CT Flashcards
what does trauma to the lungs cause?
increases positive pressure
do all leaks of fluid into pleural space require a chest tube?
no, • Small leaks of <24% are sometimes absorbed spontaneously and don’t require a chest tube
what is pleural effusion?
accumulation of fluid in the pleural space e.g.) hydrothorax, pyothorax
how do spontaneous or primary pneumo occur?
rupture of sm blister or bleb on lung or invasive procedure like subclavian IV insertion
S&S of pneumothoax?
feels sharp chest pain that worsens on inspiration or coughing as atmospheric air irritates the parietal pleura. As it worsens the pt will experience easy fatigue, rapid HR and low BP
What can tension pneumo lead to?
can lead to tracheal deviation, dec VR, and then dec CO. Pt will have sudden chest pain, dec BP, tachycardia, acute pleuritic pain, diaphoresis, dry cough, and cadiopulm arrest can occur
who is at risk for tension pneumo?
pt w chest trauma, fx ribs, invasive procedures eg central line insertion, high P mechanical ventilation
what are the gauges of chest tubes for air? fluid?
air- 12-20
fluid 24-32 french tubes
what do you suspect is draining if a chest tube is in the apical and anterior space (2nd or 3rd intercostal space)
air because air rises
what do you suspect is draining if a chest tube is in the apical and anterior space (5th or 6th intercostal space)
fluid or blood
what is a mediastinal chest tube?
what procedure is often used for?
is placed in mediastinum just below sternum and connected to drainage system. Used after open heart sx
how does a heimlich valve work?
it is attached to a catheter and positive pressure from exhalation opens valve and allows air release but valve closes on inhalation so no air gets in. not used for drain
why would you use smaller pigtail catheters? when would you not?
can they are less tramautic than large bores
can’t use them to drain blood bc too small
benefits of mobile chest drains?
lighter (decs pts pain) and self contained. Dec risk of DVT or immobility complics. Rely on gravity or dry suction for drainage. Best for pts w persistent drainage or air leaks needing prolonged therapy (theyll need ++teaching)
what are disposable systems? ex?
Atrium or Pleur-Evac chest drainage system are 1 piece molded plastic units that provide for single or multi chamber closed drainage system. Cost effective. Can facilitate auto-transfusion (in the outcomes it says to omit refrences to reinfusion of chest tube drainage)
how do single chamber systems work?
do you use this with fluid?
allow air from pneumo to bubble out of water seal and escape tough the air utlet while preventing air from reentering the intrapleural space. Not recommended for evacuation of fluid as dranage would raise the level of the water seal liquid. An inc height of fluid in the water seal inc the resistance to drainage on expiration and eventually stops the drainage
whats the difference between 2 chambers and 3 chamber systems?
- 2 chamber allows liquid to flow into the collection chamber and air frolws into the water seal chamber
- 3 chamber promotes the drainage of fluid and air w controlled suction
what is the danger of stripping to get rid of clots or fibrin?
inc intrathroacic pressure
having chest tubes >20 days leads to inc risk of what?
infection
what should you observe the water seal for?
intermittent bubbling or rise (w inspiration) and fall of fluid synchronous w resps
is it normal for constant bubbling or sudden stop of water activity?
no
what will help indicate that re-expansion of lung has occurred by looking at the water seal?
2-3 days of tidaling or bubbling on expiration should stop
how often o you note chest tube drainage?
q1 hr then q4h
is a sudden dec in chest tube drainage good?
no it could indicate a clot or obstruction
how much should be draining for you to notify someone? what does this mean?
more than 250ml/hr. could indicate a fresh bleed from thorax
do you generally see drainage from a pneumo?
no it is usually from chest tube insertion trauma
what is the purpose of the water seal?
prevents re-entry of air into the lung
whats a disadvantage of water seal system?
Must be kept upright to keep seal
- drainage chamber may fill quicly if pt has lg amount of drainage
- sterile water must be added several times a day to maint suction and water seal because of evaporation
which systems do you add sterile water to, to see if there is an air leak?
waterless system or dry system because does not already have sterile water in it, like the water seal
PPT: what is the purpose of chest tubes?
Re-expand the lung and restore normal negative pressure in the pleural space
Remove air, fluid, blood or infected matter from the pleural space
Remove fluid/blood from the mediastinum post-open heart surgery
what are contraindications for chest tubes?
May be contraindicated in patients with coagulopathy or platelet dysfunction, methocelioma or pure TB effusion
what is a pneumothorax?
when does this occur?
collection of air in pleural space causing partial or total collapse of lung Can occur with: Blunt chest trauma/tear in lung tissue Penetrating injury Spontaneous rupture of lung bleb Mechanical ventilation During surgical procedure
what causes pleural effusions?
Liver and kidney failure Congestive heart failure Infection Malignancy blocking the lymphatic system Small cell carcinoma’s often produce the most
what are the different types of chest tubes?
Straight thoracic chest tube
Small bore Heimlich valve chest tube
Pigtail chest tube
Pleur-X catheter
what are the 3 chambers that make up the drainage system?
1) collection chamber
2) water seal (underwater seal chamber)
3) suction control chamber
do you use a small bore pneumothorax tube to drain air or flu?
air (small diameter)
what is an advantage of a pigtail catheter? what is it used for?
Soft flexible catheter containing strings that run the internal length, after insertion strings are shortened, causing the proximal end to curl in, reducing the risk of perforation #8-14 Fr
Used for pleural effusions
what is a pleura-X?
