Lab 4 Flashcards
what is the purpose of chest tubes & pleural drainage
- to remove air and fluid from the pleural space
- to restore normal intrapleural pressure so the lungs can re-expand `
what is done for small accumulations of air or fluid in the pleural space
- may not require removal by thoracentesis or chest tube
- may be reabsorbed over time
where can chest tubes be inserted (3)
- ER
- at pt’s bedside
- in the OR
how are chest tubes inserted in the OR
- via thoracotomy incisions
how is a chest tube inserted in the ER or at the bedside
- the pt is placed in a sitting position or lying down w the affected side elevated
- area prepared w antiseptic solution
- site is infiltrated w a local anesthethic
- then a small incision is made
- then 1 or 2 chest tubes are placed
where is a chest tube to remove air placed
- anteriorly, thru the second intercostals space
where is a chest tube to remove blood & fluids placed
- posteriorly thru th 8th or 9th intercostal space
describe the clamping of the tubes during insertion of a chest tube
- kept clamped during the insertion
- after tubes are in place, they are connected to drainage tubing and pleural drainage, and the clamp is removed
describe the connection of chest tube to drainage systems
- each tube may be connected to a separate drainage system & suction
- or a Y-connector is used to attach both chest tubes to the same drainage system
describe the dressing for chest tibe
- tubes are sutured to the chest wall and the puncture wound is covered w an airtight dressing
most pleural drainage systems have __ basic components
3
list the 3 basic components of pleural drainage
- collection chamber
- water-seal chamber
- suction control chamber
describe the purpose of the collection chamber
- receives fluid and air from the chest cavity
- the fluid stays in this chamber while air vents to the second compartment
what should be assessed r/ the collection chamber
- drainage amt & color
- any significant changes (note: it is normal for an increase in drainage if the pt gets up to ambulate)
describe the purpose of the water-seal chamber
- contains 2 cm of water that acts as a 1-way valve to prevent backflow of air into the pt from the system
- the incoming air enters from the collection chamber, and bubbles up thru the water
describe the bubbling in the water-seal chamber (3
- initial bubbling of air when a pneumothroax is evacuated
- intermittent bubbling with exhalation, coughing, or sneezing (d/t increase in intrathoracic pressure)
- “tidalling” (fluctuations) seen which reflects the pressures in the pleural space
what does it mean if tidalling in the water-seal chamber is not seen (2)
- the lungs have re-expanded
- kink or obstruction in the tubing
where does the air go after the water-seal chamber
- the air exits the water seal and enters the suction chamber
describe assessment of the water seal chamber (2)
- assess for tidalling
- monitor for air leaks
what is the purpose of the suction control chamber
- applies controlled suction to the chest drainage system
- uses tubing with one end submerged in a column of water and the other end vented to the atmosphere
the amt of suction applied by the suction control chamber is regulated by?
- the depth of the suction control tube in the water
- NOT by the amt of suction applied to the system
the suction control chamber is filled w…
- 20 cm of water
what occurs when the negative pressure generated by suction in the suction control chamber exceeds 20 cm
- the air from atmosphere enters the chamber thru a vent, and begins bubbling up thru the water
= excess pressure relieved
describe the relationship betweeen negative pressure and suction in the suction control chamber
- an increase in suction does not result in an increase in negative pressure to the system bc any excess suction merely draws in air thru the vented tubing
the suction pressure of the suction control chamber is usually ordered to be….
-20 cm H2O
what are 2 types of suction control chambers
- wet
- dry
describe the wet suction control chamber
- the system outlined previously
what is a way to tell that wet suction is functioninf
- bubbling of the water
what needs to be done with the water in a wet suction control chamber
- needs to be added periodoically –> evaporates over time
describe a wet suction control chamber
- no water
- uses either a restrictive device or a regulator (internal to the chest drainaqge system) to dial the desired negative pressure
what indicates that the suction is working in a dry suction control chamber
- a visual alert (no bubbling)
describe assessment of the suction control chamber
- assess for gentle bubbling (if water seal ssytem)
- check suction float ball (if dry system)
what is the benefit of using a disposable plastic chest drainage system
- allow pt mobility
- decrease the risk of breaking or spilling the drainage system
what is a Heimlich valve
- another device used to evacuate air from the pleural space
describe the Heimlich valve
- consists of a rubber flutter 1-way valve within a rigid plastic tube
- attaches to the external end of the chest tube
- placed between the chest tube and the drainage bag
describe how the Heimlich valve works to remove air
- the valve opens whenever the pressure is greater than the atmospheric pressure and closes when the reverse occurs
- allows for escape of air but prevents the re-entry of air into the pleural space
- functions like a water seal
when is the Heimlich valve usually used (2)
- for emergency transport
- special care home situations
what is a benefit of small chest tubes? what are cons?
