Management and Care of Chest Tubes and Drainage Systems PDF

Management and Care of Chest Tubes and Drainage Systems This comprehensive overview will explore the critical aspects of chest tube management in clinical settings. We'll begin with the fundamental pleural anatomy and physiology that underlies chest tube function, followed by detailed instruction on...

Management and Care of Chest Tubes and Drainage Systems This comprehensive overview will explore the critical aspects of chest tube management in clinical settings. We'll begin with the fundamental pleural anatomy and physiology that underlies chest tube function, followed by detailed instruction on drainage system mechanics, including wet and dry suction systems. Daily Assessment Example: Check insertion site every 4 hours for signs of infection (redness, swelling, warmth), ensure dressing is dry and intact, and verify tube position marking hasn't changed from initial placement mark Drainage Monitoring Example: Document fluid characteristics hourly - note color (serous, sanguineous, purulent), amount (in mL), and consistency. For instance, bright red drainage >100mL/hr requires immediate physician notification Troubleshooting Scenario: If sudden cessation of fluid oscillation occurs, assess for: tube kinking (straighten tubing), clots (perform gentle milking), or system disconnection (check all connections) Our evidence-based practices focus on maintaining chest tube patency, monitoring pleural fluid dynamics, and implementing timely nursing interventions. Remember: "Tidaling" (gentle fluid oscillation) indicates proper system function, while continuous bubbling may signal an air leak requiring investigation. Anatomy and Physiology of the Pleura Pleural Membranes Negative Pressure The lungs are enveloped by a double-layered The pleural space normally maintains a serous membrane called the pleura. The outer negative pressure of -3 to -5 cmH2O during parietal pleura adheres firmly to the chest wall, inspiration, which can decrease to -8 cmH2O diaphragm, and mediastinum, while the inner during forceful inspiration. This sub- visceral pleura is inseparably attached to the atmospheric pressure, combined with lung tissue. Between these two layers lies a surfactant and surface tension, creates a potential space containing 15-20mL of clear, vacuum-like effect that keeps the pleurae in straw-colored pleural fluid with a protein close apposition. Any breach in pleural content of less than 2g/dL. This fluid acts as a integrity, whether from trauma, disease, or molecular lubricant, reducing friction during iatrogenic causes, can disrupt this delicate respiratory movements. pressure gradient, leading to partial or º Clinical Example: Think of the pleural complete lung collapse (pneumothorax). layers like two wet glass slides sliding against º Clinical Example: Consider drinking from a each other. When you try to separate them, straw - the negative pressure you create pulls they resist due to surface tension - similar to the liquid upward. Similarly, the negative how the pleural membranes maintain contact. pleural pressure "pulls" the lung open. If you This principle explains why surgeons must poke a hole in your straw (like a chest wound), break this surface tension when separating the suction fails. This is exactly what happens adhesions during thoracic procedures. in a pneumothorax, where air enters the pleural space and disrupts the negative pressure, causing lung collapse. Indications for Chest Tube Insertion Pneumothorax Symptoms of Pneumothorax A pneumothorax occurs when air enters the Sharp, pleuritic chest pain, typically worse pleural space, causing lung collapse. Consider with inspiration these common scenarios: Acute onset dyspnea with respiratory distress Case 1 - Trauma: A 25-year-old male presents after a car accident with right- SpO2 below 92% on room air sided chest pain. X-ray shows 30% Tachypnea >24 breaths/minute pneumothorax, requiring immediate chest Compensatory tachycardia >100 tube placement. beats/minute Case 2 - Spontaneous: A tall, thin 19-year- Decreased or absent breath sounds on old develops sudden chest pain while affected side studying. Found to have primary Chest X-ray showing visible pleural line and spontaneous pneumothorax >20%, collapsed lung necessitating chest tube. Paradoxical chest wall movement in severe Case 3 - Tension: A 45-year-old with cases penetrating chest wound becomes rapidly unstable with deviated trachea, requiring Real-world tip: In emergency settings, emergency needle decompression remember the "3-30" rule: immediate chest followed by chest tube. tube for penetrating wounds >3cm or pneumothorax >30% on X-ray. Hemothorax and Pleural Effusion Hemothorax Pleural Effusion A hemothorax occurs when blood accumulates Pleural effusions are classified by their etiology in the pleural space, most commonly from and fluid characteristics. Transudative blunt chest trauma (70%), penetrating injuries effusions (protein 1500mL) can cause severe syndrome (5%). Exudative effusions (protein hemodynamic instability and respiratory >3.0 g/dL, LDH >200 IU/L) are seen in compromise. pneumonia (40%), malignancy (30%), and tuberculosis (10%). Clinical Example: A 45-year-old male presents after a high-speed motor vehicle Clinical Example: An 82-year-old female accident with right-sided chest pain, BP with known CHF presents with worsening 90/60, HR 120, and dull percussion on the dyspnea, bilateral crackles, and decreased right. Chest X-ray shows opacification of breath sounds at both bases. CXR shows the right hemithorax with 2cm mediastinal bilateral costophrenic angle blunting. shift. Diagnostic findings: Pleural fluid analysis Diagnostic findings: Thoracentesis yields shows clear yellow fluid, protein 2.5 g/dL, frank blood, hematocrit >50% of serum LDH 140 IU/L, confirming transudate value Chest Tube Insertion and Purpose Thoracostomy Objectives of Chest Tube Insertion Chest tube insertion (thoracostomy) is a sterile procedure performed in the "triangle of safety" Remove accumulated air or fluid - for - between the 4th and 6th intercostal space, instance, evacuating 1.5L of blood in anterior to the midaxillary line. For example, in trauma patients with hemothorax within 4 a trauma patient with a large hemothorax after hours a car accident, a 32 French chest tube would be Maintain suction at -20 cm H2O, as seen in inserted. The procedure using 10-15mL of 1-2% post-operative thoracic surgery where lidocaine typically takes 15-30 minutes. In a continuous bubbling indicates air leak recent case, a 45-year-old male with resolution spontaneous pneumothorax had immediate Restore normal pleural pressure (typically relief of dyspnea after tube placement, with -3 to -8 cm H2O) - example: young athletes 800mL of air evacuated in the first hour. with spontaneous pneumothorax usually achieve this within 24-48 hours Re-expand the lung, such as in cases of empyema where complete expansion often occurs within 3-5 days with proper drainage Types of Chest Tubes and Indications Mediastinal Chest Tubes PleurX Catheter Mediastinal chest tubes (28-32 French size) are A PleurX catheter is a small, soft silicone inserted into the mediastinum, the area catheter (15.5 French size) tunneled under the between the lungs that contains the heart, skin into the pleural space. It's specifically aorta, esophagus, and trachea. Primary indicated for malignant pleural effusions, indications include post-cardiac surgery chronic non-malignant effusions resistant to drainage (especially after CABG or valve pleurodesis, and palliative care scenarios. replacement), management of mediastinitis, Patients or caregivers can drain 500-1000ml of evacuation of hemothorax following trauma, fluid every 48-72 hours at home using vacuum and monitoring post-thoracic surgery bleeding. bottles, reducing hospital admissions. The These tubes typically remain in place for 24-48 catheter can remain in place for several hours post-surgery, unless drainage exceeds months and requires weekly dressing changes 100ml/8hrs. to prevent infection. Clinical Examples: Clinical Examples: A 65-year-old patient after coronary artery A 72-year-old with metastatic lung cancer bypass grafting (CABG) requires managing recurrent pleural effusions at mediastinal drainage to prevent cardiac home tamponade A 60-year-old with chronic heart failure A 42-year-old trauma patient with chest requiring regular pleural fluid drainage injury needs immediate evacuation of A 55-year-old in palliative care for 800ml hemothorax mesothelioma using PleurX for symptom A 58-year-old with post-operative management mediastinitis requires drainage and antibiotic therapy How a Chest Drainage System Works 1 Expiratory 2 Gravity- Positive Dependent Pressure Drainage During normal The chest drainage breathing and system must be coughing, the kept 50-100 cm patient's positive below the patient's intrathoracic chest level to pressure (20-40 maintain a pressure mmHg) forces air gradient. This and fluid through gravitational force the mediastinal or helps drain pleural pleural chest tube effusions and into the collection blood, particularly