OXYGENATION PDF - Fundamentals of Nursing

OXYGENATION Fundamentals of Nursing NCM 112 Skills JS Wilce P. Rey, MANc, RN Structure and Function  STRUCTURE Upper Respiratory System Mouth Nose Pharynx Larynx STRUCTURE Lower Respiratory System Trachea and lungs Bronchi...

OXYGENATION Fundamentals of Nursing NCM 112 Skills JS Wilce P. Rey, MANc, RN Structure and Function  STRUCTURE Upper Respiratory System Mouth Nose Pharynx Larynx STRUCTURE Lower Respiratory System Trachea and lungs Bronchi Bronchioles Alveoli Capillary network Pleural membranes  FUNCTION 1. Pulmonary Ventilation 2. Alveolar Gas Exchange 3. Transport of Oxygen and Carbon Dioxide Factors Affecting Respiratory Function ✓ Age ✓ Environment ✓ Lifestyle ✓ Health Status ✓ Medications ✓ Stress Alterations in Respiratory Function Hypoxia Altered Breathing Patterns ✓ Eupnea ✓ Cheyne-Stokes ✓ Tachypnea respirations ✓ Bradypnea ✓ Biot’s (cluster) respirations ✓ Apnea ✓ Orthopnea ✓ Kussmaul’s breathing ✓ Dyspnea Obstructed Airway ✓Stridor ✓Adventitious breath sounds Oxygenation Oxygen Therapy ✓ Prescribed by a primary care provider to prevent hypoxia in clients who Have difficulty ventilating all areas of their lungs Have with impaired gas exchange Have heart failure ✓ In case of emergency, the nurse may initiate therapy Oxygen Therapy Safety Precautions ✓ Smoking near the patient or oxygen equipment is prohibited. ✓ Place a “No Smoking: Oxygen in Use” on client’s door, foot or head of bed, and on oxygen equipment. ✓ Instruct client and visitors about hazards of smoking. ✓ Make sure electric devices are properly working to prevent short-circuit sparks. Oxygen Therapy Safety Precautions ✓ Avoid materials that generate static electricity. ✓ Avoid the use of volatile, flammable materials near clients. ✓ Be sure that electric monitoring equipment and portable diagnostic machines are all electrically grounded. ✓ Know the location of fire extinguishers. Administering Oxygen Therapy Oxygen Delivery Systems ✓ Depends on client’s oxygen needs, comfort, and developmental considerations ✓ Flow rate (liters per minute) and percentage of inspired oxygen (FiO2) determines amount of oxygen delivered NASAL CANNULA ✓ Nasal prongs; most common and inexpensive ✓ Easy to apply; does not interfere with ability to eat or talk ✓ Relatively comfortable, permits some freedom of movement ✓ Delivers low concentration (24% to 45%) at 2-6 lpm NASAL CANNULA PURPOSES: ✓ Deliver relatively low concentration of oxygen when only minimal O2 support is required ✓ Allow uninterrupted delivery of oxygen while the client ingests food or fluids FACE MASK ✓ Cover the client’s nose and mouth ✓ Exhalation ports on the sides of the mask allow exhaled carbon dioxide to escape Simple face mask- 40-60% at 5-8 lpm Partial rebreather mask- 60-90% at 6-10 lpm; recycles 1/3 of exhaled air Nonrebreather mask- 95-100% at 10-15 lpm; one- way valve Venturi mask- 24-40 to 50% at 4-20 lpm; color- coded adapter (blue-24% at 4 lpm, green-35% at 8 lpm) FACE MASK PURPOSES: ✓ Provide moderate oxygen support and a higher concentration of oxygen and/or humidity than is provided by cannula FACE TENT ✓ Used when masks are poorly tolerated by clients ✓ Provide varying concentrations of oxygen (30- 50% at 4-8 lpm) FACE TENT PURPOSES: ✓ Provide high humidity ✓ Provide oxygen when a mask is poorly tolerated ✓ Provide a high flow of oxygen when attached to a Venturi system Administering Oxygen ASSESSMENT Skin and mucous membrane color Breathing patterns Chest movements Chest wall configuration Lung sounds Presence of hypoxemia, hypercarbia, oxygen toxicity Administering Oxygen DETERMINE Vital signs Whether the client has COPD Chest x-ray results Blood studies Oxygen saturation levels ABGs Pulmonary function tests  Administering Oxygen EQUIPMENT Oxygen supply with a flow meter and adapter Humidifier Oxygen delivery device and tubing Tape Padding for elastic band  Administering Oxygen IMPLEMENTATION Preparation: 1. Determine the need and verify the order for oxygen therapy. Perform respiratory assessment. 2. Prepare the client and support people. Assist client to a semi-Fowler’s position if possible. Inform the client and support people about safety precautions. Administering Oxygen IMPLEMENTATION Performance: 1. Introduce self and verify the client’s identity. Explain the procedure. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. Administering Oxygen IMPLEMENTATION Performance: 4. Set up oxygen equipment and the humidifier. Attach flow meter to wall outlet or tank. Make sure it is in the OFF position. Fill the humidifier bottle. Attach humidifier bottle to base of flow meter. Attach prescribed oxygen tubing and delivery device to humidifier.  Administering Oxygen IMPLEMENTATION Performance: 5. Turn on the oxygen at the prescribed rate and ensure proper functioning. Check that oxygen is flowing freely through the tubing (no kinks, connections are airtight, bubbles are present in the humidifier, oxygen is felt at the outlet of the device). Set the oxygen at the flow rate ordered. 6. Apply the appropriate oxygen delivery device.  Administering Oxygen Cannula Put the cannula over the client’s face, fitting the prongs into the nares and elastic band around the head. Pad the tubing and band over the ears and cheekbones as needed.  Administering Oxygen Face Mask Guide the mask toward the client’s face, and apply it from the nose downward. Fit the mask to the contours od the client’s face. Secure the elastic band around the client’s head. Pad the band behind the ears and over bony prominences.  Administering Oxygen Face Tent Place the tent over the client’s face, secure the ties around the head.  Administering Oxygen IMPLEMENTATION Performance: 7. Assess the client regularly. Vital signs, level of anxiety, color, and ease of respirations. After 15 to 30 minutes, depending on condition. Clinical signs of hypoxia, tachycardia, confusion, dyspnea, restlessness, and cyanosis. Review oxygen saturation or ABG results.  Administering Oxygen Cannula Assess nares for encrustations and irritation. Apply water-soluble lubricant as required to soothe the mucous membranes. Face Mask or Tent Inspect the facial skin frequently for dampness or chafing, and dry and treat as needed.  Administering Oxygen IMPLEMENTATION Performance: 8. Inspect equipment on a regular basis. Check liter flow and level of water in humidifier every 30 minutes and whenever providing care. Be sure that water is not collecting in dependent loops of the tubing. Make sure safety precautions are being followed. 9. Document findings in the client record.  Administering Oxygen EVALUATION 1. Perform follow-up based on findings that deviated from normal. 2. Report significant deviations from normal. Performing Chest Physiotherapy  PERCUSSION Sometimes called “clapping” Forceful striking of the skin with cupped hands Fingers and thumb are held together and flexed slightly to form a cup (as if scooping water) Cupped hands trap the air against the chest; trapped air sets up vibrations through the chest wall to the secretions VIBRATION Series of vigorous quivering produced by hands that are placed flat against the client’s chest wall Used after percussion to loosen thick secretions  POSTURAL DRAINAGE Drainage by gravity of secretions from various lung segments Wide variety of positions is necessary to drain all segments of the lungs; only those positions that drain specific affected areas are used May be given a bronchodilator medication or nebulization therapy prior to loosen secretions  STEPS 1. Help the patient assume the appropriate position based on the lung field that requires drainage: Apical areas of upper lobe: Sit at the edge of the bed. Place a pillow at the base of the spine for support. Place in high Fowler’s if unable to sit at edge of bed. Posterior section of the upper lobes: Supine position with pillow under hips and knees flexed. Rotate slightly away from side that requires drainage. STEPS Middle or lower lobes: Place bed in Trendelenburg position; place patient in Sim’s position. Posterior lower lobes: Keep the bed flat, position patient prone with a pillow under his stomach. 2. Let the patient remain in desired position for 10 to 15 minutes.  STEPS 3. Perform percussion over the affected lung area while the patient is in desired position: Promote relaxation by instructing the patient to breathe deeply and slowly. Cover the area to be percussed with a towel or patient’s gown. Avoid clapping over bony prominences, female breasts, or tender areas. Cup the hands, with fingers flexed and thumbs presses against the indexed fingers. Place cupped hands over lung area requiring drainage; percuss for 1-3 minutes by alternately striking cupped hands rhythmically against the patient.  