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N306 > Chest Tubes > Flashcards

Chest Tubes Flashcards

1
Q

What is Boyle’s law?

A
  • When the volume of a container increases, the pressure decreases
  • When the volume of a container decreases, the pressure increases
  • If you’re trying to squeeze as many people in a car as possible, they will be under much higher pressure in a VW Beetle than the same number of people would be in a minivan
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2
Q

How much fluid is in the pleural space in the lungs of a healthy person? What about the pressure?

A

50 cc, creating a negative pressure (-8cm water inspiration, -4cm expiration)

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3
Q

What are the indications for a chest tube placement?

A
  • Pneumothorax (depending on size)
  • Hemothorax
  • Pleural effusion
  • Empyema (bacterial infection, pus) (hard to drain)
  • Chylothorax (lymph buildup)
  • Pleurodesis of recurrent malignant effusions (removal of pleural space to prevent development of pleural effusions when frequent)
  • After cardiac surgery (3-4 tubes to prevent cardiac tamponade)
  • Generally when ~1500 mL’s of fluid and/or starting to impair resp system
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4
Q

How do we treat pleural conditions?

A

1) Remove fluid and air asap
2) Prevent drained air and fluid from returning to pleural space
3) Restore negative pressure in pleural space to re-expand lung

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5
Q

What are chest tubes attached to?

A
  • A drainage device
  • Disposable, needle-less system
  • Allows air and fluid to leave the chest
  • Contains a one-way valve to prevent air and fluid return to chest
  • Designed so device is below level of chest tube for gravity drainage (e.g. on floor)
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6
Q

How does a chest drainage system work?

A
  • Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva)
  • Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest
  • Suction can improve the speed at which air and fluid are pulled from the chest
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7
Q

What does the pleure-evac system consist of?

A
  • Collection chamber
  • Water seal chamber
  • Suction control chamber
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8
Q

Where is the suction control on the pleur-evac?

A
  • Upper left side of unit
  • Turn dial to desired suction level line (-10, -15, -20 (most common), -30, -40 cm of H20)
  • When connected to suction, increase amount of wall suction until orange float appears in window (usually 80-100 cm H20 of wall suction)
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9
Q

What is the water seal chamber?

A
  • Comes empty, with 2 cm sterile water to fill chamber
  • Allows air to exit from pleural space on exhalation and prevent air from entering the pleural cavity or mediastinum on inhalation (think of it like a straw; if you suck back, it will suck back water instead of air and it is less detrimental)
  • If above, needs to come out with a needle (at yellow port); if below, need to add sterile water
  • ALWAYS needs to be at 2 cm
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10
Q

What is the patient air leak meter?

A
  • Indicates the approx. degree of air leak from chest cavity (attached to chamber with water)
  • Observe bubbling in the columns of the patient air leak meter
  • Meter is labeled from LOW (1) to HIGH (7)
  • Expected with pneumothorax; should decrease with treatment
  • Higher the numbered column which bubbling appears, the greater the degree of air leaks
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11
Q

What is the positive pressure relief valve?

A
  • Opens with increases in positive pressure to prevent accumulation (e.g. pt coughing)
  • DO NOT OBSTRUCT positive pressure relief valve! That extra pressure cannot stay!
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12
Q

What is the high negativity float valve?

A
  • Preserves the water seal in the presence of high negativity; used to reduce negativity (valve will release some of that pressure)
  • Water floats the valve up into the closed position when excessive negativity occurs (system more negative than we want to maintain)
  • Valve opens upon decrease in negativity
  • Usually only for suction; if not operative while depressing this valve, negative pressure may be reduced to zero (atmosphere) and may result in a pneumothorax
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13
Q

Describe the action of the collection chamber:

A
  • Calibrated up to 2500 cc
  • Fluids overflow from one section to the next
  • Total capacity of chamber is 2500 cc; when close, set up a new pleur-evac (i.e. one time use)
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14
Q

When would a chest tube be clamped?

A
  • Trying to find the source of an airleak
  • 24 hrs before chest tube removal (<50-100 mL/24 hours), will have tube clamped and will assess for compromise of resp system. If not, will be taken for diagnostics to confirm.
  • Changing a pleur-evac
  • After pleurodesis for malignant effusions/sclerosis
  • NEVER clamp without an order!! If air escapes can cause a tension pneumo, which can be dangerous.
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15
Q

When would Heimlich valves be used?

