Chest Tube Article

cdunbar4's version from 2016-10-10 02:23

Reasons/locations for chest tubes

Question Answer
Chest tubes are also known as a _____________ tube or a ___________ ____________.thoracostomy tube, thoracic catheter
Purpose of chest tubes are to resolve what 3 respiratory disturbances?pneumothorax (most common reason), hemothorax or pleural effusion
Can also drain from what other area/organ?Blood from mediastinum after open-heart surgery
pneumothoraxpartial/complete lung collapse, caused by external air entering pleural space from a hole in chest wall or by hole in pleura which disrupts normal negative pressure
Location of chest tube place for a pneumothorax anteriorly near apex of lung at 2nd ICS, mid-clavicular line
Location of chest tube placement for a hemothoraxtwo chest tubes can be inserted: one at apex and one at base of lung
Pleural effusionabnormal fluid collection or transudation in pleural space d/t heart failure, surgery or malignancy
Location of chest tube placement for pleural effusionposteriorly into the 5th-6th ICS
EmpyemaCollection of purulent material in pleural space d/t: pneumonia, lung abscess or contamination or injury of pleural cavity
Location of chest tube placement for empyemaposteriorly into the 5th or 6th ICS
Location of chest tube placement for prevention of cardiac tamponade after open-heart surgeryanterior or posterior tubes, attached to same drainage device with a Y connector or 2 separate drainage devices

Tubes & drainage systems

Question Answer
Chest tube is made out of:sterile, flexible, nonthrombogenic catheter of vinyl or silicone
size20" (50cm) long and #12-#40 French diameter
Size #12-#26 French is used forpneumothorax
Size #28-#40 French is used fordraining fluids (i.e. pleural effusion)
CDUchest drainage unit
What is different about the proximal end of the tube's catheter?has several eyelets (small holes) to drain air or fluid & prevent catheter occlusion
Heimlich valvea water-seal chamber connected to chest tube (cheaper, easier to use)
When is a Heimlich valve used instead of a traditional CDU?for small, uncomplicated pneumothorax with little or no drainage that doesn't require suction

protecting patient before insertion

Question Answer
Tasks prior to insertionmonitor VS & breath sounds; O2 via nasal cannula @ 2-4L/min, monitor pulse ox
What should the F1O2 be adjusted to prior to insertion?Target SpO2 of 94% (<90% usually correlates with a PO2 of 60mmHg.
HOB should be raised to ___ degrees or higher in order to promote chest expansion & ________ muscle use.30; intercostal
Watch for early signs of hypoxemia; what are they?LOC changes, confusion, anxiety, restlessness, central cyanosis
Cardiac monitoring is necessary as well. Initially patient could get tachycardic, why?from activation of sympathetic nervous system that occurs with respiratory depression & inadequate oxygenation.
Two lab tests physician will order to confirm pneumothorax. Which test is more definitive?Chest x-ray (more definitive, it shows black areas where lung is collapsed). and ABGs
What will ABGs initially reveal?Respiratory alkalosis caused by tachypnea; if respiratory status worsens, you[ll note hypoxemia, hypercapnia and acidosis

how system works

Question Answer
Collection chamberfluid drains into chest tube via a 6' connecting tube, then into collection chamber.
Things to assess about the fluid in the collection chamberamount, rate, characteristics of drainage; can usually get a sample out of most units collection chamber for labs
Collection chamber holds up to2000mL
Water-seal chamberacts as a one-way valve so air can drain from the chest cavity, but can't return to patient. Water seal evacuates air from chest & passes through a column and bubbles into the bottom of the water seal.
Analogy for water-seal chamber being a one-way valveA cup of water with a straw in it: if you blow into the straw, air bubbles out through the water; if you try to draw air in, you get water.
suction control reuglatorwater-filled or dry suction removes chest drainage & maintains flow.
How to regulate suction on CDUconnect CDU's vacuum line tubing to wall suction and set the CDU suction to the ordered level

Prepare patient and equipment for insertion

Question Answer
Equipment to gather (aside from chest tube & CDU)povidine-iodine solution; sterile masks, gloves & drapes; local anesthetic & PPE
Prepare CDU by consulting manufacturer's instructions & hospital policyassemble suction source & connecting tubing, place CDU upright and at least 1 foot below pt.'s chest
Perform a baseline cardiopulmonary assessment in order to evaluate response to treatmentVS, breath sounds, chest excursion, skin color, SpO2, LOC, cardiac rhythm.
Check for any pertinent lab work such as:ABGs and coagulation profile
Explain procedure to patient. He will be anxious and in pain, what interventions should be implemented?Pain meds or sedation as ordered; answer any questions and be sure consent has been signed in his chart
What position should you place patient in?high Fowler's or Semi-Fowler's, and remain as still as possible & to breathe normally during procedure.

