CT

What is a hemothorax?

Blood in the pleural space

Assess CT how often

Post CT insertion q15mins x2, then in 30 mins, then every hour for four hours. then reassess pt system every 2-4 hrs

what is it important to assess when clamping a ct

RESP function: VS, chest auscultatin, any S&S of dyspnea

empyema

infection and pus in the pleural space

What is a thorascopy?

insertion of an endoscope to visually examine the inside of the chest cavity

what is a pleurodesis

instillation of a sclerosing agent into the pleural space (pleura = pleural membranee or space; desis = fusion of 2 parts into 1)

Irrigation of CT

irrigation may assist in the drainage of viscous pleural fluid (preventing clogging) must have an order for CT irrigation only RNs can irrigate CT's (students not allowed) irrigation fluid is sterile normal saline

if chest drainage system tips over

lift it back up and check the levels

What types of surgery would a CT be inserted for?

lung surgery heart surgery esopageal surgery hiatal hernia repair kidney surgery

what diameter of CT would be most appropriate for pneumothorax?

narrow diameter (air)

CT removal

need 2 RNs

• What does it mean if there is NO bubbling in the water seal chamber?

no air leak present

Tidaling?

no bubbling and CT are in pleural space, check for tidaling Tidaling is level going up and down fed cm with breathing, reflecting intrapleural pressure chafes and showing system is fxing

• How does the nurse prepare the water seal chamber?

o 1) remove the unit from the bag o 2) carefully open it using sterile technique and enter it in the sterile field o 3) fill the water seal to the 2cmh20 line o remove the pre packaged sterile ampule from the back of the drain and empty entire contents until all water fills to the indicated line o connect the chest drain to the patient o apply suction when prescribed by physician (connect to suction port) turn suction source on

What are the components of a disposable chest drainage system?

o A collection chamber into which fluids drain and volume and rate of drainage can be measured o a water seal chamber that uses sterile fluid or a mechanical one-way valve to allow air to leave the patient and prevent air from entering the patient's chest through the chest tube o a suction control chamber that uses either sterile fluid or a mechanical device to control and limit the level of suction imposed on the patient

• What should the nurse do if the chest drainage system accidentally tips over?

o Accidental knockover, upright the drain immediately and check all fluid levels, if required the water seal level may be adjusted tot eh 2cmh20. Also gently tip the drain to the right to correctly return fluid to the correct drain if it moved.

• Why would a chest tube be placed in the mediastinal space?

o After cardiac surgery to drain fluid from the pericardial sac which can lead to cardiac tamponade

• What causes subcutaneous emphysema?

o Air escaping from the pleural space and into the subcutaneous tissues

What is the pressure in the pleural space during inspiration? During expiration?

o Always negative (vacuum) • During inspiration, intrapleural pressure is approx. -8cmH20 (below atmosphere • During exhalation, intrapleural pressure is approx. -4cmH20

What is a sucking chest wound

o An open pneumothorax o With the pressure changes in the chest that normally occur with breathing, air moves in and out of the chest through the opening in the chest wall; looks bad and sounds worse, but opening acts as a vent so pressure from trapped air cannot build up in the chest

• After thoracic surgery, what type of drainage might the nurse see?

o Blood o Serosanguineous o Pleural fluid

• What are the potential benefits of autotransfusion?

o Blood is readily available, does not need to be cross matched, easy to collect and rapidly reinfused

• What does it mean if there is a sudden increase in drainage from a chest tube after a patient changes position?

o Bloody drainage can collect in the pleural space until the pt moves into a more favourable position for gravity drainange. Check the color of the drainange. If its dark, its old drainange. Fresh drainage will be more red.

What organs are found in the thoracic cavity?