STEPS 4. Perform vibration while the patient is in desired position: Place the flat surface of one hand over the lung area that requires vibration; place the other hands on top of that hand at a right angle. Instruct patient to inhale slowly and deeply. Instruct the patient to make an “fff” or “sss” sound as he exhales. As the patient exhales, press the fingers and palms firmly against the patient’s chest wall and gently vibrate with the hands over the lung area. Continue performing vibrations for 3 exhalations. STEPS 5. Allow the patient to sit up. Have him cough at the end of deep inspiration. Suction if unable to expectorate secretions. 6. If a sputum specimen is needed, collect it in a specimen container. 7. Repeat steps 1 through 5 for each lung field that requires treatment. 8. Entire treatment should not exceed 60 minutes. 9. Provide mouth care. Performing Tracheostomy Care  TRACHEOSTOMY An opening into the trachea through the neck; done for clients who need long-term airway support A tube is inserted through the opening and an artificial airway is created Components of tracheostomy tube: Outer cannula with flange Inner cannula Obturator STEPS 1. Identify the patient. 2. Assess overall respiratory status and tracheostomy site. 3. Explain the procedure. 4. Perform hand hygiene. 5. Adjust bed to comfortable working position. 6. Put on PPE. STEPS 7. Place the patient in semi-Fowler’s position and place a small, rolled towel under the patient’s shoulders to expose the neck. 8. Place a towel or linen-saver pad over the patient’s chest. 9. Don sterile gloves, or use clean technique. 10.Suction the tracheostomy if there is a need for airway clearance. STEPS 11.Remove and discard soiled tracheostomy dressing in biohazard receptacle; remove and discard gloves. 12.Place tracheostomy care equipment on the over-the- bed table and prepare equipment using sterile technique. Pour hydrogen peroxide and normal saline solution in separate sterile containers Open three 4x4 gauze packages; wet 1 with hydrogen peroxide, 1 with normal saline, keep the other one dry STEPS Open 2 cotton-tipped applicator packages. Wet one package with normal saline and the other with hydrogen peroxide. Open package containing a new disposable inner cannula. Open package of Velcro tracheostomy ties or cut a length of twill tape long enough to go around the patient’s neck two times. Cut end of tape on an angle.  STEPS 13.Don sterile gloves (or sterile on dominant and clean on non- dominant hand); keep glove on dominant hand sterile. Handle sterile supplies with dominant hand only. 14.Remove oxygen source using non-dominant hand if patient has been receiving supplemental oxygen. STEPS 15.Unlock and remove the inner cannula with the nondominant hand and care for it accordingly: Disposable inner cannula: dispose of the inner cannula in the biohazard receptacle according to agency policy Reusable inner cannula: place the inner cannula into the basin filled with hydrogen peroxide 16.Attach oxygen source to the outer cannula if possible. STEPS 17. Care for the inner cannula: Disposable inner cannula: Pick up the new disposable inner cannula, holding it by the outer locking portion Reusable inner cannula: Pick up reusable inner cannula from container of hydrogen peroxide and scrub it with sterile nylon brush, using dominant hand Immerse inner cannula in normal saline and rinse thoroughly Tap inner cannula against side of container STEPS 18.Remove oxygen source using non-dominant hand (if patient can tolerate temporary interruption; otherwise, apply oxygen blow- by as tolerated) and reinsert inner cannula into the patient’s tracheostomy in the direction of the curvature. 19.Following manufacturer instructions, lock the inner cannula in place securely. 20.Reattach the oxygen source if indicated. STEPS 21.Clean the stoma under the faceplate with the cotton-tipped applicators saturated with hydrogen peroxide, using a circular motion from the stoma site outward. 22.Use each applicator only once and then discard it. 23.Clean the top surface of the faceplate and the skin around it with gauze pads saturated with hydrogen peroxide. Use each gauze pad once and then discard. STEPS 24.Repeat steps 15, 16, and 17 using cotton-tipped applicators and gauze pads saturated with normal saline. 