Chest Tube Management Quiz

"Milking and stripping"

"Milking and stripping" chest tubes is contraindicated because it increases negative intrapleural pressure; it does not significantly affect tube patency

10. The nurse is assessing the amount of drainage in the collection chamber of the chest tube drainage unit of a patient who has a chest tube inserted for hemothorax. Which of the following amounts of drainage should be reported to the health care provider?

200ml of drainage in 1 hour rational: Drainage greater than 100mL per hour is excessive and should be reported to the health care provider as it indicates increased bleeding in the pleural space.

The water seal chamber:

Acts as a one way valve in the pleural space

Interventions if CT pulled out

Cover wound with dry, sterile dressing If you can hear air leaking from site or client had known air leak, ensure dressing is not occlusive to prevent tension pneumothorax Notify MD

Following a pneumonectomy, an appropriate nursing intervention is a. monitoring chest tube drainage and functioning.

doing range-of-motion exercises on the affected upper limb.

2. the nurse is preparing a dry suction chest tube drainage unit for a patient who is having a chest tube inserted for a pneumothorax. The nurse will set the suction control on the chest tube drainage unit at the usual setting which is:

-20 cm H20 suction Rational: the most common ordered setting is -20 cm H20 suction, the other settings are not as commonly used.

Spontaneous Pneumothorax.

A spontaneous pneumothorax typically occurs due to the rupture of small blebs (air- filled sacs) located on the surface of the lung. These blebs can occur in healthy, young individuals or as a result of lung disease such as COPD, asthma, cystic fibrosis, and pneumonia. Smoking increases the risk for bleb formation. Other risk factors include being tall and thin, male gender, family history, and previous spontaneous pneumothorax.

Which action can help identify the location of an air leak?

Clamping the tubing at intervals

Which of the following interventions can help promote lung reinflation in a patient with a chest tube?

Encouraging coughing and deep breathing

Setting up a CDU with a water suction chamber

Fill water level in suction chamber to 20 cm Connect to wall suction Increase wall suction until gentle bubbling is seen in chamber

Flail Chest

Flail chest results from the fracture of several consecutive ribs, in two or more separate places, causing an unstable segment. During inspiration, the affected portion is sucked in, and during expiration, it bulges out. This paradoxical chest movement not only prevents adequate ventilation but also increases the work of breathing.

Suction Control Chamber

Regulates amount of suction in pleural space Facilitates removal of air and secretions Amount of suction is ordered by the physician Usual setting is - 20 cm H2O suction

Types of Chest Tube Drainage Systems

Sealed: Pleuravac, Atrium, Thoraklex Heimlich valve

Interventions if CT disconnected from drainage tubing

Submerge end in 1 inch (2 cm) sterile saline to maintain water seal Notify MD immediately

thoracentesis

thoracente- sis to remove the excess fluid or air to ease breathing. Thoracentesis is also performed to introduce chemotherapeutic drugs intrapleurally.

5. During assessment of the chest tube drainage unit of a patient with a chest tube, the nurse observed the rise and fall of the water level in the water seal chamber during inhalation and exhalation. The nurse documents this as :

tidaling Rational: An air leak is bubbling in the water seal chamber. Subcutaneous emphysema is when there is a crackling sensation felt under the skin around the chest tube site. The water level must be filled to the 2 cm mark in order to allow air to escape the pleural space, but not enter.

Nursing Assessment

Comfort - good pain management Monitor vital signs, pulse oximetry Lung sounds, respiratory & cardiac status Site, Tube, Output, Patency (STOP)

hemothorax

A hemothorax is the accumulation of blood in the pleural space

Which complication can result from trapped air in the pleural space?

Tension pneumothorax: Accumulation of air in pleural space that does not escape Causes mediastinal shift and hemodynamic instability Can occur with open or closed pneumothorax

position

The semi-Fowler's or high-Fowler's position allows maximum chest expansion in clients who are confined to bed, particularly those with dyspnea

What controls the amount of suction, the chest drainage unit or the wall suction setting?

The suction control chamber on the chest tube drainage unit controls the amount of suction, not the wall suction.

what controls the amount of suction on a chest tube drainage?

The suction control chamber on the chest tube drainage unit controls the amount of suction, not the wall suction.

Hemothorax Blood in the pleural space, may or may not occur in conjunction with pneumothorax.

Manifestations Dyspnea, diminished or absent breath sounds, dullness to percussion, decreased Hgb, shock depending on blood volume lost Intervention Chest tube insertion with chest drainage system. Autotransfusion of collected blood, treatment of hypovolemia as necessary.

The nurse notes an absence of tidaling in the water seal chamber in a patient with a newly inserted chest tube. Which of the following is a possible cause?

There is a kink or obstruction in the tubing

What is a tension pneumothorax?

