Chest Tubes Flashcards
indications for chest tubes
- treat conditions that disrupt pleural space
- prevent or mitigate post op complx
- instill fluids into pleural space, such as chemo drugs or sclerosing agents to treat recurrent pleural effusions
can be blood collected from chest tubes be used?
yes for autotransfusions
what is the goal of chest tube therapy?
to promote lung re-expansion, restore adequate oxygenation and ventilation, and prevent complications
what objectives should chest tube therapy focus on?
- removing air and fluid as promptly as possible
- preventing drained air and fluid from returning to the pleural space
- restoring negative pressure within the pleural space to re-expand the lung
difference between larger and smaller chest tubes?
- larger tubes used to drain blood and transudate
- smaller tubes use to remove air
what size chest tube is used in adults?
24-40 French
how is the patient positioned during insertion of a chest tube?
depends on insertion site, whether air or fluid will be drained, and pt’s clinical status. generally the pt is supine with a wedge or bolster placed under shoulders
where anatomically is a chest tube placed?
midaxillary line between the 4th and 5th ribs on a line lateral to the nipple
potential complx
- bleeding if a vessel is cut
- risk for infection
- subcutaneous emphysema
- pneumothorax, hemothorax
what happens when subcut emphysema occurs ?
pleural space air leaks into subcut tissue, causing tissues of neck, face, and chest to swell and crepitus on palpation
how do you monitor for s&s of complx and prevent it?
- note changes in drainage amount and character, which may indicate increased bleeding or new-onset infection
- keep tubing free of kinks and occlusions
- regular dressing changes
- assess insertion site for subcut emphysema and tube migration
- monitor water levels in water seal and suction control chambers
when and what should you document?
comprehensive pulmonary assessment every 2 hours
tidaling
fluctuations in the water-seal chamber with respiratory effort; is normal
if tidaling doesn’t occur, what is happening?
tubing may be kinked or clamped, or dependent tubing has become filled with fluid
what does intermittent bubbling mean?
if it corresponds to resps in water seal chamber, it indicates an air leak from the pleural space
bubbling in water seal container is continuous. what does this mean?
leak in the system
why do we avoid milking or stripping the tube?
can generate extreme negative pressures in the chest tube and does little to maintain chest-tube patency
what can you do if you see visible clots?
squeeze hand-over-hand along the tubing and release the tubing between squeezes to help move the clots into the CDU
why do you want to avoid clamping?
prevents the escape of air or fluid, increasing the risk of tension pneumothorax
what do you do if a chest tube becomes disconnected and contaminated?
submerge the tube 1”-2” (2-4 cm) below the surface of a 250mL bottle of sterile water or saline solution until a new CDU is set up
by placing tube in sterile water or saline solution after it has been contaminated, what are we doing?
establishes a water seal, allows air to escape, and prevents air re-entry
indications for chest tube removal
- improved respiratory status
- symmetrical rise and fall of the chest
- bilateral breath sounds
- decreased chest-tube drainage
- absence of bubbling in the water-seal chamber during expiration
- improved chest X-ray findings
removal of chest tube steps
- explain procedure to pt, make sure they know how to do vasalva maneuver
- admin of analgesics
- dc suction
- position pt in semi fowlers
- remove dressing and sutures; clamp tubing
- pull out tube when pt does Vasalva; apply occlusive dressing secured with tape
- obtain CXR
what is nursing care after chest tube removal?
ongoing resp assessment, VS, monitor for drainage, comfort level
prolonged leaks
last more than 5 days after thoracic surgery
if you detect leak at insertion site what should you do?
apply petroleum gauze and sterile dressing over site
what happens with a significant internal air leak?
you can palpate subcutaneous emphysema
what leads to tension pneumothorax?
large persistent leak with no evacuation outlet
when should you dc suction before removal?
some literature suggests dc-ing suction 24hrs prior to taking out a chest tube to prevent possible air leak
when should you obtain CXR after removal?
within 2hrs of removal
what do you do in an unplanned removal?
stay calm, cover insertion site with hand, call for help, cover site with dressing, notify MRP, obtain CXR
if you didn’t see the chest tube come out, what do you do?
- If patient appears to be in respiratory distress, ask him or her to exhale forcefully as you lift your hand off the insertion site; before the patient’s next inhalation, quickly cover the site again.
- Have the patient repeat this a few times
if you’re walking with your patient and the chest tube becomes dislodged where it connects to the drainage tubing, what do you do?
- immediately close off the tubing to air with your gloved hand by crimping it or using a clamp, if readily available, or place the end of the tube in a bottle of sterile water, creating a water seal
- prepare a new sterile chest-drainage collection device, or retrieve a new sterile connector while you safely return the patient to bed
- observe the patient for s&s of respiratory decline, then reconnect the chest tube to the new drain and unclamp it
how does re-expansion pulmonary edema occur?
results from rapid removal of large amounts of air or fluid
what is a chest tube?
large catheter inserted through the thorax to remove fluid (effusions), blood (hemothorax), and/or air (pneumothorax)
what placement of chest tubes drain air?
Apical (2nd or 3rd intercostal space) and anterior chest tube placement
what placement of chest tubes drain fluid/blood?
Chest tubes placed low (usually in 5th or 6th intercostal space) and posterior or lateral
when is fluid drainage expected?
after open chest surgery and some chest trauma
when is a mediastinal chest tube used?
after open heart surgery
two chamber system vs three chamber system
- Two-chamber system permits liquid to flow into the collection chamber, and air flows into the water-seal chamber
- Three-chamber system promotes the drainage of fluid and air with controlled suction
what is similar about both two and three chamber systems?
1st chamber provides a compartment for fluid and the 2nd for either a water seal or a one-way valve
T or F: Infections can occur with chest tubes.
Yes, but rarely
management of chest tube drainage system
- Avoid dependent loops of the drainage tube; or when these loops cannot be avoided (such as when pt is sitting), lift and clear the tube every 15-30 mins
- Keep chest drainage tubing and the collection system below the level of the pt’s chest. Keep the tubing above the collection system to allow drainage by gravity.
- Tailor the length of the drainage tube to the pt. The tubing must be long enough to allow a pt to move but not so long that dependent loops hang down the side of the bed.
what can happen if tubing is coiled, looped or clotted?
drainage is impeded and can result in a tension pneumothorax
what is not considered normal in water seal chamber?
○ Constant bubbling in the water seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention
○ Constant left-to-right bubbling (when facing the indicator) or violent rocking is considered abnormal and indicates an air leak
what would a sudden decrease in drainage indicate?
possible clot or obstruction in the chest tube
what indicates fresh bleeding from the thorax?
sudden increase of more than 250mL of drainage over 1hr
what are the different colours of drainage?
- Drainage from recent open-chest surgery initially is bright red and gradually becomes serous as post-op course continues
- Blood tinged fluid = malignancy, pulmonary infarction, or severe inflmtn
- Frank blood = hemothorax
- Pus = empyema
absence of bubbling in three chamber water system indicates what?
no suction is occuring; raise suction setting to restore gentle bubbling
what happens when appropriate amount of water is added to three chamber water system?
a 2cm water seal is established
bubbling in water seal chamber indicates…
an air leak
dry suction system
○ Provides higher suction pressure levels if needed, easy setup, no water in suction-control chamber, and absence of continuous bubbling
what is the point of the water seal chamber?
it acts as a one way valve so air cannot enter the pleural space
when setting up a waterless system, what do we add and why?
15mL of NS or sterile water into diagnostic indicator injection port; Allows observation of rise and fall of water in diagnostic air leak window
