Chest Tubes PDF

Chest Tubes NURS1250  Course Student Learning Outcomes 1250: Provide safe, patient-centered, evidence-based nursing care to adults experiencing stable and unstable acute and chronic illness guided by the Caritas philosophy...

Chest Tubes NURS1250  Course Student Learning Outcomes 1250: Provide safe, patient-centered, evidence-based nursing care to adults experiencing stable and unstable acute and chronic illness guided by the Caritas philosophy Demonstrate intermediate levels of critical thinking and clinical reasoning strategies to provide quality patient care.  Concepts  Oxygenation  Infection  Comfort  Managing Care  Clinical Decision Making  Safety  Teaching and Learning Content Competencies Use the nursing process to deliver patient-centered nursing care to diverse adult Use populations experiencing stable and unstable acute and chronic health alterations Identify factors that create a culture of safety to reduce/eliminate risk or harm for Identify the adult population with diverse healthcare problems. Describe the rationale used to make clinical judgments and decisions that ensure Describe accurate and safe care of the individual patient. Describe the rationale used in determining priorities of patient care based on the Describe nursing process. Discuss Discuss the nursing management of patients experiencing closed chest drainage.  What is a Chest Tube? A chest tube is a catheter inserted through the thorax to remove air and/or fluids from the pleural space. What is the Purpose of a Chest Tube/Closed Chest Drainage Chest tubes are used Drains the pleural Can also be used to Can be used to instill to treat conditions cavity of air, blood, prevent or diminish fluids into the pleural that disrupt the pus, or lymph fluid post op space pleural space complications (Chemotherapy or (cardiac surgery) sclerosing agents) Indications for a  The potential space around Chest Tube the lungs is called the pleural cavity.  Under normal conditions, the pleural cavity is maintained by negative pressure, which is important for ensuring lung expansion with deep inspiration.  When air, blood, pus or lymph collects in the pleural cavity, negative pressure is lost and lung expansion is restricted.  Promote lung re-expansion Overall Re-establish normal negative pleural space pressure Goal of Chest Tube Restore adequate oxygenation and ventilation therapy Prevention of complications  Conditions That Disrupt the Pleural Space Pneumothorax  A collection of air in the pleural space  There is loss of negative intrapleural pressure, causing the lung to collapse.  Causes:  Primary (Occurs in the absence of lung disease or injury) Spontaneous pneumothorax is a genetic condition that occurs unexpectedly in health individuals who develop blebs (blister-like formations) on the visceral pleura. Tall, young men are at increased risk.  Secondary 1. Chest trauma (stabbing, gunshot wound, rib fracture) 2. Rupture of an emphysematous bleb 3. Tearing of the pleura from an invasive procedure (surgery, insertion of a subclavian line, mechanical ventilation  Conditions That Disrupt the Pleural Space Chylothorax Hemothorax Lymphatic fluid accumulation in the pleural space, as Blood in the pleural space, as from chest trauma, from blunt or penetrating an expanding tumor, or surgery within the trauma or chest surgery. A mediastinum. It is massive hemothorax occurs milky-white pleural when blood accumulates fluid. rapidly in the chest cavity; most often, it stems from penetrating or blunt trauma that disrupts systemic vessels.  Conditions That Disrupt the Pleural Space Pleural Effusion Empyema Excessive fluid in the pleural space. Causes: Purulent pleural fluid, which may be  Left ventricular failure associated with a  Pulmonary embolism lung abscess or  Pneumonia pneumonia.  Cancer,  Conditions that impede pleural fluid drainage (such as a tumor that blocks the lymphatic system)  It also may arise as a complication of surgery or fluid shifts, as in liver or renal failure.  Risks and Complications of Chest Tube Placement Malposition Bleeding  The chest tube is not in the  Often minor and resolves on its proper space. own.  Most common during insertion  The most common complication, resulting in persistent air or fluid in the  Bleeding into the lung may pleural space. require surgical intervention.  