Right lung, Left Lung, Heart, Aorta and great vessels, esophagus, trachea, thymus

• What safety features does the Atrium chest drainage system have?

o Built into unit, protects patient automatically o High negativity float valve - protects patient - high negativity intrapleural pressure as seen with manipulation of tubing or coughing, water will rise in chamber, u can press this vent to lower the water level in the water seal chamber. o Positive pressure relieve valve - prevents pressure build up to reduce the rsik of tension pneumothorax o Knock over protection - helps prevent fluids from shifting to different chambers if the drain is kicked or knocked over

What is a tension pneumothorax?

o Can kill o Chest wall is intact, air enters the pleural space from the lung or airway and it has no way to leave. There is no vent to the atmosphere as there is an open pneumothorax o Most dangerous when patient is receiving pressure ventilation in which air is forced into the chest under pressure o Occurs when a closed pneumothorax creates positive pressure in the pleural space that continues to build - that pressure is then transmitted to the where the ehart and great vessels lie o What makes tension pneumothorax life threatening is a mediastinal shift

• What are the nine assessment steps when caring for a patient with a chest drainage system?

o Check the dressing o check the tubing - no dependent loops o no stripping or milking o check drainage o check for bubbling o check for tidaling o check level of water o adjust bubbling o check tubing

• How should a nurse check for an air leak in the chest drainage system?

o Clamp the tubing with a special tubing clamp or rubber-tipped hemostat. Start by clamping the chest tube where it leaves the chest, and work your way down the collection chambr. Leave the clamp in place no longer than 10 seconds while you glance at the water seal chamber. Once the clamp is placed between the air leak and the water seal, the bubbling should stop.

• How does the nurse connect the suction (as ordered by the physician) and set the amount of the suction?

o Connect the suction source directly to the suction port on drain. Turn suction source on and increase vacuum to at least -80mmHg or higher

• What does it mean if the nurse sees constant bubbling in the water seal chamber?

o Constant bubbling confirm a persistent air leak in the pts thoracic cavity or possible tube connections

• Why would the Pneumostat Chest Drain Valve be used for a patient?

o Designed for patients hwo have an air leak with minimal fluid drainage o Ready to use, gravity only

• What should the nurse do if the drainage valve on the Pneumostat drain gets clogged with a blood clot?

o Do not leave syringe attached to needless acces port o Replace pneumostat with a new unit

• What conditions demonstrate that a chest tube can be removed?

o Drainage diminishes to a minimal or acceptable volume o Any air leak has minimized or disappeared o Fluctuations in the water seal chamber stop o The patient is breathing normally without any signs of resp distress o Breath sounds are equal and at baseline for the pt o Chest radiograph shows the lung re-expanded and there is no residual air or fluid in the pleural space

• How do "expiratory positive pressure", gravity, and suction work together in a chest drainage system?

o Expiratory positive pressure from the patient helps push air and fluid out of the chest (ie. Cough, Valsalva manoeuvre) o Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest o Suction can improve the speed at which air and fluid are pulled from the chest

• Why is it so important to effectively manage incisional and pleural pain?

o Failure to manage incision or pleural pain can lead to hypoventilation, putting the patient at much higher risk for complications such as atelectasis and pneumonia. Also be aware of the risk of hypoventilation assoc. with opioid analgesics and patient-controlled analgesia. Some surgeons use local nerve blocks or epidural analgesia for pain management to reduce opioid side effects.

• Why is it important to eliminate dependent loops in the tubing of a chest drainage system?

o Fluid in dependent loop can change pleural pressure from -18cmH20 to +8cmH20 and decrease fluid drained to zero within30 mins.

• Why is suction often used for patients on chest tube drainage?

o Helps improve rate and flow of fluid drainage of the pt, helps increase the rate and air flow out of the patient

• How can blood from a chest drainage system be used for autotransfusion?

o Reinfusion of the patient's own blood o Most chest drain manufactures have an optional in-line blood recovery bag that can be connected between the drainage tubing and the collection chamber so that the blood will drain into the bag before it gets to the collection chamber. When enough blood has been collected, disconnect the bag from the patient and the drainage unit, attach filtered blood tubing and administer the blood to the patient.

