Chest Tube: Closed Drainage System Management

The nurse on the previous shift set up a closed drainage system for a patient with a new pleural chest tube. The nurse on the current shift assesses the system and notices the water level is above the water seal chamber line. Which action is the most appropriate? A. Set up a new closed drainage system. B. Remove water per the manufacturer's instructions. C. Increase the suction on the wall regulator. D. Add more water to the water seal chamber.

B. Remove water per the manufacturer's instructions Rationale: If the water seal or suction control chamber is overfilled, the nurse should follow the manufacturer's instructions to remove excess water from the drainage system. During setup, the water seal chamber should be filled to the mark per the manufacturer's guidelines. There is no need to set up a new system. Turning up the suction would not be beneficial because a gentle continuous bubbling is all that is needed for suction. Suction is determined by the column of water and not by the amount of external suction. There is too much water; adding more would make the problem worse, not better.

Which condition is a complication of stripping the entire length of a pleural chest tube? A. Infection in the lungs B. New air leak C. Clotted chest tube D. Damage to the pleural tissues

D. Damage to the pleural tissues Rationale: Stripping the entire length of the chest tube is contraindicated because doing so results in transient high negative pressure in the pleural space, which can be detrimental to tissues in the pleural space. Stripping the chest tube does not cause an infection in the lungs or a new air leak and does not clot the chest tube.

During orientation, a new nurse is assessing the patient's mediastinal chest tube. Which statement by the new nurse indicates that further education is needed? A. "I do not see any tidaling in the water seal chamber." B. "The chest-drainage system is below the patient's thoracic level." C. "The chest tube should not be clamped." D. "I should observe the water seal chamber for indications of an air leak."

A. "I do not see any tidaling in the water seal chamber." Rationale: Tidaling does not occur with a mediastinal chest tube because the tube is not in the lung cavity. Tidaling occurs when the chest tube is in the pleural space and provides a continuous manometer measurement of the pressure changes in the pleural space. The CDS is below the thoracic level to prevent blood and fluids returning from the tubing back into the mediastinum, increasing the risk for infection and cardiac tamponade. The tubing should always be left open and never clamped. Occluding the tubing may cause an increase in intrathoracic pressure because air is unable to exit the system. Constant bubbling from right to left in the water seal chamber indicates an air leak. Observing the water seal chamber for indications of an air leak is appropriate.

A nurse is caring for a patient with a mediastinal chest tube. One hour after walking the patient around the unit, the nurse notices an increase in the amount of drainage from the patient's chest tube. Which statement is true regarding this finding? A. An increase in drainage after ambulation is normal but should be monitored closely. B. The patient should have a chest x-ray because tamponade may be developing. C. A decrease in the amount of drainage is normal, and the practitioner should be notified. D. An increase in serous drainage could indicate a ruptured suture line.

A. An increase in drainage after ambulation is normal but should be monitored closely. Rationale: An increase, not a decrease, in the amount of drainage from a chest tube is common after ambulation. If the patient had tamponade, the nurse would observe other signs, such as diaphoresis, hypotension, muffled heart sounds, and perhaps tachypnea. If the drainage had become sanguineous and were at least three times the actual output, a ruptured suture line would be a concern.

When the water seal chamber of a closed drainage system is overfilled, which change might the nurse expect to see? A. An increase in the work of breathing B. An increase in chest tube output C. Signs of a tension pneumothorax D. Signs of a hemothorax

A. An increase in the work of breathing Rationale: An excess level of water in the water seal chamber can increase the patient's work of breathing. The water seal chamber prevents backflow of air via water or a one-way mechanical valve and controls the amount of suction reaching the patient's pleural space. An increase in water in this chamber can increase the patient's work of breathing. Although the signs and symptoms of a tension pneumothorax are similar, an overfilled chamber does not cause a tension pneumothorax. Chest tube output is not influenced by the amount of water in the water seal chamber. A hemothorax is usually caused by trauma to the chest, not the volume of water in the water seal chamber.

A patient who has been involved in a motor vehicle crash has a pleural chest tube. The patient's air leak monitor in the water seal chamber is bubbling from right to left. Which action should the nurse take first? A. Assess the patient for a pneumothorax. B. Replace the CDS immediately. C. Clamp the chest tube. D. Reduce the amount of suction.