chamber. For when using a example, when a PleurX catheter for post-operative long-term drainage. CABG patient In practice, this coughs during means ensuring the incentive drainage unit is spirometry properly positioned exercises, you may at bedside - for observe increased instance, when a drainage and patient moves from bubbling in the bed to chair, the collection chamber. unit should be This pressure relocated to increases maintain proper significantly during height differential. coughing or A common error Valsalva occurs when the maneuvers, which unit is accidentally is why we often see placed too high surge of drainage during patient during these transport, leading activities. to reduced drainage efficiency. 3 Regulated Suction When needed, controlled suction (typically -10 to -20 cmH2O) can be applied to accelerate drainage. The suction level is carefully regulated through the suction control chamber to prevent excessive negative pressure that could damage lung tissue. For instance, in a patient with a large pneumothorax, you might start with -10 cmH2O suction and observe the digital air leak meter or water seal chamber for bubbling. If minimal drainage occurs, the physician may order an increase to -15 cmH2O while monitoring the patient for any chest discomfort or subcutaneous emphysema. Water Seal Chamber: Purpose and Assessment Purpose of the Water Seal Assessing the Water Seal Chamber Chamber The water seal chamber creates a one-way Maintain sterile water level exactly at the 2 valve mechanism that prevents atmospheric cm mark - just like measuring medication air and drained fluid from flowing back into the in a syringe, precision is crucial. If the level pleural space or mediastinum. Think of it like a drops to 1.5 cm, the seal is compromised; if water lock in a sink trap - water blocks sewer it rises to 3 cm, it's like trying to blow gases from coming up through your drain. The through a straw in a too-tall glass of water - chamber contains sterile water at a specific there's too much resistance level that forms an airtight seal while allowing Monitor tidaling: normal fluctuation is like air and fluid to exit through the underwater watching waves in a small pool - 2-8 cm seal when pleural pressure exceeds with quiet breathing (like gentle ripples), atmospheric pressure. For example, when a increasing to 10-15 cm with deep breathing patient coughs, you'll see bubbles in the water or coughing (like bigger waves) seal chamber as air is forced out, but when Check for air leaks by observing bubbling they inhale, the water prevents any backflow. patterns. Normal post-op bubbling is like occasional bubbles in a fish tank, while continuous bubbling (like a bubbling soda) may indicate a persistent air leak Document water level changes every 4 hours using a dedicated chest drainage flow sheet. For example, if you notice the level has dropped from 2 cm to 1.8 cm due to evaporation, immediately add sterile water to return it to the 2 cm mark Monitoring Air Leak and Tidaling Tidaling Monitoring for Air Leak Tidaling is the rhythmic fluctuation in the Bubbling in the water seal chamber indicates water seal chamber that reflects changes in an air leak, which is expected immediately pleural pressure during breathing. During post-op or with chest tube insertion. normal tidaling, the water level should rise 2-4 Assessment should include: cm with inspiration and fall with expiration. For Quantify leak on a scale of 1-7 using the air example, when observing a post- leak meter (e.g., Grade 2 = intermittent pneumonectomy patient, you might see the bubbling with coughing, Grade 5 = water level rise 3 cm when they inhale and continuous bubbling at rest) return to baseline upon exhaling. Document whether bubbling is continuous Absence of tidaling may indicate chest tube (as seen in bronchopleural fistula) or obstruction (e.g., blood clot in tube) or intermittent (common in post-surgical complete lung expansion, while excessive patients) movement (>8 cm) suggests high negative Note if bubbling increases with coughing or pleural pressure. For instance, if you observe deep breathing (e.g., bubbling increases 10 cm fluctuations in a patient who just had a from Grade 1 to Grade 3 when patient thoracotomy, this could indicate bronchial performs incentive spirometry) obstruction requiring immediate assessment. Alert physician if sudden increase in bubbling occurs (e.g., change from occasional bubbling to continuous streams of bubbles within one hour) Dry Suction Chamber: Function and Management Purpose of the Dry Suction Maintaining