- benefit: used in selected pts bc are less traumatic
- con: smaller = can become kinked, occluded, or dislodged more easily
the drains in small chest tubes may be… (2) which are less traumatic
- straight
- “pigtail” catheters (curled at the distal end) –> less traumatic
if a small chest tube is occluded, what can be done
- can be irrigated by the physician using sterile water
what can be performed thru pigtail catheters
- chemical pleurodesis
small chest tubes are not suitable for…
- trauma
- drainage of blood
small chest tubes and heimlich valves should be used w caution in what kinds of pts? why?
- pts on mechanical ventilators d/t potential for rapid accumulation of air and a tension pneumothorax
when should a system leak w chest tubes be suspected
- if bubbling is continuous
describe what to do if bubbling is continuous w a chest tube (suspection of system leak) (2)
- to determine the source of the leak, momentarily clamp the tubing successively from the chest tube insertion site to the drainage set, observing for bubbling to cease –> if ceases, the leak is above the clamp
- retape tubing connection
if the leak in a chest tube system continues, what should you do
- notify the physician
- may be necessary to replace the drainage apparatus or to secure the chest tube with an air-occlusive dressing
what do high fluid lvls in the water seal indicate?
- residual negative pressure
what needs to be done if there are high fluid lvls in the water seal
- may need to be vented by using the high negativity release valve available on the drainage system to release the residual pressure from the system
- do not lower water-seal column when wall suction is not operating or when the pt is on gravity drainage
describe how to maintain the tubing w a chest tube system (4)
- keep all tubing loosely coiled below chest lvl
- tubing should drop straight from bed or chair to drainage unit
- do not let tubing be compressed
- keep all connections between chest tubes, drainage tubing, and drainage collector tight, and tape at connections
what should you observe for general care of chest tube systems
- observe for air fluctuations (tidalling) and bubbling in the water-seal chamber –> should rise w inspiration and fall w expiration
what does it mean if tidalling is not observed in the chest tube system
- the drainage is blocked
- the lungs are re-expanded
- or the system is attached to suction
how do you assess for tidalling if the chest tube is connected to suction
- disconnect from wall suction to check
what should you assess for in a pt with a chest tube inserted
- assess VS, lung sounds, pain
- assess for manifestations of reaccumulation of air and fluid in the chest
- assess for bleeding
- assess for chest drainage site infection
- assess for poor wound healing
what are signs of reaccumulation of air & fluid in the chest
- decreased or absent breath sounds
what is a sign of signif bleeding w a chest tube
- > 100 mL/hr
what are signs of chest drainage site infection (4)
- drainage
- erythema
- fever
- increased WBC
describe the clamping of chest tubes (3)
- not routinely clamped
- a physician order is required
- a physician may order clamping for 24 hrs to evaluate for reaccumulation of fluid or air before discontinuing the chest tube
what should a pt w chest tube’s be encouraged to do (3)
- breath deeply periodically to facilitate lung expansion
- encourage ROM exercises to the shoulder on the affected side
- incentive spirometry every hr while awake to prevent atelectasis or pneumonia
where should the chest drainage system be positioned
- never elevate to the lvl of the pt’s chest (will cause fluid to drain back into the lungs)
- secure unit to the drainage stand
what do you do if the drainage chambers of a chest tube are full
- notify the physician and anticipate changing the system
- do not try to empty it
what should you do if the drainage system breaks
- place the distal end of the chest tubing connection in a sterile water container at a 2-cm level as an emergency water seal
describe the assessment of chest tube drainage ; what should be reported to the physician
- mark the time of measurement and fluid lvl on the drainage unit according to the unit standards
- report any changes in the quantity of characteristics of drainage (ex. clear yellow to bloody) to the physician & record the change
- notify physician if >100mL/hr drainage
describe what should be done if the drainage system is overturned & the water seal is disrupted
- return it to an upright position
- encourage the pt to take a few deep breaths, followed by forced exhalations and cough manoeuvres
describe the traditional practice of routine milking and/or stripping to maintain patency of chest tubes
- no longer recommended bc it can cause dangerously high inrtapleural pressure and damage to pleural tissue
- drainage & blood are not likely to clot inside the chest tubes bc the newer chest tubes are made w a coating that makes them nonthrombogenic
what may occur if the chest tube is not stabilized
- dislodgement of the tube
a nurse should be mindful that insertion of a chest tube, as well as its continued presence can be..
