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Chest Tube Insertion and Monitoring Unit 3 chapter 19 Nursing care of clients with respiratory disorders SectionDiagnostic and Therapeutic Procedures Chapter 19 Chest Tube Insertion and Monitoring Overview ●● ●● ●● Chest tubes are inserted into the pleural space to drain fluid, blood, or air; reestablish a negative pressure; facilitate lung expansion; and restore normal intrapleural pressure. Chest tubes can be inserted in the emergency department, at the client’s bedside, or in the operating room through a thoracotomy incision. Chest tubes are removed when the lungs have reexpanded and/or there is no more fluid drainage. Chest Tube Systems ●● Types of chest drainage systems: ◯◯ ◯◯ ◯◯ ◯◯ Single chamber systems have a water seal and a drainage collection in the same chamber. Two chamber systems have a water seal and a drainage collection in separate chambers, which allows for the collection of larger amounts of drainage. Three chamber systems have a water seal, a drainage collection, and suction control in separate chambers. Disposable chest tube drainage systems are now commonly used. View Media Supplement: ●● Water seals are created by adding sterile fluid to a chamber up to the 2 cm line. The water seal allows air to exit from the pleural space on exhalation and stops air from entering with inhalation. ◯◯ 218 Chest Tube Drainage System (Image) To maintain the water seal, the chamber must be kept upright and below the chest tube insertion site at all times. The nurse should routinely monitor the water level due to the possibility of evaporation. The nurse should add fluid as needed to maintain the 2 cm water seal level. rn Adult medical surgical nursing Chest tube insertion and monitoring ◯◯ ◯◯ ◯◯ The height of the water in the suction control chamber determines the amount of suction transmitted to the pleural space. A suction pressure of –20 cm H2O is common. The application of suction results in continuous bubbling in the suction chamber. The nurse should monitor the fluid level and add fluid as needed to maintain the prescribed level of suctioning. Tidaling (movement of the water level with respiration) is expected in the water seal chamber. With spontaneous respirations, the water level will rise with inspiration (increase in negative pressure in lung) and will fall with expiration. With positivepressure mechanical ventilation, the water level will rise with expiration and fall with inspiration. Cessation of tidaling in the water seal chamber signals lung reexpansion or an obstruction within the system. Chest Tube Insertion ●● Indications ◯◯ ◯◯ ●● Diagnoses ■■ Pneumothorax (collapsed lung) ■■ Hemothorax (blood in lung) ■■ Postoperative chest drainage (thoracotomy or open-heart surgery) ■■ Pleural effusion (fluid in lung) ■■ Lung abscess (necrotic lung tissue) Client Presentation ■■ Dyspnea ■■ Distended neck veins ■■ Poor circulation ■■ Cough Client Outcomes ◯◯ The client will maintain adequate gas exchange. ■■ ●● Poor oxygenation can quickly lead to serious consequences in older adult clients because many have decreased pulmonary reserves. ◯◯ The client will be free from pain. ◯◯ The client will remain free from infection. Preprocedure ◯◯ Nursing Actions ■■ Verify that the consent form is signed. ■■ Reinforce client teaching. Breathing will improve when the chest tube is in place. rn adult medical surgical nursing 219 Chest Tube Insertion and Monitoring ■■ Assess for allergies to local anesthetics. ■■ Assist the client into the desired position (supine or semi-Fowler’s). ■■ ●● Prepare the chest drainage system prior to the insertion per the facilities protocol (fill the water seal chamber). ■■ Administer pain and sedation medications as prescribed. ■■ Prep the insertion site with povidone-iodine. Drape the insertion site. Intraprocedure ◯◯ Nursing Actions ■■ Assist the provider with insertion of the chest tube, application of a dressing to the insertion site, and set-up of the drainage system. ☐☐ ☐☐ ☐☐ ☐☐ ■■ The chest tube tip is positioned up toward the shoulder (pneumothorax) or down toward the posterior (hemothorax or pleural effusion). The chest tube is then sutured to the chest wall and an airtight dressing is placed over the puncture wound. The chest tube is then attached to drainage tubing that leads to a collection device. Place the chest tube drainage system below the client’s chest level with the tubing coiled on the bed. Ensure that the tubing from the bed to the drainage system is straight to promote drainage via gravity. The nurse should continually monitor the client’s vital signs and response to the procedure. View Media Supplement: ●● Postprocedure ◯◯ Nursing Actions ■■ ■■ ■■ ■■ Assess the client’s vital signs, breath sounds, SaO2, color, and respiratory effort as indicated by the status of the client and at least every 4 hr. Encourage coughing and deep breathing every 2 hr. Keep the drainage system below the client’s chest level, including during ambulation. Monitor the chest tube’s placement and function. ☐☐ ☐☐ 220 Chest Tube (Image) Check the water seal level every 2 hr and add water as needed. The water level should fluctuate with respiratory effort. Document the amount and color of drainage hourly for the first 24 hr and then at least every 8 hr. Mark the date, hour, and drainage level on the container at the end of each shift. Report excessive drainage (greater than 70 mL/hr) or drainage that is cloudy or red to the provider. Drainage will often increase with position changes or coughing. rn Adult medical surgical nursing Chest tube insertion and monitoring ☐☐ ☐☐ ■■ ■■ ■■ Check for expected findings of tidaling in the water seal chamber and continuous bubbling only in the suction chamber. Routinely monitor tubing for kinks, occlusions, or loose connections. Monitor the chest tube insertion site for redness, pain, infection, and crepitus (air leakage in subcutaneous tissue). Position the client in the semi-Fowler’s to high-Fowler’s position to promote optimal lung expansion and drainage of the fluid from the lungs. ■■ Administer pain medications as prescribed. ■■ Obtain a chest x-ray to verify the chest tube’s placement. ■■ ■■ ■■ ●● Monitor the fluid in the suction control chamber and maintain the fluid level prescribed by the provider. Keep two enclosed hemostats, a bottle of sterile water, and an occlusive dressing located at the bedside at all times. Due to the risk of causing a tension pneumothorax, chest tubes are only clamped when ordered by the provider in specific circumstances, such as an air leak, during drainage system change, accidental disconnection of tubing, or damage to the collection device. Do not strip or milk tubing routinely; only perform this action when prescribed by the provider. Stripping creates a high negative pressure and can damage the client’s lung tissue. Complications ◯◯ Air leaks ■■ Air leaks can result if a connection is not taped securely. ■■ Nursing Actions ☐☐ Monitor the water seal chamber for continuous bubbling (air leak finding). If observed, locate the source of the air leak and intervene accordingly (tighten the connection, replace drainage system). XX XX Check all of the connections. Cross clamp close to client’s chest. If bubbling stops, the leak is at the insertion site or within the thorax. If bubbling doesn’t stop, methodically move clamps down the drainage tubing toward the collection device, moving one clamp at a time. When the bubbling stops, the leak is within the section of tubing or at that connection distal to the clamp. rn adult medical surgical nursing 221 Chest Tube Insertion and Monitoring ◯◯ Accidental disconnection, system breakage, or removal ■■ These complications can occur at any time. ■■ Nursing Actions ☐☐ ☐☐ ☐☐ ◯◯ If the tubing separates, the client is instructed to exhale as much as possible and to cough to remove air from the pleural space. The nurse should cleanse the tips and reconnect the tubing. If the chest tube drainage system breaks, the nurse should immerse the end of the tube in sterile water to restore the water seal. If a chest tube is accidentally removed, an occlusive dressing taped on only three sides should be immediately placed over the insertion site. This allows air to escape and reduces the risk for development of a tension pneumothorax. Tension pneumothorax ■■ Sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstruction may cause a tension pneumothorax. Chest Tube Removal ●● Provide pain medication 30 min before removing chest tubes. ●● Assist the provider with sutures and chest tube removal. ●● ●● ●● ●● 222 Instruct the client to take a deep breath, exhale, and bear down (Valsalva maneuver) or to take a deep breath and hold it (increases intrathoracic pressure and reduces risk of air emboli) during chest tube removal. Apply airtight sterile petroleum jelly gauze dressing. Secure in place with a heavy weight stretch tape. Obtain chest x-rays as prescribed. This is performed to verify continued resolution of the pneumothorax, hemothorax, or pleural effusion. Monitor the client for excessive wound drainage, signs of infection, or recurrent pneumothorax. rn Adult medical surgical nursing Chest tube insertion and monitoring Chapter 19: Chest Tube Insertion and Monitoring Application Exercises Scenario: A nurse is preparing to receive a client who has had a chest tube placed. 