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TL Chest Tubes

Nursing of the adult with a chest tube

Define pneumothorax. air in the pleural space
What are some potential causes of pneumothorax? traumatic chest injury, thoracotomy,and spontaneous in tall thin people
Define pleural effusion. fluid in the pleural space
How might fluid get into the pleural space? impaired lymphatic drainage/malignancy; changes in colloidal osmotic pressure/heart failure
Define empyema (Say ‘M’ Pie ‘E’ mah). purulent pleural fluid
How might empyema develop? lung abscess or pneumonia
Where does the chest tube go if air is to be removed from the pleural space? anteriorly through the second intercostal space – usually on the anterior aspect of the midclavicular line, second or third intercostal space
Where does the chest tube go if fluid is to be removed? posteriorly through the 8th or 9th intercostals space midaxillary line
Why do some clinicians use the 4th and 5th anterior or midaxillary intercostal space for chest tube insertion? How does this work for fluid or air removal? To prevent dissection of the pectoral muscles; tube is directed upward for air removal and downward for fluid removal
What is the function of the collection chamber in a chest drainage unit? to collect drainage from the patient’s pleural space, allow for visual inspection of the nature of drainage, and measure output
What is the function of the water seal chamber in a chest drainage unit? The tube in this chamber is submerged to prevent air from flowing back toward the patient. The water acts like a one way valve.
What is the function of the suction chamber of a chest drainage unit? The water level has to do with the strength of suction to the patient. The more the tube in this chamber is submerged the more suction to the patient.
Can the RN delegate chest tube care? no
What education should the RN provide to assistive personnel regarding care of the client with a chest tube? (P,BBCCEDSV) Proper positioning to facilitate drainage, report changes in vital signs, comfort level, SpO2, excessive bubbling in water-seal chamber, disconnection, change in drainage, bleeding , or bubbles stop
What will the nurse check during assessment of the patient with a chest tube?(BCDDubILPSSTkdcV) Breath sounds over affected lung,Chest pain,Dressing,Drainage system – upright and below level of tube insertion,Insertion site LOC,Pain scale,Signs respiratory distress,SpO2,Tubing for kinks, dependent loops, clots; Vital signs,
What signs/symptoms would alert the nurse to respiratory distress in the patient with a chest tube?(ACDHST) asymmetrical chest movements, cyanosis, decreased breath sounds, hypotension, subcutaneous emphysema at insertion site/neck, tachycardia
What signs/symptoms would alert the nurse to the possibility that her patient with a chest tube has developed a pneumothorax? respiratory distress not relieved or worsened after chest tube placement, sharp stabbin chest pain w/wo decreased BP and increased heart rate
What is the nurse’s responsibility if her patient shows signs of pneumothorax? notify physician immediately
Why monitor the chest tube patient’s pulse and BP? What might changes in these values mean? (IRP) changes in pulse and BP can indicate infection, respiratory distress, or pain
What is the nurse looking for when she assesses the insertion site of the chest tube patient? dressing is intact, no air or fluid leaking, area around site is free of drainage or skin irritation
What risks could develop if the patient’s tubing is kinked, has dependent loops, or clots? increases patient’s risk for infection, atelectasis, and tension pneumothorax
When would chest tubes be clamped? Usually not, only with physicians order (usually to assess patient’s readiness for chest tube removal) or very briefly to assess air leak, or to empty/change disposable drainage system (requires special training).
What do we use for clamps on a chest tube if the doctor orders clamping? 2 shodded (to prevent puncture) hemostats per tube
What would be a sign of leaking at the insertion site, connection between tube and drainage, or within the drainage device? Continuous bubbling in the water seal chamber
How do we find the location of a leak? By progressively moving clamps from the insertion site on down the tube until bubbling stops. When bubbling stops the leak is above the last clamp placed.
What are the expected drainage amounts and characteristics after placement of a pleural drainage system? between 100 and 300mL in the first 2 hours, 500 -1000ml in the first 24hours, bloody for first several hours changing to serous
What is the nurses responsibility if ther is more than 100mL/hour of blood drainage (except for 1st 3 hours preoperative)? Inform the physician, stay with the patient, assess vital signs, O2 sat, and cardiopulmonary status.