Air in pleural space that does not escape Increased air in the pleural space shifts organs and increases intrathoracic pressure. • Causes mediastinal shift and hemodynamic instability • Can occur with open or closed pneumothorax

The nurse identifies a flail chest in a trauma patient when

. paradoxical chest movement occurs during respiration.

For a patient with a chest tube, the physician orders gravity drainage. This means that:

.the suction tubing should be left open to air.

Chest Tube Dressings

1. Change dressing according to unit protocol and HCP preference. 2. Remove old dressing carefully. Assess the site for any evidence of inflammation or infection and culture site as indicated. 3. Cleanse the site according to protocol, maintaining strict sterile asepsis. 4. Redress with occlusive dressing. Some HCPs prefer the use of petroleum gauze dressing around the tube to prevent air leak. Date the dressing and document dressing change.

What should you do if your patient's chest tube becomes disconnected from the chest tube drainage system?

A chest tube drainage system disconnecting from the chest tube inside the patient is an emergency. Immediately clamp the tube and place the end of chest tubein sterile water or NS. The two ends will need to be swabbed with alcohol and reconnected. Bleeding may occur after insertion of the chest tube.

The nurse is informed that an assigned patient will have chest tubes removed. In preparation for the procedure, the nurse plans to

Administer intravenous pain medication Rational chest tube removal is painful so pain medication administration prior to the procedure is essential. The chest tube should not be clamped. The drainage system should need be disconnected and there is no need to empty the drainage system prior to removal. When CDU is full, the unit is replaced, there is no way to empty the drainage from it.

Water seal chamber

Allows air to leave pleural space, but prevents re-entry of air in space during inspiration Should see tidaling in this chamber initially Bubbling indicates an air leak Some devices have air leak indicator to determine severity of leak

caution

Always assess the placement of a gastrointestinal tube before instilling feeding solutions, medications, or any other solution. If the tube is incorrectly placed the client is at risk for aspiration. If the client vomits, stop the tube feeding and place the client in a side-lying position; suction the client as needed.

6. The patient has a chest tube following a thoracotomy. Continuous bubbling in the water seal chamber would alert the nurse that

An air leak may be present Rational: When the lung has fully expanded tidaling will disappear and there will be bilateral breath sounds. Signs of tension pneumothorax are diminished breath sounds, signs of decreased cardiac output and tracheal deviation. Continuous bubbling should not be seen, it indicates and air leak near the CT insertion site or somewhere in the chest drainage system.

The nurse observes a steady rise and fall of the water level in the water seal chamber. How should the nurse intervene?

Document normal tidaling

Is Tidaling normal in chest tube?

Be aware that tidaling—fluctuations in the water-seal chamber with respiratory effort—is normal. The water level increases during spontaneous inspiration and decreases with expiration. ... If bubbling in the water-seal chamber is continuous, suspect a leak in the system.

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

Document the amount of drainage every 8 hours. UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

A patient has had a chest tube in place with a dry suction chest drainage system for 3 days. What would be appropriate nursing interventions for this patient?

Change the chest tube site dressing as directed by hospital policy Encourage coughing and deep breathing Assesss patients respiratory status at least every 4 hours rational: patients should be turned at least every 2hours to promote lung expansion and drainage of pleural space. The water seal chamber should be filled to the 2 cm mark. 20 cm is the amount of water added to a suction control chamber o fa water suction chest drainage unit.

Chylothorax.

Chylothorax is the presence of lymphatic fluid in the pleural space. The thoracic duct is disrupted either traumatically or from a malignancy, and the lymphatic fluid fills the pleural space

Basic components of Chest Tube Drainage system

Collection chamber Water seal chamber Suction control chamber

9. The patient is 12 hours postoperative after thoracic surgery. During a portable chest x-ray at the bedside, the lower chest tube is accidentally pulled out. What should be the nurses first action?

Cover the insertion site with sterile gauze. Rational: When a chest tube is discontinued accidentally or by providers order, it is essential to cover the chest wall opening with sterile gauze and tape to prevent a worsening or re-currence of pneumothorax

Setting Up and Changing chest tube drainage system

Follow manufacturers recommendations and hospital policy To change set up: Clamp CT at insertion site. If previous air leak, place end in bottle of sterile water. Do not clamp! Quickly disconnect and replace units Unclamp

Describe interventions you would perform if you detected an air leak:

If bubbling is continuous, suspect a leak in the system To locate source, assess from insertion site to CDU for loose connection or nonocclusive dressing Still no luck? Clamp CT briefly at various points with rubber tipped clamps from proximal to distal . Bubbling will stop when clamp is between airleak and water seal Check hospital policy on clamping CT to assess for air leaks! If bubbling increases, there may be an air leak in the drainage system or a leak from the patient (bronchopleural leak). If the chest tube is connected to suction, disconnect from wall suction to check for tidaling. Suspect a system leak when bubbling is continuous. Retape tubing connections. Ensure that dressing is air occlusive. • If leak 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.* High fluid levels in the water seal indicate residual negative pressure. • The chest system may have to be vented by using the high- negativity release valve available on the drainage system to release residual pressure from the system. • Do not lower water-seal column when wall suction is not operating or when patient is on gravity drainage.

