Chest Tubes, PNA, TB, PE

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chest tube goals of therapy

Remove air or fluid

Prevent re-entry of drained air and/or fluid

Re-establish negative pressure in pleural space promoting lung re-expansion

Placement is based on the substance being removed- depends on pneumothorax, pleural effusion, or hemo

nursing management of chest tubes

• Assess site and dress per hospital policy

• Chest x-ray and documentation

• Pain management from incision site

• Pain in upcoming days; as lung heals and expands, rubbing against chest tube occurs

pulmonary exercises for chest tube nursing management

• Cough and deep breath

• IS and repositioning 

• Splinting 

patient assessment for chest tube nursing management

Vital signs, breath sounds, subcutaneous emphysema, drainage system assessment (how much drainage- significant with time?)

when is bubbling is an expected finding?

1. Continuous pneumothorax.

2. During first insertion into pt, temporary bc fluid bubbles

3. Intermittent as pt is inhaling, coughing, sneezing, changing position, exhaling

chest tube tidaling

if fluid does not rise with inspiration or fall with expiration, drainage system may be blocked or the system is attached to suction. disconnect if connected to suction

Collection (drainage) chamber

• Fluid fills each column from right to left

• Surface to write date/time at drainage level

Water seal chamber characteristics

• One-way valve 

• Prevents evacuated and atmospheric air from entering the patient

• ASSESS for bubbling that doesnt happen during exhalation, coughing, sneezing, or position changes

Suction Control Chamber

• Adjust based on physician order

• Wall suction set to 80mmHg or amount required

• Orange suction indicator will advance to the white triangle

What do you do when a chest tube becomes disconnected from the drainage unit?

• Take end of tubing dislodged, put in STERILE WATER

• Ask pt to cough (help pressure gradient in pleural space)

• Get new chest tube unit and attach it to pt

• Monitor pt

• Repeat chest x-ray

• Notify md

What do you do when a pleural tube accidentally comes out of the patient?

IMMEDIATELY apply airtight, occlusive dressing to the insertion site

• vaseline/petroleum gauze to insertion site

• dry gauze on top

Place tape on 3 sides of gauze allow for air escape

Notify MD

Observe for signs of respiratory distress

Prompt pt to cough if distress is present

Prepare for chest x-ray - HCP will likely order one to assess for pneumothorax or fluid accumulation

Prepare for possible reinsertion - gather supplies in case the HCP needs to reinsert a chest tube

Pneumonia (PNA)

Acute inflammation of the lung parenchyma caused by a microbial agent

bacterial, viral, fungal

predisposing factors of PNA

• Aging - 65 y/o+

• Air pollution, smoking

• Altered LOC

• Aspiration

• Bed rest/prolonged immobility

• Chronic diseases

• Malnutrition

• Immunosuppressive drugs

• Tracheal intubations, endotracheal intubations - easy hosts for bacteria

types of PNA

• Viral, bacterial, fungal

• Community acquired pneumonia (CAP)

  • Onset in the community

• Hospital acquired pneumonia (HAP)

  • Occurs 48 hours or longer post hospitalization

• Aspiration pneumonia

  • Food, secretions, going down wrong pipe

• Opportunistic pneumonia

PNA clinical manifestations

• Fever, chills, fatigue

• Cough – productive or not

• Sore throat

• Pleuritic chest pain

• Confusion, stupor, headache

• Lungs: dullness to percussion, crackles

SEVERE PNA clinical manifestations

Resp distress, dyspnea, congestion, tachypnea inc respirations, tachycardia, breath sounds - crackles, diminished lung sounds, malaise, anorexia

PNA complications

• Pleurisy - when pleura itself is inflamed

• Pleural effusion

• Empyema - collection of pus in a naturally existing body cavity

• Atelectasis

• Acute respiratory failure (ARF)

• Bacteremia - infection reached blood

• Sepsis

PNA diagnostics

• Chest x-ray (CXR) noninvasive

• Sputum sample

• Pulse oximetry, ABG

• CBC, BMP - kidney, liver, electrolytes, bicarb

• Blood culture - X2 two diff samples, blood cultures take around a day to get back, stat with broad antibiotics

PNA: Collaborative/Nursing Care

• Antibiotic therapy (ABT)

  • Macrolides (azithromycin, clarithromycin)

