and has a drop in blood pressure. The nurse auscultates the lung sounds and hears normal lung sounds on the left and very diminished lung sounds on the right. The patient's trachea appears to be deviated to the left. What should the nurse suspect? A. The patient has a tension pneumothorax. B. The patient has a pneumohemothorax. C. The patient has an open pneumothorax. D. The patient has a hemothorax.

A These symptoms are consistent with a tension pneumothorax as evidenced by the shift in mediastinal contents.

Which of the following can cause a tension pneumothorax? (Select all that apply.) A. Kinking of the chest tube. B. Accidentally tipping the waterless drainage system over. C. Obstruction by a blood clot. D. Having the suction source set too high. E. Clamping of chest tube.

A C E Tension pneumothorax can be caused by kinking or clamping of the chest tube, mechanical ventilation, cardiopulmonary resuscitation (CPR), and prolonged occlusion of chest tubes, such as obstruction of the chest tube by a blood clot.

A patient arrives in the emergency department with a stab wound to the chest with a hemothorax as a result. Which of the following findings contraindicates autotransfusion of pleural blood? A. Great vessel injury. B. Diaphragmatic disruption. C. Myocardial rupture. D. A wound 7 hours old.

D Recall that autotransfused blood must be transfused within 6 hours. If the wound is 7 hours old, clotting factors have probably been active and made the blood nontransfusable.

The nurse is preparing the equipment for removal of a chest tube. Which of the following would be unnecessary for this procedure? A. Sterile suction catheter, sterile normal saline, and sterile basin. B. Suture set, sterile scissors, and sterile gloves. C. Clean gloves and face shield, stethoscope. D. Petrolatum-impregnated gauze, 4 x 4-inch gauze, large dressing, and tape.

A Although sterile normal saline may be required for the setup of a chest drainage system if the patient has to have another chest tube inserted, a sterile suction catheter and sterile basin are not required standard equipment for the removal of a chest tube. Appropriate personal protective equipment is necessary. A stethoscope will be used to auscultate lung sounds. Sterile gloves, a suture set, and sterile scissors are necessary items for the removal of a chest tube. The health care provider will hold the petrolatum-impregnated gauze over the insertion site as the chest tube is removed to prevent air from reentering the pleural space.

Two nursing students are studying for an upcoming exam. One student quizzes the other regarding the cause of a patient's lung collapsing. What is the student's best response? A. "When the intactness of the pleural space is broken, the space fills with air and/or fluid, causing positive thoracic pressure, which collapses lung tissue." B. "Several factors can cause a lung to collapse, such as an increase in fibrous lung tissue, especially in the patient who smokes." C. "The negative pressure between the parietal pleura and the visceral pleura becomes too great." D. "The exact cause remains unknown, but it is thought a collapsed lung may occur as a result of a weakened diaphragm."

A Normally, atmospheric pressure in the pleural space is negative (−4 to −10 mm Hg). If the integrity of the pleural space is interrupted, the space fills with air and/or fluid, causing positive thoracic pressure, which collapses lung tissue.

1. The nurse and an NAP are working together to care for a group of patients. Which of the following tasks would be most appropriate for the RN to delegate to the NAP? A. Positioning the patient either sitting or lying supine on the side opposite to that where the chest tube is placed. B. Administering a pain medication the nurse has prepared 30 minutes before chest tube removal. C. Informing the patient to exhale and perform the Valsalva maneuver while the health care provider removes the chest tube. D. Auscultating the lungs sounds and obtaining vital signs once the chest tube is removed.

A The NAP may assist with positioning of the patient. Administering pain medication is the responsibility of the nurse. The nurse who prepares the medication should also administer the pain medication. Assessment is the responsibility of the nurse. Once vital signs are determined to be stable, the NAP may be instructed on the frequency of vital sign monitoring. Patient teaching is also the responsibility of the RN.

A student nurse is working as a tutor for a group of freshman physiology students. Which statement, if made by someone in the study group, would require correction? A. "Physiologically, inspiration is a passive process that requires less work than expiration." B. "Obstruction such as caused by kinking or clamping of the chest tube can result in a tension pneumothorax." C. "Besides difficulty breathing, an indication of a tension pneumothorax is a shift of the contents in the mediastinum (e.g., trachea and heart) to the opposite (unaffected) side of the chest." D. "Normally, atmospheric pressure in the pleural space is negative."

A The act of inspiration involves more muscles and effort than expiration. Expiration is a passive activity, whereas inspiration requires the muscles to push against negative pressure in the pleural cavity. Atmospheric pressure in the pleural space is normally negative (−4 to −10 mm Hg). Besides breathing difficulty, another indication of a tension pneumothorax is a shift of the contents in the mediastinum (e.g., trachea and heart) to the opposite (unaffected) side of the chest. Tension pneumothorax can also be caused by mechanical ventilation, cardiopulmonary resuscitation (CPR), and prolonged occlusion of chest tubes, such as obstruction of the chest tube by a blood clot. Patients with chest trauma, fractured ribs, or invasive thoracic bedside procedures (such as insertion of central lines) and those on high-pressure mechanical ventilation are at risk for tension pneumothorax.