For malignant plural effusions. Long term tunneled silastic catheter that can be in for months # 15.5 Fr. Allows patients to be treated at home verses in hospital increase quality of life.
what is tidaling?
indicates fluctuations in the water-seal chamber’s fluid level that correspond with respiration. On inspiration, increased negative pressure in the pleural cavity increases the water level. On expiration, decreased pleural pressure decreases the water level. Shallow breathing causes less fluctuation and labored breathing causes more.
what does no tidaling mean?
lungs have re-expanded
the drainage tubing is kinked
there is an obstruction
what does bubbling in water seal chamber mean?
continuous bubbling?
intermittent- normal
continuous- air leak in client or system (unless wet suction control, then it is normal)
if continuous bubbling abruptly stops when checking the insertion site, tubing, drainage container , what does that mean?
chest tube is loose or partially out
what is common to find in skin around the site of a CT
what does this mean?
SC emphysema
probably an air leak
when should you be concerned with air leaks? when not?
normal in first 24 hours. most often clears after a couple coughs
managed with inc suction. if its after 24 hours, clamp briefly and locate the weak
what does rapid bubbling in water seal chamber mean?
can indicate a loss of air around the incision or a tear in the pulmonary pleura
call for help
how does suction work for dry and wet suction?
dry- dial
wet- water controls (continuous bubbling means it is working)
why would suction be ordered?
Patient has inadequate strength for gravity drainage
Air leak develops without suction
To speed up air fluid/removal
assessment for Ct pt?
Site:
Patient assessment, Dressing, Bleeding, Subcutaneous Emphysema,
Tubing:
Taping/Zap strap, Looping tubing on the bed
Output:
Checking, Marking, Documenting, Position of Pleurevac
Patency:
Fluctuation, Water-seal level, Air leak/bubbling
what causes SC emphysema?
Cause: If a chest tube isn’t properly placed, or if the site dressing isn’t airtight, air can leak into the tissue around the insertion site. Eventually it can track up and down the body, sometimes causing the neck and face to swell, sometimes threatening the airway. In that case the patient should be immediately assessed for intubation - there may be no time to waste!
what are you assessing for in the water seal chamber?
filled to the right level (2cm)
bubbling (intermittent is normal)
when is tidaling rise and fall the reverse?
mechanical ventilation
how do you know wet suction is working?
bubbling is present
when can you clamp the tubes?
Momentarily to locate the source of a persistent air leak
2. Momentarily to replace drainage system
3. Physician’s order to assess whether tube can be removed
4. Physician’s order following pleurodesis (chemical or surgical procedure to disrupt the parietal pleura)
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which clamps do you use?
2 non-toothed clamps
what other nursing interventions can you do with a person with a CT>
Encourage deep breathing and coughing Incentive spirometry Mobilize/ shifting Comfort measures Nutrition and fluids (inc fluid reduces clot formation) Teaching
can you disconnect from suction to mobilize a patient?
never. need order
where must the drainage system be for a mobile client?
below insertion site or waist
what do you do when there is a sudden change in type of drainage?
Assess client
Take vital signs
Check drainage
What precipitated drainage
(cough, mobilization, position change)what do you do when the chest tube becomes disconnected from the drainage unit?
Insert end of chest tube into bottle of sterile water or N/S (keep at bedside)
Do NOT clamp
(could create a tension pneumothorax)
Connect to drainage system
what do you do when the chest tube falls out or is pulled out?
STAY with client and call for help
Call the physician STAT
Cover the insertion site with sterile petroleum dressing
Continue to assess client for signs of tension pneumothorax and respiratory distress
what determines that the lung has re-expanded?
tidaling stops
normal breath sounds and percussion
xray
minimal drainage
chest tube removal?
Disconnected from wall suction
Clean around site
Cut suture
Client to take deep breath and hold OR breath out
One person removes tube
Second person applies the dressing
(and pulls the purse string suture if present)
how much drainage should you expect in first 3 hours post-insertion?
100-300ml
how often do you check drainage post-insertion?
q15 min for 2 hours and mark on chamber
what does the drainage appear like in anterior chest tube from [neumothorax?
little to no output
what does a sudden gush from a drainage indicate?
coughing or changing positions. not necessarily active bleed
what does a clamped chest tube cause?
tension pneumo
if bubbling is continuous and you clamp to find air leak, where do you start?
near chest wall
if bubbling stops away from patient when clamping where is it? what do you do?
in tubing or connection between clamps. change tubing or secure connection
if bubbling still continues after clamping the whole tube what does this mean
in drainage system
position of pt during removal?
on side of bed stirring, supine or on side
what is a simple pneumo?
- Aka spontaneous
- Most often through rupture of a bleb or bronchopleural fistula
- Can occur in apparently healthy person w/o trauma d/t rupture of air-filled bleb or blister on lung surface
- May be assoc w diffuse insterstitial lung disease + severe emphysema
what is a traumatic pneumo?
- Air escapes from laceration in lung + enters pleural space or comes into pleural space via wound in chest wall
- Can occur from diaphragmatic tears/trauma, invasive thoracic procedures, insertion of subclavian line, transcrnchial lung biopsy, blunt or penetrating chest trauma
what is a open pneumo?
one kind of traumatic; sucking chest wounds (air passing through with each inhale, creates sucking sound), causing not only lung collapse but shift of mediastinal contents toward uninjured side w each inspiration + opposite side with expiration = mediastinal flutter/swing, creates severe circ issues
what is a cardiac tamponade?
- compression of heart as result of fluid w/in pericardial sac
- Usually caused by blunt or penetrating trauma