How would you know if the suction is set properly for a dry suction unit and a wet suction unit?

If no bubbling is seen in the suction control chamber, (1) there is no suction, (2) suction is not high enough, or (3) the pleural air leak is so large that suction is not high enough to evacuate it. Water: Amount of suction is controlled by level of water in suction chamber. Increase wall suction until gentle bubbling is seen in chamber Dry: Amount of suction is controlled by a dial on suction chamber. Increase wall suction until red disk is seen in suction chamber window (usually around 80)

chest tubes

Ineffective Breathing pattern r/t asymmetrical lung expansion secondary to pain Impaired Gas exchange r/t decreased functional lung tissue Acute Pain r/t presence of chest tubes, injury Risk for Injury: Risk factor: presence of invasive chest tube Risk for Bleeding: Risk factors: tumor eroding blood vessel, stress effects on gastrointestinal system Risk for Infection: Risk factor: immunosuppression Risk for Vascular Trauma: Risk factor: infusion of irritating medications Readiness for enhanced Knowledge: expresses an interest in learning Activity intolerance r/t pain, imbalance between oxygen supply and demand, presence of chest tubes

Nursing Diagnoses

Ineffective breathing Impaired mobility Acute pain PC: Atelectasis Anxiety PC: Tension pneumothorax

Assessing for Air Leaks

Look for continuous or intermittent bubbling in water seal chamber or air leak indicator Normal to see small amount of bubbling right after CT insertion or when client coughs As lung expands, bubbling should decrease or stop Watch pattern of bubbling; if pleural space is leaking air, intermittent bubbling occurs with respirations

3. The nurse is instructed to measure and document the amount of drainage from a patients chest tube. The nurse should:

Mark the date, time and fluid level on the outside of the drainage collection chamber of the chest drainage system. rational: Chest drainage is never removed from the unit for measuring. The tubing should never be clamped as it could cause a tension pneumothorax. It would not be cost effective to change the CDU every time drainage needed to be measured.

8. The nurse is assigned to care for a patient with a chest tube. The nurse is monitoring the patient for subcutaneous emphysema. The nurse monitors the patient for this complication by:

Palpating for crepitus around the insertion site. rational: Subcutaneous emphysema is air trapped in the subcutaneous tissues from a chest tube. It causes a crackling sensation around the insertion site that can be palpated or auscultated. It does not normally cause increased pain at the site.

7 The nurse is preparing to assess a patient with a chest tube. Which of the following assessments would the nurse perform first?

Perform a respiratory assessment RationalL Assesssing the patients respiratory status is a priority when caring for someone with a chest tube to evaluate if the patient is improving after insertion of a chest tube. The other assessments are done later.

A patient has a chest tube for a pneumothorax. While returning to bed after morning cares, the chest tube separates from the drainage system and the ends are laying on the bed. The nurse should first

Place end of chest tube in 1 inch of sterile water. If a chest tube becomes disconnected from a chest drainage system or Heimlich valve, the priority is to restore the water seal which allows air to leave the pleural space, but not re-enter. Failure to do so quickly will result in worsening pneumothorax or tension pneumothorax

While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by the nurse is most appropriate?

Reconnect the tube to the water seal. The tube should be reconnected to the water seal as quickly as possible. Assisting the client back to bed (option one) and assessing the clients lung(option three) are possible actions after the system is reconnected

4. A Patient with a pneumothorax asks, "Why did they put this tube into my chest?" . The nurse should explain that the purpose of the chest tube is to:

Remove air from the pleural space Rational: There is little to no drainage from the chest with a pneumothorax. Fluid is drained from the chest with pleural effusion. Bleeding from the pleural space is seen with hemothorax. Chest tubes cannot monitor lung function.

When evaluating the effectiveness of a chest tube inserted in a patient with a right sided pneumothorax, the nurse should assess for:

Return of bilateral breath sounds rational: Pneumothorax causes lung collapse from build up of air in the pleural space. Lung sounds would be diminished on the affected side. Return of bilateral breath sounds would indicate re-expansion of the affected lung.

Describe signs and symptoms you would monitor the client for to detect this complication.

Signs and symptoms of tension pneumothorax are; cyanosis, air hunger, extreme agitation, tracheal deviation away from affected side, subcutaneous emphysema, neck vein distention, hyperresonance to percussion

A nurse is assisting a physician with the removal of a chest tube in a patient. Which instruction by the nurse would be most appropriate to prepare the patient for chest tube removal?

Take a deep breath and hold it. The patient should be instructed to perform the valsalvas maneuver (bear down) or take a deep breath and hold it during chest tube removal. The patient should never inhale during chest tube removal as this could cause re-occurence of a pneumothorax.