When turning a patient with a right-sided hemothorax, 250 mL of dark blood pours into the chest tube container. What is the most important intervention? A. Monitoring the patient closely, obtaining a blood sample for a hematocrit, and documenting the drainage. B. Assessing vital signs and emergently transfusing 2 units of packed red blood cells to treat hypovolemia. C. Checking the chest tube system to confirm patency and calling for a chest x-ray examination immediately. D. Preparing for autotransfusion using a high-pressure rapid infuser to quickly infuse the blood.

A The color of the blood indicates that it is possibly old deoxygenated blood. Running labs to ensure that the patient's hematocrit is stable before taking any other action is the best course of the listed actions.

The nurse is assisting the health care provider with the insertion of a chest tube. Which of the following activities, if performed by the nurse, requires correction? A. The nurse tapes the connection between the chest tube and the drainage tube with a figure-eight pattern and makes sure the tubing is coiled on the floor. B. The nurse cleans the top of the vial with an alcohol wipe, then turns it upside down so the health care provider can withdraw the amount of medication needed. C. The nurse marks the drainage chamber with the start date and time, the beginning amount of drainage, and initials. D. The nurse holds the anesthetic vial so the health care provider can visualize the label and verify the contents and dosage. E. The nurse obtains the pulse, respiration, and blood pressure during the procedure. Using sterile technique, the nurse holds the drainage tube while the health care provider connects the chest tube.

A To assist the health care provider, the nurse should hold the anesthetic vial so the health care provider can see the label and verify its contents. The nurse should clean the top of the vial with an alcohol swab and turn it upside down so the health care provider can withdraw the anesthetic while maintaining surgical asepsis. The nurse should obtain the pulse, respiration, and blood pressure during the procedure. Being careful to maintain sterile technique, the nurse should hold the drainage tube so that the health care provider can connect the chest tube. The nurse should then tape the connection between the chest tube and the drainage tube with a spiral pattern. Dependent loops, of drainage tubing should be avoided, thus the length of tubing should be tailored to the patient so he or she has the ability to turn in bed, but not so long that dependent loops are likely. The nurse should mark the drainage chamber with the start date and time and the beginning amount of drainage and initial it to provide a baseline for continuous assessment of the type and quantity of drainage.

The nurse is caring for a patient who has a chest tube for a hemothorax. The nurse notices that when the patient coughs, there is a gush of blood in the drainage system. What action should the nurse take? A. Document the normal findings and continue to monitor. B. Clamp the chest tube because there has been a pressure change. C. Add more water to the suction control chamber to increase suction. D. Notify the health care provider immediately.

A When the patient coughs, it is normal to see a gush of blood; if there is continuous bleeding, it should be reported. In neither case should more water be added to the suction control chamber to increase suction. The only time a chest tube may be clamped is when checking for an air leak in the system or briefly to change or empty the drainage system.

A patient has a pleural effusion caused by a malignancy in her left lung. After a needle aspiration, she experienced a 40% collapse of her left lower lung. She had a chest tube inserted to remove the excess fluid and air that collected in her pleural space. The patient has a waterless drainage system with a diagnostic indicator, which is attached to suction. How will the nurse best determine if the patient developed an air leak? A. The nurse observes bubbling in the diagnostic indicator chamber. B. By periodically lifting and draining the tube to the collection device. C. The nurse notices the suction float ball fails to remain at the prescribed setting. Incorrect D. By clamping the tube and assessing the patient for signs of respiratory distress.

A Bubbling in the diagnostic indicator chamber indicates the presence of an air leak in a waterless chest tube drainage system, which must be identified and treated. Periodically lifting and draining the tube to the collection device is done to promote pleural drainage when a dependent loop of tubing is unavoidable. Clamping the chest tube before removal to assess patient's tolerance is no longer recommended because there is no benefit to the practice. The suction source is set too low when the suction float ball fails to remain at the prescribed setting. Increase the suction until the float ball remains at the correct setting.

The nurse is assessing a waterless chest drainage system. Which of the following would be cause for concern? A. Continuous bubbling is present in the diagnostic air-leak indicator. B. There is approximately 15 mL of fluid in the diagnostic air-leak indicator. C. After 2 to 3 days, tidaling stops. D. Gentle tidaling is present.