• What are the 3 principles of treating pleural conditions?

o Remove fluid & air as promptly as possible o Prevent drained air & fluid from returning to the pleural space o Restore negative pressure in the pleural space to re-expand the lung

What are the 3 goals of chest tube drainage?

o Remove the fluid and/or air as quickly as possible o Prevent drained air and/or fluid from re-entering the chest cavity o Re-expand the lungs, restore normal negative intrapleural pressure

What factors affect how well blood and fluid leave the chest through a chest tube?

o The length of the tube, the amount of negative pressure (suction)) applied, and the inner diameter of the tube

• Why might a physician order for a chest tube to be clamped prior to removal?

o The physician may order the tube to be clamped for several hours to stimulate chest tube removal and assess the patient's response.

• What does it mean if there is no tidalling in the water seal chamber?

o The tubing is kinked o The tubing is clamped o The patient is lying on the tubing o There is a dependent, fluid-filled loop in the tubing o Lung tissue or adhesions are blocking the catheter eyelet o No air is leaking into the pleural space and the lung has re-expanded

• Why should the chest drainage unit be kept below the level of the patient's chest?

o To enhance gravity drainage o This will cause a pressure gradient with higher pressure int eh chest and lower pressure in the drain. Fluid will move from the area of higher pressure to lower pressure.

Which conditions cause a transudate and an exudate (in a pleural effusion)?

o Transudate: clear fluid that collects in the pleural space when there are fluid shifts in the body from conditions such as CHF, malnutrition, renal failure and liver failure o Exudate: cloudy fluid with cells and proteins that collects when the pleurae are affected by malignancy or diseases such as tuberculosis and pneumonia

• What should the nurse do if the Pneumostat drain is full?

o Unit should be replaced or emptied - to empty simply attach a luer lock syringe pull plunger back and empty

• How would the nurse recognize if a patient has an air leak?

o Water seal - window into the pleural space - if air is leaving the chest, bubbling will be seen in this. Air leak meter provides a way to measure the leak and monitor over time - getting better or worse?

• What is the purpose of the water seal chamber?

o Water seal chamber is connected to the collection chamber and provides the protection of the one-way valve. It can also measure pressure.

Closed drainage system

system used to facilitate evacuation of fluid blood and air from the pleural space, mediastinum or both

what happens if you clamp a CT for too long

tension pneumothorax

the physician may order the CT to be clamped..why?

test the pt's response before removing the CT mimics not having a tube

Three bottle drainage

the patient has a large air leak into pleural space, gravity drainage may not be sufficient to evacuate the chest and suction may be required. This means the addition of a third bottle. when suction is required to increase the pressure difference between the pleural space and the drainage system, it is important to accurately regulate suction levels to avoid pt injury. If suction pressure is too high, complications can occur such as hematoma formation at distal end of the catheter and tissue invagination into the catheter eyelets. A third bottle added to the chest drainage will limit the amt of negative pressure that can be transmitted to the patient's chest. A suction control bottle has three tubes. 1. A long tube positioned so that the upper end is open to the atmosphere through the plug in the top of the bottle while the lower end is submerged under water, usually to a depth of 20 cm. 2. A short tube connected to the water seal bottle. 3. A tube that connects the bottle to the vacuum source, which can be either a portable pump or a all vacuu, regulator. When the three bottle set up is used, the max level of negatve pressure that can be transmitted to the pt's chest directly corresponds to the depth of submersion of the tube in the suction control bottle. If the tube is under 20cm of water, the max suction level the pt can be subjected to is -20cmH20.

relationship between the r lymphatic and thoracic ducts and the venous system

the r lymphatic duct is formed by the merging of the trunks (right jugular trunk, r subclavian trunk, r lymphatic duct entering r subclavian vein, r bronchomediastinal trunk). The thoracic duct collects lymph from the trunks (l jugular trunk, l subclavian trunk, thoracic duct entering l subclavian vein, l bronchomediastinal trunk) lymphatic fluid comes back through the lymphatic vessels and gets dumped back into circulation- if one of these are knicked/punctured - lymphatic fluid can drain into pleural space

what is fibrothorax

thick fibrous tissue that sticks together the visceral and parietal pleura .. leading to severe pulm restriction

CT used for?

to evacuate subset from the pleural space

Morning safety checks with CT

-drsg -depednent loops -drainage - color, Amt -water level -bubbling in the water seal chamber -check for tidaling or fluctuating -suction (at right setting on drainage system) -gentle bubbling in wet suction patient (Breathing, pain at incision site, etc) -drainage system is below pt -must have 2 CT clamps at bedside (kelly clamps)

Where do you find the parietal and the visceral pleura?

