Module 12: Management and Care of a Chest Tube and Drainage System

Question 1

identify patient populations that may require a chest tube insertion: disruption of pressure

Answer 1

• if air or fluid enters the space between the pleurae, the negative pressure that keeps the lungs against the chest wall disappears and the lung collapses

Question 2

Pleural effusion

Answer 2

• transudate is clear fluid that collects in the pleural space when there are fluid shifts in the body from conditions such as CHF, malnutrition, renal and liver failure
  
  • exudate is cloudy fluid with cells and proteins that collects when the pleurae are affected by malignancy or diseases such as tuberculosis and pneumonia

Question 3

Subcutaneous emphysema

Answer 3

• air leaks into the subcutaneous tissue
  
  • may be caused when the eyelets in the tubing are dislodged out of the pleural space but not out of the chest wall entirely
  • assessed by palpating the tissue surrounding the site and feeling a “rice krispies” sensation under the skin

Question 4

Chest tube insertion (thoracotomy)

Answer 4

• inserted between the visceral and parietal space
• Purpose:
  
  • removal of fluid and air as promptly as possible
  • prevent drained air and fluid from returning to the pleural space
  • restore negative pressure in the pleural space to re-expland the lung
  • it is the only treatment that can restore the negative pressure needed into the intrapleural space

Question 5

mediastinal chest tubes

Answer 5

• mediastinum: area of the chest cavity between the lungs; contains the heart, aorta, esophagus, trachea
• Mediastinal chest tubes:
  
  • after open heart surgery
  • traumatic chest injury
  • thoracic surgery

Question 6

Pleural anatomy

Answer 6

• membranes separate by lubricating pleural fluid
• fluid reduces friction
• negative pressure in the pleural space keeps the two pleurae together and allows the lung to expand and contract
• pleural tube aids in negative pressure

Question 7

hemothorax

Answer 7

• accumulation of blood or fluid in the pleural space
  
  • usually as result of trauma
  • risk following cardiac or thoracic surgery
  • up to 2 Litres of blood can accumulate
  • S&S:
    
    • pain, dyspnea, distant heart sounds, hypotension, tachycardia, shock- depending on amount of blood lost

Question 8

pneumothorax (open and closed)

Answer 8

• spontaneous
  
  • trauma
  • rupture of a bleb
    
    • results in :
    • air enters the pleural space
    • lung collapses
  • pneumothorax -open
    
    • opening in the chest wall (with or without lung puncture)
    • allows atmospheric air to enter the pleural space
  • pneumothorax - closed
    
    • chest wall is intact
    • rupture of the lung and visceral pleura allows air to escape into the pleural space from lung
    • air flows into the parietal space with inspiration but cannot escape with expiration
  • S&S:
    
    • pain, dyspnea, low SPO2, increased respiratory rate, increased heart rate, diminished or no breath sounds to affected side, chest x-ray changes, asymmetric chest movement, confusion, anxiety, restlessness, fatigue, nasal flaring, cyanosis

Question 9

Chest Tube Care and Maintenance

Answer 9

• assess the patient, dressing and drainage system q4h and prn
  
  • start with the patient
  • respiratory cardiac assessment including vital signs
  • dressing integrity - drainage, intact
    - asses for subcutaneous emphysema
  • tubing - free of kinks, dependent loops. obstructions
  • drainage system: connections - intact, drainage type and amount
  • presence of air leak with or without cough
  • suction as ordered by doctor
  • atrium below the level of the patient chest
• Two clamps must be available and with the chest tube at all times
• Do Not clam a chest tube unless:
  
  • specifically ordered prior to removal
  • momentarily when changing the system
  • short-term if tube accidentally disconnected from chest drainage system
  • when checking for an air leak in the tubing
• Dressing is changed daily &prn using sterile technique
• dressing must remain occlusive, dry and intact
• must wear procedure mask prior to removing old dressing

Question 10

Water Seal Chamber drainage system

Answer 10

• purpose: prevents air and fluid from entering the pleural space/mediastinum and to exit
• ensure adequate amount of fluid in water seal chamber needs to be filled to the 2 cm mark
  