Dry Suction Chamber Check the suction control dial every 4 hours to The dry suction chamber creates controlled ensure it matches the physician's orders. The negative pressure to remove air and fluid from orange bellows must rise above the white the pleural space. It typically operates at -20 triangle marker to indicate proper suction. If cm H₂O to -40 cm H₂O of suction, with most the bellows drops below the marker or adult patients maintained at -20 cm H₂O. The fluctuates, check for system leaks, loose controlled suction helps prevent lung collapse connections, or inadequate wall suction and promotes re-expansion. (should be set at -80 to -120 mmHg). Document suction levels and any adjustments in the Example: A post-operative thoracic surgery patient's chart. patient would typically start at -20 cm H₂O to evacuate residual air and fluid Troubleshooting Example: If bellows drops Example: For a large pneumothorax, the below marker - check tubing for kinks, physician might order -40 cm H₂O initially, verify wall suction is at -100 mmHg, ensure then reduce to -20 cm H₂O once air all connections are tight evacuation is confirmed Documentation Example: "0800: Dry suction chamber checked. Set at -20 cm H₂O per order. Bellows above marker. Wall suction confirmed at -100 mmHg. No adjustment needed." Nursing Responsibilities for Chest Tube Care Assessment Equipment Associated Care Monitor vital signs, breath Monitoring Change dressing using sounds, and chest Inspect tubing every 2 sterile technique every 24 movement q4h. Check hours for visible kinks or hours or when soiled. insertion site for signs of dependent loops. Ensure Document drainage infection, subcutaneous all connections are secure amount, color, and emphysema, or dressing and taped. Verify suction consistency each shift. saturation. Verify dry dial settings match Educate patient about suction chamber settings physician orders (typically deep breathing exercises, and bellows position every -20 cm H₂O). Check water mobility restrictions, and shift. seal chamber for proper alarming symptoms to fluid levels and bubbling report. Example: When pattern. auscultating breath Example: When changing sounds, compare both Example: When checking dressing, use sides of the chest tubing, ensure it follows a chlorhexidine for site systematically (apex to gentle downward path cleansing and document base). Document findings from patient to collection characteristics like "no like "diminished breath chamber without any U- erythema, slight serous sounds in right lower lobe" shaped loops that could drainage amount 1cm or "clear breath sounds trap fluid. Mark fluid levels diameter." Teach patient to bilaterally." For in water seal chamber with perform 10 deep breaths subcutaneous emphysema time/date - normal tidaling with incentive spirometer assessment, palpate should show 2-3 cm every hour while awake. around insertion site - note fluctuation with breathing. Instruct to avoid lying on any crackling sensation If continuous bubbling is the tube side and to keep like "rice krispies" under observed in water seal drainage system below the skin. chamber, this indicates an chest level during air leak requiring ambulation. investigation. Chest Tube Care and Maintenance: Assessment Patient Assessment Drainage System Assessment Monitor vital signs every 4 hours (respiratory Check drainage system connections every 2 rate 12-20/min, SpO2 >95%, heart rate 60- hours. For the water seal chamber, maintain 100/min). For example, if respiratory rate exactly 2cm of water (use marking on chamber increases to >24/min or SpO2 drops below as guide). Learn to recognize normal drainage 92%, notify physician immediately. Auscultate characteristics: fresh blood is bright red, old breath sounds in all lung fields - listen for blood is darker red, and serous fluid is straw- decreased sounds on affected side or new colored. For example, sudden change from crackles/wheezing. When checking chest dark to bright red drainage could indicate new expansion, observe for asymmetry (e.g., bleeding. Normal tidaling shows 1-2cm affected side moving less than unaffected fluctuation with breathing. Concerning side). To assess for subcutaneous emphysema, bubbling patterns include: continuous gently palpate around insertion site - it will feel bubbling (large air leak) or no bubbling with like bubble wrap or Rice Krispies under the skin cough (possible tube occlusion). When setting if present. suction at -20cm H2O, verify by checking that the orange float ball is at the -20 mark on the dial. Chest Tube Care and Maintenance: Dressing and Tubing Dressing Integrity Tubing Management Monitor the sterile occlusive dressing every 4 Ensure all connections are taped and secure. hours for signs of compromise. Check for Remove any visible kinks or dependent loops moisture, drainage, or blood at insertion site. that could trap fluid. Position tubing in a gentle Assess a 10cm radius around insertion site for downward slope without excessive tension. subcutaneous emphysema (crackling Mark drainage levels hourly and document any sensation), redness, or swelling. Replace sudden changes. Keep tubing clear of bed rails dressing immediately if wet, soiled, or non- and other equipment to prevent compression. occlusive using sterile technique. Example: When transferring a patient from bed Example: If you notice the dressing edge lifting to chair, create a "relief loop" in the tubing that during morning assessment, don't wait - allows movement without pulling. A common replace it immediately. A partially detached error is having tight tubing that pulls during dressing observed at 10am led to site position changes. contamination by 2pm in one case. ✓ DO: Use two strips of tape in an "X" ✓ DO: Change dressing if you can slip a pattern at connections finger under any edge DON'T: Allow tubing to rest under the DON'T: Apply additional tape over a patient loose dressing Chest Tube Care and Maintenance: Suction and Positioning Suction Level Drainage System Positioning Maintain prescribed suction between -10 to -20 Position the drainage system 50-100 cm below cm H₂O for most adult patients, unless the patient's chest level to optimize otherwise specified. Check the suction control gravitational drainage. Secure the system to chamber every 4 hours to ensure the water seal the bed frame, not the side rail, to prevent is bubbling and the bellows are expanded to accidental dislodgement. Ensure all tubing the 2cm mark. Immediately report any sudden remains free of dependent loops or kinks that changes in suction levels or unclear bubbling could impede drainage. Keep the system in an patterns. upright position at all times, even during patient transport. Example: If you notice the bellows have dropped below 2cm at 2pm, first check all Example: When preparing for patient connections for air leaks. A common area to transport, first secure the drainage system to check is the connection point between the the bed frame using the mounted bracket. chest tube and drainage tubing - ensure the Before moving, measure from the patient's connection is properly taped. If suction chest to the system - about arm's length is problems persist after checking connections, typically correct. During transport, maintain notify the physician immediately. this position by keeping the portable suction unit on the bed's lower equipment shelf, never on the mattress or side rails. Clamping Chest Tubes: When and Why When to Clamp Reasons for Clamping Only clamp chest tubes in these specific Clamping serves specific clinical purposes: situations: To evaluate lung re-expansion before tube Prior to removal: clamp for 1-4 hours with removal respiratory assessment every 15 minutes To prevent atmospheric air entry during During drainage system changes: clamp for system changes no more than 1 minute To identify the source of an air leak in the When assessing for air leaks: temporary drainage system clamping while observing water seal To assess patient readiness for tube chamber removal During patient transport: only if specifically Warning: Never clamp a chest tube for ordered by physician extended periods without physician orders and Clinical Example: Patient Mr. Smith has had continuous monitoring. stable chest tube drainage for 48 hours with no Clinical Example: During system change, air leak. Before removal, the tube is clamped at Nurse Johnson notices continuous bubbling in 0800, with vital signs and respiratory the water seal chamber. Before replacing the assessment at 0815, 0830, 0845, and 0900. No system, she performs a systematic air leak shortness of breath or chest pain observed, assessment: 1) Clamps tube near patient 2) confirming readiness for removal. Bubbling stops, indicating leak is not from patient 3) Unclamping reveals system requires replacement. Total clamping time: 45 seconds. Chest Tube Dressing Changes: Procedure and Assessment Dressing Change Procedure Assessment During Dressing Change 1. Perform hand hygiene and don sterile gloves, gown, and procedural mask. Example: Perform systematic site assessment: Use waterless alcohol-based sanitizer or 1. Check for signs of infection: Example: Yellow- antimicrobial soap for 20 seconds. green drainage indicates infection, while 2. Remove old dressing while assessing for clear/serous drainage is normal. Temperature saturation and odor. Example: Note if drainage spike above 38.5°C with local redness suggests has soaked through or if there's a sweet/foul site infection. smell. 