Lungs are surrounded by thin tissue called the pleura, a continuous membrane that folds over itself. • Parietal pleura lines the chest wall • Visceral pleura covers the lung (sometimes called the pulmonary pleura)

when suction is applied how much neg pressure is typically applied to the pleural space?

-20cmH20

• To what level should the nurse set the wall suction regulator if the patient's chest tube is set to suction?

-80mmhg?

What is a potential danger after pneumectomy?

Meidastinal shift --> one lung can expand to take over more space - heart will shift, diaphragm moves up to fill in space

a nurse is caring for a client with a CT to suction. what factor would have the greatest influence on whether the CT may be temporarily disconnected from suction? (i.e. to allow the client to mobilize) A. the amt of bubbling in the water seal chamber B. the amt of pleural drainage C. the presence of sanguinous drainage D. the level of suction applied to the chest drainage system,

A - the amount of bubbling in the water seal chamber . biggest factor is if they have an air leak - indicated by amt of bubbling

What if the CT does accidentally get pulled out?

1. Don clean gloves 2. place gloved hand over insertion site 3. call for help 4. apply 3 sided dressings (just like a sucking chest wound drsg) 5. call for doctor

Assessment of CT (full)

1. explain procedure to pt, assess VS, resp, pain, and drsg 2. assess ct drsg, note if drsg is secure, d&i. 3. assess for Sub Q emphysema - mark area of it with a permanent marker 4. ensure ct is anchored to chest or abdomen with a piece of tape or skin fixation device. ensure connections are taped (helps prevent inadequate dislodgement of tube) 5. ensure tubing is free of kinks and dependent loops (these increase amt of thoracic pressure req'd to expel air and drain fluid from pleural space to chest drainage system; do not milk or strip CT tubing) 6. observe fluid in tubing for fluctuations 7. if Chest drainage system is being maintained with suction briefly remove sx (water level must be maintained at 2cm. an under filled water seal chamber/air leak monitor could lead to a collapsed lung by allowing air to enter into neural space as an adequate underwater seal is not obtained) 8. observe that water seal chamber/air leak monitor is at 2cm. ask pt to breathe in and out, observe fr fluctuation in water seal chamber. 9. observe water seal chamber for bubbling. note if bubbling is on expiration, inhalation, continuous or with coughing. 10. reattach suction. mark drainage level at end of each shift and document on unit appropriate record. 11. ensure chest drainage system is maintained in an upright position - below pt's chest level secured to drainage system to vbed, floor or IV pole. note colour consistency and amt of drainage.

• What is the maximum amount of fluid that the Atrium Oasis chest drainage system can hold?

2100 mL

What size of CT should be used for adults?

24-32 Fr

• What total volume of drainage can a Pneumostat drain hold?

30 ml of collection

what diameter of CT would be most appropriate for a pleural effusion?

NARROW - fluid is fairly thin and doesn't tend to clog up tubes easily so we usually use a smaller diameter chest tube bc less chance of infection and more comfortable

• What is the difference between a "wet" and "dry" suction control system?

A wet involves the water seal - a DRY suction control system involves a mechanical one-way valve in place of a conventional water seal. The mechanical one-way valve allows air to escape from the chest and prevents air from entering the chest. An advantage of this is that it does not require water to operate and it is not position-sensitive the way a water-filled chamber is. A dry seal drain protects from air entering the patient's chest if a drain is knocked over. Drawback: does not provide same level of patient assessment info as a conventional water seal.

What is a pneumothorax?

Air b/w the pleurae

How much fluid is normally found in the pleural space?

