e3-chest tube management/pneumothorax, etc
Chamber 2 Pleur-evac
-water seal that prevents air from reentering the patient's pleural space. -As the trapped air leaves the pleural space, it will pass through chamber one before entering chamber 2. -should always contain 2cm of water to prevent air from returning to the patient. -as trapped air from the patient's pleural space passes through the water seal, which serves as a one-way valve, the water will bubble. Once all the air has been evacuated from the pleural space, bubbling of the water seal stops. *bubbling indicated air drainage from the pt*
Tidaling
-when the water in the narrow column of the water-seal chamber normally rises 2-4 inches during inhalation and falls during exhalation -an absence of fluctuation may mean that the lung has fully re-expanded or that there is an obstruction in the chest tube
Nursing management CT
-never lift drain above chest level -the unit and all tubing should be below the patient's chest level to facilitate drainage -tubing should have no kinks or obstructions that may inhibit drainage -ensure all connections between chest tubes and drainage unit are tight and secure --connections should have cable ties in place -tubing should be anchored to the patient's skin to prevent pulling of the drain -in PICU and NNU tubing should also be secured to patient bed to prevent accidental removal -ensure the unit is securely positioned on its stand or hanging on the bed
Chest tube dislodged:
-notify PCP -immediately apply pressure over chest tube insertion site -have assistant obtain sterile petroleum gauze dressing, apply as patient exhales, -secure dressing with tight seal -dressing with tape over 3 of the 4 sides may allow for escape of air if there is residual pneumothorax
No drainage in ct:
-notify PCP -observe for kink in chest drainage system -observe for possible clot in system -observe for mediastinal shift or respiratory distress
Substantial increase in bright red drainage:
-notify PCP -obtain vitals and monitor drainage -assess patients cardiopulmonary status
Tension Pneumothorax
-one way valve effect allowing air to enter the pleural space but not leave
Single Bottle CT drainage system
-open air component -drainage container -water seal allows air to exit from pleural space during exhalation, prevent air from entering pleural cavity during inhalation. -used for gravity drainage
pain management of CT
-pain management needed to participate in techniques to reduce the risk of complications, such as IS, coughing and deep breathing and ambulating. -give prescribed drugs for pain and assess the patient responses to them. -teach patients using PCA devices to self-administer the drug before pain becomes too severe -monitor VS before and after giving opioid analgesics -plan care activities around the timing of analgesia to reduce pain
Removal of CT
-painful for patient -done at bedside -after removal site is dressed and sealed with an occlusive dressing and observed for drainage -assess patient hourly for respiratory distress for the first few hours after CT removal. -respiratory distress may signal lung collapse and the need for chest tube reinsertion.
Indications for chest tube placement
-post op ie cardiac surgery or thoracotomy -pneumothorax, hemothorax, chylothorax, pleural effusions -drain is placed into pleural cavity to get rid of blood, air, and fluid accumulation, restore negative intrapleural pressure, prevents air and fluid from returning into chest.
Common finding for any pneumothorax
-reduced or absent breath sounds on the affected side -hyperresonance on percussion -prominence with the involved side of the chest, which moves poorly with respirations -deviation of the trachea toward the unaffected side (mediastinal shift) from increasing pressure on the injured side
Indications for a chest tube-thoracotomy
-removal of part of the lung or rib to examine chest cavity. CT is placed to evacuate fluid or air accumulation in chest cavity post procedure. -open thoracotomy may be needed when the blood loss is more than 1000m: from the chest or persistent bleeding at the rate of 150-200mL/hr over 3-4 hours. -Monitor VS, blood loss, I&O
Rule out air leaks in the CT
-rule out patient centered: assess respiratory status -document and report and changes in lung sounds, pulse ox, respiratory rate, or mentation. -continuous bubbling in the water seal chamber with an absence of bubbles in the suction control chamber indicated that there is a leak in the system -with a prescription, gently apple a padded clamp on the drainage tubing close to the occlusive dressing. -if the bubbling stops, the air leak may be at the chest tube insertion site or within the chest, requiting physician intervention. -bubbling that does not stop when a passed clamp is applied indicated that the air leak is between the clamp and the drainage system. Release the clamp ASAP as this assessment is made.
