NURS 321 Final

chest tubes

thoracic cavity

contains:

• right and left lungs

• mediastinum

• heart

• aorta and great vessels

• esophagus

• trachea

inhalation

when the diaphragm contracts it moves down, increasing the volume of the thoracic cavity

• when the volume increases the pressure inside decreases

• generates negative pressure

• air moves from an area of higher pressure(the atmosphere) to an area of lower pressure(the lungs)

• pressure within the lungs=intrapulmonary pressure

exhalation

when the phrenic nerve stimulus stops

• the diaphragm relaxes and moves up in the chest→ this reduces the volume of the thoracic cavity

• when the volume decreases intrapulmonary pressure increases

• air flows out of the lungs to the lower atmospheric pressure

• generates positive pressure

pleura

a thin continuous membrane that folds over itself

• parietal pleura= lines the chest wall

• visceral pleura(aka pulmonary pleura) covers the lungs'

pleural space

lies between the parietal and visceral pleural

• lined with fluid to lubricate the lungs

• he fluid allows the two membranes to glide smoothly against each other when you inhale and exhale.

• greats a negative pressure gradient that allows the lungs to expand

mediastinum

contains the heart, aorta and great vessels, esophagus, trachea

• the central compartment of the thoracic cavity located in the middle of the chest between the right and left pleural cavities that house the lungs

penumothorax

air enters the pleural space

• closed pneumothorax→ chest wall is intact, rupture of the lung and visceral pleural(or airway) allows air into the pleural space

tension pneumothorax

chest wall is intact

• air enters the pleural space from the lung or airway and has no way to leave

• there is no vent to the atmosphere as there is in an open pneumothorax

• most dangerous when patient is receiving positive pressure ventilation in which air is forced into the chest under pressure

• can case a shifted mediastinum

open pneumothorax

opening in the chest wall(with or without lung puncture)

• aka sucking chest wound→ air can vent through the opening in the chest wall

• opening acts as a vent so pressure from the trapped air cannot build up in the chest

• allows atmospheric air to enter the pleural space

• penetrating trauma→ gunshot, stab, impalement, surgery

hemothorax and pleural effusion and assessment findings

accumulation of fluid(blood for hemothorax) in the pleural space

assessment findings:

• SOB

• decreased or absent breath sounds

• pain(chest pain) on inhalation

treatment for pleural conditions

1. remove fluid and air ASAP

2. prevent drained air and fluid from returning to the pleural space

3. restore negative pressure in the pleural space to re-expand the lungs

What do you need for a chest tube insertion?

• informed consent from MRHP

• analgesic

• baseline vitals(compare post-insertion)

• equipment

• chest tube insertion tray and sutures

• bottle of sterile water

• post insertion x-ray(to confirm proper placement)

• bigger chest tubes used for blood/fluid

• smaller tubes for air

chest tube placement

remember air rises→ chest tubes for pneumothorax are placed higher up in the lungs

remember fluid falls→ chest tubes for fluid in the pleural space are placed lower in the lungs

positive vs negative pressure

• Positive Pressure: Internal pressure is higher than the outside environment. Air flows outward through any gaps or doors, which stops outside dust and germs from entering.

• Negative Pressure: Internal pressure is lower than the outside environment. Air is sucked inward, which traps internal fumes, dust, or infectious particles so they cannot escape into other areas.

chest tube mechanics

expiratory positive pressure from the patient helps push air and fluid out of the chest(coughing, Valsalva)

• gravity helps fluid drainage as long as the chest drainage system is below the level of the chest

• suction can improve the speed at which air and fluid are pulled from the chest

• keep drain below the chest for gravity drainage

monitoring an air leak

• water seal is a window into the pleural space

• if air is leaving the chest bubbling will be seen here

• air leak meter(1-5) provides a way to measure the leak and monitor over time→ is it getting better or worse?