Approx. 25 mL per lung

What are the 3 chambers in a disposable chest drain?

collection chamber: fluid drain directly into chamber, calibrated in mL fluid, write on surface to note level and time Water seal: one way valve, u tube design, monitor air leaks and changes in intrathoracic pressure Suction control chamber: u tube , narrow arm is in the atmospheric vent, large arm is the fluid reservoir, system is regulated, easy to control negative pressure

CT vs Wound Drain

CT: vents positive pressure, constant suction level, consistent flow rate, drainage occurs as long as drain is below the chest, will work even if clinician does not actively maintain the drain, can be used fora ll cardiothoracic patients, remains a closed system throughout use. Wound drain: closed system with no vent, variable suction level,. variable flow rate as suction changes drainage stops if reservoir fills (100cc ) regardless of drain position, clinician deed net for proper use, cannot be used if pt has an air leak, must be opened periodically to discard drainage

• What is the purpose of the 1st bottle in a chest drainage system?

Create a water seal...air can push down but not back

a nurse is caring for a pt who has developed fibrothorax after a longstanding lung infection. what procedure should the nurse anticipate the client needing to restore the compliance of the chest wall?

Decortication - removing outer layer of lungs - remove the fibrous layer

tension pneumothorax

EMERGENCY SITUATION build up of air within pleural space - air escapes into pleural space but does not return progressive build up of pressure in the pleural space pushes the mediastinum to the opposite hemothorax and obstructs venous return to the heart. this leads to circulatory instability and may result in traumatic arrest

• If the nurse is using a chest drainage system with "wet" suction - how much bubbling should the nurse see in the water suction chamber?

Gentle bubbling appears

What is the purpose of the third bottle in the chest drainage system?

controls negative pressure

Two bottle drainage

In a 2-bottle drainage system, fluid drains from the chest into a dedicated collection bottle. Air from the pleural space, continuing through the tubing that connects the two bottles, bubbles through the water seal and exits to the atmosphere. Adding a separate collection bottle allows the water seal to remain at an undisturbed fixed level, allowing air to leave the pleural space through a system with low resistance to air flow, regardless of fluid drainage. One and Two-bottle drainage systems rely on gravity to create a pressure gradient by which air and fluid leave the chest. Keeping the drainage system below the level of the pt's chest enhances gravity drainage; additional pressure is created when the pt exhales or coughs.

Clamping a CT

ONLY in specific circumstances BRIEFLY while reconnecting tubes BRIEFLY while changing the drainage system BRIEFLY when checking for an air leak

Closed pneumothorax causes

spontaneous - rupture of a bleb (small air-filled alveolar dilation) use of too high pressure in mechanical ventilator injury to lung following a subclavian central line insertion injury from broken ribs

what do we do to all ct connections?

TAPE

causes of empyema

TB lung abscess infection of thoracic surgical wounds

What is a pleural effusion

Transudate or exudate in the pleural space

Causes of pleural effusion?

Transudate: CHF (d/t increase blood hydrostatic pressure); liver disease (d/t decrease plasma proteins and decrease oncotic pressure) Exudate: cancer, infection, pancreatic disease (leak of enzymes), esophageal leak (perforation or complication of surgery)

Main reason a pt would need a pleurodesis?

To prevent recurrent pleural effusions

CT drsg...changing how often

change q48-72 hours and pen use sterile gauze and tape

Chest tube insertion site

chest tube is usually sutured in place by doctor, tape chest tube securely to prevent accidental removal, label tape

lymphatic fluid

chylothroax

how can you figure out if theres an air leak int he CT system, or if the air leak is in the pt?

clamp to assess area of leak start clamping closest to pt and move down remove drsg and assess

• How can the nurse check to see if there is an air leak in the Pneumostat or chest tube?

add 1 ml of water to the air leak well, bubbling in the water will confirm an air leak

