Chest Tube Procedures and Functions

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Questions and Answers

What is the primary function of a chest tube?

To introduce medications directly into the bloodstream

To remove air and/or fluid from the pleural space (correct)

To deliver oxygen directly to the lungs

To monitor the patient's heart rate

Which condition would NOT typically require the use of a chest tube?

Pulmonary embolism (correct)

Pleural effusion (fluid accumulation in the pleural space)

Post-operative cardiac surgery

Pneumothorax (air in the pleural space)

What type of pressure is normally maintained within the pleural cavity?

Neutral pressure

Positive pressure

Negative pressure (correct)

Variable pressure

Which of these is a potential use of chest tube beyond drainage?

Instilling chemotherapy or sclerosing agents Signup and view all the answers

Why is negative pressure crucial in the pleural space?

To ensure proper lung expansion with inspiration Signup and view all the answers

A patient has a chest tube inserted following a hemothorax. What is being removed by the chest tube?

Blood Signup and view all the answers

What is the primary purpose of chest tube insertion following cardiac surgery?

To prevent or diminish post-operative complications Signup and view all the answers

In which anatomical space is a chest tube placed?

The pleural cavity Signup and view all the answers

What is the primary effect of air, blood, pus, or lymph accumulating in the pleural cavity?

Restricted lung expansion Signup and view all the answers

What is the main goal of chest tube therapy in the context of pleural space issues?

To promote lung re-expansion and establish normal negative pressure Signup and view all the answers

What is the underlying cause of a primary spontaneous pneumothorax?

The presence of blebs on the visceral pleura Signup and view all the answers

Which of the following conditions is characterized by milky-white fluid in the pleural space?

Chylothorax Signup and view all the answers

What is the primary cause of a massive hemothorax?

Disruption of systemic vessels due to trauma Signup and view all the answers

Which of the following is NOT a typical cause of pleural effusion?

Direct trauma to the chest Signup and view all the answers

What is the primary characteristic of empyema?

Purulent fluid Signup and view all the answers

Which common complication can lead to secondary pneumothorax?

Emphysematous bleb rupture Signup and view all the answers

What is the primary role of a registered nurse during a chest tube insertion?

To assist with the procedure. Signup and view all the answers

In which position is a patient typically placed for chest tube insertion, with regard to the affected side?

Sitting or lying with the affected side elevated. Signup and view all the answers

If a chest tube is intended to remove air, where is it commonly inserted?

Mid-clavicular line, second intercostal space. Signup and view all the answers

Which action is essential before a chest tube insertion procedure?

Cleansing the area with an antiseptic solution. Signup and view all the answers

Which documented information is important post chest tube insertion?

The medications given, drainage amount and type, and results of post insertion chest x-ray. Signup and view all the answers

If the primary function of the chest tube is to remove fluid, where should it be placed?

Inferior and posterior in the pleural space, mid-axillary line, 7th or 8th intercostal space. Signup and view all the answers

What is the purpose of the occlusive dressing after chest tube insertion?

To prevent air from entering the pleural space and to protect the incision. Signup and view all the answers

Which of these is a likely step in preparing a patient for chest tube insertion?

Administering an analgesic or sedating agent. Signup and view all the answers

Following chest tube placement, which assessment finding requires immediate reporting?

Continuous bubbling in the water-seal chamber Signup and view all the answers

What is the primary purpose of observing for tidaling in the water-seal chamber?

To verify the patency of the chest tube system Signup and view all the answers

Which of the following is a critical action when managing the chest tube drainage system?

Keeping all tubing and the collection box below chest level Signup and view all the answers

A patient with a chest tube shows signs of respiratory distress. Which assessment finding is most concerning?

Use of accessory muscles during respiration Signup and view all the answers

What does the presence of subcutaneous emphysema indicate?

Air leakage in the tissues surrounding the chest tube Signup and view all the answers

What should be monitored at the chest tube insertion site? (Select all that apply)

Erythema Signup and view all the answers

After chest tube insertions, if the patient's breathing is labored, and the breath sounds are decreased, what is the priority nursing concern?

Re-accumulation of air or fluid in the chest Signup and view all the answers

Which intervention is essential to maintain a functional chest tube system?

Keeping the water seal chamber fluid at the appropriate level Signup and view all the answers

When changing a chest tube drainage collection box, what is the next step after obtaining the new box?

Connect the tube to the new system and turn on suction Signup and view all the answers

In a wet suction system, the suction pressure is regulated by which of the following?

The level of water in the suction control chamber Signup and view all the answers

What is a key visual indicator that a dry suction system is operating correctly?

