chest tubes and traces Flashcards
what are some signs of airway obstruction due to swelling in the neck?
- Use accessory muscles to breathe
- Suprasternal and intercostal retractions
- Stridor
- Wheezing
- Restlessness
- Tachycardia
- Cyanosis
describe an endotracheal (ETT)
- Don’t require incision
- Quick insertion
- used for short term mechanical ventilation
- Useful for administering inhaled gases
describe a tracheostomy
- more invasive/ versatile
- used for short or long term ventilation
- permanent or temporary
how is a tracheostomy put in?
- surgical incision made into the trachea
- creates stoma > airway managed by this
if a person has an underlying problem and is being treated with a tracheostomy and its corrected what could potentially happen?
- removal of tube
- tracheostomy closed
what are the components of a cuffed tracheostomy ?
- tracheostomy tube
- inner cannula
- obturator
describe the inner cannula of the cuffed tracheostomy
- smaller tube that fits into the tracheostomy
- can be removed easily to get gummed up respiratory secretions out
- usually disposable
- replaced every day or more often if client has thick secretions
describe the obturator of the cuffed tracheostomy
- used to insert tracheostomy then removed
- kept at beside
describe the cuff on the cuffed tracheostomy
- connected to a little tube and port where syringe can be attached
- uses a luer lock connection > used to fill the cuff with air > no air can flow past tracheostomy tube once in client
- has a pilot light
what is a pilot light in a cuffed tracheostomy?
- located close to where syringe is attached
- small balloon
- when inflated means cuff is filled
- when deflated means cuff is deflated
what does a pilot light on a cuffed tracheostomy tell a healthcare worker?
whether tracheostomy cuff is inflated or not just by looking at it
describe a laryngectomy
- surgical removal of larynx (contains vocal cords)
- can look like tracheostomy from outside
- end of trachea sutured to edges of stoma > once healed plastic tube may not be needed
when is a laryngectomy performed?
when person had advanced cancer of the larynx that can’t be managed by a more conservative treatment
Why is it important to now if someone has a laryngectomy if you have to give CPR?
- airway is completely separated from mouth, nose and esophagus
- need to ventilate through stoma in neck
- use smaller paediatric bag valve mask
What additional safety equipment is needed at the bedside when a client has a new tracheostomy?
- replacement trach tube
- obturator
- spare inner cannula
- suction supplies
- spare trach ties/ trach collar
- equipment to replace trach tube if dislodged
when a client has a new tracheostomy, what safety equipment needs to be close by and not necessarily right at bedside?
manual resuscitation device (proper size/ mask)
what are the clinical manifestations of respiratory failure?
- increased RR
- increased work of breathing
- use of accessory muscles to breathe
- decreased oxygen saturation
- cyanosis
- anxiety
What are clinical manifestations of bleeding at the tracheostomy site?
- noticeable bleeding > caused by elevated BP or coughing
- decreased BP
- blood in respiratory secretions
what are the clinical manifestations of infection at the tracheostomy site?
- increased pain
- swelling
- redness
- exudate
- increased drainage
- elevated temp
- chills
- rigors
- elevated WBC count
what are the clinical manifestations of a pneumothorax ?
- decreased breath sounds or decreased air entry in 1 or both of lung fields
- chest pain
- dyspnea
- elevated RR
- decreased oxygen saturation
What is subcutaneous emphysema?
air leaks into subcutaneous tissues around tracheostomy
What are clinical manifestations of subcutaneous emphysema?
- swelling of the neck
- extending up into the jaw or down into chest
- on palpation tissue feels crackly
what are the long term complications of having a tracheostomy?
- tracheal stenosis
- tracheomalacia
- granuloma formation
- tracheoesophageal fistula
in regards to long term complications of having a tracheostomy, describe a tracheal stenosis
- narrowing of the trachea
- caused by irritation at the trach site from cuff being inflated to much
in regards to long term complications of having a tracheostomy, describe a tracheomalacia
- trachea becomes weak/ flaccid
2 structure of trach changes
- collapse during high flow
- coughing, crying, eating
- caused by poorly fitted tube
- damages tracheal tissues
in regards to long term complications of having a tracheostomy, describe a granuloma formation
- hyper granulation tissue grows at trach site > may occur distal to site inside trach
- hyper granulation tissue friable/ bleeds easily
in regards to long term complications of having a tracheostomy, what causes a granuloma formation?
- ill-fitting tube
- chronic inflammation/ infection
in regards to long term complications of having a tracheostomy, describe tracheoesophageal fistula
- fistula between esophagus and trachea
- gastric content can enter resp tract and air can enter stomach > cause pneumonia and abdominal distension
what is a fistula?
abnormal connection between 2 different parts of the body
What causes a tracheosophageal fistula?
- friction between cuff of trach tube and nasogastric tube in esophagus
- injury > when trach was originally created
How often does a trach need to be cared for?
- twice a day or more frequent if needed
What does routine tracheostomy care entail?