CT for pnuemothorax

air rises in chest, so CT needs to be inserted at the APEX of the lung to allow the air to escape CT has 1 way valve so that air doesn't go back

assessment following thoracic surgery/ct placement

assess the CT BP (may have hypotension d/t blood loss or vasodilation) irregular pulse (thoracic surgery and placement of a CT near the heart may result in a dysryhtmia (i.e. atrial fib) sucutaneous emphysema --> leakage of air into the subQ tissue (often around the CT site) changes in Amt or quality of pleural drainage (sudden increase or decrease in drainage - not a concern when pt is going from bed to mobilizing - probably an affect of gravity, not a concern when related to position change, otherwise report it) increase in frank blood (thick, not dilute) appearance of milky looking drainage (lymphatic) appearance of purulent looking drainage (infection) appearance of greenish drainage (stomach secretions)

Preventing problems- prevent chest drainage system from tipping over

be secured to floor, bed, or an IV pole

Hemothorax

blood in the pleural space

Pneumothorax - what types?

close (no external wound) or open (opening in chest wall)

what do you do with a sucking chest wound

cover with a vented drag - occlusive drsg: prevents air from moving through drsg -tape on 3 sides creates a temporary one way valve - vented drsg - pulls drsg down and air out if there is an accidental chest tube removal - put an airtight product like plastic on top and tape on 3sides

What does lymphatic fluid look like?

creamy and white

what is a thoracostomy?

creation of a surgical opening in the chest (thoraco - chest ; ostomy - creating an opening)

Mediastinal space

down the centre of the chest (tissues in the centre of the chest cavity) - space in thoracic cavity between the lungs

Report the following to a physician

drainage greater than 100ml/hr sudden decrease or sudden absence of drainage change in characteristics of chest drainage - changes to cloudy, milky, really bloody

products of infection

empyema

pleural fluid?

exudate/transudate --> pleural effusion

Sub Q emphysema f

feels like crackling rice crispies not uncommon to have a bit near the CT site of injury monitor for growing/shrinking Air under the skin

CT for pleural effusions

fluid is heavier than air so CT needs to be inserted at the BASE of the lung to drain a pleural effusion. Need to use a chest drainage system where the fluid output can be measured (i.e. Atrium Oasis).

What is the purpose of the 2nd bottle in a chest drainage system

for when fluid needs to be drained from the chest...collects the drainage (attached to the water seal bottle)

What happens if the CT does get disconnected?

have pt exhale and cough clamp chest tube cross-wise with kelly clamps disinfect ends of tube with chlorexidine and re-connect if drainage tube is grossly contaminated, replace whole drainage system, then connect to CT have pt exhale and cough tape connections

blood

hemothorax

tx of empyema

in addition to drainage with CT: antibiotic therapy monitor for development of fibrothorax

• What should a nurse do if a patient accidentally pulls out the chest tube?

o If the patient has an air leak from the chest tube, indicated by bubbling in the water seal chamber, cover the site with a sterile dressing,. Tape it on only three sides. This allows air to escape thorugh the fourth side, preventing air accumulation and the risk of tension pneumothorax. Stay with the pt while a colleague calls the physician STAT and gets the equipment so a new tube can be placed. If there was no air leak evident, apply a sterile occlusive dressing and monitor the pt carefully for any signs of resp distress. Notify physician, who will typically order a radiograph to see if the lung is expanded and if the pt needs to have a chest tube reinserted.

• What are the benefits of mobile chest drainage systems?

o It allows patients to get up and walking which is a step towards the goal of early discharge

• Why does blood draining from a chest tube typically not clot?o

o It becomes defibrinogenated and should not clot - tahts why this she blood can be used for autotransfusion.

• How is the amount of suction regulated on a chest drain? Is it the depth of the water in the suction bottle, or is it the reading on the vacuum regulator?

o It is the depth of the water in the suction bottle that determines the amount of negative pressure that can be transmitted to the chest, it is NOT the reading on the vacuum regulator.

