Exam 2: Chest Tubes and Pleural Drainage Flashcards
As fluid or air accumulates in the pleural space, what happens?
Pressure will change from negative to positive -> lungs collapse.
What is the purpose of a chest tube?
Drains the pleural space and resets negative pressure for proper lung expansion.
What size chest tube is used for blood?
36-40 F
Large
What size chest tube is used for fluid?
24-36F
Medium
What size chest tube is used for air?
12-24F
Small
What size chest tube is used to keep tube in place?
10-14F
What position is the patient placed during a chest tube insertion?
Arm raised above the head of the affected side to expose midaxillary area.
elevate head to 30-60 degrees to lower diaphragm to allow for maximum lung expansion.
Chest Tube Insertion Procedure
- Antiseptic and local anesthetic is used.
- Small incision over the rib, advancing upward over the rib to avoid intercostal nerves and blood vessels behind inferior rib
- Once inserted, tube is connected to pleural drainage system.
- Chest tube is closed with sutures.
- Wound covered with occlusive dressing or Vaseline.
- CXR used to confirm proper placement
Nursing Management: Chest tubes
Monitor comfort and use appropriate pain relieving interventions
Two Types of Drainage
- Flutter or Heimlich Valve
2. Pleural Drainage
Flutter or Heimlich Valve
One-way rubber valve w/ plastic tube
Emergency transport & small mild pneumothorax
Drainage bag attached to flutter must have vent -> tension pneumothorax
Pleural Drainage
Three compartments: each w/ separate function.
Large and less portable.
Components of pleural drainage system
- Inserted anteriorly, 2nd intercostal space: removes air (in supine position because air accumulates in the top most)
- 8-9 intercostal space: removes fluid d/t concept of dependency
First Chamber
“Collection Chamber”
Receives fluid and air from pleural or mediastinal space.
Drained fluid stays while air moves to the second chamber.
Normal amount of fluid collected in the first chamber is
5-15 mL
Colors of fluid collected in the first chamber
Normal is serous yellow in appearance.
Sanguineous for blood.
Possible a mixture of both.
Serious, sanguineous (should become serous-sanguineous and then completely serous)
Nursing management for pleural drainage system
After 24 hours, fluid must be <100,150 mL for removal consideration.
After insertion, monitor EVERY HOUR for 4 hours. Then monitor every 4 hours afterward.
Second Chamber
“Water Seal Chamber”
Always contains 2 cm of water acting as a one way valve. (Air can come into this chamber, but it cannot move back into the chest tube).
A water seal of any system detects
Air leaks.
(Incoming air enters the collection chamber and bubbles up the water preventing back flow of air to the patient’s system)
Intermittent Bubbling in the Second Chamber
Normal during exhalation, coughing and sneezing
Brisk bubbling occurs for
Pneumothorax
Continuous bubbling
Worrisome.
May indicate a break in the integrity of the system.
Nursing Implications after observing continuous bubbling in the second chamber
Look at patient and see if they have dyspnea.
Check if chest tube is intact or if sutures have become loose.
Clamp your tube for a second to assess for a break in the tube.
Tidaling
Fluctuation of the water.
Sudden stop is worrisome (may be d/t an occlusion)
Gradual cessation indicates lungs reexpanding.
Third Chamber
Controls the amount of pressure being pulled from the chest.
Needs to be set to at least a minimum of 80.
Wet Suction Control
- Uses column of water with the top end vented to the atmosphere to control the amount of suction from the wall regulator.
- Amount of suction applied is regulated by the amount of water in the third chamber not the wall suction.
A nurse observes continuous bubbling in the third chamber during wet suction control, what should the nurse do?
Nothing. Continuous bubbling is expected here.
Dry Suction
Contains no water.
Visual alert for working suction is a dial.
Nursing Management of Chest Tubes: Maintenance
Keep tubing straight as much as possible below chest level
Keep all connections tight and sealed
Keep appropriate water level—sterile water
Mark the time of measurement and fluid level
Observing bubbling/tidaling in water seal chamber: If no tidaling is observed
Draining system may have an occlusion
Lungs reexpanded
System is attached to suction
Observing bubbling/tidaling in water seal chamber: If bubbling increases
Air leak in the drainage system
Leak from patient
If bubbling is continuous, the nurse must
determine leakage by clamping from distal to proximal until bubbling stops
Clamp, assess, unclamp
Drainage should NEVER
Be elevated to the level of the chest
The nurse should encourage
Deep breathing
ROM to affected side
Incentive spirometer why while awake to prevent atelectasis or pneumonia.
When performing chest tube care, you should not
- Strip or milk chest tubes
- Clamp during transport or for long periods of time (can cause tension pneumothorax d/t rapid accumulation of air)
If drainage tube breaks, the nurse must
- Place the distal end of the drainage tube in sterile water at 2 cm.
- Reestablish a new water seal system and attachment of new drainage system asap.
If the drainage system is overturned and the water seal is disrupted, what should the nurse do?
Return it to an upright position and encourage the patient to take a few deep breaths followed by forced exhalations and cough maneuvers.
Nursing Management of Chest Tubes: Assessment
Respiratory assessment after insertion
Assess that the chest tube is patent and intact.
Subcutaneous emphysema
Pt. Can develop air leaks around the site and into tissue.
Air pocketing around site or under skin is abnormal!
“Crackling sensation”
Harmless if small.
Severe Subcutaneous Emphysema
Sweeping of head and neck w/ potential airway compromise
Mark area to see if it expands
Pneumothorax: Percussion
Will have hyper-resonance upon percussion
Hemothorax/Pleural effusion percussion
Dull percussion
When can chest tubes be removed?
When lungs are re-expanded and fluid drainage ceased/minimal.
Usually gravity drainage 24 hours before removal (passive suctioning)
Chest tube removal
Medications are given 30-60 minutes prior to removal.
Petroleum jelly dressing.
Removed by physician.
CXR is done.
What position is the patient placed in during a chest tube removal?
Valsalva maneuver, holding breath or bearing down.