25.Dry the skin and outer cannula surfaces by patting them lightly with the remaining dry gauze pads. STEPS 26. Remove soiled tracheostomy stabilizers: Velcro tracheostomy holder With an assistant stabilizing the tracheostomy tube, disengage the Velcro on both sides of the soiled holder and remove it gently from the eye of the faceplate Discard the Velcro holder in the nearest biohazard receptacle Twill tape tracheostomy holder With an assistant stabilizing the tracheostomy tube, cut ties with bandage scissors Remove ties gently from eyes of faceplate and discard STEPS 27. Have the patient flex his neck and apply new stabilizers: Velcro tracheostomy holder Unfasten Velcro and thread one end of the tracheostomy holder through the eyelet of the faceplate and fasten the Velcro Bring the holder around the back of the neck and thread remaining end of holder through empty eyelet and fasten the Velcro Place one finger under the holder to make sure holder is securing tracheostomy effectively, but is not too tight STEPS Twill tape tracheostomy holder Thread one end of the twill tape into one of the eyelets of the tracheostomy faceplate, continue to thread the twill tape through the eyelet, bringing both ends of the tape together Bring both ends of the twill tape around the back of the patient’s neck Thread the end of the twill tape that is closest to the patient’s neck through the back of the eyelet in the faceplate Have the assistant place one finger under the tape while tying the two ends together in a square knot STEPS 28.Insert a precut, sterile tracheostomy dressing under the faceplate and new tracheostomy stabilizers. 29.Dispose of used equipment/supplies in the appropriate biohazard receptacle, according to agency policy. Performing Suctioning SUCTIONING Aspirating secretions through a catheter connected to a suction machine Done when clients have difficulty handling their secretions in order to clear air passages Suction catheter: Open- or whistle-tipped Have a thumb port on side to control the suction SUCTIONING Oral and oropharyngeal suctioning removes secretions from the upper respiratory tract Nasopharyngeal and nasotracheal suctioning provides closer access to the trachea and requires sterile technique Endotracheal intubation and tracheostomy irritate the airway, causing excessive secretion production; sterile suctioning is necessarya Complications Hypoxemia Trauma to the airway Nosocomial infection Cardiac dysrhythmia (related to hypoxemia) Prevention of Complications HYPERINFLATION Giving the client breaths that are 1 to 1.5 times the tidal volume set on the ventilator Three to five breaths are delivered before and after each pass of the suction catheter HYPEROXYGENATION Done either through a manual resuscitation bag or through the ventilator Performed by increasing the oxygen flow (usually 100%) before suctioning and between suction attempts OROPHARYNGEAL, NASOPHARYNGEAL, AND NASOTRACHEAL SUCTIONING PURPOSES: Remove secretions obstructing the airway Facilitate ventilation Obtain secretions for diagnostic purposes Prevent infection from accumulated secretions Assessment Assess for indications of suctioning: Restlessness Gurgling sounds during respiration Adventitious breath sounds Change in mental status Skin color Rate and pattern of respirations Pulse rate and rhythm Decreased oxygen saturation Planning Equipment:  Towel or moisture-resistant pad  Portal or wall suction machine with tubing, collection receptacle, and suction pressure gauge  Sterile disposable container for fluids  Sterile NSS or water  Goggles or face shield  Moisture-resistant disposal bag  Sterile suction catheter (#12 to #18 Fr for adults, #8 to #10 Fr for children, and #5 to #8 Fr for infants)  Clean gloves  Sterile gloves  Water-soluble lubricant Implementation (Performance) 1. Introduce self and verify identity. Explain the procedure. 2. Perform hand hygiene and observe other appropriate infection control procedures. 3. Provide privacy. 4. Prepare the client. Position conscious person with a functional gag reflex in semi-Fowler’s position with head turned to side fro oral suctioning or with neck hyperextended for nasal suctioning. Position an unconscious client in lateral position, facing you. Place the towel over the pillow or under the chin. Implementation (Performance) 5. Prepare the equipment. Set pressure on the suction gauge, and turn on the suction. Wall unit: Adult: 100 to 120 mmHg Child: 95 to 110 mmHg Infant: 50 to 95 mmHg Portable unit: Adult: 10 to 15 mmHg Child: 5 to 10 mmHg Infant: 2 to 5 mmHg  Implementation (Performance) For Oral and Oropharyngeal Suction Moisten the tip of the Yankauer suction catheter with sterile water or saline. Pull the tongue forward as necessary using gauze. Do not apply suction during insertion. Advance the catheter about 10 to 15 cm along one side of the mouth into the oropharynx. Apply suction to secretions that collect in the vestibule of the mouth and beneath the tongue.  