• consistent bubblinh on inspiration and expiration means a leak is present

• common leaking areas→ insertion site, connection between thoracic cavity and drainage unit or drainage system

Assesment of chest tube

PATCH

PAtient

Tubing

CHamber

Assessing patient with chest tube

• LOC

• vital signs

• Respiratory effort(breath sounds, rate, depth, ease, cough and sputum production, non-symmetrical chest excursion)

• color of skin

• body position

• pain/restlessness/tracheal position

• dressing→ dry, clean/intact

• excessive bleeding at site

• Subq emphysema

subcutaneous emphysema

air becomes trapped in the subcutaneous tissue

S&S:

• skin has a “rice crispy”/ bubble wrap feeling

• swelling of the skin

• SOB

• pain→ Sore throat, neck ache, or chest discomfort. [1, 2]

chest tube system

look→ sutures loosened or eyelet outside wall

listen→ hissing or air leak

feel→ Subq emphysema/mark area

collection chamber

• Charting→ I/O

• calibration(2cc to 200/10cc to 2000)

• full/changing system/disposal

• suction ay ordered level, wall regulator at 80 mmHg

• air leak meter for bubblinh and fluctuating

chest tube complications

• sudden increase in drainage(especially bloody drainage)

• vigorous bubbling in the air leak meter

• tachypnea and tachycardia with SOB

chest tube scope of practice 321

Under indirect supervision:

• apply and discontinue suction

• measure drainage

• change dressing

• MAY NOT remove

removal of chest tubes

as a nursing student or RN you cannot remove the chest tube!

• physician or NP removes

• provide analgesic ½ prior

• purse string suture/occlusive dressing

• sutures out 7-10 days

• dispose of in biohazard container

• monitor VS/LOC/respiratory effort

Heimlich valve

small valve attached to the catheter used for small pneumothorax

• when the patient breathes in it creates negative pressure, the tube collapses on itself stopping the air from entering the chest

What safety equipment is needed at the bedside for chest tube?

• Two padded/occlusive clamps — available for emergencies, such as accidental disconnection or when specifically directed by policy/provider.

• Sterile occlusive dressing — for an accidental chest-tube dislodgement or emergency dressing change.

• Petroleum-based gauze (e.g., Vaseline gauze) — can be used for an emergency occlusive dressing if the tube comes out.

• PPE — gloves and other PPE as indicated.

• Suction setup — if suction is prescribed; ensure the system is functioning and connected appropriately.

• Spare drainage system/tubing — available in case the drainage system becomes damaged or contaminated.

parenteral nutrition

infusion of nutrients to sustain nutritional balance when we cannot access the GI tract

• 3 components→ carbohydrates, lipids, amino acids

• based on the specific needs of each patient

goal of parenteral nutrition

1. meet caloric needs until patient can transition to enteral nutrition

2. transition to enteral nutrition to prevent villous atrophy(when villi shrink or disappear) and cell shrinkage→ preserve GI function

3. preventing complications→ GI cell shrinkage can lead to translocation of bacteria and lead to septicemia

indications for parenteral nutrition

• patient is unable to digest or absorb enteral nutrition→ non-functional GI tract, extended bowel reset

• patient in high stressed physiologic state→ sepsis, burns, head injury

• perioperative TPN→ perioperative bowel reset

carbohydrates in parenteral nutrition

the body’s main source of energy, one of the 3 main macronutrients

• dextrose is most commonly used because it is easily metabolized and stimulates the secretion of insulin

• tolerated in large quantities

amino acids

building block of proteins

• 1 g amino acids=1 g protein

• proteins maintain structure and help with wound healing

• if protein is low the body will seek it out in the muscles and vita organs

• 
  

lipids

aka fat emulsions are long chain fatty acids

• high concentration of calories→ 9 cal/g

• may contain egg yolk as an emulsifer→ check patient food allergies

• maintain connective tissue integrity

• fat emulsions are isotonic

• available in 10, 20, 30% concentrations

non-functional GI tract causes

• massive small bowel resection

• GI surgery

• paralytic ileus

• intestinal obstruction

• severe malabsorption

• chemo, radiation therapy

• trauma to head, neck, abdomen

• Inflammatory bowel disease exacerbation

• severe diarrhea

• moderate to severe pancreatitis

peripheral parenteral nutrition

in the peripheral vein, for short term needs

• IV is <10% dextrose in combination with amino acids and lipids→ to be less irritating to the vein and is not as calorie dense

total parenteral nutrition(TPN)

administered via central line

• Iv solution are >10% dextrose→ uses a large vein for dilution

• requires an infusion pump→ 40 cc-60 cc/hr for amino acid dextrose(travasol)