A Bubbling indicates the presence of an air leak, which must be identified and treated. The lung is reexpanding normally when a gentle tidaling is present in the diagnostic air-leak indicator. If after 2 to 3 days tidaling stops, the lung is usually reexpanded. The diagnostic air-leak indicator does require a small amount of fluid (e.g., 15 mL of fluid). This indicator is important for monitoring the function of the waterless system.

A patient with a hemothorax and hemoglobin of 8 mg/dL is to have an autotransfusion of chest tube drainage. Which of the following would be a contraindication? A. Collected blood in the chest drain for 8 hours. B. An autotransfusion system (ATS) bag used for collection of chest tube drainage. C. A low hemoglobin level. D. Chest tube drainage collecting at a rate of 100 mL/hr.

A Collected blood never remains in the chest drain or ATS blood bag for more than 6 hours before autotransfusion. A low hemoglobin level is an indication for need of a blood transfusion or autotransfusion of chest tube drainage. Blood loss of 50 to 100 mL/hr through a chest tube indicates active bleeding and is an indication for reinfusion of chest tube drainage. An ATS bag should be used for collection of chest tube drainage because it contains a filter to remove extraneous materials and microemboli.

The health care provider has removed the patient's chest tube. The health care provider then covers the site with occlusive petrolatum gauze. What is the purpose of this dressing? A. To prevent the entrance of air into the pleural cavity. B. To prevent bacteria from entering the chest tube site. C. To provide more soothing comfort of excoriation at the chest tube site. D. To stop bleeding more rapidly at the chest tube site.

A The primary purpose of the petrolatum gauze dressing is to prevent the entrance of air into the chest. The petrolatum dressing is an occlusive dressing. Any type of dressing could be used if the concern were only to prevent bacteria from entering the exit wound. Petrolatum gauze is unable to stop bleeding more rapidly. Pressure helps stop bleeding; however, there should be minimal bleeding, if any.

1. While assessing an intubated patient, the nurse notes that the patient is pale, hypotensive, tachycardic, and has oliguria. The patient has a hemothorax on the right side and bilateral femur fractures. The chest tube has drained 350 mL over the previous 2 hours. What does the nurse know? A. This patient is hypovolemic from blood loss and is an appropriate candidate for autotransfusion. B. The patient requires decreased cardiac output to decrease his heart rate and compensate for hypovolemia. C. The patient should begin receiving dopamine for his blood pressure and large amounts of fluid should be infused to facilitate increased urine output. D. The patient is hypovolemic and a poor candidate for autotransfusion because of the increased risk of a transfusion reaction.

A The signs and symptoms indicate that this patient is hematologically compromised. The volume of blood in the chest tubes makes the patient an ideal candidate for autotransfusion.

The nurse is monitoring the functioning of a three-chamber water-seal drainage system. Which of the following would negatively affect the functioning of this type of chest tube drainage system? (Select all that apply.) A. If the chest tube drainage system is tipped over. B. Evaporation of water in the suction control chamber. C. Evaporation of water in the water-seal chamber. D. Evaporation of fluid in the collection chamber.

A B C It is the level of water in the suction control chamber that maintains suction pressure. The nurse must be alert to the level of sterile water or normal saline in the water-seal or suction control chamber and be able to replace it as necessary to maintain proper functioning of the system. If the system is tipped or falls over, the integrity of the water-seal can be affected. The drainage system must remain upright to function properly.

An 18-year-old man presents with shortness of breath and chest pain, which he says has gotten progressively worse since yesterday. He is diagnosed with a spontaneous pneumothorax. The patient will have a chest tube inserted that will be connected to a disposable three-chambered closed chest drainage system with suction. The patient's preprocedure vital signs are: temperature 99° F orally, pulse 77, respiration 30 with diminished breath sounds on the right, blood pressure 120/80, and SaO2 85%. Which findings support the diagnosis of spontaneous pneumothorax? (Select all that apply.) A. Respiration. B. Lung sounds. C. Oxygen saturation. D. Blood pressure. E. Temperature. F. Pulse.

A B C The temperature, pulse, and blood pressure are within the normal range for a man of his age. The respiratory rate is above normal, and there are abnormal lung sounds. The oxygen saturation is below normal, supporting the diagnosis of a spontaneous pneumothorax. In an 18 year old, vital signs should return to normal once the tube is in place.

What clinical signs and symptoms should a nurse expect in a patient who requires chest tube insertion for a pneumothorax? (Select all that apply.) A. Shallow respirations at a rate greater than 20 breaths per minute. B. Anxious and restless. C. Cyanotic. D. Pulse oximetry reading greater than 95%. E. Chest pain. F. Normal depth of breathing at a rate less than 20 breaths per minute. G. Diaphoretic.

A B C E G Shallow, rapid respirations would be expected for the patient requiring a chest tube. The patient who is in need of a chest tube is usually in respiratory distress and has abnormal respiration rate and depth. The patient being anxious and restless and possibly cyanotic before chest tube insertion may indicate a lack of oxygen. A patient in respiratory distress is often sweating. Chest pain is associated with a pneumothorax, indicating that the patient needs a chest tube.

