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CHEST TUBE INSERTION AND MONITORING

CHEST TUBES are inserted in the pleural space to drain fluid, blood, or air; reestablish a negative pressure; facilitate lung expansion; and restore normal intrapleural pressure Can be inserted in the emergency department, at the clients bedside by placing the client in a sitting or lying position, or in the operating room through a thoracotomy incision.

TYPES OF DRAINAGE SYSTEMS: 1. SINGLE CHAMBER SYSTEMS The most basic chest drainage system. Consists of a chest tube connected to one water sealed drainage bottle. The single bottle is both collector and water seal. This system cannot handle large volumes of fluid of air drainage. As fluid drains from the chest tube, it mixes with the water in the bottle and raises the water level, making it harder for the patient to exhale

The following are key points for managing a one bottle system: A. Keep the intake tube below the fluid level in the drainage bottle to prevent drawing air into the pleural space with inhalation. B. Maintain the tubing about 2 cm below the water level. As tubing length below the water increases, more effort is required to exhale. C. Take precautions to see that the bottle is not accidentally tipped over, uncovering the long vent tube and allowing air to enter the pleural space. 2. TWO CHAMBER SYSTEM Has one bottle that connects directly with the chest tube and serves as a collection bottle. The second bottle serves as the water seal bottle; it maintains negative pressure. Because no water is mixed with chest drainage, the amount of drainage can be measured more accurately. This can handle large amounts of fluid drainage, but its design can still contribute to labored breathing. 3. THREE CHAMBER SYSTEM A third bottle is connected to the water seal bottle and placed to suction. This creates controlled negative pressure within the system. The suction control bottle has three vent tubes: one connected to suction, one connected to the water seal bottle, and a long middle tube with one end open to air at the top and the other end submerged in sterile water inside the bottle. Suction pressure is expressed in centimetersof water; the length of the long tube that is submerged in water is usually 15 to 20 cm for adults. The depth of submerssion determines the maximum suction possible within the system.

THREE CHAMBER SYSTEMS (CLOSED DRAINAGE SYSTEM) THREE MAIN COMPARTMENTS: 1. COLLECTION CHAMBER - collects the drainage and measures the volume, rate and consistency Measure and document the amount of drainage. Chest drainage is grossly bloody immediately after surgery. This does not continue for longer than several hours. Fluid volume should raise and tube patency should be check regularly to ensure proper drainage. 2. WATER SEAL CHAMBER - One way valve that allows air and drainage to leave the pleural space but not return. Water seal are created by adding sterile fluid to a chamber up to the 2 cm line. The water seal allows air to exit from the pleural space on exhalation and prevents air from entering with inhalation. Air and fluid travel through the drainage tubes and enter the water seal chamber, bubbling up into the atmosphere on expiration. Constant bubbling indicates AIR LEAK. TIDALING (movement of water level with respiration) is the fluctuation of water in the water seal chamber during respiration. With spontaneous respirations, the water level will rise with inspiration (increase in negative pressure in lung) and will fall with expiration. With positive pressure, the water level will rise with expiration and fall with inspiration. Cessation of tidaling in the water seal chamber signals lung reexpansion or an obstruction within the system. To maintain the water seal, the chamber must be kept upright and below the chest tube insertion at all times. The nurse should routinely monitor the water level due to the possibility of evaporation. The nurse should add fluid as needed to maintain the 2cm water seal. All seals must be tight to ensure that atmospheric air does not enter the chamber and cause the lung to collapse.