The chest tube will need to be  Pay special attention to repositioned patients on anticoagulation therapy or with a clotting disorder  Risks and Complications of Chest Tube Placement cont. & Lung trauma Infection perforation of the  Increases with duration of tube diaphragm placement  During insertion if the chest tube is inserted too low.  Sterile technique is essential for placement  Watch for oozing, drainage or erythema at insertion site  High risk category are those that are immunocompromised  Risks and Complications of Chest Tube Placement cont. Subcutaneous emphysema With Without  Air leaks from the pleural space into the subcutaneous tissue after a chest tube placement.  Tissues of the neck, face, axilla and chest swell.  There may be crepitus (crackling) on palpation  If severe can cause compression of the upper airway and jugular venous distention Preparing Patient for Chest Tube Placement  Chest tubes can be placed  Monitor the patient (vital in the Emergency room, signs, electronic patient bedside or in the operating room. monitoring equipment)  The tube is inserted by a  An analgesic or sedating properly trained health care agent may be given provider  Patient is placed in sitting  Registered nurses assist with the procedure or lying position, with  Explain procedure to affected side elevated. patient. Informed consent The patient’s arm is should be obtained, if brought over the head and possible. secured.  Provide supplemental  Area is cleansed with an oxygen antiseptic solution  Preparing Patient for Chest Tube Placement cont.  A local anesthetic is given to the area  A small incision is made and the chest tube is inserted.  The chest tube is sutured to the chest wall  The insertion site is covered with an occlusive dressing  The chest tube is connected to the drainage system  Chest Tube Dependent on the Placement function that the chest tube performs  If the function of the tube is to remove air, the chest tube is most commonly inserted at the mid- clavicular, second intercostal space, near the apex of the lung.  If the function of the tube is to remove fluid, the chest tube is placed inferior and posterior in the pleural space, mid-axillary line, 7th or 8th intercostal space. Documentation after Initial Chest Tube Placement  Vital signs before and  Were cultures sent. after the procedure.  How did the patient  Chest tube size and tolerate the procedure. insertion site.  Medications given.  Physician inserting the  Results of the chest x- chest tube. ray post chest tube  Drainage present: type insertion. and amount  Patient and family  Type of drainage teaching. system and the ordered suction pressure  Nursing Care After Chest Tube Placement Ongoing Patient Assessments SPECIFIC TO CHEST TUBE GENERAL  Assess for any manifestations of re-  Vital signs accumulation of air and fluid in the chest  Pain  Decreased or absent breath sounds  Respiratory rate and  Signs of respiratory distress pattern  Tachypnea  Respiratory status  Dyspnea  Respiratory depth  Shortness of breath  Ease of respiration  Tachycardia  Oxygen saturation  Decreased  Absent breath sounds  Use of accessory muscles  Nursing Care After Chest Tube Placement Ongoing Patient Assessments cont.  Inspect the chest tube insertion site for drainage, erythema, subcutaneous emphysema  Look for signs of infection (fever, increased WBC)  Pain/discomfort (medicate as needed)  Check for subcutaneous emphysema (crackling sensation under the skin during palpation)  Skin color  Nursing Care After Chest Tube Placement Management of the Drainage System Follow (assess) the tubing from the insertion site to the box  Ensure that the dressing is occlusive, dry and intact  Secured on all 4 sides of dressing  Keep all tubing and collection box, below chest level (No dependent loops  Do not let patient lie on tubing. No kinks or occlusions  Ensure all tubing connections are tightly secured Nursing Care After Chest Tube Placement Management of Chest Drainage  Observe for tidaling (should see)  Tidaling – fluctuation (movement up/down) of the fluid in the water-seal chamber as the patient breaths  Observe for intermittent bubbling in the water-seal chamber (should see)  This indicates the system is removing air from the pleural  *Continuous bubbling (shouldn’t see) indicates an air leak in the system (REPORT)  Keep the water seal chamber fluid at the appropriate level. Add sterile water as needed, due to evaporation. Nursing Care After Chest Tube Placement Management  of Chest Drainage Do not clamp the tube, milk or strip the tube.  