→ 10-20 cc/hr lipid emulsions

TPN complication: pneumothorax

air enters pleural space

• causes→ catheter insertion

• S&S: SOB, chest pain, coughing

peripheral IV catheter

most commonly used invasive device

• fail 35-50% of the time

• types: short or midline peripheral catheter

Phillips 16 steps for PIV

1. authorized prescriber

2. hand hygiene

3. collect your equipment and prepare the space

4. patient identification and psychological preparation→ explain procedure to patient

5. site selection, vein dilation, and visualization technology

6. attention to pain management

7. catheter selection(22-24 g= standard)

8. gloving

9. site prep

10. vein entry

11. catheter stabilization and dressing management

12. labeling the site

what to consider when selecting a vein?

• vein condition→ soft, straight, palpable(observe vein refill)

• age

• patient preference→ place the IV in the patient’s non-dominant hand

• patient activity: How does the patient ambulate?→ avoid placing IV on the side they ambulate

• medications- anticoagulants

• medical conditions→ avoid starting IV on affected site of stroke. e.g. mastectomy avoid starting IV on masectomy site

sites associated with greater risk for nerve injury

• cephalic vein at wrist

• antecubital fossa(AC)

• palm side of wrist

superficial veins of the dorsum of the hand

• cephalic vein→ 1st choice(good for first start. Avoid wrist)

• metacarpal veins(not ideal for older adults)

• basilic vein

superficial veins of the forearm

how to distend veins

• gravity→ place arm lower than heart'

• clench the fist(with ball or rolled cloth)

• taping or stroking downwards on the vein

• warm compress(warm blanket)→ dry heat=preferred

• BP cuff→ pump cuff to 30 mmHg

• tourniquet→ 10 cm above venous puncture site

IV catheter gauge

bigger number=smaller gauge

smaller number= bigger gauge

• always prefer smaller gauge→ they take up less space in the vein allowing blood to flow to the catheter and cause less trauma

• 22-24 gauge→ used for most patients

• 20-24→ blood transfusion

  • use smaller gauge in large vein for caustic meds→ e.g. cephalic vein & 22-24 gauge

two methods to venipuncture

• direct→ approach directly over vein at 15-30 degree angle

• indirect→ enter the skin slightly adjacent to the vein, direct device to side of the vein

documentation for PIV insertion

• date and time of insertion

• site prep→ how did you prepare the iste?

• needle gauge and length of device

• patient response

• type of dressing

• what did you do with the IV→ e.g. saline lock

• ongoing assessment

post-insertion assessment

• atleast Q4h for alert and oriented patients

• Q1-2 hours critically ill patient’s or adult’s with sensory deficits

• Q1h→ pediatrics and neonatal patients

• 
  

mechanical complications of parenteral nutrition

• pneumothorax

• air embolus

• thrombosis

• infection

• catheter occlusion

mechanical complication of TPN- air embolus

cause: catheter insertion, during tubing/cap change, sudden dislodgement

• S&S→ increased RR, apnea, hypotension, wheezing

• intervention: Trendelenburg- head down, left side down (air flows up→ goal is to trap air into the right atrium and ventricle to minimize entry of air emboli to blood flow going out)

-put on oxygen and get help

• prevention→ valsvala maneuver curing cap change(bearing down)

valsvala maneuver

a breathing technique where you try to exhale forcefully against a closed airway (by pinching your nose and closing your mouth or throat) for about 10 to 15 seconds

mechanical complication of TPN- pneumothorax

air enters the pleural space

cause: catheter insertion

• S&S→ SOB, chest pain, coughing

mechanical complication of TPN- infection

cause: dressing changes

• solution of TPN has high glucose and lipid content→ breeding ground for infection(pathogens feed off the nutrients)

• S&S: high temp(fever), drainage, swelling, chills

• response→ swab for culture and remove the line if needed

• Prevention→ strict asepsis when caring for central line

student scope of practice for TPN

• parenteral medications are a high alert med that needs an independent double check→ - this means that two health care professionals need to provide their signature. Students can participate in the process of the IDC with their primary RN or instructor but cannot sign for TPN as one of the two signatures.