  • the water will evaporate over time and a low water level will not provide a water seal
• assess for tilting
• observe for air lea

Question 11

Monitoring Air Leak

Answer 11

• water seal is a window into the pleural space
• when air is leaving the pleural space, bubbling will be seen here, bubbling is normal if a patient’s lung is not totally inflated
• air leak meter (1-5) provides way to “measure” the leak and monitor over time

Question 12

Dry Suction Chamber

Answer 12

• purpose: to facilitate air and the fluid removal
• ensure the dry suction dial is set according to physician orders
• the bellows in the suction indicator should be past the triangle

Question 13

How a Chest Drainage System Works

Answer 13

• expiratory positive pressure from the patient helps push air and fluid out of the chest (cough,valsalva)
• gravity helps fluid drainage as long as the chest drainage system is below the level of the chest
• suction can improve the speed at which air and fluid are pulled from the chest

Question 14

nursing responsibilities involving drainage system and CT

Answer 14

• assessment
• monitoring the equipment
  
  • chest tube
  • drainage system
• performing associated care
  
  • dressing changes
  • monitoring drainage output

Question 15

tension pneumothorax

Answer 15

• paradoxical chest movement
• tracheal deviation
• decreased breath sounds on the affected side
• hypotension and decreased spO2
• cyanosis
• chest pain

Question 16

Pleural of site infection

Answer 16

monitor drainage and site for door and purulent drainage

Question 17

Hemorrhage

Answer 17

• report drainage > 100ml/h
  
  • report change of drainage from serous to sanguineous (bright red, frank)
  • report increase in rate of sanguineous drainage

Question 18

Chest tube Dislodges

Answer 18

• occlude the hole, or atmospheric air can get into the pleural space, tension pneumothorax will result
  
  • call for help, ask for chest tube dressing and jelonet
  • switch hand and secure with dressing
  • and do chest assessment and prep for chest tube insertion

Question 19

Assessment of Dressing/site of chest tube

Answer 19

• assess dressing
  
  • intact
  • drainage/shadowing
  • dated
• remove the old dressing with clean gloves and assess for drainage
  Assessment of the site
• inspect for infection, drainage, redness, swelling, air leak around tube
• assess the surrounding tissue for subcutaneous emphysema by palpating
• ensure the sutures are intact
• ensure the tube is secure and has not been dislodged

Question 20

Dressing change for Chest tube

Answer 20

• sterile technique
• needs to occlusive
• wrap the tubing to cover the entire insertion site with jelonet and or use the sterile individual packets of petroleum jelly to occlude the insertion side
• drainage sponges x2, 4x4 gauze x1, secure with medic, sign and date
• assess for SQE and air leaks pre and post dressing change

Question 21

Demonstrate changing the chest tube drainage system

Answer 21

• change the system before the collection chamber is completely full, when there is evidence of contamination or loss of underwater seal
• prepare new system
• clamp chest tube with non toothed metal clamps
• disconnect old tubing from chest drainage at the locking connector - clean the connector on the tube with chlorhexidine swab

Question 22

Demonstrate troubleshooting techniques for common chest tube problems

Answer 22

• situations
  
  • new air leak
  • water level below 2cm
  • suction plunger not meeting triangle
• fill the water level using a blunt fill need
• check the wall suction and its integrity

Question 23

Demonstrate documentation pertinent to the patient with a chest drainage system

Answer 23

• dressing changes and or dressing appearance
• amount of suction orin not on suction
• pre scene of air leak and subcutaneous emphysema
• amount and type of drainage
  
  • mark drainage level on collection chamber with date and time - document on I/O flow sheet
• patient response including pain, vitals, and respiratory assessment and teachings

Question 24

Removing A chest tube

Answer 24

1. doctors order is required
2. resolutions of pneumothorax - car ordered to determine
3. < 30 ml of pleural drainage over the predceding 24 hour period
4. absent of air leak on valsalva maneuver of forceful cough (if one existed previously)