3. SUCTION CONTROL CHAMBER - using suction to assist drainage from the pleural cavity and help the lung reexpand. Suction at 10 to 20 cm H20 may be applied to the chest drainage system if gravity is not doing the trick. Suction is regulated by the amount of water in the water seal chamber. The more the water in the chamber the more the pressure created. The height of the water in the suction control chamber determines the amount of suction transmitted in the pleural space. A suction pressure of 20cm H2O is common. The application of suction results in continuous bubbling in the suction chamber. The nurse should monitor the fluid level and add fluid as needed to maintain prescribed level of suctioning. Closed chest drainage systems should be placed lower than the patients chest so that gravity can assist drainage. If suction is greater than 50 cm H20 this can cause LUNG DAMAGE. INDICATIONS FOR CHEST TUBE INSERTION: Pneumothorax Hemothorax Postoperative Chest Drainage (thoracotomy procedures, coronary artery bypass) Pleural Effusion Lung Abcess

PREPARATIONS PRIOR TO PROCEDURE: Verify consent form signed. Assess the clients understanding of the procedure and provide education as needed. Assess for allergies to local anesthetics. Assist the client into the desired position (supine or semi fowlers) Prepare the chest drainage system in advance of insertion per protocol (for example, fill the water seal chamber). Administer pain and sedation medications as prescribed. Prep the insertion site with Betadine. Drape insertion site.

DURING THE PROCEDURE: Assist the provider with insertion of chest tubes, application of a dressing to the insertion site, and set- up of the drainage system. The chest tube tip is positioned up toward the shoulder (pneumothorax) or down toward posterior (hemothorax or pleural effusion) The chest tube is sutured to the chest wall and an airtight dressing is placed over the punctured wounds. The chest tube is then attached to drainage tubing that leads to a collective device. Place the chest drainage system below chest level with tubing coiled on the bed. Ensure that the tubing from the bed to the drainage system is straight to promote drainage by gravity. Throughout the procedure, the nurse should continually monitor vital signs and the clients response to the procedure.

AFTER THE PROCEDURE Assess the clients vital signs and respiratory status at least every 4 hour. Encourage coughing and deep breathing every 2 hours. Keep the drainage system below chest level, including during ambulation. Monitor chest tube placement and function. Check the water seal level every 2 hour and add water as needed. Document the amount and characteristics of drainage every 8 hour by marking date, hour, and drainage level on the container at the end of each shift. Report excessive drainage to the primary care provider. Drainage will often increase with position changes or coughing. Monitor the fluid in the suction control chamber and refill as needed. Check for expected findings of tidaling in water seal chamber and continuous bubbling in suction chamber. Routinely monitor tubing for kinks, occlusions or loose connections. Monitor the chest tube insertion site for redness, pain, infection, and crepitus (air leakage in subcutaneous tissue) Position the client to promote lung expansion. Place the client in the Semi Fowlers position to evacuate air and in the High Fowlers position to drain fluid. Administer pain medication as prescribed. Obtain chest x-ray to verify chest tube placement. Keep two covered hemostats, a bottle of sterile water, and occlusive dressing visible at bedside at all times.

NOTE:

Chest tubes are removed when the lungs have re expanded and /or there is no more fluid drainage.

Due to risk of causing a tension pneumothorax, chest tubes are only clamped per a primary care provider order in specific circumstances: While assessing for an air leak During a drainage system change When there is accidental disconnection of drainage tubing When there is damage to collection device While assessing readiness for tube removal DO NOT STRIP or MILK tubing routinely; only do so by primary care provider. Stripping creates a high negative pressure and may damage lung tissue.

CHEST TUBE REMOVAL Provide pain medication one half hour before removing chest tubes. Assist with suture removal. Instruct client to take deep breath, exhale, and bear down, and bear down (valsalva maneuver) or to take deep breath and hold it (increases thoracic pressure and reduces risk of air emboli) during chest tube removal. Apply air tight sterile petroleum jelly gauze dressing. Secure in place with elastophast tape. Obtain chest x- ray as prescribed. This is done to verify continued resolution of the pneumothorax, hemothorax, or pleural effusion. Monitor the client for excessive wound drainage, signs of infection, or recurrent pneumothorax.