2. Evaluate tissue integrity: Example: Feeling 3. Clean insertion site with chlorhexidine in a rice-krispie sensation when touching skin circular motion from center outward. Example: indicates subcutaneous air. Normal tissue Use 30-second scrub with 2% chlorhexidine, should be smooth and uniform. maintaining sterile technique within 4-inch 3. Verify tube security: Example: If initial mark radius. was at 15cm at skin level, any change suggests 4. Apply split 4x4 sterile gauze around tube, migration. Check that all sutures are tight and followed by second sterile gauze layer. intact. Example: Create "butterfly" configuration with 4. Assess drainage characteristics: Example: split gauze to fully surround tube. Bright red drainage suggests active bleeding; 5. Secure with occlusive transparent dressing pink-tinged is expected initially. Continuous extending 2-3 inches beyond insertion site. bubbling in water seal chamber indicates air Example: Use extra-large transparent dressing leak. (typically 8x10 inch) to ensure complete seal. Documentation Tip: Record exact Change dressing every 24 hours or immediately measurements like "2cm area of redness" if compromised. Example: Replace if patient rather than just "redness noted." sweating heavily causes edge lifting. Subcutaneous Emphysema: Assessment and Cause Subcutaneous Emphysema Assessing for Subcutaneous Emphysema Subcutaneous emphysema occurs when air escapes into the subcutaneous tissue, During each dressing change, systematically commonly due to chest tube complications palpate in a 6-inch radius around the insertion such as dislodged eyelets from the pleural site using these steps: 1) Place your gloved space, tube migration, or improper positioning. fingers flat against the patient's skin, 2) Apply For example, if a patient's chest tube marking gentle pressure with your fingertips in a changes from 15cm to 17cm at the skin level, systematic circular pattern, starting at the this suggests tube migration. Another common insertion site, 3) Note any areas where you feel scenario is when chest tube eyelets become or hear crackling. The characteristic crackling positioned against the chest wall instead of or crepitus sensation (similar to pressing on within the pleural space. The condition can bubble wrap or running your fingers through extend from the chest wall into the neck, face, rice krispies) indicates trapped air in the tissue. and abdomen if left untreated - for instance, a Document specific findings, such as "crepitus patient may notice swelling around their neck present 4cm superior and 3cm lateral to or difficulty buttoning their shirt collar. insertion site" rather than just "crepitus Immediate notification to the provider is present." Also note practical symptoms like required if detected. "patient reports new difficulty lying flat" or "increased tightness when turning head to right side." Chest Tube Dressing Change: Technique and Materials Sterile Technique Materials Use strict sterile technique throughout the Required materials include: sterile gloves, entire dressing change procedure. Begin by mask, and gown; chlorhexidine solution for performing hand hygiene and donning sterile cleaning; Jelonet or petroleum gauze for site gloves. Create a sterile field using a barrier occlusion; split 4x4 drain sponges; regular 4x4 drape. Clean the insertion site with gauze for padding; transparent semi- chlorhexidine in a circular motion from center permeable dressing or paper tape for securing; outward. Maintain sterility of all supplies and and clean disposal bag for old dressing. the chest tube site throughout the procedure. Practical Step-by-Step Example Setup (2-3 minutes) 1 Position all materials on sterile field: - Place sterile drape on bedside table - Arrange supplies in order of use - Pour chlorhexidine into sterile cup Site Cleaning (3-4 minutes) Demonstrate circular cleaning technique: - Start directly at tube insertion - Work 2 outward in 4-inch diameter - Use 3 separate chlorhexidine swabs - Allow 30 seconds to dry Dressing Application (4-5 minutes) 3 Layer materials in this order: - Split drain sponge around tube - Petroleum gauze at insertion - 4x4 gauze for padding - Secure with transparent dressing Final