Which of the following findings in a patient with a chest tube would require follow-up by the nurse? (Select all that apply.) A. Constant right-to-left bubbling in the diagnostic air-leak indicator. B. Constant bubbling in the water seal. C. Rise and fall of fluid in the diagnostic air-leak indicator of a waterless system. D. Sudden increase of 300 mL drainage in 1 hour. E. Constant gentle bubbling in the suction control chamber of a water-seal system.

A B D Constant bubbling in the water seal is considered abnormal and requires immediate attention. Notify a health care provider when there is a sudden increase of more than 250 mL of drainage over 1 hour, which can indicate fresh bleeding from the thorax. In the water-seal system, constant gentle bubbling in the suction control chamber when it is connected to suction is an expected finding. In the waterless system a rise and fall of fluid in the diagnostic air-leak indicator synchronous with respirations is an expected finding. Constant right-to-left bubbling (when facing the indicator) or violent rocking in the waterless system is considered abnormal and is indicative of an air leak.

During assessment of a patient's record, what items are areas of concern that should be brought to the attention of the health care provider before chest tube insertion? (Select all that apply.) A. A consent form lacks a signature. B. The patient has had a stroke and is receiving anticoagulants. C. The patient quit smoking 1 month ago. D. The patient has arthritis, which is being treated with aspirin. E. Regular caffeine use has been noted. F. The patient has a hemoglobin value of 9 g per dL. G. The patient regularly uses an antiplatelet agent.

A B D F G Anticoagulation therapy such as aspirin, warfarin, or heparin or platelet aggregation inhibitors such as ticlopidine can increase procedure-related blood loss. A low hemoglobin value is significant because it indicates that the patient has a lower oxygen-carrying capacity. Further bleeding could negatively affect the patient. The health care provider should be notified if a signed consent form is missing, because this procedure cannot be performed without a complete signed consent as a result of of the risks involved. It is unnecessary to notify the health care provider if the patient is a smoker or uses caffeine regularly because these factors have little impact on this procedure.

Which of the following chest tube tasks is the Physician/Advanced Practice Nurse (APN) responsible for performing? (Select all that apply.) A. Administering local anesthetic. B. Obtaining informed consent. C. Taping all tubing connections. D. Administering pain medication. E. Removing a chest tube. F. Monitoring of water levels in the collection device. G. Turning on wall suction. H. Monitoring of patient vital signs and physical assessment.

A B E It is the responsibility of the physician to provide informed consent, explaining the purpose, procedure, and complications to the patient. The physician will inject the local anesthetic and allow time for it to take effect. The physician orders the level of suction to be used (amount of water to be added) to the suction control chamber and for the wall suction setting. The physician determines when the chest tube should be removed and is the one who implements removal. The physician performs the initial dressing of the chest tube site after insertion. You have many responsibilities as well. You tape all tubing connections with 1-inch tape to secure an airtight system. You administer the prescribed pain medication before the procedure, allowing time for it to take effect. You turn on the wall suction to the prescribed setting after the chest tube is inserted and connected to the drainage system. You monitor the water level in the collection device and add water as necessary when evaporation occurs to maintain the prescribed level. You perform a continuous assessment of the patient, including vital signs.

Which of the following are indications a patient is ready to have his chest tube removed? (Select all that apply.) A. Less than 50 mL of drainage in 24 hours. B. Absence of tidaling for 24 hours. C. Vital signs within normal limits. D. Absence of bubbles in water-seal compartment. E. Absence of water in the water-seal compartment. F. Resonance on percussion of lungs. G. Drainage is serous in color.

A B F Reexpansion is indicated by the absence of tidaling for 24 hours, drainage decreased to less than 100 to 150 mL per day, normal percussion of lung sounds (i.e., resonance), and normal breath sounds bilaterally. The health care provider may also order a chest x-ray examination to confirm total lung reexpansion. Normal vital signs may be present when a patient's lungs are still compromised. Additional evaluation is required to determine chest tube removal. Drainage is expected to change to serous; however, the amount of drainage is more indicative of lung reexpansion than the color. The absence of water in the water-seal compartment may occur with evaporation and should be replaced for proper functioning of the chest tube. The absence of bubbles in the water-seal compartment indicates that the air leak is resolved but does not confirm that the lung has reexpanded.

A nursing student is helping care for a patient with a chest tube. The nursing student asks the staff nurse what determines the level of suction in the chest tube. What is the correct response? (Select all that apply.) A. "The suction float ball indicates the amount of suction the patient's intrapleural space is receiving in a waterless system." B. "Whether it is a two-chamber or three-chamber system determines the level of suction. Three-chamber systems have more area to collect drainage, creating a greater negative intrapleural pressure." C. "The depth of fluid in the suction control chamber of a water-seal system determines the highest amount of negative pressure that can be present within the system." D. "The setting of the wall suction determines the amount of negative pressure present within the water-seal system."