- painful to the pt
describe how to obtain a sample from a chest tube (4)
- form a loop in the tubing in an area to get the most recently drained fluid
- swab the sampling site of the tubing w antiseptic and allow to air-dry
- aspirate from the sampling site w syringe –> cap syringe –> label w pts name, date, time, and source of specimen
- send to labratory
describe the changing of chest tube dressings
- not routinely changed
- if there is visible drainage, notify the physician
describe chest tube dressings if ordered (6)
- remove old dressing carefully to avoid removing unsecured chest tube
- assess the site & culture site if needed
- cleanse the site w NS
- apply sterile gauze and tape to secure the dressing
- date the dressing
- document dressing change
What should be assessed r/t chest tube dressings/tubings (7)
- check for subcut emphysema (“rice krispies”) around the site
- check if dressing is dry & intact
- check occlusive dressings (ex. jelonet)
- ensure chest tube secure
- check for dependent loops, clotting, coiled drainage tubing
- follow tubing from insertion site to chamber
- check for signs of infection
some physicians prefer ____ for chest tube dressings; why?
- some prefer use of petroleum gauze
- to prevent an air leak
describe how to set up the suction control chamber in dry suction systems (3)
- after connecting pt to system, turn the dial on the chest drainage system to amt ordered (usually -20 cm pressure)
- connect suction tubing to a wall suction source
- increase the suction until the correct amt of negative pressure is indicated
how do we keep the suction control chamber at the appropriate water lvl
- add sterile water as needed
what does it mean if there is no bubbling in the suction control chamber (3)
- there is no suction
- the suction is not set high enough
- the pleural air leak is so large that suction is not high enough to evacuate it
describe the process of maintaining the water lvl in the suction control chamber (4)
- add sterile water as needed
- keep the muffler covering the suction control chamber in place to prevent more rapid evaporation of water and to decrease the noise of bubbling
- after filling the suction control chamber to the ordered suction amt, connect the suction tubing to the wall suction
- dial the wall suxction regulator until continuous gentle bubbling is seen in the suction control chamber
why is the clamping of chest tubes during transport or when the tube is accidentally disconnected no longer advocated?
- the danger of rapid accumulation of air in the pleural space causing tension pneumothorax is far greater than that of a small amt of atmospheric air entering the pleural space
when might chest tubes be momentarily clamped
- to change the drainage apparatus
- to check for air leaks
clamping for more than a few moments is indicated only when?
- when assessing how the pt will tolerate chest tube removal –> stimulates chest tube removal and identify if there will be negative clinical repercussions with tube removal
when is clamping of the chest tube to stimulate chest tube removal done?
- 4-6 hrs before the tube is removed
- pt is monitored closely
if a chest tube becomes disconnected, what is the most important intervention
- immediate re-establishment of the water seal system and attachment of a new drainage system ASAP
- may be immersed in sterile water (~2cm) until the system can be re-established
what is a CVAD
- a catheter that is placed into large blood vessels (ex. subclavian vein, jugular vein) when access to the vascular system is needed frequently
what 3 methods can central venous access be achieved
- centrally inserted catheters
- peripherall inserted catheters (PICCs)
- implanted ports
who can insert: a centrally inserted catheter? PICC? implanted port?