Chamber 3 Pleur-evac
-suction control of the system -wet or dry suction *wet* -fluid level in chamber three is prescribed by the PCP (usually -20cm water) -chamber is connected to wall suction, which is turned up until there is gentle bubbling in the chamber. *dry* -PCp prescribed the suction level to be dialed in on the device. -When connected to wall suction, the regulator is set to the amount indicated by the device's manufacturer. -both suction determined by device, not wall suction.
Dressing after removal
-surgeon applies sterile occlusive dressing after removal -secures it in position with wide tape -if air is heard from the chest tube site, reinforce the occlusive dressing and immediately notify PCP
When to notify PCP or rapid response team
-tracheal deviation -sudden onset of dyspnea -pulse ox below 90% -drainage greater than 70ml/hr in adults -drainage greater than 3ml/kg/hr in peds -observe eyelets of chest tube -chest tube falls out - have 4x4 available -drainage stops (in first 24 hours) -chest tube disconnects from system (put end of tube in a container of sterile h20, maintain below client's chest)
Assessment of CTs
-vital signs w pulse ox -lung sounds -drainage site -skin around neck and site for crepitus -drainage color, consistency, output -tube kinking, constant bubbling = leakage -coagulation studies -first dressing = do not change for 48 hours, change done by physician who placed tube
CT setup/insertion
-hand hygiene -open drain package using sterile technique -prepare drain as per manufactures instructions -pass sterile end of tubing to doctor -apply suction to drain if ordered -secure drain and tubing to bed and patient -secure all connections with sable ties -hand hygiene -Tube should NEVER be clamped. Why? *could result in back flow, and cause increasing pressure inside the pleural cavity.
Indications for removal of CT
-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 findings
ND-Diagnosis for CT
-ineffective breathing pattern r/t chest tube placement AEB... -impaired tissue integrity r/t chest tube -knowledge deficit r/t therapy regimen of CT placement
ND-Evaluation in CT management
-lung expansion -absence of pain -regain optimum respiratory status -regain optimum physical activity -chest rube removal per PCP order -regain tissue integrity
Tension pneumothorax
-buildup of air within pleural space, causes compression of chest cavity affecting blood reuturn to the heart -chest tube placement evacuates the air from the chest, expanding the lung -air is trapped into pleural space during expiration -increases pressure in thorax (compared to atmospheric pressure) which puts pressure on the heart -increased pressure on the heart causes tachycardia
Chamber 1 - Pleur-evac
-collects fluid drained from patient -fluid measured hourly during first 24 hours *-The fluid in chamber 1 must never fill to the point that is comes into contact with any tubes! If the tubing from the patient enters the fluid, drainage stops and can lead to a tension pneumothorax!*
Safety guidelines-CT management
-constant bubbling left-to-right or violent rocking is considered abnormal and indicated an air leak -notify PCP when there is a sudden increase of more than 250mL of drainage over 1 hour which can indicate fresh bleeding from the thorax -
Three bottle CT drainage system
-contains h2o seal, fluid collection, and suction bottle. -each has a separate tube, connecting to h20 seal, suction, and fluid collection bottles.
Pleur-evac drainage system
-disposable system that contains suction system, h2o seal, and fluid collection in one container. -suction pulls more air compared to gravity.
