Week 2 Material Chest Tubes

Question 1

drainage systems for chest tubes

Answer 1

• Most often a disposable, three-chamber system
  
  • First chamber - drainage collection
  • Second chamber - water seal
  • Third chamber - suction control (wet or dry)

Question 2

water seal of a chest tube drainage system

Answer 2

• add 2cm sterile fluid (NS) minimum, recommendation varying by manufacturer
• Creates occlusive (one way) seal, allowing air to exit but not enter chest cavity
• Keep chamber upright and below chest level at all times to maintain seal
• Add fluid as needed to maintain water seal

Question 3

tidaling in the water seal (2nd chamber) drainage system for chest tubes

Answer 3

• Tidaling (movement of fluid level with respiration) is expected in this chamber
  
  • Fluid level rises with each inspiration/fall with expiration under normal resp
  • Under positive pressure ventilation (mechanical ventilator), fall with inspiration, rise with expiration
  • Cessation of tidaling = lung reexpansion
  • Continuous bubbling = air leak in system

Question 4

wet suction in a chest tube drainage system

Answer 4

• Amount of suction determined by height of water in suction control chamber
  
  • Pressure of ~20cm H2O commonly Rx’d
  • Continuous bubbling in chamber
  • Monitor fluid level and add additional as needed

Question 5

dry suction in a chest tube drainage system

Answer 5

• Connected to wall suction
• Amount of suction Rx’d by provider
• Regulator on chest tube drainage system set to manufacturer recommendations
• ~20cm H2O typically amount of suction

Question 6

possible indications for a chest tube

Answer 6

• Pneumothorax
• hemothorax
• post-operative chest drainage: from thoracotomy or open heart surgery
• pleural effusion
• pulmonary empyema: accumulation of pus in the pleural space due to pulmonary infection, lung ascess, or infected pleural effusion

Question 7

client presentation indicating need for a chest tube

Answer 7

• dyspnea
• distended neck veins
• hemodynamic instability
• pleuritic (sharp) chest pain
• cough
• absent or reduced breath sounds on the affected side
• asymmetrical chest wall movement
• hyperresonance on percussion of affected side (pneumothorax)
• dullness or flatness on percussion of affected side (hemothorax, pleural effusion)

Question 8

preprocedure considerations for chest tube insertion

Answer 8

• Verify consent form signed
• Assess allergies to local anesthetic
• prep insertion site with povidone-iodine
• put client in desired position: supine or semi-Fowler’s
• prepare drainage system prior to chest tube insertion–>fill water seal chamber
• administer meds

Question 9

Intraprocedure considerations for chest tube insertion

Answer 9

• Assist provider
  
  • Tube insertion, dressing of insertion site
  • place chest tube drainage system below client’s chest level with tubing coiled on the bed
    
    • ensure tubing from bed to drainage system is straight

Question 10

post procedure considerations for chest tube insertion

Answer 10

• Client positioned in semi- to high-fowlers position
• Maintain sterile water, two hemostats, occlusive dressing at bedside
  
  • Only clamp tube when prescribed in specific circumstances due to risk of tension pneumo
• assess V/S, breath sounds, color, and resp effort at least every 4 hours
• monitor chest tube placement and fcn:
  
  • check water seal level every 2 hour, add fluid as needed
  • document amt and color of drainage hourly for first 24 hours and then at least every 8 hours
• DO NOT clamp chest tube (tension pneumo) or milk/strip tubing

Question 11

what to monitor on a client with a chest tube?

Answer 11

• Continually monitor VS and client response to procedure
• Assess VS, BS, SaO2, skin color, resp effort at least Q4H or as indicicated by client status
• CXR FOR PLACEMENT
• Routinely monitor drainage system
• Insertion site for redness, pain, infection, subq emphysema

Question 12

how to monitor drainage system when client has a chest tube?

Answer 12

• Must be below chest level, free of kinks, unoccluded, firmly connected
  
  • Securely tape all connections between chest tube and drainage system
• Color and amount of drainage into system
  
  • Report >70mL/hr to provider
  • Report red or cloudy drainage to provider
  • Assess drainage Q1H 24 hours, then q8H
• Chest water seal Q2H, adding fluid as needed
  
  • Should see tidaling in water seal chamber and continuous bubbling in suction chamber

Question 13

medications to administer in regards to chest tube insertion

Answer 13

• pre-procedure administration of pain meds and sedatives

Question 14

goal of chest tube insertion

Answer 14

• Resolution of pneumo, hemo, drainage, effusion, empyema
• Reestablish negative pressure in pleural space, facilitating lung expansion

Question 15

list the possible complications associated with chest tubes

Answer 15

• air leaks
• accidental disconnection, system breakage, or removal
• tension pneumothorax

Question 16

explain air leaks as a complication of chest tubes

Answer 16

• Diagnostics
  
  • Monitor water seal chamber for continuous bubbling
  • Check all connections!
• Interventions
  
  • Notify provider
    
    • May order padded clamp to locate air leak
      
      • REMOVE IMMEDIATELY TO PREVENT TENSION PNEUMOTHORAX
  • Tighten connections or replace broken drainage system
  • Ensure connections securely taped

Question 17

explain accidental disconnections, system breakage, or removal as a complication of chest tubes

Answer 17

• Diagnostics
  
  • Chest tube will be disconnected or broken
• Interventions
  
  • Client to exhale as much as possible and then cough
    
    • Removes air from pleural space
  • If drainage system is compromised, submerge end of chest tube in sterile water
    
    • Restores water seal
  • Dress insertion site with dry, sterile gauze if tube is accidentally removed

Question 18

explain tension pneumothorax as a complication of chest tubes

Answer 18

• Diagnostics
  
  • Assessment findings
    
    • Tracheal deviation, absent breath sounds, JVD, respiratory distress, asymmetry of chest, cyanosis
  • Sucking chest wound, prolonged clamping of tubing, kinks of obstruction in tubing, high PEEP with mechanical ventilation
• Interventions
  
  • Air will need to removed from chest
    
    • Unclamp/unkink tubing

Question 19

chest tube removal

Answer 19

• pain meds 30 min prior to removal
• assist provider with sutures and chest tube removal
• instruct client to take deep breath, exhale, and bear down OR take a deep breath and hold it during removal
• apply airtight sterile petroleum jelly gauze dressing
  
  • secure with tape
• obtain CXR to verify resolution of problem
• monitor for wound drainage or signs of infection