Download CHEST TUBES: pages 854-868

Chest Tube Insertion and Care
Chest tubes are used to ensure expansion of the lung by removal of fluid and/or air from
the pleural space. A chest x-ray can indicate where the chest tube needs placed. Doctors
order and place chest tubes.
CHEST TUBE PLACEMENT
WHERE TUBE PLACED
CONDITION
POSSIBLE CAUSES
Pneumothorax: Air in the •Trauma, surgery invasive
Anteriorly near the apex of
pleural space that limits
pulmonary procedures,
the lung at the second
lung expansion.
bronchoscopy, COPD and
intercostals space (ICS),
smoking, chest trauma,
midclavicular line
Tension pneumothorax:
Air that continues to
CPR, and mechanical
increase pressure and
ventilation.
decrease lung expansion,
venous return and cardiac
•Forceful coughing or
output
rupture of a bleb in the
lung: spontaneous
pneumothorax
•Procedures such as
percutaneous needle
puncture or central line
insertion: iatrogenic
pneumothorax
Hemothorax: An
accumulation of blood in
the pleural space. Usually
it's a combination of both
air and blood called a
hemopneumothorax
Pleural effusion: An
abnormal fluid collection or
transudation in the pleural
space.
Empyema: A collection of
purulent material in the
pleural space
Prevention of cardiac
tamponade after openheart surgery: Blood that
could cause cardiac
tamponade if not removed
from the mediastinum
Open chest procedures,
blunt or penetrating trauma
Two chest tubes may be
inserted, one at the apex and
one at the base of the lung
Heart failure, surgery
malignancy
Posteriorly into the fifth or
sixth ICS
Pneumonia, lung abscesses,
or contamination or injury
of the pleural cavity
Bleeding associated with
surgery
Posteriorly into the fifth or
sixth ICS
May insert anterior and
posterior chest tubes to the
same drainage device with a
Y connector or to two
separate drainage devices
Nursing 2002-June 2002, Volume 32 Number 6, Pages 36-43
HOW DOES THE THREE-CHAMBER SYSTEM WORK?
The pleurevac is based on an old system where 3
glass bottles in a series were used to drain and
fluid and/or air from the pleural space. It is
based on the theory that you want the fluid
and/or air to be drained out and to have nothing
sucked back in during inspiration.
1. Collection chamber: Fluid drains into chest tube and into the collection chamber.
2. Water seal chamber: Acts as one-way valve so air can drain from chest but can't
return to patient (think of a cup of water with a straw-you can blow air into but
you can't suck it back out).
3. Suction-control regulator: Water-filled or dry suction removes the chest drainage
and maintains the flow. Connect to a suction set up and use regulator to ordered
level.
Equipment
1. Disposable chest drainage as ordered
2. Suction source and setup (wall canister or portable)
3. Sterile water or normal saline
4. Nonsterile and sterile gloves
5. Sterile gauze sponges
6. Local anesthetic
7. Chest tube tray (all items are sterile)
8. Dressings: petrolatum gauze, split chest tube dressings, several 4 X 4 inch gauze
9. dressings, 2 large gauze dressings, and 4-inch tape or elastic bandage
10. Head cover
11. Face mask/face shield
12. 2 rubber tipped hemostats
13. 1-inch adhesive tape for taping connections
Demonstrated Satisfactory = S
Needs Improvement
Must Redemonstrate =NI
Procedure
Check orders ensuring that appropriate site
is ordered. (right/left/bilateral)
Ensure consent is signed.
Wash hands, check client identification and
explain procedure is about to begin.
Position patient.
Gather equipment and set up chest tube.
Remove water seal system from package
and hook over foot of bed.
(Check with physician for amount of
suction desired). NOTE: Atmospheric
vent on top of water seal chamber must
never be blocked-never use anything but
cap specifically designed for air vent.
Assist physician with procedure.
Wash hands and apply gloves.
Administer any medications that may
have been ordered.
Assist in providing psychological support
to client.
Show and hold anesthetic upside down
facing physician.
S
NI
After physician had placed chest tube
assist with attaching drainage tube to chest
tube.
Tape all connections in double spiral with
1-inch adhesive tape.
Turn suction on
Coil extra tubing on bed with patient and
adjust tubing to hang in straight line to
drainage chamber.
After tube is placed, assist client to
comfortable position with HOB elevated to
facilitate air or fluid removal.
Dispose of used equipment
Remove gloves and wash hands
Document procedure according to agency
policy .
Check for post insertion orders such as
chest X-Ray to check tube placement.
Nursing Implications
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Bulky dressings can kink tube cover with Vaseline gauze and
opsite or other small dressing
Two tubing clamps at bedside only for emergency, vaseline gauze
and extra drainage system readily available. Clamping the tube
and forgetting to unclamp can lead to a tension pneumothorax.
Monitor for tracheal deviation (shift) this is a medical which is a
late sign of tension pneumothroax and is a medical emergency.
Immediately report drainage of >200 of blood in a 1 to 2 hour
time frame. Watch for increased restlessness or anxiety.
Notify physician for decreased or absent breath sounds on CT side.
Assess drainage collection container immediately after insertion
and every 4 hours for: fluctuations in the air leak indicator, air
bubbles in the air leak indicator, suction set at ordered level.
Chart insertion site, location and tube size.
Immediately after insertion and every 4 hours assess: comfort
level, breath sounds, heart rate, blood pressure, temperature,
respiratory rate and rhythm, O2 sats >96%, drainage for amount,
color and consistency, dressing for occlusiveness and drainage
from insertion site, chest wall at insertion site for subcutaneous
emphysema.
Every shift mark volume of drainage with date, time and initials.
Procedure
Check orders
Ensure consent is
is signed
Gather equipment
Wash hands
Apply gloves
Check I.D.
Position client
Set up chest tube
Position of tubing
after insertion
Disposal of used
equipment
Remove gloves and
wash hands
Documentation
Post insertion
orders
S
NI
Questions
1. What are some reasons patients would require a chest tube?
2. Where are chest tubes placed? Is it the same place for everyone?
Why/why not?
3. What is the greatest risk for a patient with chest tubes? How can it be
prevented?
4. What should be done if bubbling in the suction control chamber stops?
5. What does bubbling in the underwater-seal chamber indicate? Should it
be corrected, or not? Under what circumstances is bubbling OK? When is
bubbling not normal?
6. Should a chest tube ever be clamped? If yes, under what circumstance?
1. How can other various complications be prevented in a patient with a
chest tube?
8. What would you do if your patient with a chest tube had to be
transported off the floor for a procedure?
9. What should be done if a chest tube falls out or is pulled out?
10. List the observations that should be made about a chest tube and write
a brief focus note illustrating HOW it should be documented. (Use back of
sheet)