NURS 370 Med Surgical: Module 2: Basics of Chest Tube Management Video Notes

When A Pt Has a Chest Tube: Assessment of Patient

1. Breath sounds

2. Monitor Sp02

3. Symmetric lung expansion

4. Signs of respiratory distress:

A) Tachypnea

B) rapid/shallow breathing

C) Use of accessory muscles

D) This could indicate problems with the chest tube setup or that things are not draining properly.

5. Pain level:

A) Prevents patients from breathing deeply and properly.

B) Use of analgesics

6. If able, encourage the patient to ambulate, cough, take deep breaths

When A Pt Has a Chest Tube: Assess the Drainage

1. Color

2. Consistency

3. Amount

4. Changes over time, especially changes that indicate status decline:

A) New Frank Blood (>100mL/hr)

B) Drainage greater than 200mL/hr

5. Monitor and Record:

A) Initially q/hr possibly more frequent.

B) As drainage slows, Q4 or Qshift

C) Mark levels (date/time)

6. Facilitate Movement and Positioning:

A) Helps facilitate drainage.

B) Semi or High Fowlers

C) Side to side turns/position

D) May lead to increased or large drainage initially.

When A Pt Has a Chest Tube: Assess Dressing

1. Clean, dry, intact

2. Daily dressing changes

A) Date and time

B) More frequent as needed if it becomes saturated, etc.

C) Clean and prep area with CHG or Betadine

D) Clean area around CT

D) CT itself, at least 2cm around insertion site.

E) Gauze in/around the site as well as under the tube and then laid over it.

F) Drain sponges

G) Secure everything down with the CT via chest tube tape.

H) Secure further down the tube as well to prevent pulling and accidental removal.

I) Xeroform Dressing: More common with trauma. Creates an airtight seal.

When A Pt Has a Chest Tube: Insertion site Assessment

1. Has there been movement of the chest tube, especially outward?

2. Daily Chest x-ray to check placement, especially that the drain tube fenestration (holes) are in the pleural space within the chest wall

3. Check Sutures: Are the intact/secure

4. Signs of infection: Redness, Swelling, Fever

5. Discoloration of skin

6. Drainage around outside the CT: Type and amount.

7. Subcutaneous emphysema or trapped air (crepitus):

A) May be present initially especially due to trauma.

B) Mark around the area to monitor for expansion or movement.

When A Pt Has a Chest Tube: Assess Drainage unit Position

Keep unit below patient. Why? Let Gravity Do Its Thang.

When A Pt Has a Chest Tube: Assess Tidaling

1. Oscillation of the water level by the water seal.

2. Normal as a result of changing intrapleural pressures throughout and due to the respiratory cycle.

3. Spontaneous breathing:

A) Inspiration = neg pressure = Upward movement

B) Expiration = positive pressure = Downward movement

4. Positive pressure ventilation (opposite):

A) Insp = positive pressure = downward movement

B) Exp = negative pressure = upward movement

5. More apparent in patients with suction off. Decreased tidaling when on.

6. What does it mean if tidaling stops.

A) Pts lung has fully expanded

B) Possible air leak

C) Kink or obstructed tube

7. High water level in Tidaling chamber:

A) Result of high negative pressure due to big deep breaths or coughing.

B) There is a button to release this pressure on the back of the device, but suction must be on in order to use this.

When A Pt Has a Chest Tube: Assess for an Air Leak

1. Will show as bubbling in the water sealed chamber.

2. Marked numerically to show severity (1-5)

3. Intermittent, continuous, not present bubbling.

4. Pts with pneumothorax or new chest tube will have initial bubbling that is normal.

When A Pt Has a Chest Tube: What To Do: Persistent Air Leak

1. If new, Alert provider

2. Alveolar/Broncho-plueral fistula or something that is allowing air to continue to go from the respiratory system to the pleural space.

3. Risk factors for pts on steroids, significant trauma, non-compliant lungs, emphysema, high PEEP/ Pressure, significant scar tissue.

4. Can also be a result of the insertion site:

A) Excessive space around the CT site.

B) CT dislodgement

C) Tubing or connection problems

D) Collection chamber issue (rare)

Persistent Air Leak: Immediate Identification of the Leak Location

What To Do:

1. Pinch around insertion site

2. Use clamps on CT :

A) No longer than 10 seconds to check for leaks. This is important, as if the pt does have a continuous leak driven by an internal problem, this can lead to a tension pneumothorax.

B) If leak stops while CT is clamped, and pinching around the skin at insertion site did not stop it, the leak is coming from inside the patient.

C) Clamp below the collection point where the tubing and chest tube come together. If its stops here, the leak is coming from that connection. Make sure it is tight.

D) If still persistent, work our way down clamping about every 12 inches to identify where the problem in the tubing could be coming from.

E) If still leaking, then its the rare case where the collection unit is faulty.

When A Pt Has A Chest Tube: Assess Tubing

1. Avoid kinks and occlusions

2. Avoid dependent loops:

A) Will increase intrapleural pressure

B) Prevent lung expansion

3. Ensure integrity of connections via tape spiraling around connections. Area that connects chest tube to tubing is a high risk spot for clot development and entrapment of clots.

When A Pt Has A Chest Tube: How to Perform Sampling

1. Not done often

2. Sample collection port. Luerlock for a syringe. Dependently collect fluid and draw sample from port.

3. Sample w/ needle from tubing:

A) Clean site

B) 20g or smaller needle

C) Dependent collection of fluid

D) Draw sample

E) Self sealing tubing.

Emergency Supplies to Have For Dislodgement

1. Petroleum gauze

2. 4x4 gauze

3. Transparent dressing

4. CT clamp

What To Do: Dislodgement: Tubing Disconnected from CT

1. Very first thing is to grab and cover tubing end with hand and grab the clamp and clamp the chest tube.

2. Time is of the essence, no >10seconds

3. Take end of the CT and insert it into sterile water and then clamp it. This will reestablish the water seal and buy more time to get a new drainage unit set up.

4. Prepare new drainage unit

5. Inform provider

6. Chest xray

What To Do: Dislodgement: Chest Tube Completely Dislodged or Pulled Out

1. Cover insertion site with hand and call for help.

2. If pt is able to assist, have them cough and exhale as long as they possibly can to keep air from reentering the pleural space.

3. Uncover insertion site while the pt exhales and recover when they stop.

4. Prepare sterile occlusize dressing.

5. Take the petroleum gauze and open it up. Put it underneath three to four layers of 4x4 gauze at the insertion site and cover it with transparent dressing creating a three boarder seal. This will allow air to escape but not reenter.

6. Let provider know immediately.

7. Chest Xray 8. New CT insertion

CT Maintenance: Drainage unit is Full

1. Replace it.

2. Atrium unit will need to have tubing at the CT clamped.

3. Then disconnect accordion tubing from the standard tubing and connect it to the new Atrium unit.

4. Unclamp tubing and CT

5. Keep eye on water seal level at the zero level.

6. No dependent loops

7. Milking CTs: Risky so better not to do it as it can cause negative pressure.