Check (1-2 minutes) 4 Verify proper application: - Dressing fully sealed - Tube properly secured - No kinks in tubing - Site visible through dressing Changing the Chest Drainage System When to Change Step-by-Step Procedure Change the drainage system in these specific Preparation: Set up new drainage system situations: with sterile water exactly at 2cm mark (use measuring tape to verify) Collection chamber reaches 2/3 full Safety First: Apply clean gloves and mask. (Example: If morning check shows 1800mL Position patient at 30-45 degrees semi- in a 2000mL chamber) Fowler's Visible contamination (Example: Blood Critical Steps: - Place first clamp 6 inches clots in tubing or visible bacterial growth) from patient's chest - Place second clamp 3 Water seal drops below 2cm (Example: inches from first clamp Example: Like During evening rounds, water level closing off a garden hose with two clips measures 1.8cm) Connection: - Disconnect old system (takes Real-world scenario: If during your 2PM ~5 seconds) - Scrub connector with assessment you notice the collection chamber chlorhexidine (count to 30) - Connect new contains 1900mL and the next assessment isn't system (should take less than 10 seconds) until 6PM, change the system now rather than Verification: Ask patient to cough or take risking overflow. deep breath - you should see gentle bubbling in water seal chamber Documentation of Chest Tube Care Documentation Items Charting Drainage Document chest tube care every 4 hours and Mark drainage levels on collection chamber PRN including: dressing integrity and last q4h using permanent marker. Note date, time, change date, suction level (maintain at -20 cm and your initials. Record cumulative 24-hour H2O unless ordered otherwise), drainage on I/O sheet at 0700. For significant presence/absence of bubbling in water seal changes (>100 mL/hr), notify physician chamber, extent of subcutaneous emphysema immediately. Document color changes or (measure area in cm), and drainage sudden increases in output. Include drainage characteristics (serous, serosanguineous, or position (e.g., "Patient drainage at 450 mL, bloody). Note patient's pain level using 0-10 marked at 3rd gradation line at 1400"). scale and respiratory status. Example 24hr documentation: "0700: Example entry: "Dressing intact, dry and Previous 24hr output = 350mL. Chamber occlusive. Last changed 5/15 @ 0800. markings: 0700(150mL/JD), Suction at -20 cm H2O, consistent bubbling 1100(+50mL/JD), 1500(+75mL/JD), in water seal. No subcutaneous 1900(+45mL/JD), 2300(+30mL/JD), emphysema noted. Drainage 0300(+50mL/JD)" serosanguineous. Pain 2/10 at rest. RR 16, Example urgent note: "1345: Sudden SpO2 98% on RA." increase in drainage noted - 150mL in past hour, changed from serosanguineous to bright red. MD notified, new orders received." Troubleshooting Common Chest Tube Issues Common Issues Troubleshooting Steps Key chest tube issues include continuous First assess the drainage system systematically: bubbling in water seal chamber indicating an 1) Check all connection points using a air leak (e.g., constant bubbling at rest that clockwise inspection pattern - verify tight fit at increases with coughing), water level falling insertion site, drainage ports, and suction port. below 2 cm mark compromising seal 2) For water levels, use sterile water/saline to effectiveness (should maintain 2-3 cm depth), refill chambers to marked lines (e.g., 2 cm in and suction control chamber not maintaining water seal, 20 cm in suction control). 3) To -20 cm H₂O. Watch for visible kinks in tubing, identify air leaks, apply soapy water solution especially at patient's side rail or when tubing with cotton swab to each connection - bubbles loops below chest level. Example: Patient indicate leak site. 4) For suction issues, confirm turning in bed may create dependent loops wall suction gauge reads -80 to -120 mmHg causing fluid backup. before adjusting drainage unit. Document specific findings like "Air leak identified at connection between chest tube and drainage tubing, sealed with tape reinforcement at 1430." Monitoring for Potential Complications Tension Pneumothorax Infection and Hemorrhage Assess every 2 hours for signs of tension Monitor insertion site q4h for signs of infection: pneumothorax: asymmetric chest expansion redness extending >2cm from insertion site, (paradoxical movement), tracheal deviation to warmth, swelling, foul odor, or purulent opposite side, absent/decreased breath drainage. Check drainage output q1h - notify sounds on affected side, BP dropping below provider immediately