A C In a water-seal system, the depth of fluid dictates the amount of negative pressure. For example, 20 cm of water is approximately 20 cm of water pressure. Any additional negative pressure applied to the system is vented into the atmosphere through the suction control vent. The setting of the wall suction is unrelated to the amount of negative pressure within the water-seal system. In a water-seal system, turning the wall suction up higher will only make the system noisier without increasing the amount of suction on the patient's intrapleural space. In a waterless system, the suction float ball dictates the amount of suction in the system. The float ball allows only the level of suction dictated by its setting. The amount of drainage a drainage system can hold is unrelated to the level of suction in the chest tube.

The nurse is assisting the health care provider to insert a chest tube. Which of the following actions, if performed by the nurse, would require correction? (Select all that apply.) A. The nurse coils the tubing on the patient's bed. B. The nurse tapes the connection between the chest tube and the drainage tube with a spiral pattern. C. The nurse hands the nonsterile anesthetic vial to the health care provider when ready. D. The nurse marks the drainage chamber with the start date and time, the beginning amount of drainage, and the nurse's initials. E. Using sterile technique, the nurse holds the drainage tube while the health care provider connects the chest tube.

A C The nurse should first perform hand hygiene and make sure the patient is informed as to what is taking place. The nurse may premedicate the patient according to health care provider's orders with a sedative or analgesic. The collection system should be set up and checked for proper functioning. The nurse should then assist the patient to an appropriate position and provide psychological support to the patient. To assist the health care provider, the nurse should hold the anesthetic vial so the health care provider can visualize the label and verify the contents and dosage. The nurse should clean the top of the vial with an alcohol wipe and then turn it upside down so the health care provider can withdraw the amount of drug needed. Handing the vial to the health care provider would contaminate the health care provider's sterile gloves. Using sterile technique, the nurse should hold the drainage tube while the health care provider connects the chest tube. Next the nurse should tape the connection with a spiral pattern. To promote pleural drainage, the nurse should keep the tubing straight, not allowing it to hang in a dependent loop from the bed. The length of the tubing should be tailored to the patient. The nurse should mark the drainage chamber with the date and time that drainage was begun and initials. Finally, the nurse should clean up the area, perform hand hygiene, and document.

Which of the following chest tube tasks is the nurse responsible for performing? (Select all that apply.) A. Monitoring of water levels in the collection device. B. Removing a chest tube. C. Taping all tubing connections. D. Administering pain medication. E. Obtaining informed consent. F. Turning on wall suction. G. Administering local anesthetic. H. Monitoring of patient vital signs and physical assessment.

A C D F H It is the responsibility of the physician to provide informed consent, explaining the purpose, procedure, and complications to the patient. The physician will inject the local anesthetic and allow time for it to take effect. The physician orders the level of suction to be used (amount of water to be added) to the suction control chamber and for the wall suction setting. The physician determines when the chest tube should be removed and is the one who implements removal. The physician performs the initial dressing of the chest tube site after insertion. You have many responsibilities as well. You tape all tubing connections with 1-inch tape to secure an airtight system. You administer the prescribed pain medication before the procedure, allowing time for it to take effect. You turn on the wall suction to the prescribed setting after the chest tube is inserted and connected to the drainage system. You monitor the water level in the collection device and add water as necessary when evaporation occurs to maintain the prescribed level. You perform a continuous assessment of the patient, including vital signs.

A patient has a mediastinal chest tube inserted following surgery. Which of the following indicates a tension pneumothorax may be developing in the patient? (Select all that apply.) A. Hypotension. B. Change in color of drainage. C. Tachycardia. D. Tidaling in the water-seal chamber. E. Shift of trachea to unaffected side of chest. F. Decreased cardiac output.

A C E F A tension pneumothorax is a type of pneumothorax in which air can enter the pleural space but cannot escape via the route of entry. The contents in the mediastinum (e.g., trachea and heart) shift to the opposite (unaffected) side of the chest, which causes an increased pressure on the great vessels such as the vena cava, causing a decreased venous return and subsequent cardiac output. Other symptoms of a tension pneumothorax include hypotension, tachycardia, and muffled heart sounds. Tidaling and change in color of drainage do not indicate that a tension pneumothorax is developing.