COMPLICATIONS & NURSING IMPLICATIONS 1. AIR LEAKS Prevention: all connections should be taped. Check connections regularly. Protect connections from accidental disconnection. Monitor water seal chamber for continuous bubbling (air leak finding). If observed, locate source of air leak and intervene accordingly (tighten connection, replace drainage system). Check all connections Cross clamp close to clients chest. If bubbling stops, the leak is at insertion site or within thorax. If bubbling doesnt stop, methodically move clamps down the drainage tubing toward the collection device, moving one clamp at a time. When the bubbling stops, the leak is within the section of tubing or at the connection distal to the clamp. ACCIDENTAL DISCONNECTION, SYSTEM BREAKAGE, OR REMOVAL If the tubing separates, the client is instructed to exhale as much as possible and cough to remove as much air as possible and to cough to remove as much air as possible from the pleural space. The nurse cleanses the tips and reconnects the tubing. If the chest tube drainage system breaks, the nurse immerses the end of the tube in sterile water to restore water seal. If a chest tube is accidentally removed, an occlusive dressing taped only three sides should be immediately placed over the insertion site. This allows air to escape and reduces risk for the development of a tension pneumothorax. TENSION PNEUMOTHORAX Sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstruction may cause a tension pneumothorax.

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CARE OF THE CLIENT WITH CHEST TUBE Assessment 1. Assess respiratory status every two hours or according to agency policy. Note rate, rhythm, depth, and ease of respirations. Also note anxiety and chest discomfort. Auscultate lungs and percuss lung fields. Check for symmetry of chest movement. Rationale: Assess the presence of air or fluid in pleural cavity, fluid in the lungs, and tension pneumothorax. Assess for fluid fluctuation (with respiration) in the water seal chamber/ bottle. Rationale: Fluctuations indicate changes in pressure in the pleural space, which occur when child breathes and the lung has not fully expanded. 2. Note the amount and color of drainage from chest tube. Mark the level at the beginning of each collection and at the end of every shift. Note: If the client is actively bleeding , assess drainage frequently, every 10 15 minutes. 3. Check dressing at least once a shift to assure it is clean, dry, and intact.

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Note: Dressing should be covered with adhesive tape. Change dressing in accordance with agency policy. Inspect entry site for drainage, inflammation, or subcutaneous emphysema. Assess clients level of discomfort and medicate as ordered. Rationale: Manipulation of chest wall and insertion of chest tube are painful. Assess functioning and integrity of drainage system every two hours according to agency policy. Check for appropriate level of water in water seal and suction chambers/ bottles and refill with sterile water or saline as needed. Check for appropriate setting of wall suction. Assess for bubbling in water seal chamber/ bottle. Rationale: Indicates leak. Check drainage tubing for kinks or obstructed flow. There should be no dependent loops of tubing or tubing laid horizontally on bed. Rationale: Kinks, obstructions, and dependent loops interfere with chest tube drainage. Check all connections between tubing to be sure they are tight and taped. Rationale: Loose connections cause air leaks and ineffective drainage. Check that the system is below the level of the client. Rationale: Facilitates drainage. Do not strip or milk unless specifically ordered by physician. Rationale: Stripping creates hazardously high pressure in the pleural cavity, which can damage lung tissue and pleura. Transporting the client with a chest tube. Disconnect from wall suction but keep connected to water seal. Rationale: prevents air from entering the pleural space. Do not clamp chest tube during transport. Rationale: No fluid or air can escape from pleural cavity when tube is clamped and potential for tension pneumothorax is increased. Keep drainage system below level of chest and upright. Rationale: Facilitates drainage and maintains water seal. Have chest tube clamp at bedside to clamp off tube: If bubbling occurs in water seal chamber while system is on suction. Note : To check for air leak place clamp at various points moving from the chest to the drainage system. Bubbling stops once clamp is placed between the air leak and the water seal. When changing the tube or replacing the drainage system. Rationale: Prevents air from entering the pleural cavity. When drainage system is cracked. Rationale: Prevents air from entering the pleural cavity. During chest tube removal. Rationale: Prevents air from entering the pleural cavity.

DOCUMENTATION 1. 2. 3. 4. Results of assessment of respiratory status. Amount and color of chest tube drainage. Condition of dressing. Results of assessment of drainage system.

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