The patient experienced left sided chest trauma 3 hours ago, which included simple fractures of three ribs. During an assessment, the nurse observed that the patient has increased dyspnea, tachycardia, hypotension, pulse oximetry of 86% and a tracheal deviation. Which complication should the nurse suspect?

Tension pneumothorax Rational: Tension pneumothorax is caused by increased air trapping in a pleural space causing pressure buildup in the thoracic cavity. The increased pressure can become so severe that it puts pressure on the heart causing decreased ability of the heart to pump resulting in hypoxia are signs of decreased cardiac output (tachycardia, hypotension). Severe tension pneumothorax can cause tracheal deviation. Flail chest causes asymmetrical and uncoordinated chest wall movement due to fracture of 3 or more consecutive ribs or fracture of the sternum and several ribs. Pulmonary contusion cannot be assessed by observing chest wall movement. ARDS causes severe hypoxemia, there is not affect on the trachea.

which of the following statements about care of a patient with a chest tube is correct?

The chest tube set up should be assessed for latency, kinks and air leaks frequently Rational: patients should be repositioned every 2 hours to promote lung re-expansion and chest drainage. Chest drainage will increase with repositioning as it allows trapped drainage to mobilize. Chest tube should never placed in a dependent loop as this may cause drainage to be strapped in the patients pleural space which could prolong resolution of the problem or cause infection.

1. The nurse is caring for a patient who has a chest tube connected to a water suction chest tube drainage system. The nurse will increase the amount of wall suction

Until gentle bubbling is observed in the suction chamber Rational: wall suction for a dry chest drainage unit would be increased until the red float is visible in the window, indicating adequate suction amounts. Usually this can be achieved with a setting of around 80 mmHg. With wet suction, the wall suction is increased until gentle bubbling is seen.

In which chamber would you look for an air leak?

Water seal chamber

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.

While monitoring a patient with a water suction control chest tube drainage system, the nurse would notify the physician of

new air leak or increase in size of an air leak rational: gentle bubbling indicates the wall suction is set at the proper amount. Drainage of 50ml in one hour is normal. Fluctuation of water in the water seal chamber with respirations is called tidaling and is a normal finding that does not need to be reported.

Compared to closed chest drainage systems with wet suction, drainage systems with dry suction are often used to:

provide high negative pressure.

Chest tube insertion and removal

require sterile technique and must be done without introducing air or microorganisms into the pleural cavity. Removal of a chest tube is a brief but quite painful pro- cedure. Medicate the client before the removal. Remove the dressing around the tube and prepare the dressing that will cover the insertion site. This will be an occlusive dressing if there is no purse-string su- ture around the insertion site to prevent air from entering the chest. Generally, the primary care provider performs the removal but, in some areas, specially trained nurses may be permitted to do so.

The physician plans to remove a patient's chest tube. Which of the following signs suggests that the pneumothorax has resolved?

Clear lung sounds that extend to the periphery.

What is the purpose of the water seal chamber?

contains 2 cm of water, which acts as a one-way valve. Incoming air enters from the collection chamber and bubbles up through the water. The water prevents backflow of air into the patient.

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

400 mL of blood in the collection chamber The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take?

Administer the prescribed morphine. Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because 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. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.

Nursing Interventions

CDU below chest level Securely tape connections Change dressings per policy or HCP order. Follow standard precautions and PPE Good pain management Cough & Deep breathe Q2 hrs Reposition client Q 2 hours

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

Chest tube connected to suction The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.

Potential Complications

Chest tube disconnected from drainage unit Chest tube accidently pulled out New air leak develops

Suction control chamber

Gentle (not vigorous) bubbling should be noted in the 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.

Iatrogenic Pneumothorax.

Iatrogenic pneumothorax can occur due to laceration or puncture of the lung during medical procedures. For example, transthoracic needle aspiration, subclavian catheter insertion, pleural biopsy, and transbronchial lung biopsy all have the potential to injure the lung. Barotrauma from excessive ventilatory pressure during manual or mechanical ventilation can rupture alveoli or bronchioles. Esophageal procedures may also be involved in the development of a pneumothorax. Tearing during insertion of a gastric tube can allow air from the esophagus to enter the mediastinum and pleural space.

Flail Chest Fracture of two or more adjacent ribs in two or more places with loss of chest wall stability

Manifestations paradoxical movement of chest wall, respiratory distress. May be associated hemothorax, pneumothorax, pulmonary contusion Intervention O2 as needed to maintain O2 saturation, analgesia. Stabilize flail segment with positive pressure ventilation (intubation and mechanical ventilation). Treat associated injuries. Surgical fixation.

Cardiac Tamponade Blood rapidly collects in pericardial sac, compresses myocardium because pericardium does not stretch, and preventsventricles from filling.

Manifestations Muffled, distant heart sounds, hypotension, neck vein distention, increased central venous pressure Intervention Medical emergency: pericardiocentesis with surgical repair as appropriate.