What size are chest tubes? large bore usually 34 -36 French)
How does a one way valve system work? the tube collapses on inspiration and opens on expiration (or when chest pressure exceeds atmospheric pressure)
Name 4 disposable water seal drainage systems. Pleur-evac, Medi-evac, Atrium, Thoraseal
Name the three chambers of a pleural drainage system. collection, water-seal, suction control
What is the collection chamber for? where drainage from the patient goes; calibrated so that amount of drainage can be assessed
When are there bubbles in the water seal chamber? When first connected (air in system and from patient’s interpleural space), but should stop and become intermittent after a short time. Intermittent bubbling can be seen with exhalation, coughing or sneezing, continuous bubbling indicates a leak
What does fluid rising with inhalation and falling with expiration mean if seen in the waterseal chamber? Describe how observations would differ if client is on a ventilator. means the unit is functioning normally (fluid falls with inspiration/rises with exhalation if patient is on a ventilator)
What does no bubbling in the water seal chamber mean? not enough suction, healed pneumothorax, clot or kink in tubing
How long does it usually take for a large pneumothorax to heal? 48-72 hours
What might the nurse suspect if there is an abrupt cessation of tidaling in the water seal chamber? reexpanded lung or kinked/clogged tube
What is the usual amount of suction ordered? -20cm H2O
Where and when would an open thoracotomy take place? Closed thoracotomy? Open thoracotomy is inserted during time of surgery; Closed thoracotomy at the bedside
How is the patient positioned for a thoracotomy? sitting or lying with the affected side up
Describe the incision procedure for a thoracotomy tube under normal and emergency circumstances. after the area is prepped and local anesthesia is injected a small incision is made or in case of emergency a removable trocar (metal guide in the middle of the chest tube) is used
What happens immediately after the tube is placed? the tube is connected to the chest drainage system and the MD sutures the tube to the chest wall
How are the connections and insertion site handled? all connection are securely taped to maintain airtight system; occlusive sterile dressing is applied to the insertion site; pneumothorax- petroleum gauze is often used to prevent air from being sucked into the pleural space
Discuss the use of Chest X-ray for the client with a chest tube. CXR are used to check tube position and whether lung has re-expanded
What assessments will the nurse make to gather information about the clients general respiratory status (6)? abnormal chest movements;anxiety, bilateral breath sounds > q 2hours; cyanosis; quality of respirations;VS > q 4hr;
What signs and symptoms would alert the nurse to potentially worsening pneumothorax (CCHRIIST)? confusion, cynosis, hyperresonance,increased absent breath sounds; increased respiratory distress,restlessness, sudden sharp chest pain, tachycardia,
What signs and symptoms would alert the nurse to possible hemothorax (3abcd)? diminished or absent breath sounds, dyspnea, cyanosis
How often do we assess the chest drainage system? hourly
What do we check when assessing the chest drainage system (5)? system below patient’s chest, free of kinks, dependent loops, obstruction; color and amount of drainage; dressing and subcutaneous emphysema; tidaling (ok) or continuous bubbling (bad) in water seal chamber
What is the nurse’s responsibility if the drainage changes from dark to bright sanguineous or if the amount of drainage exceeds 200mL/hr for 2 hours Report to MD
What are some applicable nursing diagnoses for the patient with a chest tube (3)? Ineffective breathing pattern; Impaired gas exchange rt decreased lung expansion; anxiety r/t perceived risk of CT dislodgement, system disruption, inability to breathe
What are some nursing goals or signs of success for impaired gas exchange and ineffective breathing (6)? (ABCCERS) ABGs approaching normal;breath sounds equal, clear; even and unlabored; cxr shows lung re-expansion ,RR 16-20/min, symmetrical expansion
Name 2 nursing goals for the anxiety a patient with a chest tube may have. Patient describes necessary precautions, Patient describes what is expected in terms of drainage
What are some nursing interventions that help with ineffective breathing pattern and impaired gas exchange(8)? Maintain patent system; retape all connection; monitor/care for CT dressing; no kinks/clogs/dependent loops in tubing; TCDB (splint with pillow); pain management; Milk per protocol/MD; notify MD if no fluctuation
What is the nurse’s responsibility if the system breaks? Place end of tube in sterile H2o or Saline; hold below chest level; immediately replace system; momentary clamping okay if air entering pleural cavity
Why can clamping a chest tube lead to tension pneumothorax? Air is trapped and creates pressure that works against lung expansion
What change in the trachea would result from a tension pneumothorax? deviation
What is the nurse’s responsibility if the CT is accidently removed? cover wound with occlusive dressing (in an emergency a gloved hand will work); tape 3 sides, leave one open to avoid tension pneumothorax
What can be done to avoid placing pressure on the chest tube if the client wants to lie on the side of the insertion site? use a rolled towel
Give several signs that a patient is ready for chest tube removal (CCFA). CXR confirms full re-expansion, no fluctuation of fluid, cessation bubbling in water seal chamber, adequate gas exchange
Discribe how a chest tube is removed (4). How long does it usually take for the incision to heal? provide medication 30 minutes before procedure, patient is instructed to bear down and cough while tube is quickly removed, Vaseline gauze and sterile dressing placed over site, monitor for respiratory distress after; usually takes about a week to heal
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