- implanted port & centrally inserted catheter = physician
- PICCs = specialized nurse
what do CVADs allow for (5)
- enable frequent, continuous, rapid, or intermittent admin of fluids & meds
- allow for the admin of drugs that are potential vesicants
- allow for admin of blood & blood products
- allow for admin of parental nutrition
- may be used for hemodyanmic monitoring and venous blood sampling
CVADs are indicated for what types of pts? (2)
- pts w limited peripheral vascular access
- pts who have a projected need for long-term vascular access
what are advantages of CVADs (3)
- reduced need for multiple venipunctures
- decreased risk of extravasation injury (but can still happen if the device is displaced or damaged)
- immediate access to the central venous system
what are disadvantages of CVADs (2)
- increased risk of systemic infection
- invasiveness of the insertion procedure
what are some examples of medical conditions that are indications for CVADs (13)
- cancer (chemo)
- infection (long term anitbiotics)
- pain (long term pain meds)
- drugs that increase the risk of phlebitis
- parental nutrition
- solutions w higher dextrose content
- multiple diagnostic blood tests/samples over a period of time
- blood transfusions over a period of time
- renal failure (hemodialysis or continuous renal replacement)
- shock, burns (infusions of high volumes of fluid & electrolyte replacement)
- hemodynamic monitoring (measuring CVP to assess fluid balance)
- heart failure (ultrafiltration)
- autoimmune disorders (plasmapheresis)
what are centrally inserted catheters (CVCs)
- CVADs whose catheter rests in the distal end of the SVC near its junction w the right atrium
- the other end of the catheter exists thru a separate incision on the chest or abdominal wall
CVCs are available as…. (4)
- single
- double
- triple
- or quadruple lumen catheters
what is the benefit of multilumen catheters
- useful in critically ill ots bc each lumen can be simultaneously used to provide a different therapy
ex. incompatible drugs can be infused in separate lumens without mixing, and a third lumen can provide access for blood sampling
what is a tunnelled vs nontunelled catheter
- A non-tunneled catheter is inserted directly into a central vein but the tunneled variety uses an extender piece that is placed into the subcutaneous tissue, in addition to the central catheter
- tunnelled = surgically placed
where are non-tunnelled catheters usually placed (3)
- in the subclavian vein
- internal jugular vein
- femoral vein (rare)
who are non-tunnelled catheters best for
- pts with short-term needs in an acute care setting
what is the benefit of tunnelled catheters (3)
- suitable for long-term needs
- provides stability
- decreases infection risk
what must be done after placement of a CVC
- verify accurate placement by chest radiography
- must be done before it is used
care requirements for a CVC includes (4)
- injection cap change
- cleansing
- flushing
- dressing change
what is an important consideration w Hickman catheters
- clamps are needed to make sure the valve is closed
what is an important consideration w Groshong catheters
- has a valve that opens as fluid is withdrawn or infused - remains closed when not in use
what is a PICC
- central venous catheter inserted into a vein in the arm
where are PICC lines inserted
- inserted at or just above the antecubital fossa
- advanced to a position w the tip ending in the distal one third of the SVC
what type of lumens are available w PICCs (3)? which are preferred?
- single
- double –> preferred
- triple lumens
PICCS are used w which pts?
- pts who need vascular access for 1 week to 6 months (can be in place for longer if needed)
the technique for placement of a PICC line involves..
- insertion of the catheter thru a needle with the use of a guide wire or forceps to advance the line
what are advantages of a PICC over a CVC (4)
- lower infection rate
- fewer insertion related complications
- decreased cost
- ability to be inserted at the pt’s bedside or in the outpt area
what are complications of CVADs (6)
- catheter occlusion
- phlebitis
- embolism
- catheter-related infection (local or systemic)
- pneumothroax
- catheter migration
if phlebitis occurs w CVADs, when does it usually happen?
- 7-10 days after insertion
what are important considerations w PICCs
- do not use the arm w the PICC to obtain a BP reading or draw blood
what might cause a catheter occlusion w a CVAD 4)
- clamped or kinked catheter
- tip against wall of vessel
- thrombosis
- precipityate buildup in lumen
what are clinical manifestations of catheter occlusion (2)
- sluggish infusion or aspiration
- inability to infuse or aspirate
describe nursing & collaborative management for catheter occlusion (5)
- instruct pt to change position, raise arm, cough
- assess for and alleviate clamping or kinking
- flush w NS with a 10 mL syringe (do not force)
- fluroscopy to determine cause & site
- anticoag or thrombolytic agents
what are possible causes of an embolism r/t CVADs (3)
- catheter breakage
- dislodgement of thrombus
- entry of air into circulation
what are clinical manifestations of embolism (4)
- chest pain
- resp distress
- hypotension
- tachycardia
describe nursing management for embolism (4)
- admin O2
- clamping catheter
- place pt on left side w head down (air emboli)
- notify physician
what are possible causes of a catheter-related infection with CVADs (3)
- contamination during insertion or use
- migration of organisms along catheter
- immunosuppressed pt
what are signs of a local infection r/t CVADs (5)? systemic (3)?
