Chest Tubes

Suction control chamber: interventions

1. gentle (not vigorous) bubbling should be noted in the suction control chamber of a wet suction system

Chest Tubes

drainage system that returns negative pressure to the intrapleural space

Tidaling

the rise and fall of fluid within a closed-chest drainage system with inhalation and exhalation (up with inspiration and down with expiration)

Water seal chamber: interventions

1. monitor for fluctuation of the fluid level in the water seal chamber 2. fluctuations in the water seal chamber stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has re-expanded 3. if the client has a known pneumothorax, intermittent bubbling in the water seal chamber is expected as air is drained from the chest, but continuous bubbling indicates an air leak in the system 4. notify the PHCP if there is continuous bubbling in the water seal chamber

Portable chest drainage system:

1. small and portable chest drainage systems are also available and are dry systems that use a control flutter valve to prevent the backflow of air into the client's lung. 2. principles of gravity and pressure, and the nursing care involved, are the same for all types of systems, and these systems allow greater ambulation and allow the client to go home with the chest tubes in place.

Water-filled Suction control chamber

1. the suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest 2. this chamber is filled with various levels of water to achieve the desired level of suction; without this control, lung tissue could be sucked into the chest tube 3. gentle bubbling in this chamber indicates that there is suction and does not indicate that air is escaping from the pleural space (YELLOW ARROW)

Water seal chamber

1. the tip of the tube is underwater, allowing fluid and air to drain from the pleural space and preventing air from entering the pleural space 2. water oscillates (moves up as the client inhales and moves down as the client exhales). 3. excessive bubbling indicates an air leak in the chest tube system

Dry suction system

1. this is another type of chest drainage system. because this is a dry suction system, absence of bubbling is noted in the suction control chamber 2. a knob on the collection device is used to set the prescribed amount of suction; then the wall suction source dial is turned until a small orange floater valve appears in the window on the device (when the orange floater valve is in the window, the correct amount of suction is applied

A nurse is caring for a client with a chest tube after being injured in a car accident. Which action of the nurse best describes how to maintain the water seal on the tube? a. Maintain the water at 12 cm or more in the chamber b. Ensure that the chest tube chamber is kept upright c. Keep the head of the client's bed flat d. Maintain the chest tube at the level of the client's waist or above

The answer is B. A chest tube has more than one compartment that manages fluid and air that is removed from the client's pleural cavity. The water seal allows the air to be removed from the pleural space but prevents air and fluid from entering by acting as a one-way valve. The nurse can ensure the patency of the water seal by ensuring that the chamber is upright and by keeping 2cm of water in the water seal chamber.

A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first? a. The client with tidaling in the drainage tubing b. The client with suction pressure set at -20 cmH2O c. The client with continuous bubbling in the drainage chamber d. The client whose drainage system is standing on the floor

The answer is C. Continuous bubbling in the chamber reflects an air leak, meaning there could be a hole in the tubing or it could be dislodged. This client is the priority to be seen first. Note - a client with a pneumothorax will have bubbling in the chamber during breathing, which is a normal, expected finding. But it will fluctuate with breathing, not be continuous.

What are chest tubes used for?

to remove abnormal accumulations of air and fluid from pleural space

Drainage collection chamber

1. located where the chest tube from the client connects to the system 2. drainage from the tube drains into and collects in a series of calibrated columns in this chamber

Collection chamber: interventions

1. monitor drainage; notify the PHCP if drainage is more than 70 to 100 mL/hr or if drainage becomes bright red or increases suddenly 2. mark the chest tube drainage in the collection chamber at 1 to 4 hour intervals, using a piece of tape

An unlicensed assistive personnel is taking care of a patient with a chest tube. The nurse should intervene when she observes the unlicensed assistive personnel a. looping the drainage tubing on the bed b. securing the drainage container in an upright position c. stripping or milking the chest tube to promote drainage d. reminding the patient to cough and deep breathe every 2 hours

The answer is C. If chest tubes are to be milked or stripped, this procedure should be done only by the professional nurse. This procedure is no longer recommended, as it may dangerously increase pleural pressure, but there is no indication to milk the tubes when there is no bloody drainage,a sin a pneumothorax.

If a pneumothorax is present and the client has a chest tube, what type of bubbling would be expected in the water chamber? a. Tiny bubbles b. Intermittent c. Constant d. No bubbling

The answer is B. Intermittent bubbling is noted when a pneumothorax occurs. As long as there is air in the pleural space, there will be intermittent bubbling in the chamber.

If chest tube is pulled out of the chest accidently:

pinch the skin opening together, apply an occlusive sterile dressing, cover the dressing with overlapping pieces of 2 inch tape and call the PHCP immediately

A client has fluid in the pleural space and the nurse is preparing for a chest tube insertion. The nurse knows that the insertion site will be located at which of the following locations? a. 8th or 9th intercostal space b. Under the ribs through the diaphragm c. Through the sternum d. 2nd intercostal space

The answer is A. When a client has a chest tube placed to remove fluid, the insertion site is around the 8th or 9th intercostal space.

A nurse is caring for a client who has a chest tube because of a pneumothorax. The nurse can tell the certified nursing assistant to check which of the following? a. The client's respiratory rate b. Whether there is increased drainage in the last four hours c. Whether the chest tube is tidaling d. The level of the water seal on the chest tube

The answer is A. When caring for a client who has a chest tube, the nurse cannot delegate its care to unlicensed assistive personnel due to the assessment required for management. The only measure the certified nursing assistant can perform in this case is to check the client's respiratory rate, as this is part of obtaining vital signs.

