420 Chest tube Practice

Where are chest tubes typically placed?

4th and 5th intercostal space

Chest tube removal

Ask client to take a deep breath and hold it or Deep breath, exhale, and bear down (Valsalva Maneuver)

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding?

Check the drainage system for an air leak. Rationale: Continuous bubbling in the water seal chamber is NOT normal and indicates there is an air leak. However, oscillation of the water in the water seal chamber is normal.

The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY?

Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system. Rationale: A new system needs to be obtained, however, in order to maintain a water seal until the new system arrives you will need to place the tubing 1 inch in sterile water or sterile saline to regain a water seal.

You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention?

Document your findings as normal. Rationale: The assessment findings are normal. All the other options are incorrect.

The nurse is assessing the functioning of a chest tube drainage system in a client with hemothorax. Which of the following findings should prompt the nurse to notify the physician?

Drainage amount of 100ml in the drainage collection chamber. Rationale:Drainage of more than 70 to 100 mL/hour is not normal and requires the immediate notification of the physician.

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

Dry suction chest tube system

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you

Gather supplies needed which will include a petroleum gauze dressing per physician preference. Place the patient in Semi-Fowler's position. Pre-medicate prior to removal as ordered by the physician. Have the patient take a deep breath, exhale, and bear down during removal of the tube

Indications for chest tube removal

Improved respiratory status symmetrical rise and fall of chest bilateral breath sounds decreased chest tube drainage absence of bubbling in the water seal chamber during expiration improved chest XRAY

A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system?

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

water seal chamber of chest tube

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 )

What don't you do to a chest tube?

Never milk, strip, or clamp the chest tube Clamping may be used depending on provider in cases: Clamping prevents the escape of air or fluid, increasing the risk of tension pneumothorax.

While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention?

Place a sterile dressing over the site and tape it on three sides and notify the physician

The nurse is handling a client with a chest tube. Suddenly, the chest drainage system is accidentally disconnected, what is the most appropriate action for the nurse to take?

Place the end of the chest tube in a container of normal sterile saline. Rationale: If a chest drainage system is disconnected, the nurse can place the end of the chest tube in a container of normal sterile saline to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. Option A: The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected. Option B: The nurse should not clamp the chest tube because doing so increases the risk of tension pneumothorax. Option D: The nurse should apply an occlusive dressing if the chest tube is pulled out and not if the system is disconnected.

In the event of chest tube disconnection what do you do?

Submerge the tube 1''-2'' below the surface of 250 ml bottle of sterile water. This establishes a water seal, allows air to escape and prevents air reentry.

What is the goal of having a chest tube placed?

The goal is to get the lung back to a NEGATIVE Pressure!!!

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this?

The lung may have re-expanded or there is a kink in the system.

A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find?

The water in the chamber will decrease during inspiration and increase during expiration. Rationale: When a patient is receiving mechanical ventilation the water in the water seal chamber will oscillate oppositely than if the patient were breathing on their own. Therefore, the water in the chamber will decrease during inspiration and increase during expiration.

Equipment for chest tube

Tray 24-40 French system Emergency Bagging at the bedside sterile water vaseline/gauze Clamp (not used at PVMC)

wet chamber chest tube

classic suction

What are you assessing for in chest tubes?

look at skin for redness, warmth, buildup at insertion site. Listening to breath sounds q2hrs., inspecting skin for crepitus (air sacks in subq tissue). symmetrical breathing. Monitor oxygen saturation Observe for bubbling which can indicate an air leak.

suction control chamber

pressure applied to suction in order to remove air and fluid from pleural cavity. Sterile water placed in chamber to 20 cm line or prescribed amount. Turn on wall vacuum until slow gentle continuous bubbling.