The presence of an orange bellows being expanded Signup and view all the answers

Which of the following is NOT an indication for chest tube removal?

Fluid drainage has started Signup and view all the answers

What is the recommended taping method for a chest tube dressing if the tube becomes dislodged?

Tape the dressing on three sides only Signup and view all the answers

What is the primary reason for avoiding clamping, milking, or stripping a chest tube?

To avoid a significant increase in negative pressure in the lung. Signup and view all the answers

Why should the chest drainage box always be kept below the patient's chest level?

To prevent fluid from draining back into the lungs. Signup and view all the answers

When documenting chest tube drainage, what is considered a critical change that should be reported to the healthcare provider?

A sudden increase in the quantity of the drainage. Signup and view all the answers

According to the guidelines, how should the nurse manage a full chest drainage collection box?

Replace the full collection box with a new one. Signup and view all the answers

What is the purpose of keeping rubber-tipped or padded hemostats at the bedside of a patient with a chest tube?

To clamp the tube in an emergency if the drainage system is compromised. Signup and view all the answers

According to the guidelines, what position is recommended for a patient whose chest tube has been dislodged at the chest wall?

High Fowler's position to assist patient's breathing Signup and view all the answers

In the event of a chest tube dislodgement at the insertion site, why is the dressing taped on three sides only?

To allow air to escape and prevent a tension pneumothorax. Signup and view all the answers

If a chest tube becomes disconnected from the drainage system, what is the priority nursing action?

Submerge the distal end of the tube in sterile water. Signup and view all the answers

Study Notes

Chest Tubes

Chest tubes are catheters inserted through the thorax to remove air and/or fluid from the pleural space.
Purpose of chest tubes/closed chest drainage: Treat conditions that disrupt the pleural space, drain pleural cavity (air, blood, pus, lymph fluid), prevent/diminish postoperative complications (cardiac surgery), and instill fluids (chemotherapy or sclerosing agents) into the pleural space.

Indications for a Chest Tube

The potential space around the lungs is called the pleural cavity.
Under normal conditions, the pleural cavity is maintained by negative pressure, crucial for lung expansion during breathing.
When air, blood, pus, or lymph collects in the pleural cavity, negative pressure is lost, hindering lung expansion.

Overall Goal of Chest Tube Therapy

Promote lung re-expansion
Re-establish normal negative pleural space pressure
Restore adequate oxygenation and ventilation
Prevent complications

Conditions That Disrupt the Pleural Space

Pneumothorax: A collection of air in the pleural space. Loss of negative intrapleural pressure causes lung collapse.
- Primary: Occurs in the absence of lung disease or injury. Spontaneous pneumothorax is a genetic condition with unexpected occurrences in healthy individuals who develop blebs on the visceral pleura. Tall, young men are at increased risk.
- Secondary: Develops due to chest trauma (stabbing, gunshot wound, rib fractures), rupture of an emphysematous bleb, or tearing of the pleura from an invasive procedure (surgery, insertion of a subclavian line, mechanical ventilation).
Chylothorax: Lymphatic fluid accumulation in the pleural space, often from chest trauma, tumors, or surgery within the mediastinum. Milky-white pleural fluid.
Hemothorax: Blood in the pleural space, due to blunt or penetrating trauma or chest surgery. A massive hemothorax is when blood rapidly accumulates in the chest cavity, resulting from penetrating or blunt trauma that disrupts systemic vessels.
Pleural Effusion: Excessive fluid in the pleural space, caused by left ventricular failure, pulmonary embolism, pneumonia, cancer, or conditions that impede pleural fluid drainage (such as a tumor blocking the lymphatic system) or complications from surgery or fluid shifts(e.g., liver or renal failure).
Empyema: Purulent pleural fluid, potentially from a lung abscess or pneumonia.

Risks and Complications of Chest Tube Placement

Malposition: The chest tube is not in the proper space. This is the most common complication leading to persistent air or fluid in the pleural space
Bleeding: Often minor and resolves on its own. Bleeding into the lung may require surgical intervention, common during insertion.
Infection: Increases with the duration of tube placement. Sterile technique is crucial. Watch for oozing, drainage, or erythema at the insertion site. High risk category includes immunocompromised patients.
Lung Trauma and Diaphragm Perforation: During insertion, lung trauma and diaphragm perforation can occur if the chest tube is inserted too low.
Subcutaneous Emphysema: Air leaks from the pleural space into the subcutaneous tissue after chest tube placement. Tissues of the neck, face, axilla, and chest swell, and there may be crepitus on palpation.