1. A patient with a hemothorax has a posterior chest tube located laterally in the fifth intercostal space connected to a water-seal drainage system. Preprocedure vital signs were: temperature 98.6° F, pulse 110, respiration 26 and shallow, blood pressure 94/52, and oxygen saturation 87%. The nurse is evaluating the patient's outcome. The health care provider should be notified of which of the following findings? (Select all that apply.) A. Asymmetrical chest movement. B. Bubbling in water-seal chamber immediately after chest tube insertion. C. Temperature 98.0° F, pulse 80, respiration 20, blood pressure 124/80, pulse oximetry 93%. D. 500 mL of drainage in 24 hours. E. Temperature 98.0° F, pulse 124, respiration 28, blood pressure 80/50, pulse oximetry 85%. F. Bright red drainage 8 hours after insertion in the collection chamber. G. Drainage changing to serous color.

A E F After the procedure, the patient's vital signs should move toward normal. You should notify the health care provider if the patient's blood pressure drops and pulse increases significantly because this may be an indication of bleeding. If the patient's respirations increase and the patient has more difficulty breathing, increased chest pain, decreased oxygen saturation, asymmetrical chest movement, or mediastinal shifting, the nurse should notify the health care provider because this indicates either a worsening of condition or development of a tension pneumothorax. The patient's drainage should change from a bloody appearance to a more serous color. The amount of drainage may be 500 to 1000 mL in the first 24 hours. You should report bright red drainage because this indicates active bleeding. When you initially connect the system to the patient, bubbles are expected from the water-seal chamber. These are from air that was present in the system and in the patient's intrapleural space. After a short time, this bubbling stops and tidaling is noted.

A patient has just had a chest tube removed. Before the procedure, the patient received pain medication. The patient's vital signs at the time of receiving the pain medication were BP 120/80, pulse rate 76, respiratory rate 20, pulse oximetry 95%, and temperature 98.1° F orally. The nurse reassesses the patient after the procedure. Which of the following would require notifying the health care provider? A. The patient is exhibiting facial grimacing and may require an additional dose of pain medication. B. BP 100/60, pulse rate 96, respiratory rate 30, and pulse oximetry 90%. C. BP 126/84, pulse rate 72, respiratory rate 16, pulse oximetry 95%, and temperature 98.2° F. D. It is standard procedure to notify the health care provider of vital sign results, regardless of their reading.

B A drop in blood pressure, increase in pulse and respiratory rate, and decline in PaO2 may indicate that the patient's lung has collapsed. The health care provider is notified of abnormal results. The patient was premedicated before the procedure and may have facial grimacing for a reason other than pain. Have the patient rate his pain on a 0-to-10 pain scale to reassess pain level.

1. Which of the following is an expected finding for a chest tube located in the sixth lateral intercostal space? A. Over time the volume of drainage decreases and the color changes from serous to sanguineous. B. Over time the volume of drainage decreases and the color changes from sanguineous to serous. C. Over time the volume of drainage increases and the color remains sanguineous. D. There is no drainage; only air escapes the pleural space.

B A hemothorax that is resolving properly will have a decrease in the volume of drainage and a color change of drainage from sanguineous (red) to serous. A hemothorax with complications will have steady or increased volume without fluid color change. A pneumothorax (with the usual chest tube location of the second or third intercostal space) will resolve as air is expelled from the pleural space.

A patient is being prepared for open-heart surgery. Where would you expect the chest tube to be located when the patient returns from surgery? A. In the fifth or sixth intercostal space. B. In the mediastinum, just below the sternum. C. In the second or third intercostal space. D. Posteriorly or laterally.

B A mediastinal chest tube is placed in the mediastinum, just below the sternum. Mediastinal chest tubes are inserted for open-heart surgery patients to drain fluid away from the pericardial sac. Placing a chest tube in the second or third intercostal space is for the resolution of a pneumothorax. A chest tube located in the fifth or sixth intercostal space either posteriorly or laterally is the typical placement to remove blood or fluid from a hemothorax.

The nurse is assisting the health care provider with the insertion of a chest tube. Before the procedure, the nurse prepares the drainage system to ensure that it will operate correctly. The nurse opens the drainage system and adds sterile water to the suction control chamber according to the manufacturer's directions. The nurse then connects the tubing to the suction control chamber and to the suction source. The nurse clamps the tube that will go to the patient and turns the suction on to check the system for any air leaks. Because no air leaks are found, the nurse unclamps the tube and leaves the suction on so that it is ready to be connected to the patient. Which step made by the nurse requires correction? A. The nurse performed all steps correctly. B. The nurse should turn the suction off before it is connected to the patient. C. The nurse should not clamp the tube that will go to the patient. D. The nurse should not connect the tubing from the suction control chamber to the suction source.

B Before the patient receives the chest tube, the nurse should ensure that the system is functioning properly. The nurse should open and prepare the drainage system according to the manufacturer's directions. Connect the tubing to the suction control chamber and to the suction source. Clamp the tube that will go to the patient. Turn the suction on and check the system for any air leaks. The nurse should then turn the suction off before it is connected to the patient.

