TEST 3 - Chest Tubes and Ostomy Flashcards
Chest Tube
What is it?
A catheter inserted through the thorax into the pleural space for:
Removing fluid and/or air
Preventing air or fluid from reentering the pleural space
To reestablish normal intrapleural and intrapulmonic pressures
Lung _______________occurs as the fluid or air is removed from the ____________ space.
reexpansion, intrapleural
What are five conditions that require a chest drain insertion
Pneumothorax Haemothorax Pleural effusion Empyema After cardiothoracic surgery
Conditions Requiring Chest Drain Insertion
Pneumothorax
Presence of air in the pleural space. Air can come from the lung, trachea or oesophagus or it can be caused by chest trauma.
Pain (sharp and pleuritic) r/t to atmospheric air irritating the parietal pleural
Dyspnea
Conditions Requiring Chest Drain Insertion
Hemothorax
Collapse of the lung caused by an accumulation of blood and fluid in the pleural cavity
Pain
Dyspnea
Shock if severe blood loss
Conditions Requiring Chest Drain Insertion
Pleural effusion
Accumulation of fluid in the intrapleural spaces Pain Dyspnea Adventitious lung sounds Nonproductive cough Causes: Tumor Infection (Tb) Pulmonary infarction Trauma
Conditions Requiring Chest Drain Insertion
Empyema
Accumulation of pus in the pleural space Cause Bacterial infection (pleurisy, Tb) Pain Dyspnea Fever
Conditions Requiring Chest Drain Insertion
Tension pneumothorax/hemothorax
Air/fluid in the pleural space that does not escape Continued increase in amount of air shifts intrathoracic organs and increases intrathoracic pressure S & S Cyanosis, ↓ O2sat, ↓ BP, ↑ HR Air hunger Violent agitation Tracheal deviation Subcutaneous emphysema Neck vein distention Hyperresonance to percussion ** Medical emergency **
Location of Chest Tubes
For air
Placed high b/c air rises Apical 2nd or 3rd intercostal space Anterior Allows evacuation of air into atmosphere Little or no drainage present in collection chamber Semi-Fowler’s
Location of Chest Tubes
For fluid
Placed low b/c of gravity will localize in the lower portion of the lung cavity when client is sitting upright Usually 5th or 6th intercostal space Posterior or lateral to drain fluid Applying suction assists this drainage High Fowler’s
Location of Chest Tubes
Mediastinal
Placed in the mediastinum just below the sternum
Drains blood and fluid
Attached to drainage system
There will be no tidling (fluctuations) since tube is not placed in lung cavity
Common with open heart surgery
Chest Drainage System
1st compartment
Receives fluid and air from the chest cavity
Fluid stays in chamber while the air vents to 2nd compartment
Chest Drainage System
2nd compartment (water–seal chamber)
compartment (water–seal chamber)
Contains 2 cm of water (acts as one way valve)
Chest Drainage System
3rd compartment (suction control chamber)
Applies controlled suction to the chest drainage system
Suction pressure ordered usually
Rubber flutter one-way valve attached to the catheter
Valve opens whenever the pressure is greater than atmospheric pressure
Closes when the reverse occurs
No drainage chamber is used with this device
Used in emergencies and for some transfers
Hemlick valve
Water-Seal System
Collects air or fluid
As it enters the drainage collection chamber, this air/fluid pushes the air present in the chamber through the water seal and into the atmosphere
Chest tube system must remain upright
If tubing clamped, mechanism won’t work
Two-chamber water-seal system
Water-Seal System
Used when suction required
Chamber is filled to the set volume for the prescribed amount of suction i.e. 20 cm of H20 for a suction of – 20 cm of H20 pressure
Sterile water may need to be added (evaporation)
The wall or portable suction device is turned up until the water in the suction control bottle exhibits a continuous, gentle bubbling
Three-chamber water-seal system
Water-Seal System
Fluid is not required for setup
If system tips, does not disrupt
Water seal replaced with a one-way valve
Suction chamber does not depend on water
Contains a float ball which is set by a suction control dial once suction turned on
15 ml of fluid required for the diagnostic air-leak indicator
Gentle tidaling = normal reexpansion of lung
No tidaling x 2-3 days = fully reexpanded
Fluid bubbling left to right = air leak → must locate leak
Two-chamber waterless system
Expected Drainage
Post-op mediastinal chest tube
< 50 – 200 ml/hr or ~ 500 ml/24 hrs
Sanguinous initially, then serous over time
Expected Drainage
Pleural tube
Btw 100-300 ml in first 3 hours
500-1000 ml/24 hours
Grossly sanguinous in first several hours post-op to serous
Expected Drainage
If sudden gush of dark blood =
client position change
◦dark it’s ok
If _____ _____ or > ____ ml/hr = √ client and notify physician
bright red or > 100 ml/hr
◦fresh blood is emergent and may require further surgery
Milking or stripping creates excessive _______ ________ _________
negative intrapleural pressure
Apprehension
Respiratory distress
Subcutaneous emphysema
Early Signs of Complications
What if:
Air leak unrelated to client’s respirations occurs
Locate source using shodded hemostats
Notify physician
What if:
No drainage
√ for kink
√ for possible clot in chest drainage system
√ mediastinal shift or resp. distress
Notify physician
What if:
Chest tube is dislodged
Immediately apply pressure over chest tube insertion site
Apply an occlusive gauze dressing and tape three sides
Notify physician STAT
Prepare for replacement of the tube
What if:
Substantial ↑ in bright red drainage
√ VS √ drainage √client’s cardiopulmonary status Notify physician Prepare for the OR
What if:
Continuous bubbling in water-sealed chamber indicating leak btw client and water seal
•Bubbling indicates a leak btw client and water seal
Tighten loose connections √ agency policy for cross-clamping chest tube Unclamp chest tube Reinforce dressing Notify physician
Assessment:
Air leak can occur at insertion site, connection between tube and drainage, or within drainage device itself. Determine when the air leak occurs during respiratory cycle (e.g. inspiration or expiration). Continuous bubbling is noted in water-seal chamber, and water seal indicates a leak during the inspiratory and expiratory phases
WHAT IS THE INTERVENTION
check all connections between the chest tube and drainage system. Locate leak by clamping tube at different intervals along the tube. Leaks are corrected when constant bubbling stops. If pres- ent on chest drainage system, such as the Sahara S 1100a Pleur-Evac, observe the air leak meter to determine the size of the leak.