Implementation (Performance) For Nasopharyngeal and Nasotracheal Suction Open the lubricant. Open the sterile suction package. Set up the cup or container, touching only the outside. Pour sterile water or saline into the container. Put on sterile gloves (or nonsterile glove on dominant hand and sterile glove on dominant hand). With sterile gloved hand, pick up the catheter and attach it to the suction unit. Implementation (Performance) 6. Make an approximate measure of the depth of insertion of catheter and test the equipment. Measure the distance between the tip of the client’s nose and the earlobe. Mark the position on the tube with fingers of sterile gloved hand. Test pressure of the suction and the patency of the catheter by applying your sterile gloved finger or thumb to the port or open branch of the Y- connector to create suction. If needed, apply or increase supplemental oxygen. Implementation (Performance) 7. Lubricate and introduce the catheter. Lubricate catheter tip with sterile water, saline, or water-soluble lubricant. Remove oxygen with nondominant hand, if applicable. Without applying suction, insert the catheter the premeasured distance into either naris and advance it along the floor of the nasal cavity. Never force catheter against an obstruction. Implementation (Performance) 8. Perform suctioning. Apply finger to the suction control port to start suction, and gently rotate the catheter. Apply suction for 5 to 10 seconds while slowly withdrawing the catheter, then remove finger from the control and remove the catheter. A suction attempt should only last 10 to 15 seconds (insertion, suctioning, withdrawal). Implementation (Performance) 9. Rinse catheter and repeat suctioning as above. Rinse and flush the catheter and tubing with sterile water or saline. Relubricate the catheter and repeat suctioning until air passage is clear. Allow sufficient time between each suction for ventilation and oxygenation. Limit suctioning to 5 minutes in total. Encourage client to breathe deeply and to cough between suctions. Use supplemental oxygen, if appropriate. Implementation (Performance) 10. Obtain specimen if required. 11. Promote client comfort. Offer to assist with oral or nasal hygiene. Assist to a position that facilitates breathing. 12. Dispose of equipment and ensure availability for next suction. 13. Assess effectiveness. 14. Document relevant data.  TRACHEOSTOMY AND ENDOTRACHEAL SUCTIONING Outer diameter of the suction catheter should not exceed one- half the internal diameter of the tracheostomy or endotracheal tube so that hypoxia can be prevented Use sterile technique to prevent infection Open method is frequently used; closed airway/tracheal suction system (in-line suctioning)  TRACHEOSTOMY AND ENDOTRACHEAL SUCTIONING PURPOSES: Maintain a patent airway and prevent airway obstructions Promote respiratory function Prevent pneumonia Assessment Assess for: Presence of congestion on auscultation of the thorax Not ability or inability to remove secretions through coughing Planning Equipment:  Resuscitation bag (Ambu bag) connected to 100% oxygen  Sterile towel (optional)  Equipment for suctioning  PPE  Sterile gloves  Moisture-resistant bag Implementation (Performance) 1. Introduce self and verify identity. Explain the procedure. 2. Perform appropriate infection control procedures. 3. Provide privacy. 4. Prepare the client. Place in semi-Fowler’s if not contraindicated. Provide analgesia prior as necessary. Implementation (Performance) 5. Prepare the equipment. Attach resuscitation apparatus to the oxygen source and adjust flow to 100%. Open sterile supplies. Place sterile towel, if used, across chest below tracheostomy. Turn on suction and set the pressure accordingly. Put on PPE as necessary. Put on sterile gloves. Hold catheter in dominant hand and the connector in the nondominant hand, attach suction catheter to suction tubing. Implementation (Performance) 6. Flush and lubricate the catheter. Using dominant hand, place the catheter tip in the sterile saline solution. Using thumb of nondominant hand, occlude thumb control and suction a small amount of the sterile solution through the catheter. Implementation (Performance) 7. If the client does not have copious secretions, hyperventilate the lungs with a