Online Lecture - Chest Tube Management

The lungs are covered by a membrane called:

Pulmonary Pleura or Visceral Pleura

Interior of the thoracic cavity can be divided into three distinct areas:

1. mediastinum 2. left lung chamber 3. right lung chamber

Frequently, how many catheters are inserted:

2

A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. While planning care for a stationary chest tube drainage system, which purpose of the first chamber will the nurse consider?

Collect drainage

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, what type of pressure will be reestablished?

Negative pressure in the pleural space

The inside of the rib cage is lined by a membrane called:

Parietal Pleura

A client with a pneumothorax has a chest tube inserted and attached to a closed chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" How does the nurse explain the function of the water?

Prevent reflux of air back into the chest.

What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly?

Rises with inspiration and falls with expiration

(Ocean) Positive Pressure Release Valve:

Safe guard against tension pneumothorax to release accumulating positive pressure when such clinical conditions may arise * tamper resistant design located on top of the drain

If air, fluid, or blood were to enter the space between these two membranes, the space created is known as:

a pleural space * this is an abnormal occurrence and results in labored breathing

To restore the chest to its normal condition all ____ and ____ must be removed:

air fluid

During respiration:

air moves in and out of the lungs in response to changes in intrapleural pressure caused by movement of the diaphragm and chest wall

During prolonged periods of accumulating vacuum pressure, float valve will:

automatically lower high vacuum pressure down to a lower level

The lower boundary or "floor" of the thoracic cavity:

diaphragm composed of muscle

What causes the air in the vacuum to escape?

chest wall opened by surgery or chest injury + the in rush of air causes the vacuum in the patient's pleural cavity to escape

Under normal conditions, the visceral pleura and the parietal pleura are:

closely held to one another being separated by only a very thin film of lubricating fluid called *pleural fluid

Oasis =

dry chest drainage system

Chest drainage device purpose:

is to help reestablish normal vacuum pressures by removing air or fluid in a closed, one-way fashion

Pleural fluid

keeps the two pleural surfaces in contact while allowing them to slide smoothly over one another during breathing

Changes in intrathoracic pressure can be determined by:

observing the level of the blue tint water and float ball in the graduated water seal column

The degree of negative pressure in the pleural cavity changes during:

respiration

To manually lower the height of the water seal column when connected to suction:

temporarily depress the manual vent located on top of the drain until the blue water column lowers to the desired level * it is not recommended to depress the manual vent when suction is not connected or not operating

If air accumulates in the pleural space and has no means to escape, pressure within this space can rise significantly. This is known as:

tension pneumothorax

The presence of negative pressure or vacuum between these two membranes is what helps hold:

the visceral pleura in close contact with the parietal pleura at all times

When monitoring a patient's chest drainage system it is important to periodically check:

the water level in the chest tube operating system

Ocean =

wet suction chest drainage system

Without full lung expansion the patient experiences:

* pain * great difficulty breathing pneumothorax hemopneumothorax

The chest wall is composed of:

* ribs * sternum * thoracic vertebrae interlaced and covered with intercostal muscle to form a semi-rigid structure

Chest tube removal procedure:

1. have all equipment set up 2. cut the stitch 3. hold tube 4. get dressing ready 5. prepare patient -- patient will hold their breath and bare down (this makes sure that any air that is outside of the chest can't go back inside) 6. have dressing ready to cover tube entrance as you pull the tube out, immediately cover the exit 7. continue to cover the dressing as appropriate

Discharge parameters for chest tube removal:

1. output: <150cc over 24 hours 2. air leak: none for 24 hours 3. residual pneumothorax: none or small and stable

The physician orders for the suction to be changed from negative 40 centimeters of H2O to negative 20 centimeters of H2O. After changing the suction setting, what will the nurse do to bring the float ball and blue water down to the lowest level in order to release pressure?

Depress the negative pressure vent at the top of the system when moving from high to low.

(Ocean) Leave the stopcock in what position at all times:

ON - even when not in sure

A client has a closed chest drainage system in place. What should the nurse do to determine the amount of chest tube drainage?

Refer to the date and time markings on the outside of the collection chamber.

The nurse is preparing the chest drainage system prior to insertion of a chest tube. What type of fluid does the nurse instill in the drainage system to fill the water seal drainage?

Sterile water

The nurse connects the closed drainage system to -20 centimeters of suction per physician orders. How does the nurse determine the suction is engaged?

The bellow is engaged to the delta mark in the E chamber.

What safely controls the amount of suction pressure provided to the patient? (Ocean)

The volume and height of water in the control chamber

Pneumothorax placement:

anteriorly near the lungs apex

Since the normal negative pressure or vacuum is no longer present the lungs may:

partially or fully collapse

Ocean: What to Check for during Operation:

* all patient tubes and suction connection should be routinely checked to ensure proper leak proof operation and chest tube patency

Assessing patient air leaks (Ocean):

* continuous bubbling observed in the water seal = persistent air leak in either the patient's thoracic cavity or possible tube connections * intermittent bubbling with gentle float ball oscillation = presence of an intermittent air leak * no bubbling with minimal float ball oscillation at the bottom of the water seal = no air leak present * bubbling from right to left = must be present to confirm an active air leak * air bubbles passing through the graduated air leak monitor help the clinician assess air leak patterns and patient air leak trends * visual detection of air leaks from a low volume of one to a large air leak volume of 5

Follow-Up Care for Chest Tube Removal:

* leave the dressing on for 48 hours and keep dry * after 48 hours replace dressing with bandage * schedule 1-2 week follow up * watch for redness, pain (call right away and let physician know)

The need for chest drainage is used also following:

* open heart surgery * chest trauma

Depending on your hospital preferred sampling technique, samples of drainage fluid can be:

* taken directly from the patient tube by forming a temporary dependent loop and inserting a 20 gauge (do not puncture tube with an 18 gauge or larger needle) or smaller need with syringe at a shallow angle * on selected models samples can be taken directly from the luer lock sampling port located on the patient tube connector

A chest drainage system provides a means for removing air, blood, or fluid from:

* the pleural space or mediastinal cavity

A client is admitted to the hospital for a surgical resection of the lower left lobe of the lung. After surgery the client has a chest tube to a closed chest drainage system. What should the nurse do to determine if the chest tube is patent?

Check the amount of bubbling in the suction control chamber.

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take?

Check the tube to ensure it is not kinked.

A water seal is a simple one-way valve which allows:

air to exit the chest and prevents air from returning to the patient under normal conditions * it also a very useful diagnostic tool as it can show even the smallest trends of an air leak as well as changes in intrathoracic pressure

A tension pneumothorax can cause a potentially life threatening situation called:

mediastinal shift

Hemopneumothorax placement aka pleural effusion:

more laterally in the lower part of the chest to facilitate more efficient fluid drainage

Under normal conditions there is always _______ pressure in the pleural cavity:

negative

Controlled release valve design protects:

patient against prolong exposure to excessive negative pressures which can accumulate as a result of repeated patient tube milking or stripping

When the system is connection to suction:

patient intrathoracic pressure will equal the suction control setting plus the float ball water column level

For gravity drainage applications:

patient pressure will equal the float ball water column level only

Each ocean chest drain incorporates a high negativity float valve which is located at the top of the water sealed chamber -- during normal or deep inspiration the float valve will allow:

thoracic patients to draw as much intrathoracic pressure as they may require during each respiratory cycle