- changing trach dressing if soiled/ wet
- changing trach ties if soiled/ wet
- cleansing around trach site with sterile saline
- changing/ cleansing inner cannula
What type of trach has a reusable inner cannula?
cuff less tracheostomy
How often do inner cannulas need to be cleaned?
- check for patency every 12hrs
- disposable inner cannula > changed every 24hrs
- non-disposable inner cannulas > cleaned every 24hrs
what do you do in the case of accidental decannulation?
- do not replace tube
- assess ABCs
- stay with patient
- ask someone to cal RT STAT and call doctor
- if client can’t breathe maintain satisfactory O2STAT and call code blue
What is the process of weaning a patient off of a tracheostomy?
- takes about 2-7 days
- deflate trach cuff
- replacing cuff tube with a smaller uncured tube
- capping/ corking trach tube
- removing (decannulating) trach tube
in regards to the process of weaning a patient off of a tracheostomy describe replacing cuffed tube with a smaller uncuffed tube
- client should maintain adequate breathing and oxygenation
- client is breathing through trach and mouth/nose
in regards to the process of weaning a patient off of a tracheostomy describe capping/ corking the trach tube
- cap that covers opening in trach tube
- client is only breathing through mouth/nose
- if client feels SOB and O2STAT drops remove cap> allows client to breath through trach again
in regards to the process of weaning a patient off of a tracheostomy describe removing (decannulating) trach tube
- tube is removed
- stoma covered with sterile folded gauze/ tape
- stoma starts to heal/ permanently close
describe ches tubes
- drainage tubes used to remove air/ fluid from chest cavity
- usually placed in pleural space
- if needed > placed into mediastinal space (around heart)
What are indications for chest tubes?
- pneumothorax
- pleural effusion
- hemothorax
- empyema
- chylothorax
- thoracic or chest surgery
in regards to chest tubes, describe a pneumothorax
- air in pleural space
- mainly air and some pleural fluid coming out
in regards to chest tubes, describe a pleural effusion
- fluid in the pleural space
- yellow or amber
- clear or cloudy
in regards to chest tubes, describe a hemothorax
- blood in pleural space
- caused by trauma
- blood draining from chest tube
in regards to chest tubes, describe empyemma
- pus or purulent drainage builds up in pleural space
- caused by condition > pneumonia or lung abscess
- drainage from chest tube would appear purulent
in regards to chest tubes, describe a chylothorax
- lymphatic fluid leaks into pleural space
- due to trauma or complication of chest surgery
- chest tube drainage appears milky white
in regards to chest tubes, describe a thoracic or chest surgery
- surgery of heart or lungs
- tubes placed after surgery in the pleural or mediastinal space to drain air, blood, or serous fluid resulting from surgery
What can cause a pleural effusion
- to much hydrostatic pressure in blood vessels
- not enough plasma proteins (albumin) in blood stream
- inflammatory or infectious process in lungs
in regards to a pleural effusion describe to much hydrostatic pressure in blood vessels
- forces fluid to be pushed out of blood vessels into pleural space
- happens in HF especially left sided
in regards to a pleural effusion describe not enough plasma proteins (albumin) in blood stream
- helps maintain plasma oncotic pressure
- not enough cause fluid to leak out of blood vessels
- happens when person is malnourished, or liver failure
in regards to a pleural effusion describe inflammatory or infectious process in lungs
- produces exudate
- can be caused by pulmonary emboli, lung infections, lung cancer
describe a thoracotomy
- chest open to perform surgery on lungs
- used when person has lung cancer > all or part of lung removed
- chest tubes placed at bottom of lung
- incision curves with rib
describe pigtail drains
small- bore chest tube
- curled end
- smaller in diamater
- less painful than some larger diameter tubes
- used to drain air and pleural fluid
- thick fluid can clog pigtail
describe tension pneumothorax
- build up of air in pleural space
- every breath causing increased pressure in pleural space
- compresses affected lung, airways and blood vessels
- if not treated ASAP can prevent heart from filling/ pumping/ cause both lungs to collapse
caused from kinked chest tube
What does a tension pneumothorax result in?
structures being shoved to opposite side of chest
describe an atrium oasis closed drainage system with water seal drain
- used after trauma or surgery
- has 3 compartments
what are the compartments of the atrium oasis closed drainage system wit water seal drain?
- one chamber that collects drainage
- one chamber with a water seal > allows air to escape from chest tube but doesn’t allow air to get back in
- suction control chamber that allows nurse to regulate amount of suction that’s applied the chest tube
describe a pneumostat chest drain valve
- one way valve
- has a very small collection chamber
- only used when physician doesn’t anticipate much drainage
- can’t be attached to suction
- small/ portable > makes mobilizing easier
What types of cancers are malignant pleural effusion associated with?
- lung
- breast
- leukemia
- lymphoma
describe malignant pleural effusions
- most common in last 4-6 months of life
- inflammation around cancer causes fluid to build up in pleural space
- cancer can prevent normal drainage of pleural fluid
When is a PleurX chest drain used?
when a client has chronic condition that continuously causes fluid to build in chest > needs to be drained periodically
What does a PleurX chest drain look like?