Drainage colors from CT
-drainage from decent open chest surgery is initially bright red and gradually becomes serous as the post op course continues -blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation -drank blood indicated a hemothorax -pus indicated an empyema (collection of pus in the pleural cavity)
Additional findings with a tension pneumothorax
-extreme respiratory distress and cyanosis -distended neck veins -hemodynamic instability
Post care interventions
-frequent respiratory assessments -maintain closed system -keep collect bottles below chest -check tubing for patency -measure drainage -monitor water level -monitor h2o seal -assist client with positioning
Drainage 2
-from mediastinal tube, expect less than 100ml/hr immediately after surgery and no more than 500ml in the first 24 hours -from posterior chest tube, expect between 100-300ml in the first 3 hours after insertion, with a total of 500-1000 ml expected in the first 24 hours. Drainage is grossly bloody during first several hours after surgery and changes to serous
nu alert-water seal CT
*for a water-seal chest tube drainage system, 2cm of water is the minimum needed in the water seal to prevent air from flowing back into the patient. Check the water level every shift and ass sterile water to this chamber to the level marked on the indicator*
nu alert-CT strip
*manipulation of the CT should be kept to a minimum. Do not vigorously strip the chest tube because this can create up to -400cm of water negative pressure and damage lung tissue*
Bubbling in the chamber
-means there is air drainage from the patient -seen when intrathoracic pressure is greater than atmospheric pressure, such as when the pt exhales, coughs, or sneezes. -blocked or kinked tubes can also stop bubbling -excessive bubbling may indicate air leak -after 2-3 days tidaling or bubbling on expiration is expected to stop, indicating that the lung has reexpanded.
Two bottle CT drainage system
-Contains H20 seal and fluid collection bottle. -Fluid collects in separate bottle from water seal bottle. -Drainage depends on amount of suction ass to systems.
Chest tube removal
-Kelly clamps -chloraprep or betadine -suture removal kit -vasaline gauze, or adaptic -dry sterile 4x4s -tegaderm or occlusive dressing -red bag for disposal
Removal of CT 2
-Optimal timing of chest tube removal depends on the paitent -removal at full inspiration because it maximally expands the lungs and minimizes the potential space between the plurae. -another recommendation is for chest tube removal at end expiration when the pressure difference between the chest cavity and the atmospheric is the lowest.. -half of the chest tube is removed at full inspiration and half at full expiration -all patients preformed valsalva maneuver during removal
Flutter Valve
-a one way valve system that is small and portable for transport or ambulant patients
ND Outcomes for Chest tubes
-adequate ventilation -adequate lung expansion -diminished fluid accumulation in pleural cavity -complication resolved.
Closed pneumothorax
-air collection in chest/pleural space causing the lung to partially or fully collapse -W/O any outside wound -chest tube placement allows air to escape space causing lungs to reflate.
Management of Chest tubes 1
Measure output -Notify MD if output exceeds limit according to protocol (70mL/hr adults, 3mL/kg/hr for peds) Removal -Keep 4x4 gauze adn tape available for accidental or removal per order
Chylothorax
A collection of lymph fluid in the pleural space (during surgery)
Treatment of tension pneumothorax.
A tension pneumothorax requires IMMEDIATE DECOMPRESSION using a NEEDLE (14 gauge) THORACOSTOMY (Over the 3rd Rib [2nd INTERCOSTAL SPACE] at the MIDCLAVICULAR LINE) followed by CHEST TUBE PLACEMENT SIgns and Symptoms 1. Severe Respiratory Distress 2. Tracheal Deviation to Contralateral Side 3. Distended Neck Veins (↑ JVP) 4. Hypotension
Pneumothorax
collection of air in the pleural space
hemothorax
Collection of blood in the pleural space
Chest tube sizes
Infants and small kids: 8-12 fr Large children/small adults: 16-20 fr Adult: 24-32 fr Large adults: 36-40 Fr
Under water seal drain
drainage system of 3 chambers consisting of a water seal, suction control and drainage collection chamber. Designed to allow air to fluid to be removed from the pleural cavity, while also preventing backflow of air or fluid into the pleural space.
Pleural effusion
exudate in the pleural space (bleeding, infection, or abcess)