What is the importance of keeping water at the prescribed centimeter level in the suction control chamber? A. If the fluid level gets too low, the negative pressure created could cause damage to the pulmonary tissues. B. As the fluid level decreases with evaporation, the amount of suction declines. C. It prevents the suction from being so noisy as it bubbles. D. It is important to not let evaporation dry out the patient s lungs, which could impede reinflation.

B Sterile water is added several times a day because of evaporation. As the fluid level decreases, the amount of suction also declines. A prescribed amount of sterile fluid (e.g., 20 cm of water) is poured into the suction control chamber, which is then attached to a suction source by tubing. The amount of sterile water added depends on the manufacturer's recommendations. The chamber is filled to the set volume for the prescribed amount of suction. The wall or portable suction device is turned up until the water in the suction control bottle exhibits a continuous, gentle bubbling. If the suction source delivers more negative pressure than the suction control chamber water level allows, there is no danger because atmospheric air is pulled into the suction control chamber through an inlet, causing the excess suction to dissipate. The extra air pulled into the chamber causes vigorous bubbling. If this occurs, lower the suction source setting to reduce noise and evaporation of the fluid.

The NAP has asked how to be of assistance during insertion of a chest tube. What activities can a NAP assist with related to insertion, maintenance, and removal of a chest tube? (Select all that apply.) A. Resolve problems with the chest tube. B. Report that the chest tube is kinked. C. Explain the procedure to the patient. D. Provide assistance to the health care provider during the procedure. E. Positioning of the patient to facilitate drainage. F. Gather personal protective equipment for the procedures. G. Report patient complaints of discomfort or pain.

B E F G NAP can report patient complaints of pain or discomfort to the nurse. NAP can report problems with the chest tube but should avoid attempting to resolve them because these skills are outside a NAP's training. NAP may gather equipment but should leave sterile packages closed. NAP may help position the patient to facilitate drainage after placement. Because of the complexity of the procedure, NAP should avoid attempting to explain the procedure to the patient, as patient teaching is the responsibility of the nurse. In addition, the NAP is unable to recognize if an emergent situation is developing. Finally, the nurse should assist the health care provider in chest tube insertion or removal.

The nurse is caring for a patient with a chest tube. Which of the following findings would require follow-up with the health care provider? A. Absence of tidaling with a mediastinal chest tube for 24 hours. B. Gentle fluctuations are noted in the diagnostic indicator of the waterless drainage system. C. Absence of tidaling for 24 hours with an apical chest tube. D. The waterless chest tube drainage system was accidentally tipped over.

C A halt in bubbling for 24 hours and a decrease in drainage to less than 100 to 150 mL per day are good indicators that the patient's lung has reexpanded. Tidaling is absent with a mediastinal chest tube because its function is to prevent blood from accumulating around the heart rather than to reexpand a collapsed lung. Accidentally tipping over a waterless system can occur without compromising the patient's condition. The nurse should simply upright the system. The lung is reexpanding normally when a gentle tidaling is present in the diagnostic air-leak indicator.

The patient is anxious about having his chest tube removed. He states, "I'm afraid my lung will just collapse again. Is there anything I can do to help? What is the nurse's best response? A. "Yes, you can lie very still and focus on taking normal breaths while the health care provider removes the chest tube." B. "There's nothing you can do to keep that from occurring, so you might as well relax. I'm sure you'll be just fine." C. "Yes, you should exhale completely and bear down while the chest tube is being removed. We will tell you when." D. "There is no reason to worry. That rarely happens, and if it does the doctor will just insert a new chest tube."

C Having the patient exhale completely and perform the Valsalva maneuver will prevent air from being sucked into the chest as the tube is removed. A complication associated with removal of chest tubes is recurrent pneumothorax, which results from atmospheric air reentering the pleural cavity. This occurs when the patient inhales during tube removal. If a recurrent pneumothorax occurs, the health care provider may insert another chest tube. However, this is not the best response because it fails to comfort the patient and fails to instruct the patient regarding appropriate action. Telling the patient there is nothing he can do and saying he'll just be fine are both inaccurate and offer only false reassurance.

What effect will increasing the suction source, creating more negative pressure, have on a three-chamber water-seal chest tube drainage system connected to suction? A. It will increase the frequency of emptying the drainage collection device. B. It will increase the rate of lung expansion. C. It will create more vigorous bubbling and faster evaporation of water. D. It will damage lung tissue if the negative pressure is too great.

C Increasing wall suction creates more vigorous (and louder) bubbling and faster evaporation of water from the chamber. The level of water in the suction control compartment maintains the level of suction. The rate of lung reexpansion may be affected by a low water level (as fluid level decreases, the amount of suction also decreases) or by a drainage system that is too full and needs emptying. The chest tube drainage system has a built-in release valve to prevent tissue damage. If the suction source delivers more negative pressure than the suction control chamber water level allows, atmospheric air is pulled into the suction control chamber through an inlet, causing the excess suction to dissipate.