Assess for location of leak by clamping chest tube with two rubber- shod or toothless clamps close to the chest wall. If bubbling stops, air leak is inside patient’s thorax or at chest insertion site.
WHAT IS THE INTERVENTION?
Unclamp the tube, reinforce chest dressing, and notify health care pro- vider immediately. Leaving chest tube clamped can cause collapse of lung, mediastinal shift, and eventual collapse of other lung from buildup of air pressure within the pleural cavity.
If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down drainage tubing away from pa- tient and toward suction control chamber. When bubbling stops, leak is in section of tubing or connection between the clamps.
WHAT IS THE INTERVENTION
Replace tubing, or secure connection and release clamps.
If bubbling still continues, this indicates the leak is in the drainage system.
WHAT IS THE INTERVENTION
Change the drainage system. Make sure chest tubes are patent: re- move clamps, eliminate kinks, or eliminate occlusion.
Assess for tension pneumothorax; indicated by: • Severe respiratory distress • Low oxygen saturation • Chest pain • Absence of breath sounds on affected side • Tracheal shift to unaffected side • Hypotension and signs of shock • Tachycardia
WHAT IS THE INTERVENTION
Obstructed chest tubes trap air in intrapleural space when air leak originates within the thorax. Notify health care provider immediately, and prepare for another chest tube insertion. A one-way fl utter (Heimlich) valve or large-gauge needle may be used for short-term emergency release of pressure in the intrapleural space. Have emer- gency equipment, oxygen, and code cart available because condi- tion is life threatening.
Water-seal tube is no longer submerged in sterile fluid due to evaporation.
WHAT IS THE INTERVENTION
Add sterile water to water-seal chamber until distal tip is 2 cm under surface level.
Removal of Chest Tube
THE FIRST THING TO MANAGE?
PAIN
Removal of Chest Tube
Reassure client Assist physician Dispose of equipment Assess client post removal Lung sounds Subcutaneous emphysema Resp. distress VS Comfort level Dressing Prepare for x-rays
A patient is resting quietly after a chest tube insertion, and gentle tidaling is seen in the water seal chamber. What action should the nurse take?
A) Check the functioning of the chest tube system
B) Perform a complete respiratory assessment
C) Document the observation
D) Increase the setting on the suction control chamber
C) Document the observation
. The nurse is assessing a patient 8 hours after open heart surgery and notes the following findings: T99, P104, R24, BP 106/68, SpO2 96 on 2 L/min of oxygen via nasal cannula, urine output 36 mL/hour, and mediastinal chest drainage averaging 120 mL/hour. Based on the assessment findings, what would the nurse anticipate doing within the next few hours?
A) Reinfusing the blood drained through the mediastinal tube
B) Increasing the amount of pain medication received via the PCA machine
C) Giving a bolus of intravenous (IV) fluid through a new 22-gauge catheter
D) Increasing the amount of oxygen by changing the nasal cannula to a mask
A) Reinfusing the blood drained through the mediastinal tube
The nurse is preparing a patient to have her chest tube removed. What information needs to be included in the preprocedural patient education provided by the nurse?
A) The patient needs to take a deep breath in as the tube is removed.
B) A radiograph will be obtained as soon as the tube has been removed.
C) The procedure is painful, and a higher dose of medication will be given.
D) The patient needs to hold her breath while the tube is being removed.
D) The patient needs to hold her breath while the tube is being removed.
A patient is being readied to have a chest tube inserted. Special care needs to be taken if the patient currently is taking medication from which drug classification? A) Antibiotic B) Antiviral C) Antispasmodic D) Anticoagulant
D) Anticoagulant
A patient with a chest tube has a history of confusion and erratic behavior. The nurse should make certain that what supplies are at the patient’s bedside?