The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should: a. continue to monitor the patient b. check all connections for a leak in the system c. lower the drainage collector further from the chest d. clamp the tubing at progressively distal points away from the patient until the tidaling stops

The answer is A. continue to monitor the patient

The nurse is caring for a client with a chest tube. While assessing the tubing, the nurse notes a clot in the tubing. What action is appropriate in order to remove the clot from the tubing? a. Squeeze by sections moving from the client to the chest tube chamber b. Strip the tubing starting from the client toward the chest tube chamber c. Milk the tubing d. Strip the tubing starting from the chest tube and moving toward the client

The answer is A. Squeezing with one hand then releasing before squeezing further down is the best evidence-based way to clear a chest tube of a clot.

Chest tube drainage systems: additional interventions

1. an occlusive sterile dressing is maintained at the insertion site 2. a chest radiograph assesses the position of the tube and determines whether the lung has re-expanded 3. assess respiratory status and auscultate lung sounds. assess chest tube dressing for drainage and palpate surround tissue for crepitus 4. monitor for signs of extended pneumothorax or hemothorax 5. keep the drainage system below the level of the chest and the tubes free of kinks, dependent loops, or other obstructions 6. ensure that all connections are secure 7. encourage coughing and deep breathing 8. change the client's position frequently to promote drainage and ventilation. 9. do not strip or milk a chest tube unless specifically directed to do so by the PHCP and if agency policy allows it 10. keep a clamp (may be needed if the system needs to be changed) and a sterile occlusive dressing at the bedside at all times. 11. never clamp a chest tube without a written prescription form the pHCP; also, determine agency policy for clamping a chest tube 12. if the drainage system cracks or breaks, insert the chest tube into a bottle of sterile water, remove the cracked or broken system, and replace it with a new system 13. depending on the PHCP's preference, when the chest tube is removed, the client may be asked to take a deep breath and hold it, and the tube is removed. or, the client may be asked to take a deep breath, exhale, and bear down (Valsalva maneuver). a dry sterile dressing, petroleum gauze dressing, or Telfa dressing (depending on the PHCP's preference) is taped in place after removal of the chest tube

When should the nurse check for leaks in the chest tube and pleural drainage system? a. there is continuous bubbling in the water seal chamber b. there is constant bubbling of water in the suction control chamber c. fluid in the water seal chamber fluctuates with the patient's breathing d. the water levels in the water seal dn suction control chambers are decreased.

The answer is A. The water seal chamber should bubble intermittently as air leaves the lung with exhalation in a spontaneously breathing patient. Continuous bubbling indicates a leak.

The nurse is caring for a client with a chest tube. The nurse will refrain from clamping the chest tube because which of the following could happen? a. Barrel chest b. Tension pneumothorax c. Airway constriction d. Pneumonia

The answer is B. Clamping a chest tube can cause a tension pneumothorax, because it becomes a one-way valve for air to enter the pleural space, but the air cannot escape because the tube is clamped. The trachea will deviate away from the affected side in this situation, and the client will present with chest pain, dyspnea, hypoxia and hypotension.

A client has a right chest tube in place after recovering from a pneumothorax. The provider is preparing to remove the chest tube. Which nursing action is most appropriate as part of chest tube removal? a. Apply direct pressure to the chest wall for five minutes after tube removal b. Place a clamp on the tube after it has been removed from the client's chest c. Instruct the client to perform the Valsalva maneuver while the tube is being removed d. Administer pain medication five minutes before starting

The answer is C. Chest tube removal is typically done by a provider, who removes the sutures holding the tube in place and pulls it out of the client's chest. The nurse can assist by administering pain medication to the client approximately 30 minutes before starting the procedure. The nurse should ask the client to bear down or perform the Valsalva maneuver as the tube is coming out. This increases pressure inside the chest cavity and reduces the risk of an air embolism.

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? a. Water-seal chamber has 5 cm of water. b. No new drainage in collection chamber c. Chest tube with a loose-fitting dressing d. Small pneumothorax at CT insertion site

The answer is C. If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

A 36-year-old client must have a chest tube placed after an injury from a motor vehicle accident. The nurse is preparing to assist the provider with a chest tube placement in the left lung. In which position should the nurse place the client? a. Prone with a support under the abdomen b. Trendelenburg c. Supine with the left arm behind the head d. Left side-lying

The answer is C. When assisting with a chest tube insertion, the nurse should place the client in the supine position for the best access for the provider to reach the chest site. A towel or roll of blankets may be placed behind the shoulder blades to elevate the chest slightly and to cause chest expansion. If able, the client may be alternatively positioned sitting at the side of the bed, leaned over a table.

A nurse is caring for a client with a chest tube. He notes that the dressing around the client's tube insertion site is wet and there is some crepitus with mild palpation. Which actions by the nurse are most appropriate in this situation? Select all that apply. a. Prepare for replacement of the tube b. Keep the tubing below the level of the insertion site c. Remove the tube and place an occlusive dressing over the site d. Notify the provider to evaluate the level of suction e. Gently milk the tubing to remove clots, if present

The answers are: A, B, and D. To avoid back flow of fluid, the tubing must be kept below the insertion site. Crepitus indicates subcutaneous emphysema. The tube will need to be replaced to correct the air leak. Subcutaneous emphysema may develop in a client with a chest tube if air leaks under the skin, causing crepitus and swelling of the face and neck. The nurse should notify the physician right away and prepare to replace the tube.

The nurse is assessing the functioning of a chest tube drainage system in a client with chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply a. excessive bubbling in the water seal chamber b. vigorous bubbling in the suction control chamber c. drainage system maintained below the client's chest d. 50 mL of drainage in the drainage collection chamber e. occlusive dressing in place over the chest tube insertion site f. fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

The answers are: C, D, E, and F. The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure; it may occur during exhalation, coughing, or sneezing. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hr is considered excessive and requires notification of the surgeon. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.