- tunneled indwelling pleural catheter with intermittent drainage
- chest tube is meant to stay in place for long time
- egg shaped drain sealed to maintain vacuum until punctured by T-plunger
how do clients use a Pleura chest drain?
- fluid builds up in pleural space and starts causing pain/ difficulty breathing
- drain connected to PleurX catheter and fluid drains
- when drainage is done catheter is disconnected from drain and catheter is coiled up on client’s chest/ covered with sterile dressing until needed again
Who is a pleurX chest drain meant for?
people living in community who need chest tube
What is included in a chest tube drainage system assessment?
- respiratory assessment
- assess for subcutaneous emphysema
- check dressing
- check tubing: eliminate dependent loops
- check tubing: connection are taped
- follow tubing to wall suction (if ordered)
- assess amount and type of drainage
- assess bubbling in the water seal chamber
- assess for tidying (fluctuating)
- check water level in the water seal chamber
- check amount of suction matches doctor order
- check drainage system is secured (prevent tipping)
in regards to the assessment for a chest tube drainage system, describe respiratory assessment
- trachea is midline
- chest expansion is symmetrical
- lung auscultation
- air entry > may be decreased if lung partially collapsed
in regards to the assessment for a chest tube drainage system, describe assess for subcutaneous emphysema
- air leaks out through tissues around chest tube into subcutaneous tissues
- observe/ palpate for swelling and crepitus (crunching sensation) in tissues around chest tube
in regards to the assessment for a chest tube drainage system, describe chef tubing: eliminate dependent loops
check tubing from chest tube to drainage system/ eliminate any loops
in regards to the assessment for a chest tube drainage system, describe follow tubing to wall suction
- follow suction tubing from drainage system to wall suction
- wall suction needs to be strong enough to activate suction in the drainage container (around 80mmHg)
in regards to the assessment for a chest tube drainage system, describe assess amount and type of drainage
- should be light yellow, straw coloured fluid
- some blood is fine
- record amount of drainage
in regards to the assessment for a chest tube drainage system, describe assess bubbling in the water seal chamber
- get client to take deep breath and blow out
- if air leak in client or system will cause bubbles to escaper through water seal chamber
in regards to the assessment for a chest tube drainage system, describe assess for tidalling (fluctuating)
- level of fluid is fluctuating up/ down as they breathe
- any fluid in tubing of drainage system will fluctuate as well
- indicates changing pressures in pleural space
in regards to assessing tidalling (fluctuating) explain what happens with a collapsed lung when it re-expands
- fluctuations should become less and less
- once client is healed/ close to nurse shouldn’t be able to see any tidalling when client takes deep breath
in regards to the assessment for a chest tube drainage system, describe check water level in the water seal chamber
- should be right at 0 mark
- water can evaporate if client has chest tube drainage system for long time > bubbling causes this
- water to low/ high nurse can adjust with sterile water
in regards to the assessment for a chest tube drainage system, describe check amount of suction matches doctor order
- suction ordered nurse sets specific suction on front of drainage system
in regards to the assessment for a chest tube drainage system what happens if suction is greater or less than 20cm?
- suction > 20cm red bellow expand across window
- suction <20cm not strong enough to pull red bellows all the way across > should still be ablate see
- no suction ordered nurse should disconnect system from wall suction
in regards to the assessment for a chest tube drainage system, describe check drainage system is secured (prevent tipping)
- ensure bellow chest tube site
- can be taped to floor > not normally done
- normally taped to bottom of IV pole > make mobilizing easier for patient
in regards to the assessment for a chest tube drainage system, what happens if drainage system falls over?
- stand upright
- tilt over to right side > get drained fluid back into correct columns
describe an air leak in a client with a chest tube
- air is escaping out from the chest tube drainage system through water seal chamber
- will look like bubbles
what can cause an air leak in a client with a chest tube?
- break/ crack in collection devise
- crack/ break or disconnection in tubing
- inside client (pneumothorax)
nursing education to promote health and avoid complications with chest tubes
- adequate nutrition
- staying hydrated
- managing pain effectively
- monitor for signs of infection
- changing positions frequently to prevent skin breakdown
What do you do if a chest tube is pulled out?
- put on clean gloves/ cover site with gloved hand
- call for help
- have assistant get non-adherent dressing (mepitel), 4X4 gauze and tape
- apply dressing over site, cover with gauze, tape on 3 sides > creates 1 way valve
- once dressing in place, one nurse stay with client to ensure they don’t go into distress, other nurse calls doctor ASAP/ reports
describe toothless Kelly clamps in regards to chest tubes
- always have 2 at bedside
- used when looking for air leak
What might the doctor get the nurse to do with Kelly clamps if they’re thinking about removing chest tube?
- get nurse to clamp tubing overnight or longer
- if client can stand this chest X-ray ordered to see lungs remaining fully expanded/ underlying problem resolved