A) Extremity restraints and rubber-tipped (shodded) hemostats
B) Petroleum gauze and Elastoplast
C) Suction catheters and a new chest drainage set
D) An incentive spirometer and a jacket restraint
B) Petroleum gauze and Elastoplast
Surgical opening into the abdominal wall for fecal or urinary elimination
stoma
A stoma can be _______________ or ___________
*Temporary
When healing is required i.e. trauma, diverticulitis
*Permanent
Cancer
Various segments of the colon
Colostomy
Ileum of the small intestine
Ileostomy
Ureter diversion
Urostomy
Only with a ________ ________ the stool consistency can be formed
Sigmoid Colostomy
Types of Stomas
End
Loop
Double barrel ostomy
Characteristics of Stomas
Colour - Rose to brick red
Viable stoma mucosa
Characteristics of Stomas
Colour - Pale
May indicate anemia
Characteristics of Stomas
Colour - Blanching, dark red to purple
Inadequate blood supply to stoma or excessive tension on the bowel at time of construction
Characteristics of Stomas
Colour - Black
Necrotic stoma
Characteristics of Stomas
Edema
Mild to moderate
Normal in the initial post op period
Trauma to the stoma
Any medical condition that results in edema
Characteristics of Stomas
Edema
Moderate to severe
Obstruction of the stoma
Allergic reaction to food
gastroenteritis
Characteristics of Stomas
Bleeding
Small amount
Oozing from the stoma mucosa when touched is normal b/c of its high vascularity
Characteristics of Stomas
Bleeding
Moderate to large amount
Could indicate coagulation factor deficiency
Stomal varices 2o portal hypertension
Lower GI bleed
Things to consider when a client has a ostomy
7
Body image and self-esteem Leakage Odour Social activities Resources for support Self-care Complications
S = T = O= M = A =
S = set up your equipment T = take off old equipment O = observe stoma and peristomal skin M = measure stoma A = assemble and apply new system
ABCDs of Stoma Assessment and Pouching
A = Assessment (7)
# of stoma(s) location type shape viability drainage size
ABCDs of Stoma Assessment and Pouching
B=Certification Boards
C= Complications
Bleeding Necrosis Prolapse Laceration Retraction Stenosis Hernia Irritation
ABCDs of Stoma Assessment and Pouching
D = Different and determining pouching systems
Differences
Fecal vs urinary Adhesive vs nonadhesive One piece vs two piece Precut vs cut to fit Disposable vs reusable Drainable vs closed end
Determining pouching systems
Correct skin barrier and pouch Fit of skin barrier and pouch Correct measurement of stoma Skin barrier intact Any peristomal skin problems that will alter system needed How often system needs changing When should pouch be emptied
Empty the ostomy bad when it’s ___ ____
1/3 full
Chewing food is essential to avoid a _________ ___________
Potential obstruction
Drink at least ______ ml/day to prevent ________ unless on fluid restrictions
3000, dehydration
ADL’s
When doing health teaching, inform the client to avoid foods that increase _____, ______, _______
gas, odour, stool formation
Unexpected Outcomes
Peristomal skin is irritated, reddened, tender, burning sensation or has overgrowth Necrotic stoma No urinary output Thick stools Leakage
A patient who had a urinary diversion done yesterday just had his drainage bag emptied of 250 mL of yellow urine with mucus, which was his output for the past 6 hours. What is the appropriate action for the nurse to take? A) Record the output and description B) Notify the physician of low output C) Palpate the patient's abdomen D) Assess the patient's pain level
A) Record the output and description
A patient asks about what to expect regarding the consistency of stool after his transverse colostomy to be performed tomorrow. Which response by the nurse best addresses this?
A) “What is your major concern about having the surgery tomorrow?”
B) “The stool will be thin and watery after you establish your eating pattern.”
C) “The consistency of the stool will vary from thick liquid to semiformed stool.”
D) “We’ll talk about this at length after you have recovered from the anesthesia.”
C) “The consistency of the stool will vary from thick liquid to semiformed stool.”
A male Amish patient is recovering from surgery 2 days ago when a colostomy was performed. Which approach by the nurse is most important?
A) Allowing the patient to do as much of his care as he wishes
B) Assigning a male caregiver to him for his hygiene and toileting
C) Asking the family to stay with him as much as possible for support
D) Pulling the curtain whenever anything is being done with the patient
B) Assigning a male caregiver to him for his hygiene and toileting
The patient calls the surgeon’s office 4 weeks after her colostomy was performed, stating that the stoma seems to be shrinking. Which statement by the nurse is most appropriate?
A) “A slight decrease in the size of the stoma is expected.”
B) “Don’t worry about the size of the stoma.”
C) “Because that’s unusual, I’ll let the doctor know.”
D) “As long as the stoma isn’t purple or black, it’s okay.”
A) “A slight decrease in the size of the stoma is expected.”
The fecal ostomy pouch is leaking, but it’s several hours too soon to change the skin barrier wafer. What is the appropriate action for the nurse to take?
A) Perform a full abdominal assessment
B) Ask the patient what he wants to do
C) Change the wafer now
D) Pad the skin around the stoma until it is time to change the wafer
C) Change the wafer now