for bloody output >100 90/60 mmHg, SpO2 falling under 92%, mL/hr for 2 consecutive hours, sudden change circumoral cyanosis, and sharp pleuritic chest from serous to sanguous drainage, or clots in pain. Document respiratory rate (normal range tubing. Maintain strict sterile technique during 12-20/min) and work of breathing. dressing changes to prevent infection. Example: If during assessment you notice the Example: If at 0800 you notice 120mL of bright right side of the chest isn't moving with breaths red drainage and at 0900 there's another while the left side is moving excessively, along 110mL, document exact amounts and time: with the trachea deviating to the left and BP "0800: 120mL bright red drainage noted, MD reading 85/55 mmHg, these are immediate red notified. 0900: Additional 110mL bright red flags requiring physician notification. drainage, totaling 230mL in 2 hours." For Document findings as: "Right chest with infection monitoring, measure and document minimal expansion, left chest hyperexpanded, the exact diameter of any redness, e.g., "2.5cm tracheal deviation to left noted at 1400, BP area of erythema noted at 3 o'clock position 85/55, SpO2 88% on RA." relative to insertion site." Chest Tube Dislodgement: Recognition and Management Recognition of Dislodgement Immediate Management Watch for key indicators of chest tube 1. Immediately apply petroleum gauze and dislodgement: sudden air leak around sterile occlusive dressing over the site (like insertion site (e.g., bubbling sound when covering a straw hole in a drink cup to prevent patient coughs), audible sucking sound (similar air entry). 2. Position patient on affected side to air escaping from a tire), visible tube (e.g., if right chest tube dislodged, place migration (original marked position at skin has patient on right side). 3. Administer oxygen as moved >2cm), and increased subcutaneous needed - typically start with 4L/min via nasal emphysema (feels like Rice Krispies under the cannula and titrate to maintain SpO2 >95%. 4. skin when palpated). For example, a patient Contact physician STAT and prepare who was previously stable may suddenly emergency equipment including new chest report sharp chest pain when turning in bed, tube kit (size 28-32Fr for adults), sterile accompanied by SpO2 dropping from 98% to dressing sets, and local anesthetic (typically 92%. The collection chamber's water seal 10mL of 1% lidocaine). Monitor vital signs chamber may show decreased or absent every 15 minutes - for instance, if BP drops oscillation where it was previously swinging 2- from 120/80 to 100/60, or if respiratory rate 3cm with breathing. increases from 18 to 28, notify physician immediately. Removing the Chest Tube: Preparation and Procedure Preparation Procedure Gather essential supplies: sterile gloves, mask, 1. Loosen all securing sutures except the and gown; sterile occlusive petroleum gauze anchoring suture. 2. Instruct patient to perform dressing; 2-0 silk suture for closing; multiple Valsalva maneuver or exhale slowly. 3. Clamp 4x4 sterile gauze pads; tape; clean scissors; and tube for 1-2 minutes to ensure no respiratory hemostats. Position patient in semi-Fowler's compromise. 4. During patient's exhalation, position (30-45 degrees). Perform hand quickly remove tube while assistant hygiene and don personal protective immediately covers site with petroleum gauze. equipment. 5. Quickly tie anchoring suture. 6. Apply pressure dressing. Practical Example: When preparing supplies, arrange them in order of use on your sterile Clinical Tips: For the Valsalva maneuver, ask field - for instance, place gloves and PPE at the patient to "bear down like you're blowing up a front, followed by removal supplies, then balloon" or "exhale like you're blowing out dressing materials. This proven arrangement birthday candles." When removing the tube, helps prevent contamination and saves critical use a smooth, steady motion at a 45-degree time during the procedure. angle - imagine "following the natural curve of the chest wall." For pressure dressing, use the "palm-width rule": ensure dressing extends one palm-width beyond the insertion site in all directions. Post-Chest Tube Removal: Patient Monitoring and Care Monitoring Care Check vital signs every 15 minutes for first Position patient properly - for example, use 2-3 hour, then hourly for 4 hours. For example: pillows to achieve the correct 30-45 degree angle. When checking pressure dressing, it Normal blood pressure range: 120/80 should feel firm but not tight enough to restrict mmHg (report if >140/90 or