resuscitation bag before suctioning. Summon an assistant if available. Using dominant hand, turn on oxygen to 12 to 15 lpm. If receiving oxygen, disconnect the oxygen source using nondominant hand. Attach resuscitator to the tracheostomy or endotracheal tube. Compress the Ambu bag 3 to 5 times, as the client inhales. Observe rise and fall of the client’s chest. Remove resuscitation device and place it on the bed or client’s chest with connector facing up. Implementation (Performance) Variation: Using a Ventilator for Hyperventilation If the client is on a ventilator, use the ventilator for hyperventilation and hyperoxygenation. Use mode providing 100% oxygen for 2 minutes and then switches back to the previous oxygen setting or a manual breath or sigh button. Implementation (Performance) 8. If the client has copious secretions, do not hyperventilate with a resuscitator. Instead: Keep the regular oxygen delivery device on and increase the liter flow or adjust the FiO2 to 100% for several breaths before suctioning. Implementation (Performance) 9. Quickly but gently insert the catheter without applying any suction. With your dominant thumb off the suction port, quickly but gently insert the catheter into the trachea through the tracheostomy tube. Insert the catheter about 12.5 cm for adults, or until the client coughs or you feel resistance. Implementation (Performance) 10.Perform suctioning. Apply suction for 5 to 10 seconds only placing the nondominant thumb over the thumb port. Rotate the catheter by rolling it between your thumb and forefinger while slowly withdrawing it. Withdraw the catheter completely, and release the suction. Hyperventilate the client. Suction again, if needed. Implementation (Performance) 11.Reassess the client’s oxygenation status and repeat suctioning. Observe respiration and skin color. Check pulse if necessary using nondominant hand. Encourage to breathe deeply and to cough between suctions. Allow 2 to 3 minutes with oxygen, as appropriate between suctions when possible. Flush catheter and repeat suctioning until the air passage is clear and the breathing is relatively effortless and quiet. After each suction, pick up resuscitation bag with nondominant hand and ventilate the client with no more than three breaths. Implementation (Performance) 12. Dispose of equipment and ensure availability for next suction. Flush catheter and suction tubing. Turn off suction and disconnect catheter from the suction tubing. Wrap catheter around sterile hand and peel the glove off, discard. Replenish sterile fluid and supplies. Be sure that ventilator and oxygen settings are returned to presuctioning settings. Implementation (Performance) 13. Provide for client comfort and safety. For conscious patients, place in semi-Fowler’s position. For unconscious patients, Sims’ position aids in the drainage of secretions from the mouth. 14. Document relevant data. Collecting Sputum Specimen DEEP BREATHING AND COUGHING EXERCISES Facilitates respiratory functioning by helping remove secretions from the airways Coughing raises secretions high enough, enabling the client to expectorate them Breathing exercise are indicated for clients with restricted chest expansion (COPD) or clients recovering from thoracic surgery Types: Abdominal (diaphragmatic breathing) Pursed-lip breathing Abdominal Breathing Permits deep full breaths with little effort Pursed-Lip Breathing Helps client develop control over breathing Pursed lip creates a resistance to the air flowing out of the lungs, thereby prolonging exhalation and preventing airway collapse by maintaining positive airway pressure Purse lip as if to whistle and breathe out slowly and gently, tightening the abdominal muscles to exhale more effectively Inhale to a count of 3 and exhale to a count of 7 STEPS 1. Position patient in a high or semi-Fowler’s position, or sitting on the edge of the bed. 2. Drape a towel or linen-saver pad over the patient’s chest. 3. If patient has an abdominal or chest incision, have the patient splint the incision with a pillow. 4. Hand the patient a glass of water and an emesis basin and have him rinse his mouth. STEPS 5. Provide patient with specimen container. Advise to avoid touching the inside of the container. 6. Ask the patient to breathe deeply for three or four breaths, and then ask him after a full inhalation, to hold his breath, and then cough. 