• anything with a central line must be done under direct supervision

mechanical complication of TPN-catheter occlusion

cause: line care and position of patient

• S&S→ slow sluggish flow

• prevention→ proper line care, flush and lock lines as indicated

mechanical complication of tpn thrombosis

• cause: line care

• S&S→ swelling, pain, redness, discoloration of skin

• response→ communicate with physician

metabolic complications of TPN

• hypo/hyperglycemia

• hypercapnia

• electrolytes

metabolic complications of TPN-hyper/hypoglycemia

hyperglycemia: TPN solution can have excess dextrose

• increase in glucose can decrease neutrophils and create risk of short term infection

• S&S→ thirst, headache, lethargy, high blood glucose

• response→ admin insulin, monitor blood sugar

hypoglycemia:

• cause→ sudden discontinue of infusion

• S&S: low blood sugar, diaphoresis, shaking, confusion, loss of consciousness

• Response: hang D10W

metabolic complications of TPN- hypercapnia

excessive rates of carbohydrate infusion

• increase CO2 retention(>45 mmHg)

• S&S: anxiety, SOB

• response: oxygen

metabolic complications of TPN- electrolytes

monitor Na, Ca, K, Cl, PO4, Mg

S&S: ??

prevention→ monitor I/O, check lab values

what to monitor when giving parenteral nutrition

• Intake and output→ watch for signs of fluid overload(crackles, edema, tachycardia, weight gain. do focused respiratory assessment)

• Blood glucose q6h for 24 hrs

• weight

• lab values→ electrolytes and liver panels

• complications→ metabolic and mechanical

travasol- amino acid dextrose(AAD)

• maximum infusion time→ 24 hrs from priming

• tubing change→ every 24 hrs

• filter→ 0.22 or 0.2 micron filter

• store in fridge if not immediately hung→ remove 30 mins prior to hanging(warm to room temp)

• use bags in sequence!B

lipid emulsion

• maximum infusion time→ 12 hours from priming

• tubing changes→ when infusion is complete(12 hrs)

• filter→ 1.2 micron

• store at room temp

• 10, 20, 30% emulsions

• have an indicator at the back→ yellow=safe, black=exposed to air(do not use!!)

olimel

3 in 1 parenteral solution

• max infusion time→ 24 hours from priming

• tubing changes→ every 24 hrs

• 1.2 micron filter

• remove from fridge 30 minutes before hanging(warm to room temp)

• only need 1 infusion pump chamber

what do you need to initiate parenteral nutrition?

• physician orders

• equipment: infusion set, 0.22 micron filter for AAD, 1.2 micron for lipids, 2 infusion pumps(or 1 for olimel/3 in 1) → remove AAD from fridge 30 minutes prior

• name, expiry bag #

• assess AAD and lipids for discolouration, leaks, crystallization

• if TPN stopped for more than 8 hours, change bag

how does TPN impact a patient’s self-image

• Psychosocial & Body Image Impact: Central lines, tethering pumps, and weight shifts serve as constant visual reminders of illness, disrupting physical self-concept and independence.

• Social Disruption: Inability to participate in normal eating leads to loss of food-centered social connection, feelings of isolation, and potential public stigma.

• Nursing Interventions: Promote autonomy through self-care education, advocate for cyclic PN (off-pump daytime hours), normalize social mealtimes, and provide sensory/oral care.

RN roles and responsibility with parenteral nutrition

• assist in identifying patient who are candidates for PN→ "if the gut works use it”(" TPN should only be advocated for when Enteral Nutrition (EN) is either impossible, inadequate, or contraindicated.)

• assessment→ electrolytes, nutritional and hydration status

• signs and symptoms of hypo/hyperglycemia→ monitor blood glucose levels

• measure weight

• Ins/Outs

• collaborate/communicate→ with patient/family, dietician, pharmacist, physician