NRSG 301 Chest Tubes

What is pleurisy?

inflammation of the pleura

What is a pleural effusion?

Pleural fluid

What is a hemothorax?

Blood

Caused by:

- Trauma

- Surgery

- Cancer

- Complication of anticoagulants

What is a pneumothorax?

Air

What is a chlyothorax?

Lymphatic fluid

Caused by:

- trauma

- leak

- cancer

What is an empyema?

Products of infection

Caused by:

- TB

- lung abscess

- infection of surgical wounds

Why would someone need a chest tube

*Lung/thoracic surgery

*Cardiac surgery

*Esophageal surgery

*Hiatal hernia repair

*Kidney surgery

*Trauma to thoracic cavity

Type will depend on surgical approach, use of an open vs laparoscopic procedure and the expectation of pleural drainage

History

*WWII (1939-1945):

- Routine use of chest tubes for thoracotomy/sternotomy

*Korean War (1950-1953):

-Chest tubes used in acute trauma

*Deknatel (1967)

-First integrated disposable chest drainage unit

-Based on 3 bottle system

What is the number 1 cause of a pleural effusion?

HF

What can cause a pleural effusion?

CHF due to increased blood hydrostatic pressure (TRANSUDATES)

- liver disease due to decreased plasma proteins and decreased oncotic pressure (TRANSUDATES)

- cancer (EXUDATES)

- infection (EXUDATES)

- pancreatic disease (leak of enzymes) (EXUDATES)

- esophageal leak (perforation or complication of surgery) (EXUDATES)

What are the causes of a closed pneumothorax?

-Spontaneous – rupture of a bleb (small air-filled alveolar dilation)- found more in a tall, thin male

-Use of too high

- use of too high pressure on a mechanical ventilator

- subclavian central line insertion

-Injury to lung following subclavian central line insertion

- injury from broken ribs

-Smoking, vaping, pleuraderma (thickening of ;ung tissue), SARS, COVID.

What are the causes of a open pneumothorax?

Penetrating chest trauma- ex: gunshot or stabbing. Results in a sucking chest wound.

- should be covered with a vented dressing until medical attention (and placement of chest tube is received: occlusive dressing, tape on 3 sides).

What are signs and symptoms of a pneumothorax?

• Increased RR and effort

• Dyspnea

• Pleuritic chest pain

• Decreased movement of the

affected side of the chest

• Decreased breath sounds on

auscultation of the affected side

• Falling blood pressure

• Rising pulse

• Tracheal deviation away from the

affected side

• Cool, mottled skin; and

• Subcutaneous Emphysema

How do you treat a pneumo?

Rest and limit of physical movement

Dx- with CT and X-ray

At what rate of drainage should you be concerned when a patient has a chest tube?

Over 100 ml/hr

What is a 8-12 chest tube used for?

Infants and young children

What is a 16-20 chest tube used for?

Children and young adults

What is a 24-32 French used for?

Most adults

What is a 36-40 French chest tube used for?

Large adults

What must be assessed when a patient has a chest tube?

Pain assessments

In what incra,ents are the markings on chest tubes?

2 cm

What should you check during a morning safety check?

1- check breathing depth, effort, sob, use of O2 and pain

2- start at patient and work way down

3- dressing site

4- functioning of equipment

5- is it attached to suction? Should it be?

6- is safety equipment at the bedside? (Saline, dressing, Kelly clamps)

Assessed every 2-4 hours

What should be checked when a patient has a chest tube?

• Assess patient first!

• Dressing

• Tubing: sort out the twisted tubing, dependent loops,

checking connections, taped connections

• Drainage (colour, amount)

• Water level in the water seal

• Is there bubbling in the water seal chamber?

• Briefly stop suction and check water level in water

seal and check for bubbling.

• Check for tidalling/fluctuating

• Suction (is it at the right setting on drainage system?)

• Drainage system is below patient

• Check for 2 chest tube (Kelly) clamps

• Is the drainage system upright and secure?

What is a sign of cardiac tamponade?

Mufffled or distant heart tones are a sign, BP may lower, irrlefular pulse (Q4 vitals doe 24 hours then QID)

Why should a patient after lung surgery be in semi fowlers?