A

With uncomplicated pneumo or little to no drainage

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16
Q

Describe the procedure prior to insertion:

A
  • Obtain informed consent
  • Complete Baseline vital signs (HR, RR, BP, Sp02)
  • Complete respiratory assessment
  • Gather equipment if procedure is done at bedside
  • Thoracotomy tray
  • Chest tube
  • Dressing material (mepore tape, drain sponge)
  • Pleur-evac
17
Q

Describe post insertion procedure:

A
  • Prepare patient for chest x-ray
  • Vital Signs (HR, RR, BP, Sp02) – see agency policy for frequency
  • Respiratory assessment
  • Palpate around site for subcutaneous air
  • Note drainage amount, colour, type
  • Note the presence of bubbling in the water seal chamber
  • Have two padded clamps at bedside
  • 250-500ml bottle of sterile water
18
Q

Describe ongoing patient assessment:

A
  • At the start of shift and every four hours (or more frequently depending on findings and agency policy)
  • Respiratory assessment
  • Vital signs
  • Presence of chest pain
  • Trachea position
  • Chest tube dressing intact
  • Presence of subcutaneous emphysema (feels like rice-krispies under the skin)
19
Q

Describe system assessment:

A
  • System below level of patient’s chest
  • Tube free of kinks, or external obstruction and coiled on patients bed
  • All connections secured
  • Color and amount of drainage – should be marked at start of shift and according to policy
  • Fluctuation of fluid level in water-seal chamber
  • Constant bubbling in water-seal chamber (if pneumo or suction present) (disconnect from suction if you want to see if there is an air-leak)
  • Float in appropriate location indicating appropriate suction
20
Q

What do you do if a chest tube falls out or dislodges?

A
  • Stay with patient and call for help
  • Monitor VS and respiratory status
  • If air leak unknown, place gauze and tape three sides (allow air expiration)
  • If no air leak present, cover site with occlusive dressing and secure
21
Q

What do you do if the tubing disconnects?

A
  • Cleanse both ends with alcohol swab
  • Notify physician
  • If visibly contaminated, place chest tube in bottle of sterile water until new system can be set up
  • If unit tips integrity compromised, replace unit
22
Q

Describe chest tube documentation:

A
  • Respiratory assessment
  • Condition of the chest tube insertion site
  • All tubings and connections tight
  • Colour, consistency, and amount of any drainage
  • Presence of subcutaneous emphysema
  • Presence of tidalling in water seal chamber
  • Presence of bubbling in water seal chamber
  • Amount of suction
  • Patient tolerance and education
23
Q

When is it time to come out?

A
  • No air leak evident the day before considering chest tube removal
  • Drainage less than 50cc/8 hours or 100cc/day
  • Patient able to tolerate chest drainage system being brought to water seal from suction
  • Chest x-ray shows complete re-expansion of the lung
24
Q

Describe post removal documentation:

A
  • Tolerance of the procedure
  • Respiratory Assessment
  • Vital signs (HR, RR, BP, Sp02)
  • Post procedure dressing
  • Patient teaching
25
Q

If a mediastinal tube is inserted after heart surgery, how much drainage is expected?

A
  • Less than 100 cc/hr immediately after surgery

- No more than 500 cc in first 24 hours

26
Q

How much drainage is expected from a posterior chest tube?

A
  • 100 to 300 cc first 3 hours after insertion
  • Total of 500 to 1000 cc in first 24 hours
  • May be grossly bloody during first several hours after surgery and then change to serous
27
Q

What might a sudden gush of drainage result from aside from active bleeding?

A

Coughing or changing patient’s position, releasing pooled/collected blood

28
Q

What does fluctuation or stopping of movement in the water-seal chamber indicate?

A

Either the lung is fully expanded or the system is obstructed

29
Q

Why is stripping chest tubes controversial?

A

Greatly increases negative pressure inside the tube, causing lung injury

30
Q

Where might an air leak occur?

A
  • At insertion site
  • Connection between tube and drainage device
  • Within drainage device itself
  • Locate leak by clamping tube at different intervals
  • Leaks corrected when constant bubbling stops
  • If bubbling stops while clamped close to patient, air leak is inside patient’s thorax or at insertion site; un-clamp to prevent collapse, reinforce dressing and notify physician immediately
31
Q

What are the S&S of tension pneumothorax?

A
  • Severe resp distress
  • Dyspnea
  • Low O2 sat
  • Chest pain (stabbing)
  • Absence of breath sounds on affected side
  • Tracheal shift towards unaffected side
  • Hypotension and signs of shock
  • Tachycardia
  • Can be life threatening!
32
Q

If the rate of drainage increases dramatically, there is need to rapidly alert physician. What amounts would this be?

A

20 cc over 4 hours (50 cc/hr)

N306 (8 decks)

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