Assisting with insertion

Question Answer
First, the clinician will drape & prepare insertion site with povidine-iodine solution, then...local anesthetic, incision, insert tube
Once tube has been inserted, what should you do before you start suction?attach the patient-connecting tube to the drainage device and secure it to device with tape or whatever policy advises.
What is the CDU suction usually set at?-20 cm H2O
Wall-suction needs to be set to at least what pressure?-80 mmHg or greater (multiple drains like 2 mediastinal tubes require more vacuum)
Clinician will suture it place once unit is working properly, what should you dress the site with after they apply petrolatum gauze?sterile split-drain sponges covered by sterile 4x4 gauze and secure with 2: tape
Patient will need chest x-ray to confirm placement. What do you document after confirmation?assessments b4/after, chest tube size & insertion site, insertion date/time, who inserted it, whether drainage was present and the amount color & type; how pt. tolerated procedure; medications they received; results of xray; patient & family teaching

Assess and prevent complications

Question Answer
How often should you assess cardiopulmonary status?Q4H at least
How often should you examine chest tube insertion site?Q8H for inflammation, signs of infection, or subcutaneous emphysema; get daily chest x-rays as ordered to check for lung re-expansion
Change dressing at insertion site as ordered. If it is dry w/o signs of infection, when would be the first time you'd change it?Probably not until the 3rd day after insertion
How to promote drainage and lung re-expansioncough, deep breathing; splint insertion site & pain meds PRN; change position Q2H
Can the patient lie on the side of the insertion site?Yes, as long as there are no kinks in the tubing
Why is there a gush of output suddenly the first time a patient sits up?Old drainage coming out of the pleural space
Monitor output how often?Usually Q2-4H
If you notice the drainage tube dangling from the side of your patient's bed, what should you do?Coil it up on the bed
Why do we use the "milk" method of getting clots out of drainage tubes instead of "stripping" it?Stripping the tube causes a dangerous increase in intrathoracic pressure & doesn't lead to any significant increase in output
If there is an air leak in the tubing system, what do you see going on in the water seal chamber?Continous bubbling
If there is bubbling that is intermittent, what does that usually correspond with?pleural space is leaking air, corresponds to their respirations. This should resolve as lung re-expands
Negative pressure in the water-seal chamber indicates negative pressure in the pleural space. Is this good or bad?This is good! The goal of chest tube therapy is to increase negative pressure in pleural space
Signs of subcutaneous emphysemaCollection of air or gas under skin: usually painless, feels spongy on palpation. Sometimes can spread to neck, chest and face → call physician

Improvement and removal

Question Answer
Signs of improvement less DOE, less chest pain on inspiration
Parameters for chest-tube removalx-ray shows lungs have reexpanded, respiratory status normal, drainage over the last 24hrs. is < 100mL
Before removal of chest tube, what does the order "place the tube on water seal" mean?discontinuing suction, usually 24 hours before anticipated removal. Watch for deterioration in respiratory status while his chest tube is on water seal (lung may not remain inflated or he can get another pneumothorax)
Nursing role/implementation during removal of chest tubeExplain procedure, premedicate 15 min prior. Instruct to take a deep breath and hold it when told to.
Once tube is removed, what type of dressing should be applied to site?sterile, occlusive dressing. Observe patient for any changes in resp. status; get chest x-ray


Question Answer
What if chest tube becomes dislodged?immediately cover site (leave 2-3 sides open) with a dry, sterile dressing & call clinician
What if chest tube becomes disconnected from the CDU or CDU breaks?submerge distal end in 1" of sterile 0.9% NaCl solution or sterile water to create a liquid seal while you prepare and attach a new CDU
When should the CDU be changed?If it breaks or if it is full.
Steps to changing CDU units.1. prepare new CDU unit 2. remove current CDU from suction, clamp chest tube w/ a rubber-tipped hemostat, disconnect connecting tube from CDU 3. Quickly connect new CDU, unclamp tube & secure all connections 4. Resume suction & make sure new unit is functioning normally

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