Tension Pneumothorax Air in pleural space that does not escape Increased air in the pleural space shifts organs and increases intrathoracic pressure

ManifestationsCyanosis, air hunger, extreme agitation, tracheal deviation away from affected side, subcutaneous emphysema, neck vein distention, hyperresonanceto percussion Intervention Medical emergency: needle decompression followed by chest tube insertion with chest drainage system.

Pneumothorax: Air in pleural space

ManifestationsDyspnea, decreased movement of involved chest wall, diminished or absent breath sounds on the affected side, hyperresonance to percussion Intervention Chest tube insertion with chest drainage system. The pleural space contains a few milliliters of lubricating fluid to reduce friction when the tissues move. When air enters this space, the change to positive pressure causes a partial or complete lung collapse As the volume of air in the pleural space increases, the lung volume decreases. This condition should be suspected after any trauma to the chest wall.

Chest Tube Definition

Tube placed in pleural space to remove air/fluid and restore negative pressure Sterile technique used Tube size range from 12 French to 40 French

Chest tube removal

Medicate 30 minutes prior to removal Removal done by MD or MD designee Prepare dressing Remove suction Cut sutures Actual removal done by MD or specially trained RN Instruct client to perform valsalva manuever during CT removal Apply occlusive dressing (usually stays on for 48 hours) CXR 30-60 minutes after procedure The chest tubes are removed when the lungs are reexpanded and fluid drainage has ceased or is minimal. In some centers, suction is discontinued and the chest drain is on gravity drainage for 24 hours before the tube is removed. Gather dressing supplies and petroleum jelly dressing. Explain the procedure to the patient. The tube is removed by the HCP or an advanced practice nurse in most settings. The suture is cut, and with the patient holding his or her breath or bearing down (Valsalva maneuver), the tube is removed. The site is immediately covered with the airtight dressing to prevent air from entering the pleural space. The pleura will seal off, and the wound usually heals in a few days. A chest x-ray is done 30 to 60 minutes post-chest tube removal to evaluate for pneumothorax or reaccumulation of fluid. Observe the wound for drainage, and reinforce the dressing if necessary. Assess the patient for respiratory distress, which may signify a recurrence of the original problem.

What is tidaling and where would you look for it?

Normal fluctuation of the water within the water-seal chamber is called tidaling

Tidaling:

Normal fluctuation of the water within the water-seal chamber is called tidaling. This up and down movement of water in concert with respiration reflects intrapleural pressure changes during inspiration and expiration. Investigate any sudden cessation of tidaling, since this may signify an occluded chest tube. Gradual reduction and eventual cessation of tidaling are expected as the lung reexpands.

Concept of Negative Pressure in Lungs

Normal pressure in lungs is negative Inspiration: increases negative pressure, air enters Expiration: decreases negative pressure, air leaves Injury : Air or fluid enters pleural space, negative pressure lost, lung unable to expand

Nursing responsibilities regarding drainage systems include the following:

Monitor and maintain the patency and integrity of the drainage system. Assess the client's vital signs, oxygen saturation, cardiovascular status, and respiratory status. Check the breath sounds bilaterally and check for symmetry of breath sounds. Observe the dressing site at least every 4 hours. Inspect the dress- ing for excessive and abnormal drainage, such as bleeding or foul- smelling discharge. Palpate around the dressing site, and listen for a crackling sound indicative of subcutaneous emphysema. Subcutaneous emphysema, which is air in the subcutaneous tissues, can result from a poor seal at the chest tube insertion site. • Determine level of discomfort with and without activity and med- icate the client for pain if indicated. • Encourage deep-breathing exercises and coughing every 2 hours (this may be contraindicated in clients who have had a lung re- moved). Have the client sit upright to perform the exercises, and splint the chest around the tube insertion site with a pillow or with a hand to minimize discomfort. • Reposition the client every 2 hours. When the client is lying on the affected side, place rolled towels beside the tubing. Frequent position changes promote drainage, prevent complications, and pro- vide comfort. Rolled towels prevent occlusion of the chest tube by the client's weight. • Assist the client with range-of-motion exercises of the affected shoulder three times per day to maintain joint mobility. • Ensure that the connections are securely taped and that the chest tube is secured to the client's chest wall. • Keep the collection device below the client's chest level.• Frequently check the water-seal and suction control chambers. The water can evaporate and water may need to be added to the chamber. The water-seal level should fluctuate with respiratory effort.• Assess the drainage in the tubing and collection chamber. The drainage is measured at regularly scheduled times (check agency policy). Mark the date and time at the fluid level on the drainage chamber. The unit is not replaced until almost full. • Avoid aggressive chest tube manipulation (e.g., milking or strip- ping the tube). Milking can create excessive negative pressure that can harm the pleural membranes and/or surrounding tissues and cause the client pain Avoid clamping the chest tube because this increases the risk of a tension pneumothorax. You can clamp the tube for a moment to replace the drainage unit or to locate the source of an air leak, but never when transporting a client or for any extended period of time. If the tube becomes disconnected from the collecting system, sub- merge the end in 2.5 cm (1 in.) of sterile saline or water to maintain the seal. If the chest tube is inadvertently pulled out, the wound should be immediately covered with a dry sterile dressing. If you can hear air leaking out of the site, ensure that the dressing is not oc- clusive. If the air cannot escape, this would lead to a tension pneumo- thorax. A tension pneumothorax occurs when there is buildup of air in the pleural space and it cannot escape, causing increased pressure. This pressure can eventually compromise cardiovascular function. When transporting and ambulating the client: a. Keep the water-seal unit below chest level and upright. b. Disconnect the drainage system from the suction apparatus before moving the client and make sure the air vent is open. Use standard precautions and personal protective equipment while manipulating the system and assisting with insertion or removal.