A. Assess the patient for a pneumothorax. Rationale: The nurse should assess the patient for a pneumothorax. The water seal acts as a one-way valve. Bubbles moving from right to left in the water seal chamber indicate an air leak either in the patient or in the CDS; therefore, the patient should be assessed first for a pneumothorax. An air leak is expected when the chest tube is initially placed and the pneumothorax is evacuated, but it should not persist afterward. The amount of suction should not be reduced without a practitioner's order. The CDS may need to be replaced if the air leak is determined to be in the CDS, but the patient should be assessed first. The chest tube may be clamped to help determine where the air leak is located but the patient should be assessed first.

When managing a CDS, which action should the nurse take? A. Ensure that the system remains at the head of the bed if the patient is in the prone position. B. Ensure that the chest tube is not stripped. C. Clamp the tube if the drainage collection system becomes damaged. D. Ensure that the tubing is looped off the side of the bed to prevent kinking.

B. Ensure that the chest tube is not stripped. Rationale: Stripping pleural chest tubes is not recommended because it may cause large fluctuations in intrathoracic pressure. When a patient is in the prone position, the tubing should be placed along the patient's side, parallel to the insertion site and extended off the foot of the bed to prevent kinking. If the drainage collection system breaks, the end of the chest tube should be placed in a container of sterile water until a new collection system can be set up. The tube should not be clamped. Looping the tubing off the side of the bed may cause an obstruction from a clot forming in the dependent loop and increased pressure in the lung. Tubing should be placed along the patient's side parallel to the insertion site.

When transporting a patient with a mediastinal tube, which action is the most appropriate? A. Ensuring that portable suction equipment is available during the transport B. Ensuring that the tubing is clamped before removing it from the suction source C. Ensuring that the CDS is below the thoracic level D. Ensuring that tidaling occurs throughout transport

C. Ensuring that the CDS is below the thoracic level Rationale: When transporting a patient, the nurse should keep the chest tube drainage system below the thoracic level because the pressure in the thoracic cavity must be greater than that in the drainage unit. The tubing should always be left open and never clamped. Occluding the tubing may cause an increase in intrathoracic pressure because air is unable to exit the system. Portable suction is not needed during transport; the suction source may be removed as long as the system stays below the insertion site. In general, tidaling does not occur with a mediastinal chest tube because the tube is not in the lung cavity.

When assessing a patient with a mediastinal tube, what should the nurse remember? A. A widening pulse pressure is a sign of cardiac tamponade. B. The tubing should be clamped every hour to assess for air leaks. C. The CDS must be kept below the thoracic level. D. Tidaling in the CDS is an expected finding.

C. The CDS must be kept below the thoracic level. Rationale: The nurse should keep the CDS below the thoracic level to prevent blood and fluids returning from the tubing back into the mediastinum, increasing the risk for infection and cardiac tamponade. The tubing should always be left open and never clamped. Occluding the tubing may cause an increase in intrathoracic pressure because air is unable to exit the system. A narrowing pulse pressure, not widening pulse pressure, is a sign of cardiac tamponade and must be reported promptly. In general, tidaling does not occur with a mediastinal chest tube because the tube is not in the lung cavity.

A nurse notices that a patient's chest tube drainage looks milky. The practitioner requests a sample of the fluid be sent to the laboratory. What should the nurse do? A. Ensure that the practitioner obtains the sample when the chest tube is placed. B. Insert a large gauge needle into the dependent loop after it is cleaned. C. Insert a small gauge needle into the grommet on the system. D. Insert a small gauge needle into the dependent loop after it is cleaned.

D. Insert a small gauge needle into the dependent loop after it is cleaned. Rationale: To collect a sample of chest tube drainage, the nurse should use a small gauge needle and insert it directly into the resealable connecting tubing after proper cleaning. If output is minimal, a small portion of the tubing may be placed into a dependent loop just until enough fluid is collected for a sample. Large gauge needles may damage the self-sealing capability of the tubing. The grommet port on the system is for removing excess water or saline in the water seal chamber, not for obtaining a sample of chest tube drainage. Although a sample of fluid may be collected upon insertion of the chest tube, it is not common to see chylous drainage immediately.