1. Which of the following items should the nurse have placed in the client’s room? (Select all that apply.) Oxygen Sterile water Enclosed hemostat clamps Indwelling urinary catheter Occlusive dressing Suction source Bladder scan machine 2. While assessing the client, the nurse notices that the client’s chest tube has become dislodged. Which of the following actions should the nurse take first? A. Place the tubing into sterile water to restore the water seal. B. Apply sterile gauze to the site. C. Tape or clamp all connections. D. Assess the client’s respiratory status. 3. A nurse is assessing the functioning of a client’s chest drainage system. Which of the following are expected client findings? (Select all that apply.) Continuous bubbling in the water seal chamber Gentle constant bubbling in the suction control chamber Rise and fall in the level of water in the water seal chamber with inspiration and expiration Exposed sutures without dressing Drainage system is upright at chest level 4. A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side during removal. B. Hold his breath. C. Inhale deeply during removal. D. Perform the Valsalva maneuver during removal. rn adult medical surgical nursing 223 Chest Tube Insertion and Monitoring Chapter 19: Chest Tube Insertion and Monitoring Application Exercises Answer Key Scenario: A nurse is preparing to receive a client who has had a chest tube placed. 1. Which of the following items should the nurse have placed in the client’s room? (Select all that apply.) X Oxygen X Sterile water X Enclosed hemostat clamps Indwelling urinary catheter X Occlusive dressing X Suction source Bladder scan machine Oxygen, sterile water, hemostat clamps, an occlusive dressing, and a suction source are all indicated for this client. If the tubing becomes disconnected, the end connected to the client can be placed in sterile water to restore the water seal. The hemostat clamps should be used to check for air leaks. An indwelling urinary catheter and a bladder scan machine are not indicated for a client who has a chest tube. NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures 2. While assessing the client, the nurse notices that the client’s chest tube has become dislodged. Which of the following actions should the nurse take first? A. Place the tubing into sterile water to restore the water seal. B. Apply sterile gauze to the site. C. Tape or clamp all connections. D. Assess the client’s respiratory status. Using the airway, breathing, and circulation (ABC) priority setting framework, the application of sterile gauze to the site should be the first action for the nurse to take. Placing the tubing into sterile water to restore the water seal is part of this process, but not the priority. Taping or clamping all connections is part of this process, but not the priority. Assessing the client’s respiratory status is part of this process, but not the priority. NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures 224 rn Adult medical surgical nursing Chest tube insertion and monitoring 3. A nurse is assessing the functioning of a client’s chest drainage system. Which of the following are expected client findings? (Select all that apply.) Continuous bubbling in the water seal chamber X Gentle constant bubbling in the suction control chamber X Rise and fall in the level of water in the water seal chamber with inspiration and expiration Exposed sutures without dressing Drainage system is upright at chest level Continuous bubbling in the water seal chamber indicates an air leak. The nurse should cover the insertion site with an airtight dressing. A dressing should be in place around the chest tube. The drainage system should be maintained upright and below the client’s chest level. A rise and fall in the level of water in the water seal chamber indicates a good connection between the chest wall and the chamber. It also indicates that the system is working well. Gentle bubbling is an expected finding because air in the chest is being removed. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures 4. A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side during removal. B. Hold his breath. C. Inhale deeply during removal. D. Perform the Valsalva maneuver during removal. The client should be instructed to take a deep breath, exhale, and bear down (Valsalva maneuver) or to take a deep breath and hold it during tube removal. An airtight dressing is applied following removal. Placing the client on his left side during chest tube removal is not indicated. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures rn adult medical surgical nursing 225
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