Indications for Chest Tubes

Pneumothorax -Open: air enters through opening in chest wall -Closed: no external wound -Tension: =Accumulation of air in pleural space that does not escape =Causes mediastinal shift and hemodynamic instability =Can occur with open or closed pneumothorax Hemothorax Pleural effusion Empyema Post-op cardiac surgery to prevent cardiac tamponade

Portable chest drainage system:

Portable chest drainage system: 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; 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.

Setting up a CDU with a dry suction chamber

Turn dial on suction chamber to prescribed setting (usually - 20 cm) Connect to wall suction Increase wall suction until red disk is seen in suction chamber window (usually around 80)

Goals of Chest Tube Placement

Restore negative pressure Drain collected fluid, blood or air Allow monitoring of bleeding

The nurse is preparing to assist the physician with the removal of a chest tube. The nurse gathers items that will be needed for the procedure. Which of the following items would not be required for chest tube removal?

Telfa dressing

A client has a chest tube attached to a chest drainage unit. As part of a routine nursing care, the nurse would ensure that:

The connection between the chest tube and the drainage system is taped and that an occlusive dressing is maintained at the insertion site.

Types of Suction control Chambers

Water: Amount of suction is controlled by level of water in suction chamber Dry: Amount of suction is controlled by a dial on suction chamber

Air leak

air leak chamber filled to 2 cm level, note fluctuations or "tidaling", when controlled by water seal suction, should be no bubbles in chamber

Chest tubes and closed drainage systems relieve pneumothorax by:

restoring negative pressure in the pleural space.

Heimlich valve

a one-way flutter valve through which air can escape from the chest cavity but cannot re-enter it A Heimlich valve may be used for ambulatory clients. The Heimlich valve is a one-way flutter valve that allows air to escape from the chest cavity, but prevents air from reentering.

pleural effusion

a pleural effusion exists when there is excessive fluid in the pleural space.

Dry suction system

1. This is another type of chest drainage system and 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).

Prioritize nursing interventions appropriate for patients with chest tube drainage systems.

1. Monitor the patient's clinical status. Assess vital signs, lung sounds, and pain. 2. Assess for manifestations of reaccumulation of air and fluid in the chest (↓ or absent breath sounds), significant bleeding (>100 mL/hr), chest drainage site infection (drainage, erythema, fever, ↑ WBC), or poor wound healing. Notify HCP for management plan. 3. Evaluate for subcutaneous emphysema at chest tube site. 4. Encourage the patient to breathe deeply periodically to facilitate lung expansion and encourage range-of-motion exercises to the shoulder on the affected side. Encourage use of incentive spirometry every hour while awake to prevent atelectasis or pneumonia.

Chest Drainage

1. Never elevate the drainage system to the level of the patient's chest because this will cause fluid to drain back into the lungs. Secure the unit to the drainage stand. Change the unit if the collection chamber is full. Do not try to empty it. 2. Mark the time of measurement and the fluid level on the drainage unit according to the unit standards. Report any change in the quantity or characteristics of drainage (e.g., clear yellow to bloody) to the HCP and record the change. Notify HCP if >100 mL/hr drainage. 3. Check the position of the chest drainage container. If the drainage system is overturned and the water seal is disrupted, return it to an upright position and encourage the patient to take a few deep breaths, followed by forced exhalations and cough maneuvers. 4. If the drainage system breaks, place the distal end of the chest tubing connection in a sterile water container at a 2-cm level as an emergency water seal. 5. Milking or stripping chest tubes is no longer recommended, since 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.

water seal chamber of chest tube

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. Monitor for evacuation of air which will show as bubbles as they exhale it should bubble (this chamber works with their respirations as they breath it tidals) If bubbling stops that means the tube if ready to come out Continuos bubbling in this chamber is bad it should be intermittent ) a. Monitor for fluctuation of the fluid level in the water seal chamber. b. Fluctuation 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 reexpanded. c. 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. d. Notify the HCP if there is continuous bubbling in the water seal chamber.

How should you assess for a leak in a chest tube drainage system?