• When are the only times that a nurse should clamp a chest tube?

o Locate an air leak o Replace a drain o Connect or disconnect an in-line autotransfusion bag

• What is the purpose of the water seal chamber?

o Middle chamber that allows air to leave the chest, prevents air from entering the chest, one way valve, monitor bubbling for air

• What assessments and nursing interventions with respect to the respirations of a patient with a chest tube?

o Note the rate, regularity, depth, and ease of respirations. Listen for changes in breath sounds, paying particular attention to the symmetry of sounds. If breath sounds are asymmetrical, double check the chest drainage system to assure it is patent and working properly. Diminished breath sounds on the affected side may indicate re-accumulation of air or fluid in the pleural space. o Every hour or 2 have the pt take in deep breaths and cough. Explain that this helps keep the lungs expanded and makes breathing easier o Be sure to teach splinting of the thoracic incision if u are caring for a post-op patient. when the pt coughs have him or her place a pillow over the incision and squeeze or hug the pillow close to the chest wall during coughing.

Why is a mediastinal shift dangerous to the patient

o Occurs when the pressure gets so high that it pushes the heart and great vessels into the unaffected side of the chest - these structures are compressed from external pressure and cannot expand to accept blood flow o Mediastinal shift can quickly lead to cardiovascular collapse - vena cava and r side of the heart cannot accept venous return, with no venous return, there is no cardiac output and with no cardiac output = not able to sustain life

one bottle drainage system

o One-Bottle drainage: simplest way to drain a chest - set up a single bottle with a tube submerged to a depth of 2 cm under water. One short tube leads out of the bottle through the plug at the top, allowing air to vent to the atmosphere. The submerged tube is connected to the pt tubing. Placing the distal end of the tube under water creates a water seal. The water seal provides a low-resistance one-way valve that allows air to leave the chest while preventing outside air from being pulled into the chest during breathing. Positive pressure exceeding +2cmH20 will push air down the tube. The air will bubble through the water and leave the chest drain system through the atmospheric vent (the smaller tube). The one-bottle setup is a combo water seal and fluid collection bottle. As fluids drain from the chest into the bottle, the level of the initial sterile fluid combined with drainage will rise. Thus, the submerged tube will be deeper than 2 cm. The higher the fluid level, the more pressure it takes to push air through the fluid as it leaves the chest.

What is the difference between an open pneumothorax and a closed pneumothorax?

o Open pneumothorax: opening in the chest wall (with or without lung pucture); allows atmospheric air to enter the pleural space; seen with penetrating trauma (stab, gunshot, impalement) o Closed: chest wall is intact, rupture of the lung and visceral pleura (or airway) allows air into the pleural space; chest wall is intact; a patient who is breathing spontaneously can have an equilibration of pressures across the collapsed lung- the pt will have symtpoms but it is not life threatening

• What is a "typical" volume of postoperative bleeding after chest surgery or trauma?

o Over 100ml/hr is excessive drainage. Even bleeding after chest trauma is seldom more than 200-300 ml/hr. if drainage is greater the pt will likely have an exploratory thoracotomy. After cardiac surgery, mediastinal drainage is usually les than 300mL in the first hour, less than 250ml in the second hour, and less than 150 ml/hr after that.

• How are chest tubes positioned if the patient has a pneumothorax? If the patient has a hemothorax or pleural effusion?

o Pneumothorax: end of the tube is directed anterior and superior in the pleural space near the apex of the lung. Typically this will be at the level of the second or third intercostal space o Hemothorax or pleural effusion: chest tube is directed inferior and posterior in the pleural space since gravity will pull fluid toward the base of the lung in a patient who is upright or in semi-fowler's position. Again, the tube is placed in the mid-axillary line at about the seventh or eigth intercostal space.