7. Instruct the patient to expectorate the secretions directly into the specimen container. STEPS 8. Tell the patient to repeat deep breathing and coughing until an adequate sample is obtained. 9. Cover the specimen container with the lid immediately after the specimen is collected. 10. Label the specimen, containing the name of the test and collection date and time. STEPS 11. Place the specimen in a plastic bag with a biohazard label. Attach a completed laboratory requisition form. 12. Send specimen immediately to the laboratory or refrigerate if transport might be delayed. Caring for Patient with Chest Tube CHEST TUBES AND DRAINAGE SYSTEMS Double-layered pleural membrane disrupted by lung disease, surgery, or trauma leads to loss of negative pressure between layers, causing the lung to collapse Pneumothorax Air collects in the pleural space Hemothorax Blood or fluid collects in the pleural space  CHEST TUBES AND DRAINAGE SYSTEMS Chest tubes are inserted into the pleural cavity to restore negative pressure and drain collected fluid or blood Chest tubes for pneumothorax are often placed in the upper anterior thorax (air rises); chest tubes used to drain fluid are generally placed in the lower lateral chest wall Chest tubes are then connected to a sealed drainage system or a one-way valve that allows air and fluid to be removed from the chest cavity but prevents air from entering from the outside  Water-Seal Drainage System Composed of suction control chamber, water seal chamber, and a closed collection chamber When the client inhales, the water prevents air from entering the system from the atmosphere; during exhalation, air can exit the chest cavity, bubbling up through the water Should always be kept below the level of the client’s chest to prevent fluid and drainage from being drawn back into the chest cavity  Nursing Responsibilities 1. Monitor and maintain patency and integrity of the drainage system. 2. Assess the client’s vital signs, oxygen saturation, cardiovascular status, and respiratory status. 3. Observe dressing site at least every four hours. Inspect for abnormal drainage, palpate for subcutaneous emphysema. 4. Determine level of discomfort and medicate for pain if indicated.  Nursing Responsibilities 5. Encourage deep breathing and coughing exercises every 2 hours (CI: pneumonectomy). Splint the chest around the insertion site. 6. Reposition client every 2 hours. When lying on affected side, place rolled towels beside the tubing. 7. Assist with ROM exercises of the affected shoulder 3x/day.  Nursing Responsibilities 8. Ensure that the connections are securely taped and that chest tube is secured to the client’s chest wall. 9. Keep the collection device below the client’s chest level. 10.Frequently check the water seal and suction control chambers.  Nursing Responsibilities 11.Assess drainage in the tubing and collection chamber. Mark the date and time at the fluid level on the drainage chamber; replace unit only when almost full. 12.Avoid aggressive chest tube manipulation. 13.Avoid clamping the chest tube (tension pneumothorax). Clamp for a moment only when replacing unit or locating source of air leak, but NEVER when transporting a client or for any extended period of time.  Nursing Responsibilities 14.In case of disconnection of tube from collecting system, submerge end in 1 inch of sterile water or saline. If chest tube is pulled out, immediately cover wound with a dry, sterile dressing. Ensure that dressing is not occlusive. 15.During transport: Keep the water-seal unit below chest level and upright. Disconnect the drainage system from the suction apparatus before moving the client, making sure the air vent is open.  ASSISTING WITH INSERTION OF CHEST TUBE (DISPOSABLE WATER-SEAL SYSTEM) 1. Obtain and prepare prescribed drainage system: Disposable water-seal system without suction. Remove cover on water-seal chamber and fill with sterile water or normal saline; fill to 2-cm mark or as indicated. Replace cover on water-seal chamber.  ASSISTING WITH INSERTION OF CHEST TUBE (DISPOSABLE WATER-SEAL SYSTEM) Disposable water-seal system with suction. Remove cover on the water-seal chamber and fill with sterile water or normal saline to the 2-cm mark. Add sterile water or normal saline solution to the suction-control chamber. Add the amount of fluid specified by the physician, typically at 20 cm. Attach the tubing from the suction-control chamber to the connecting tubing attached to the suction source. 