Assessing for an air leak: Clamp off suction for one minute. An air leak is present if there is constant bubbling in the water-seal chamber. An air leak alerts the nurse that he or she must assess for the location of the leak by checking the connections from the chest drainage unit to the insertion site.

What are the 3 components of a chest drainage unit (CDU)?

Collection chamber (Drainage collection chamber): -Collects fluid/drainage Most hold 2000 ml The chest tube connects to a 6 foot connection tube that leads to the drainage collection chamber -If the chamber fills up, get a new box Water seal chamber: Allows air to leave pleural space, but prevents re-entry of air in space during inspiration Should see tidaling in this chamber initially Bubbling indicates an air leak Some devices have air leak indicator to determine severity of leak -promotes 1 way direction (one-way flow out of the pleural space which will prevent air from moving back up the system and into the chest) -The drainage chamber and water seal are connected by a straw-like channel that allows the drainage to remain in the first chamber and the air to go down into the water of the water seal chamber -This chamber contains 2 cm of water which acts as a one-way valve. In other words, we are preventing backflow. -Any air exits the water seal chamber and enters the third chamber called the suction control chamber. This allows any air to be vented out through the air vent found at the top of the suction control chamber Suction control chamber Regulates amount of suction in pleural space Facilitates removal of air and secretions Amount of suction is ordered by the physician Usual setting is - 20 cm H2O suction -If the client needs suction to remove air and fluid, this chamber controls the amount of pressure applied -Sterile water is placed in this chamber up to the 20cm line. This is the usual prescribed amount. -Turn on the wall vacuum suction until you have a slow, gentle continuous bubbling. Chest drainage unit. Both units have three chambers: collection chamber; water-seal chamber; and suction control chamber. Suction control chamber requires a connection to a wall suction source that is dialed up higher than the prescribed suction for the suction to work. A, Water suction. This unit uses water in the suction control chamber to control the wall suction pressure. Water: Amount of suction is controlled by level of water in suction chamber B, Dry suction. This unit controls wall suction by using a regulator control dial. Dry: Amount of suction is controlled by a dial on suction chamber

What should you assess on a patient with a CDU?

Comfort - good pain management Monitor vital signs, pulse oximetry Lung sounds, respiratory & cardiac status Site, Tube, Output, Patency (STOP) - Assess patient for respiratory distress and chest pain (may indicate chest tube is not functioning properly, breath sounds over affected lung area, and stable vital signs - Observe for increase respiratory distress Observe the following: -Chest tube dressing, ensure tubing is patent -Tubing kinks, dependent loops or clots -Chest drainage system, which should be upright and below level of tube insertion

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate?

Continue to monitor the collection device. Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

Interventions for Air Leaks

If bubbling is continuous, suspect a leak in the system To locate source, assess from insertion site to CDU for loose connection or nonocclusive dressing Still no luck? Clamp CT briefly at various points with rubber tipped clamps from proximal to distal . Bubbling will stop when clamp is between airleak and water seal Check hospital policy on clamping CT to assess for air leaks!

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion?

Low Fowler's Rationale: To facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims' positions are inappropriate positions for this procedure.

What if the collection device tips over?

Return CDU to the standing position Check for an intact water seal (2 cm level) If water seal is not intact, refill and notify MD Check drainage levels in all three sections of collection chamber and remark

STOP

S = Site Assessment Observe dressing site at least Q 4 hours Palpate around site for subcutaneous emphysema T = Tube Assessment Ensure tubing connections securely taped or gun tie Keep tubing free of kinks and dependent loops Check water seal level Ensure suction at appropriate setting or tubing unclamped if to water seal only Check vaseline gauze policy O = Output Measure fluid hourly for first 24 hours, then per unit policy Call MD for drainage > 100cc/hr, sudden increase or decrease in drainage Document amount, characteristics of drainage Reposition client every 2 hours to facilitate drainage P + Patency Maintain drainage unit below chest level Check suction settings Monitor patency of tubing and drainage system Have client cough and deep breathe and change position to dislodge clots Follow institutional policy for clots

Documentation

Site and settings of chest tube Drainage characteristics and amount Respiratory assessment and pertinent interventions Pain assessment Air leak present? Monitor the progress Sample Documentation 9-2-2013 0800: R chest tube to - 20 cm H2O suction. Site with dressing dry and intact. 50 mL serosanguinous drainage noted in past hour. No air leak noted. Lungs clear bilaterally, slightly diminished in R base. Taught C&DB, IS to perform every 1-2 hours. Rates pain at 3/10. Morphine 2 mg given IV.--------------------J. Brown RN

Equipment to Keep at Bedside in case of emergency

Sterile gauze 2 inch wide tape Bottle of sterile water Alcohol wipes

When palpating around a patient's chest tube insertion site, the nurse detects crepitation. Which complication should the nurse suspect?