• What range of suction can be selected by the rotary suction control dial?

o Pre set to -20cmH20 , can be adjusted from -10 to -40cmH20

• What does it mean if the red bellows is visible in the suction window?

o Provides visual indication of sufficient suctioning levels (adequate suction regulation_

• Is suction always required to pull air out of the pleural space and pull the lung up against the parietal pleura?

o Recent research has shown that suction may actually prolong air leaks from the lung by pulling air through the opening that would otherwise close on its own, if suction is required, we must add a third bottle too our two bottle system

• What type of dressing is recommended for a chest tube?

o Recommend using a transparent dressing to allow a direct visualization of the insertion site and to reduce the risk of limited movement a bulky dressing can cause

How do the pressures inside the thoracic cavity change as a person breathes in and breathes out?

o When the diaphragm contracts, it moves down, increasing the volume of the thoracic cavity. When the volume increases, the pressure inside decreases. Air moves from an area of higher pressure, the atmosphere, to an area of lower pressure, the lungs. Pressure within the lungs is called intrapulmonary pressure. o Exhalation occurs when the prhrenic nerve stimulus stops. The diaphragm relaxes and moves up in the chest, this reduces the volume of the thoracic cavity. When volume decreases, intrapulmonary pressure increases. Air flows out of lungs to the lower atmospheric pressure.

• How should the nurse position a patient with a chest tube?

o While patient is in bed, enhance drainage by changing the patient's position regularly and placing him or her in high or semi-fowler's position to facilitate gravity drainage of pleural fluid. Coil tubing on bed, and let it fall in a straight line to the collection chamber of the chest drain. Avoid dependent loops in the pt tubing since they can impede drainage from the chest. Chest tube should not be clamped during patient movement. Any drain should be kept blow the level of the chest tube to facilitate gravity drainage.

What are the 3 common components that are found in all chest drainage systems?

o a collection chamber that collects fluid drainage and allows measurement of drainage volume o a one-way water seal chamber or mechanical valve that lets air leave the chest and prevents outside air from getting in o a suction control chamber or mechanical valve that limits the amount of negative pressure that is transmitted to the chest; this feature allows the safe use of suction to facilitate quicker evacuation of air and/or fluid

pneumectomy

one whole lung is removed

• Where are the TWO places that a patient might have an air leak if the nurse sees bubbling in the air leak chamber?

patients thoracic cacity or possible tube connctions

Open pneumothorax Causes

penetrating chest trauma (ie gunshot or stabbing) results in a sucking chest wound should be covered with a vented dressing until medical attention (and placement of ct) is received accidental chest tube removal

What is pleurodesis?

permanenly obliterates the space b/w the pleura and prevents reaccumulation of fluid --> causes membranes around the lungs to stick together and prevent build up of fluid in the space b/w the membranes (pleural space)

Pleural Effusion in xray

pleural fluid is more dense so it shows up more opaque than the side with the lungs expanded

Types of CT drains and valves for pneumothorax?

pneumostat and heimlich chest drain valve (blue to white)

air

pneumothorax

Chylothorax

presence of lymphatic fluid in the pleural space

What happens during a pleurodesis?

pt may either be sedated in the OR or at bedside physician may inject lidocaine (numbness/loss of feeling to reduce discomfort) physician injects sclerosing agent (sterile talc) - causes inflammation and scarring on the pleural surfaces so the parietal and visceral pleura adhere and fuse and fluid cannot build up, pt needs to be turned in multi positions (to distribute the agent) - the pt is left with a CT until the drainage is minimal --- usually 24-48 hours some anti neoplastic drugs can be used - but they are very irritating as well cause inflammation

Lung surgery - post surgery positioning/ ct placement

semi or high fowlers helps to promote expansion of diaphragm - allows air to rise to the lung apex, allows fluid to sink to the base usually not problem for the pt to lie on back (with HOB raised) or slightly to one side or the other alert and oriented pts will usually assume a position that allows good oxygenation

cylothorax causes

trauma leak following surgical procedure cancer

Hemothorax causes

trauma surgery cancer complication of anticoagulant therapy

What is transudate?

type of pleural effusion --> result of heart disease or liver disease --> increased hydrostatic pressure, decreased colloid osmotic pressure, CLEAR, lack of plasma proteins)

what is exudate?

type of pleural effusion --> result of inflammatory products --> CLOUDY, may look infected even if they are not

Wedge resection

wedge of tissue is taken out of lung (closer to surface of lung, smaller amt of tissue)

lobectomy

whole lobe of lung is removed

what diameter would be most appropriate for a hemothorax?

wide