This can cause a significant increase in negative pressure in the lung. Clamping may result in a tension pneumothorax.  Clamping the tube momentarily to change the collection box is acceptable  Never elevate the drainage box above patient’s chest level (will cause fluid to drain back into lungs) Nursing Care After Chest Tube Placement Management of the Drainage System  Monitor and document the amount and color of the drainage  Clearly mark the drainage level on the collection box with date and time.  Document values into output. (Any sudden change in the quantity and characteristics of the drainage should be reported to the provider)  Expectation is that the amount of drainage will decrease over time  Assist patient to:  Change positions/cough and deep breath  helps re-expand the lung and promote fluid drainage  NEVER TRY TO EMPTY THE COLLECTION BOX. IF THE COLLECTION CHAMBERS ARE FULL, A NEW COLLECTION BOX IS REQUIRED.  Tube Dislodgement or Disconnection Emergency Equipment at Bedside  Keep rubber tipped or padded hemostats at bedside  Vaseline gauze  Dry sterile dressing  Tape  Sterile water  Tube Dislodgement The chest tube comes out of the patient at the chest wall What should the nurse do?  Instruct the patient to perform the Valsalva maneuver  At the end of expiration immediately cover the insertion site with a new Vaseline gauze and a dry sterile dressing taped on 3 sides only (the dressing on the image would be removed)  Taping on 3 sides reduces the likelihood of a tension pneumothorax by preventing air from entering the wound during inhalation but allowing air to escape during exhalation  Taping on 3 sides is ONLY if the tube has become dislodged at the chest wall  Keep patient in a high Fowlers position.  Stay with the patient  Ask another nurse to contact the provider Tube Disconnected: The chest tube becomes disconnected from the tubing connected to the box What should the nurse do?  Immediately submerge the distal end of the tube (2 cm) in sterile water. This creates a temporary water seal.  Stay with the patient. Assess vital signs  Ask another nurse to bring you a new drainage collection box. Do not connect back to the old collection box.  Set up the new box, connect the tube to the system, and turn on the suction.  Notify the provider  Wet and Dry Suction Systems Wet Suction System: Water level is usually placed at -20 cm of pressure Wet suction control systems regulate suction pressure by the height of the column of water in the suction control chamber.  Wet and Dry Systems Dry Suction System  Dry suction control systems regulate suction pressure mechanically  There is not a suction column to put water  Since there is no bubbling in the dry suction control chamber, the orange bellows are used as a visual indicator of suction operation.  Wet Suction Water Seal Dry Suction Water Seal  Chest Tube Removal Indications for removing the chest tube  When lungs are fully expanded  Fluid drainage has ceased  Improved chest x-ray  Improved respiratory status PLEASE NOTE: Chest Tube Dressings 1. The dressing should be occlusive (secure on all 4 sides) when the chest tube is in the patient and after the chest tube is discontinued by the healthcare provider. 2. The dressing should be taped on 3 sides only if the chest tube becomes dislodged (comes out) from the patient in an emergency situation. This allows air trapped in the pleural space to be expelled  Chest Tube Removal Assisting the Healthcare Provider  Educate the patient and provide support  Premedicate to relieve pain and reduce anxiety  Gather supplies (sterile gloves, suture removal kit, hemostats, occlusive dressing)  Place patient in a semi-fowlers position and pad the area.  Remove dressing and cut sutures  Practitioner clamps the chest tube  Have patient perform Valsalva maneuver and the tube is quickly removed  Immediately cover with occlusive dressing  Post Chest Tube Removal Patient Care  Site is covered with a Vaseline gauze and an occlusive dressing (4 sides taped)  The pleura will seal itself off and the wound will heal within a few days  Chest x-ray is done after removal to evaluate any re- accumulation of air or fluid  Observe the wound for drainage  Ongoing, comprehensive respiratory assessments for signs of respiratory distress.  Assess patient’s comfort level, medicate for discomfort as needed.