Subcutaneous emphysema

Subcutaneous emphysema/crepitus

Subcutaneous emphysema can occur from air leaking into the tissue surrounding the chest tube insertion site. A "crackling" sensation will be felt when palpating the skin. A small amount of subcutaneous air is harmless and will be reabsorbed. However, severe subcutaneous emphysema can cause drastic swelling of the head and neck with potential airway compromise. A collection of air or gas under the skin, subcutaneous emphysema—crepitus—is usually painless and feels spongy on palpation. Small amounts of subcutaneous emphysema around the tube insertion site are commonly absorbed. However, if the tube is improperly placed or has an air leak, air may move from the insertion site into the neck, chest, and face and cause pain. In this case, notify the clinician.

Which of the following are signs of tension pneumothorax?

Tension pneumothorax is a medical emergency, with both the respiratory and cardiovascular systems affected. Manifestations include dyspnea, marked tachycardia, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention, cyanosis, and profuse diaphoresis. If the tension in the pleural space is not relieved, the patient is likely to die from inadequate cardiac output or severe hypoxemia. Hypotension and tachycardia

When a patient has a chest drainage system with dry suction, which of the following controls the amount of suction the patient receives?

The amount of suction on the suction control dial.

Insertion Sites

To remove air To remove fluids Mediastinal tubes

A patient with a left-sided pneumothorax undergoes chest tube insertion and closed chest drainage. Two days later, the nurse auscultates diminished breath sounds at the apex of the left lung. What should the nurse suspect?

Unresolved pneumothorax

What are the priority nursing interventions for the management of a patient with a chest tube?

Wash the hands with soap and warm water and put on a pair of sterile gloves. Remove the patient's old dressing and insect the site of the chest tube for bleeding, redness, air leaks, skin discoloration, condition of sutures, and color and amount of drainage.

Which three chambers are found in a closed drainage system?

Water seal, suction control, and drainage collection chambers

The nurse is monitoring the function of a client's chest tube drainage system and notes that the fluid in the water seal chamber is below the 2-cm mark. Which interpretation should the nurse make?

Water should be added to the chamber. Test-Taking Strategy: Use the steps of the nursing process. Focus on the subject and the data in the question. It makes sense to add water to the chamber if the water level is too low. The water seal chamber should be filled to the 2-cm mark to provide an adequate water seal between the external environment and the client's pleural cavity to prevent air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should remedy this problem by adding water until the level is again at the 2-cm mark. Options 1, 2, and 3 are incorrect interpretations. Remember that evaluation is the fifth step of the nursing process.

pneumothorax

When air collects in the pleural space, it is known as a pneumothorax

chest tube placement

a chest tube is a hollow device inserted into the thoracic cavity to remove fluid or gas

To detect the recurrence of a pneumothorax, expect the patient to undergo:

a chest x-ray

Collection chamber

a. Monitor drainage; notify the HCP if drainage is more than 70 to 100 mL/hour or if drainage becomes bright red or increases suddenly. b. Mark the chest tube drainage in the collection chamber at 1- to 4-hour intervals, using a piece of tape. Collects fluid/drainage Most hold 2000 ml

During chest tube removal, the nurse should make Sure that the patient:

bears down

chest tube

chest tube Tube that returns negative pressure to the intrapleural space; used to remove abnormal accumulations of air and fluid from the pleural space. If enough fluid or air accumulates in the pleural space, the negative pressure becomes positive and the lungs collapse. As a result, chest tubes are inserted to drain the pleural space, reestablish negative pressure, and allow for proper lung expansion.

Chest Tubes and Water-Seal Drainage

set-Up and Insertion 1. Make sure patient is aware of the procedure and informed consent is obtained. 2. Gather equipment. • Thoracotomy tray • Chest drainage unit (CDU) • Chest tube • Bottle of sterile water • 1% lidocaine • Suction tubing and collection container • Occlusive dressing 3. Prepare CDU. • 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. 4. Position and support the patient to minimize movement during procedure. Drainage System 1. Keep all tubing loosely coiled below chest level. Tubing should drop straight from bed or chair to drainage unit. Do not let it be compressed. 2. Keep all connections between chest tubes, drainage tubing, and the drainage collector tight, and tape at connections. 3. Observe for air fluctuations (tidaling) and bubbling in the water-seal chamber. • If tidaling (rising with inspiration and falling with expiration in the spontaneously breathing patient) is not observed, the drainage system is blocked, the lungs are reexpanded, or the system is attached to suction. • If bubbling increases, there may be an air leak in the drainage system or a leak from the patient (bronchopleural leak). 4. If the chest tube is connected to suction, disconnect from wall suction to check for tidaling. 5. Suspect a system leak when bubbling is continuous. • Retape tubing connections. • Ensure that dressing is air occlusive. • If leak 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.* 6. High fluid levels in the water seal indicate residual negative pressure. • The chest system may have to be vented by using the high- negativity release valve available on the drainage system to release residual pressure from the system. • Do not lower water-seal column when wall suction is not operating or when patient is on gravity drainage.