  • Doxycycline

• Oxygen - Nc, Venti mask, nonrebreather - always on 15

• Antipyretics typically tylenol q4 q6 650mg

• Pneumococcal vaccine

• Nutrition therapy

• Health promotion

  • Rest, fluids, incentive spirometer- tell pt to take it home 6-8 wks breathing exercise. Mist humidifier at home

• Ambulatory and home care

TB

airborne transmitted bacterial infection - Mycobacterium tuberculosis

what precautions are used for TB

isolation

TB: Risk Factors/Transmission

• Contact with person having active TB

• Immunocompromised status

• Malnutrition - low protein, higher risk catching infections

• Overcrowding

• Substandard housing, homelessness

• Inadequate health care

• Substance abuse

• High risk jobs

TB active vs dormant

pt has to have active TB to be able to spread, can be dormant for years

TB clinical manifestations

• Low grade fever -2-10 weeks

• Pleuritic chest pain from congestion

• Blood tinged cough - if ADVANCED

• Night sweats

• Fatigue

• Weight loss

TB diagnostics

• TB skin test

  • Mantoux (PPB)

• QuantiFERON Gold 

• Chest X-ray (CXR)

• AFB smear

• Sputum culture

  • 3 positive results

first line meds for TB and edu

Isoniazid - months

Rifampin - months - body fluids (orange)

• Edu: Rifampin is the longest, body fluids might be orange as se of meds.

Pyrazinamide - weeks ~8weeks

Ethambutol - weeks, monitor vision changes

stick to entire regimen even if they feel better

TB nursing interventions

• Promote airway clearance

• Advocate treatment adherence

• Promote activity and nutrition

• Monitor and manage complications:

  • Malnutrition

  • Medication side effects

  • Multiple drug resistance (INH, rifampin)

Pulmonary Embolism (PE)

• blockage of the pulmonary artery

causes of PE

Blood clot, DVT, fat embolism

Saddle PE

pe causes impaired gas exchange at alveoli level - can be fatal

PE risk factors

immobility/surgery

prolonged air travel

tourniquets

History of VTE

Cancer

Heart failure (HF) - blood pooling

Obesity

Clotting disorders

Pregnancy

Oral contraceptives/Hormone therapy

Smoking

PE Nursing care

• Diagnostics 

  • D-dimer - confirms presence of clot

  • CT ANGIO OF THE CHEST

  • V/Q scan

• Treatment

  • drug therapy (anticoagulants) Heparin drip - does not dissolve clot but prevents from getting bigger

  • Pulmonary embolectomy and/or IVC filter

  • promote early ambulation

• Prevention is key

• Bleeding precautions

  • use soft toothbrush, shave with electrical razor, avoid hard candy, do not strain, avoid bumping into furtniture, wear supportive stockings

tracheostomy indications

Surgical incision in the trachea to establish an airway

• Indications:

  • Bypass upper airway obstruction

  • Long-term mechanical
    ventilation

  • Permit oral intake and
    speech with long term
    mechanical ventilation

what equipment should be at bedside for a pt with a tracheostomoy

• Trach of same size and smaller → in case trach is dislodged

• Obturator

• Ambu bag (BVM)

cleaning of trach tube

sterile technique when cleaning the inner cannula to avoid transmitting microorganisms to the lungs, use brush to clean and rinse cannula with normal saline

Sterile gloves are worn when removing the inner cannula

dominant hand stays sterile throughout procedure

completely dry the inside of the inner cannula prior to replacing it

client may be preoxygenated before removing the inner cannula with high flow oxygen via tracheal mask, NOT NASAL CANNULA

trach routine assessment and care

• Assess tracheostomy site every shift minimum (or more often)

• Observe for redness, inflammation, edema, ulceration, infection

• Sterile dressing changes every 12-24 hours (or more often if needed) Do NOT change tapes for first 24 hours after placement

• Clean around stoma with normal saline not hydrogen peroxide

• Apply sterile pre-cut dressing never cut it yourself

• Use 2-person technique: one stabilizes, one changes

PE clinical manifestations

• Dyspnea, SOB, tachypnea 

• Cough, chest pain, crackles, wheezing 

• Hemoptysis (coug up hblood bc ↑ pressure + lung tissue damage leading to bleeding in vascular level)

• Fever, tachycardia (monitor BP), syncope