Week 6+7 Chest tubes

Question 1

What are indications for chest tubes?

Answer 1

Used to tx conditions that disrupt the pleural space; may be used to prevent or mitigate post op complications; can be used to install fluids into the pleural space such as chemotherapy drugs or sclerosing agents to tx recurrent pleural effusions; blood collected from chest tubes may be used for auto transfusion

Question 2

What is the overall goal of chest tube therapy?

Answer 2

to promote lung re-expansion, restore adequate oxygenation and ventilation, and prevent complications.

Question 3

What are the 3 primary objectives of chest tube therapy?

Answer 3

1. removing air and fluid as promptly as possible.
2. preventing drained air and fluid from returning to the pleural space
3. restoring negative pressure within the pleural space to re-expand the lung.

Question 4

In a water seal chamber, water will fluctuate as the patient breathes in and out. Explain when the water increases and decreases. How does this differ from positive pressure machine vent?

Answer 4

Water increases with inspiration and decreases with expiration. It is the opposite if the patient is on positive pressure machine vent.

Question 5

What if the water in the water chamber is not fluctuating at all. What could be the issue?

Answer 5

The lung may have re-expanded or there is a kink some where.

Question 6

Subcutaneous emphysema/crepitus?

Answer 6

When Co2 escapes into tissues.

Question 7

What do you do if the chest tube becomes dislodged?

Answer 7

Cover with a sterile dressing and tape on 3 sides (allows air to escape and prevents tension pneumothorax) and notify MRP

Question 8

What happens if the system breaks?

Answer 8

insert tubing 1 inch into bottle of sterile water and get new system.

Question 9

Why do we not like milking or stripping the tubing?

Answer 9

It increases negative pressure.

Question 10

Why is clamping not recommended?

Answer 10

it increases the risk of tension pneumothorax.

Question 11

Why do we ask patients to do the Valsalvas maneuver during chest tube removal?

Answer 11

Prevents air from entering pleural space during removal

Question 12

Do all chest tubes drainage systems use water seal chambers?

Answer 12

No, some use a one way valve to let air escape, and prevent atmospheric air from re-entering.

Question 13

What is the difference between “wet’ suction” and “dry” suction in a chest tube drainage system?

Answer 13

“Wet” suction devices require the addition of sterile water into the “suction control chamber” of the drainage device. Tubing is then attached from that chamber to a suction source, for instance wall suction. The amount of suction depends on how high the column of water is in the chamber, for example 20 cm high. Bubbling in this column indicates that the suction is on.
“Dry” suction devices do not depend on a column of water to provide suction. A dial on the upper left side of the device is set to the ordered amount of suction. Tubing is attached from the device to the suction source, for instance wall suction. The ordered amount of suction is dialled in on the chest drainage unit so this controls the amount of suction not the wall suction dial.

Question 14

What is the purpose of the “water seal chamber” in a chest tube drainage system?

Answer 14

This chamber allows air to escape from the patient’s pleural space without allowing air from the atmosphere to enter the patient. Think of a drinking straw placed into a glass of water. You can blow air out through the straw, but can’t suck air back through the water.

Question 15

What are the three chambers in a three chamber chest tube drainage system for?

Answer 15

One collects drainage from the patient, one provides a water seal for air to escape from the patient and one provides suction (either wet or dry).

Question 16

With regard to chest tubes, what is an air leak? Is it an expected thing or an unexpected thing?

Answer 16

An air leak can be: In the patient’s chest, for example when the surgeon opens the chest and atmospheric
air rushes in. This is expected, and chest tubes remove this unwanted air. In the chest tube drainage system. This is NOT an expected thing, and nurses must
quickly determine where the leak in the system is and take steps to control it.

Question 17

What is the difference between a Heimlich valve and a chest tube?

Answer 17

Heimlich – attaches to chest tube. One way “flutter valve” allows release of air and/or very minimal drainage. Air does not enter via the valve back in to the pleural space. See pictures on page 716 Perry & Potter (2018). There is no drainage chamber with this device, therefore it can’t be used for a hemothorax or to drain fluid from a pleural effusion. it is lighter and easier to ambulate with.

Question 18

What signs exhibited with a pneumothorax?

Answer 18

Decreased breath sounds on the affected side, decreased SpO2, chest pain, dyspnea, tachycardia, asymmetric chest movements

Question 19

Why is it important to encourage deep breathing and coughing?

Answer 19

Helps lung re-expansion and prevents complications. Patient can use incentive spirometer too. Teach patient to splint chest tube site while practising deep breathing. Administer analgesics. Adequate pain management promotes DB &C, and mobilization, thus preventing complications. Teach re: frequent repositioning

Question 20

What specific nursing assessments must be made regarding drainage?

Answer 20

Quantity and quality of drainage
Amount of drainage marked on chest drainage unit
Colour, consistency, clots (e.g. sang. Serosang, purulent)
Don’t be surprised if sudden increase when pt. repositions self/coughs etc.

Question 21

The water-seal chamber is to be maintained at the 2 centimeter level. Discuss what the
implications are for levels above and below the 2 centimeter water level. Describe your
nursing actions to correct these situations should they occur.

Answer 21

Above – this leads to increased suction. Nursing action press pressure release valve

Below – may not seal atmospheric air from entering
Add water through yellow disc

Question 22

The pt with a chest tube is on bed rest for the time being. Discuss problems and implications of immobility to the patients
overall health.

Answer 22

Immobility leads to pooling of resp secretions, decreases depth of resps, risk of DVT and air embolism. Depending on physician orders, she may be on bedrest while on suction. If ordered, she can ambulate in her room, as long as there is no tension on the drainage unit or tubing. A Dr. order is required to disconnect the tube from suction and change to straight drainage. There are portable suction units that can be used if the patient needs to go for a test, but these also require an order.

Question 23

what is the emergency equipment that should be at the bedside?

Answer 23

clamps (need 2 toothless chest tube clamps over chest tube); sterile drsg kit; occlusive drsg; waterproof tape; sterile gloves; bottle of sterile water or NS at bedside

Question 24

S+S of mediastinal shift?

Answer 24

displaced trachea; marked cyanosis; asymmetrical resps; hypoTN; tachycardia; sharp stabbing pain

Question 25

amounts of drainage to be concerned about?

Answer 25

Mediastinal: less than 50-200ml/hr post op and 500 ml/24 hr. Pleural: post op 100-300 mL first 3 hours and 500-1000ml/24 hr. Over 100 ml/hr after first 3 hours post op is of concern. Peds: 3ml/kg/hr for 2 consecuative hrs call physician