What is a normal expected outcome after insertion of a chest tube? A. Asymmetrical chest movement. B. Increased chest pain. C. Normal rate and depth of breathing. D. Diaphoretic. E. Cyanotic. F. Shallow, rapid respirations.

C The patient should be breathing more easily and at a normal rate (12 to 20 breaths per minute) and depth after the procedure. The patient who is free of respiratory distress should appear calm. The patient who is free of respiratory distress should have warm, dry skin of a normal skin tone for the patient. The patient should be free of chest pain. Chest pain or asymmetrical chest movement may indicate a possible tension pneumothorax.

Which of the following tasks associated with a chest tube is the responsibility of the nurse? A. Inserting the chest tube, connecting it to a drainage system, and monitoring output. B. Obtaining informed consent before the procedure. C. Removing the chest tube when the order is received. D. Setting up equipment, positioning the patient, and monitoring patient status.

D Health care providers are usually responsible for the insertion of chest tube catheters. The nurse is responsible for assisting during a chest tube insertion. This includes being responsible for equipment setup, positioning a patient, and monitoring the patient's status before, during, and after the procedure. It is the responsibility of the health care provider to obtain informed consent from the patient before inserting a chest tube. The nurse should verify the presence of a signed informed consent document before the start of the procedure. It is the responsibility of the health care provider to remove the chest tube.

An RN and an NAP are caring for a group of patients. Which of the following would be an appropriate action for the nurse? A. Delegate milking the chest tube to the NAP while the RN administers pain medication to the patient. B. Delegate assisting the health care provider in chest tube insertion to the NAP so the RN can take report on a new admission. C. Delegate to the NAP clamping the chest tube while ambulating the patient in the hall 3 times a day. D. Delegate to the NAP informing the nurse if there is disconnection of the chest tube system or sudden bleeding.

D The NAP should be instructed to inform the nurse if there is disconnection of system, change in type and amount of drainage, sudden bleeding, or sudden cessation of bubbling. Only a nurse may assist health care providers with chest tube insertion because of the level of skill required. Milking chest tubes should be done only when there is a health care provider's order and an organizational policy covering this practice. Although assisting with ambulation may be delegated, chest tubes are never routinely clamped when the patient is ambulating and/or during transportation to another location.

Which postprocedure chest tube insertion vital sign schedule meets the minimum needs of a postoperative patient? A. Every 10 minutes for the first hour. B. Every 15 minutes for the first hour, then every 30 minutes for the next hour, then every hour for the next 4 hours. C. Every 15 minutes times 2, then every hour times 4, then every 4 hours. D. Every 15 minutes for the first 2 hours.

D Every 15 minutes for the first 2 hours is a minimum and assumes that the patient's vital signs remain stable and/or improve.

To gain the patient's cooperation during the procedure, the nurse is instructing the patient regarding chest tube removal. The patient asks why he must exhale completely and hold it while bearing down while the chest tube is being removed. What is the nurse's best response? A. "It prevents movement of the chest wall so tissue will not be damaged as the tube is removed." B. "It prevents drainage from being sucked back into the lung cavity." C. "It will help push the tube out making removal of the tube easier and less painful." D. "It prevents air from being sucked into the chest tube allowing the lung to collapse."

D Having the patient exhale completely and hold it while bearing down prevents air from being sucked into the chest as the tube is removed. A complication associated with removal of chest tubes is recurrent pneumothorax, which results from atmospheric air reentering the pleural cavity.

Which of the following would indicate the patient with a chest tube connected to suction is ready to have the chest tube removed? A. There is hyperresonance upon percussion. B. There is presence of a mediastinal shift. C. The drainage has changed from sanguineous (red) to serous. D. There are 500 mL of drainage in 24 hours. E. After 2 hours, tidaling has ceased. F. After 3 days, tidaling has ceased for 24 hours.

F Indications that the patient may be ready to have the chest tube removed include absence of tidaling for 24 hours and less than 100 to 1550 mL of drainage in 24 hours. Cessation of tidaling after 2 hours may indicate that the suction has been shut off or the tube is obstructed. Five hundred milliliters in 24 hours is the expected amount of drainage in an adult with a mediastinal chest tube. The expected drainage in an adult with a pleural tube is 500 to 1000 mL in 24 hours. A change in fluid color does not indicate that the patient is ready to have the chest tube removed, although it is an expected change with time. A mediastinal shift is an indication of a tension pneumothorax. Although resonance on percussion may indicate that the lung is reinflated, hyperresonance is an indication of a potential tension pneumothorax.