- local: red, tenderness, purulent drainage, warmth, edema
- systemic: fever, chills, malaise
describe nursing management for catheter-related local infection (3)
- culture of drainage from the site
- warm, moist compress
- catheter removal if indicated
describe nursing for management for a systemic catheter-related infection (4)
- blood cultures
- antibiotic therapy
- antipyretic therapy
- catheter removal if indicated
what is a possible cause of a pneumothorax r/t CVADs
- perforation of visceral pleura during insertion
what are clinical manifestations of pneumothorax r/t CVADs (4)
- decrease in or absent breath sounds
- resp distress
- chest pain
- unilateral distension of the chest
describe nursing management for a pneumothorax r/t CVAD (3)
- admin O2
- position in semi-fowlers
- prep for chest tube insertion
what are possible causes of catheter migration r/t CVADs (5)
- improper suturing
- insertion site trauma
- changes in intrathoracic pressure
- forceful catheter flushing
- spontaneous movement
what are clinical manifestations of catheter migration (5)
- sluggish infection or aspiration
- edema of chest or neck during infusion
- pt complaint of gurgling sound in ear
- dysrhytmias
- increased external catheter length
describe nursing management for catheter migration (2)
- fluroscopy to verify position
- assistance w removal and new CVAD placement
what is an implanted infusion port
- CVC connected to a single or double implanted subcutaneous injection port
- catheter is placed into the desired vein and the other end is connected to a port that is surgically implanted in a subcut pocket on the chest wall
- port consists of a metal sheath w a self-sealing silicone septum
how are drugs inserted thru an implanted infusion port
- drugs are slowly injected thru the skin, into the port
- after being filled, the reservoir slowly releases the medicine into the blood stream
how is the implanted infusion port accessed
- via the septum by means of a special noncoring needle that has a deflected tip
what is the purpose of the deflected tip used to access an implanted infusion port
- prevents damage to the septum that could render the port useless
what is the benefit of implanted infusion ports (3)
- convenient for long-term therapy
- can remain in the body for years
- offers cosmetic advantages
what is the care requirements for an implanted infusion port
- requires regular flushing
what may occur within the port septum of an implanted infusion port
- formation of “sludge” = accumulation of clotted blood and drug precipitate
nursing management of CVADs includes: (4)
- assessment
- dressing change and cleansing
- injection cap changes
- flushing
catheter and insertion site assessment includes.. (7)
inspecting the site for:
- redness
- edema
- warmth
- drainage
- tenderness or pain
- observe the catheter for misplacement or slippage
- comprehensive pain assessment
what should particularly be noted when completing a pain assessment for someone w a CVAD (4)
- chest pain
- neck discomfort
- arm pain
- pain at the insertion site
what type of dressing is preferred for CVADs?
- transparent semi-permeable –> allow observation of the site without having to be removed
transparent CVAD dressings can be left in place for how long?
- up to 1 week
when should CVAD dressings be changed
- when ordered
- if becomes damp, loose, soiled
what is the cleansing agents of choice for cleaning of the skin around the catheter insertion site? why?
chlorhexidine
- its effects last longer
- improved killing of bacteria
when are injection caps changed
- at regular intervals according to institution policy
- when they are damaged from excessive punctures
what should the pt be taught during cap changes
- to turn the head to the opposite side of the CVAD insertion site
if the catheter cannot be clamped during cap change, what should be done
- pt asked to lie flat in bed
- perform the Valsalv manoeuvre
(to prevent air embolism)
what is one of the most effective ways to maintain lumen patency and prevent occlusion of a CVAD
- flushing
what type of syringe is to be used to flush CVADs
- syringe w a barrel capacity of 10 mL or more to avoid excess pressure on the catheter
what should you do if resistance is felt when flushing a CVAD? why?
- do not apply force
- this could result in rupture of the catheter or in the creation of an embolism if a thrombus is present
what method is preferred when flushing a CVAD
- push-pause method (1-2mL with each push)
- creates turbulence = promote the removal of debris that adheres to the catheter lumen
during the removal of a CVAD, the pt is instructed to?
- perform the Valsalva manoeuvre as the last 5-10 cm of the catheter is withdrawn
what should be done immediately after removal of the CVAD
- apply pressure to the site w sterile gauze to prevent air from entering and to control bleeding
what else is done after removal of a CVAD
- inspect the catheter tip to ensure it is intact
- after bleeding stops, an antiseptic ointment and sterile dressing are applied to the site
what indicates a problem w chest tubes
- bubbling in the water seal chamber = air leak
- no tidaling in the water seal chamber (either = occlusion of lung re-expansion)
what indicates a problem w chest tubes
- bubbling in the water seal chamber = air leak
- no tidaling in the water seal chamber (either = occlusion of lung re-expansion)
what medical emergency may occur w chest tubes
- pneumothorax