2. Position the patient according to the indicated insertion site. 3. Don PPE. ASSISTING WITH INSERTION OF CHEST TUBE (DISPOSABLE WATER-SEAL SYSTEM) 4. Provide support to the patient while the physician prepares the sterile field, anesthetizes the patient, and inserts and sutures the chest tube. 5. As soon as CT is inserted, attach it to drainage system using a connector. 6. Using sterile technique, wrap petroleum gauze around the chest tube insertion site. 7. Place a precut, sterile drain dressing over the petroleum gauze. ASSISTING WITH INSERTION OF CHEST TUBE (DISPOSABLE WATER-SEAL SYSTEM) 8. Place a second sterile, precut, drain dressing over the first drain dressing with the opening facing in the opposite direction from the first one. 9. Place a large drainage dressing over the two precut dressings. 10.Secure the dressing in place with 2-inch silk tape, making sure to cover dressing completely. 11.Write date, time, and initials on dressing. ASSISTING WITH INSERTION OF CHEST TUBE (DISPOSABLE WATER-SEAL SYSTEM) 12.Using spiral taping technique, wrap 1-inch silk tape around the chest tube starting above the connector and continuing below the connector. Reverse the wrapping by taping back up the tubing until above the connector. 13.Cut an 8-in long piece of 2-in tape. Loop one end around the top portion of the drainage tube and secure the remaining end of the tape to the chest tube dressing. ASSISTING WITH INSERTION OF CHEST TUBE (DISPOSABLE WATER-SEAL SYSTEM) 14.If suction is prescribed, adjust suction source until gentle bubbling occurs in the suction-control chamber. If not, leave the suction tubing open. 15.Make sure that drainage tubing lies with no kinks from the chest tube to the drainage chamber. 16.Prepare the patient for a portable chest x-ray. ASSISTING WITH INSERTION OF CHEST TUBE (DISPOSABLE WATER-SEAL SYSTEM) 17. Place two rubber-tipped clamps at the patient’s bedside for special situations. 18. Place a petroleum gauze dressing at the bedside in case the chest tube becomes dislodged. 19. Keep spare disposable drainage system at the patient’s bedside. 20. Position for comfort. 21. Maintain patency. Free of kinks Inspect air vent Drainage system is below the insertion site  CHANGING THE DRAINAGE SYSTEM 1. Identify the patient. 2. Explain the procedure. 3. Perform hand hygiene. 4. Put on clean gloves.  CHANGING THE DRAINAGE SYSTEM Assessing the Drainage System 5. Observe dressing around the CT insertion site and ensure that it is dry, intact, and occlusive. 6. Check that all connections are secured. Feel for subcutaneous emphysema. 7. Check tubing for dependent loops or kinks. The drainage collection device must be positioned below the tube insertion site.  CHANGING THE DRAINAGE SYSTEM Assessing the Drainage System 8. If the CT is ordered to be suctioned, note the fluid level in the suction chamber and check it with the amount of ordered suction. Look for bubbling in the suction chamber. 9. Observe water-seal chamber for tidaling. Add water as necessary to maintain the level at 2-cm mark.  CHANGING THE DRAINAGE SYSTEM Assessing the Drainage System 10.Assess amount and type of fluid drainage. Measure drainage output at the end of each shift by marking the level on the container. 11.Remove gloves and perform hand hygiene.  CHANGING THE DRAINAGE SYSTEM Changing the Drainage System 1. Obtain two padded Kelly clamps, new drainage system, and bottle of sterile water. Add water to water-seal chamber until the 2-cm mark is reached. 2. Put on clean gloves. 3. Apply Kelly clamps 1.5” to 2.5” from insertion site and 1” apart, going opposite directions.  CHANGING THE DRAINAGE SYSTEM Changing the Drainage System 4. Remove suction from current drainage system. Do not pull on the chest tube. 5. Keeping the end of the chest tube sterile, insert the end of the new drainage system into the chest tube. Remove Kelly clamps. Apply plastic bands. 6. Assess patient, remove gloves, perform hand hygiene.  ASSISTING WITH REMOVAL OF A CHEST TUBE 1. Identify the patient and explain procedure. 2. Perform hand hygiene. 3. Administer pain medication as prescribed. Premedicate patient 10 to 15 minutes before removal. 4. Put on clean gloves. 5. Provide reassurance.  ASSISTING WITH REMOVAL OF A CHEST TUBE 6. After physician has removed chest tube and secured occlusive dressing, assess patient’s lung sounds, respiratory rate, oxygen saturation, and pain level. 7. Anticipate the physician to order chest x-ray. 8. Dispose of equipment appropriately and perform hand hygiene.