• Semi- or high-Fowlers helps to promote

expansion of the diaphragm

• Allows air to rise to the lung apex

• Allows fluid to sink to the base

• Usually no problem for patient to lie on

back (with HOB raised), or slightly to one

side or the other

• Alert and oriented patients will usually

assume a position that allows good

oxygenation

What should you be looking for if you note continuous bubbling in the water seal chamber?

Suspect an air leak

What should you suspect of a chest tube has no fluctuation of water in the water seal chamber?

Lung may have re-expanded or there is a kink or occlusion in the tubing

What is a priority nursing diagnosis for a patient with a chest tube?

Impaired gas exchange

What do you do if the chest tube gets pulled out?

1. Don clean gloves

2. 4. Place gloved hand over insertion site

3. Call for help

4. Apply 3-sided dressing (just like for sucking chest wound)

5. Call doctor

What do you do if a chest tube gets disconnected?

1. Have patient exhale and cough

2. Clamp chest tube cross-wise with Kelly clamps

3. Disinfect ends of tube with Chlorhexidine or alcohol and re-connect

• If drainage tube is grossly contaminated, replace

whole drainage system (e.g. Atrium Oasis) then

connect to chest tube

4. Tape connections

5. Unclamp

When can you clamp a chest tube?

▫ Briefly while re-connecting tubes

▫ Briefly while changing the drainage system

▫ Briefly while checking for an air leak

- for Assesment of vital signs and auscultation if ordered by a doctor

What can happen if you clamp a chest tube for too long?

Tension pneumothorax

What is the purpose of a P-Eggy drain?

Small and portable drainage system equipped with quick air leak confirmation

How do you empty a P-Eggy chest drain?

1- using syringe attach to leur lock which has a 1 way valve and withdraw fluid

2- measure amount and colour and document on NN and In/output

What supplies do you need to change a large bore dressing change?

● Clean gloves and additional

PPE as per risk assessment

● Sterile gloves

● Sterile dressing tray:

● Wide occlusive tape

● Sterile normal saline to clean

site

● 4x4 gauze drain sponges, or

other dressing as per MRP

preference

● Absorbent cover dressing

What supplies do you need to change a small bore/pigtail dressing?

Clean gloves and additional

PPE as per risk assessment

● Sterile gloves

● Sterile dressing tray

● 2% Chlorhexidine & 70%

alcohol swabstick to clean site

● Transparent dressing

● Securement device (e.g.

StatLock™)

How many nurses are needed for a chest tube removal?

2 RNs and 1 LPN

What is a thoracostomy?

Creation of a surgical opening in the chest

What is a thoractomy?

incision into the chest wall

What is a pleurodesis?

Instillation of a sclerosisng agent into the pleural space

What is a thoracoscopy?

The insertion of an endoscope to visually examine the inside of the chest cavity

What is decortication?

removal of thick, fibrous membrane from visceral pleura

What should be known about the irrigation of chest tubes?

• Irrigation may assist in the drainage of viscous

pleural fluid (preventing clogging)

• Must have an order for chest tube irrigation

• Only RNs can irrigate chest tubes (students are

NOT allowed)

• Irrigation fluid is sterile normal saline

• Review policy and procedure if this opportunity

arises

What is Obstructive Sleep Apnea?

• Obstructive sleep apnea (OSA) is characterized by episodes of a complete (apnea) or partial collapse hypopnea) of the upper airway with an associated decrease in oxygen saturation or arousal from sleep.

• This disturbance results in fragmented,

nonrestorative sleep

What does a CPAP do?

Continuous positive airway pressure is a treatment option for sleep apnea. As you sleep, CPAP provides air at a pressure just high enough to prevent the collapse of your airway. The pressurized air is provided through a mask that seals with your mouth or nose.

What are nursing considerations for a CPAP machine?

● RT usually will check patient's own CPAP when they come into hospital

● If patients take any new medications that cause respiratory depression, nurses need to be aware of more possible complications

● Patients who have had surgery usually have more respiratory monitoring post-op due to anaesthetic