Preparing the Patient for Chest Tube Placement

Monitor vital signs, electronic monitoring equipment
Administer analgesics or sedatives as needed
Patient positioning (sitting or lying, affected side elevated)
Arm positioning (brought over head and secured)
Area cleansing with an antiseptic solution.
Explain procedure to patient, obtain informed consent (if possible)
Provide supplemental oxygen
Local anesthetic is given to the area
A small incision is made
The chest tube is inserted and sutured to the chest wall.
Chest tube is connected to the drainage system.

Preparing a Patient for Chest Tube Placement cont.

Steps are illustrated by pictures that show incision at midaxillary line, between 4th and 5th ribs, lateral to nipple.
Clamping of a rib over vessels needs to be avoided.
Insertion site to be explored by a finger.
Using clamps, chest tube will be guided into the place.

Dependent on the Function that the Chest Tube Performs

Air Removal: Tube insertion at the mid-clavicular, second intercostal space, near the apex of the lung
Fluid Removal: Tube placement inferior and posterior in the pleural space, mid-axillary line, 7th or 8th intercostal space

Nursing Care After Chest Tube Placement - Ongoing Patient Assessments

General: Vital signs, pain, respiratory rate and pattern, respiratory status, respiratory depth, ease of respiration, oxygen saturation
Specific to Chest Tube: Assess for re-accumulation of air or fluid in the chest; decreased or absent breath sounds; signs of respiratory distress; tachypnea, dyspnea, shortness of breath, tachycardia, decreased breathing, absent breath sounds, use of accessory muscles.
Tube Insertion Site for Drainage and Signs of Infection: Drainage, erythema, subcutaneous emphysema, signs of infection (fever, elevated WBC count).

Ongoing Patient Assessments (cont)

Pain/discomfort (medicate as needed)
Subcutaneous emphysema (crackling sensation under the skin)
Skin color

Management of the Drainage System

Ensure that the dressing is occlusive, dry, and intact, secured on all 4 sides.
Maintain tubing and drainage system below chest level.
Do not let patient lie on tubing, prevent kinks and occlusions
Tightly secure all tubing connections
Observe for tidaling (fluctuation, movement up/down in the water-seal chamber as the patient breaths)
Observe for intermittent bubbling in the water-seal chamber

Management of Chest Drainage - (cont)

Do not clamp, milk, or strip the tube
Clamping to temporarily change drainage box is OK.
Do not elevate drainage box above patient's chest level.
Monitor and document drainage amount and color
Document drainage values
Assist patient with position changes, coughing, and deep breaths to facilitate fluid drainage.
Collection box to be changed if necessary for increased quantity and drainage type.

Tube Dislodgement or Disconnection

Keep rubber-tipped or padded hemostats, Vaseline gauze, dry sterile dressing, and tape at bedside.
Sterile water is also crucial.
Instructions for patient performing Valsalva Maneuver or submerge distal end of chest tube (2cm) in sterile water.
Cover insertion site with new Vaseline gauze or sterile dressing taped on 3 sides only. Taping on 3 sides only prevents tension pneumothorax
Patient positioning (High Fowler's).
Ask another nurse to contact provider

Tube Disconnected (cont)

Immediately submerge the distal end of the tube (2 cm) in sterile water for a temporary water seal.
New drainage collection box to be brought in by another nurse.
Tube connection to the new drainage box
Turn on suction system
Notify the provider

Wet and Dry Suction Systems

Wet System: Regulates suction pressure by the water column height in the suction control chamber.
Dry System: Mechanically regulates suction pressure. No water column; orange bellows are the visual indicator of suction operation.

Chest Tube Removal

Indicated when lungs are fully expanded, fluid drainage has stopped, improved chest x-rays & improved respiratory status.
Occlusive dressing (4 sides taped)
Comprehensive Respiratory Assessments
Patient Comfort
Post-removal chest x-ray is typically done.

Assisting the Healthcare Provider During Chest Tube Removal

Educate patient and provide support
Premedicate to relieve pain and reduce anxiety
Gather supplies (sterile gloves, suture removal kit, hemostats, occlusive dressing)
Position patient in semi-Fowler's and pad the area
Remove dressing and sutures
Practitioner clamps the tube
Patient performs Valsalva maneuver
Tube is quickly removed
Immediately cover wound with an occlusive dressing.

Post Chest Tube Removal Patient Care

Cover site with Vaseline gauze and an occlusive dressing (4 sides taped)
Follow up chest x-ray
Monitor wound for drainage
Comprehensive respiratory assessments

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Description

Test your knowledge on the primary functions and uses of chest tubes in medical practice. This quiz covers various conditions that necessitate chest tube insertion, as well as the physiology related to the pleural cavity. Discover key concepts related to fluid drainage and pressure maintenance in the thoracic space.