Download NK6-J - Closed Chest Drainage Policy

Nursing Care Procedures
Subject:
Page:
RESPIRATORY CARE
Policy #:
1 of 9
Title:
Revision of:
CLOSED CHEST DRAINAGE (PLEUR-EVAC® SAHARA SYSTEM)
14.01
Effective Date:
3/09
1/19/2010
“NMH Framework for Nursing Practice and Guiding Principles for Care Delivery are based on
the work of Virginia Henderson”.
I.
PURPOSE
A. The purpose of this policy is to allow a nurse to access it as a guide in the care,
management and troubleshooting of chest tubes and the collection system.
B. The purpose of this procedure is to provide instruction to a physician and/or mid-level
provider (once approved/credentialed by NMH Medical Staff Board) in performing the
surgical placement of chest tubes (CT).
II.
INDICATIONS FOR USE
A. To evacuate air and/or fluid from pleural space.
B. To maintain lung expansion in the presence of pleural disruption, and;
C. To instill a sclerosing agent in the presence of malignant effusion.
III. EQUIPMENT
FROM SENTACT (possible floor stock in ICU units) FROM Floor Stock
Chest Tube Insertion Tray
Chest Tube
Pleur-evac Chest Drainage System with
Sterile Towels
Sterile Gowns
Sterile Gloves
1% Lidocaine- 20ml x 2
5ml and 10ml syringes
18g and 25g needles
Chlorhexidine gluconate x 3
Connector tubing and connectors
Silk or Paper Tape (2’’) for dressing
Suction apparatus (wall suction set-up)
Sterile 4x4s (3)
Ordered sedative/opiod/anxiolytic
Consent form
Bedside monitor (Dynamap)
Title:
CHEST DRAINAGE (PLEUR-EVAC® SAHARA SYSTEM)
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Policy #
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IV. GENERAL INFORMATION:
A. The physician or midlevel provider will specify the size of the CT to be inserted.
B. Wall suction to a Pleur-Evac system is the preferred means of providing suction to a
chest tube.
C. While a CT is ordered to be placed on suction, it is required for the RN to discuss with
the service regarding patients’ ability to leave the floor with the CT off suction for a
test/procedure, including a chest x-ray (CXR).
D. CTs are NOT to be stripped by nurses. (Exception: In the CTICU with cardiac surgery
patients according to the provider’s specific orders.)
E. CTs are not to be clamped by nurses, except when specifically ordered by the
physician/mid-level provider as noted below.
F. Chest tube clamps (located on the Pleur-Evac tubing; blue clamp) are applied only in
the following situations:
1. Momentarily, when changing Pleur-Evac collection containers;
2. For control of drainage during initial insertion of a CT for a large pleural effusion
and to prevent re-expansion pulmonary edema (as ordered by MD and/or mid-level
provider); A specific order will be placed by MD/mid-level provider regarding the
following:
a. Period of time that clamp will be applied
b. Amount of fluid to be drained at one time
c. The goal at the end of the clamping is to leave the chest tube safely unclamped
and to suction.
3. For several hours prior to removal of a CT, only upon a MD/mid-level provider
order. The goal of this procedure is to ensure that the lung will stay inflated once
the chest tube is pulled (the clamp “simulates” a pulled chest tube). The nurse is
responsible to monitor patient clinically for any signs of respiratory distress,
including dyspnea and desaturation. If these occur, the nurse is to inform service
immediately and unclamp CT.
G. Chest tube clamps are NOT applied during transportation of patients, unless
specifically ordered by MD/mid-level provider.
H. Pleur-Evac systems must be kept in an upright position below the level of the chest at
all times.
I. Autotransfusion may be performed per unit protocol using this system in approved
units, ie CTICU.
V.
SPECIAL INSTRUCTIONS:
A. SET-UP Pleur-EVAC
1. Open the package by grasping the bottom edge of flap and pulling up toward the
sterile opening.
2. Remove the unit – asking the provider if it is required to be maintained sterile or
clean.
3. Obtain syringe from behind the Pleur-Evac unit and fill the air leak meter with the
water using the needleless injection site (clean technique).
4. Pull out the blue stand from under Pleur-Evac system and place on the floor. Avoid
taping this blue stand to the floor, to encourage ambulation..
Title:
CHEST DRAINAGE (PLEUR-EVAC® SAHARA SYSTEM)
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Policy #
14.01 NCP
VI. PROCEDURE
A. Insertion Steps
1. Together with the physician or midlevel provider, explain the procedure to the
patient and provide emotional support.
2. Perform and document in Powerchart a TIME-OUT.
3. Administer pain medication/sedative as ordered by MD/mid-level provider before
and during the procedure.
4. Prepare Pleur-Evac system and have available for physician/provider inserting the
chest tube. The air leak meter must be filled with water to the fill range.
5. The physician or midlevel provider:
a. Applies chlorhexidine gluconate to the insertion area.
b. Dones sterile gown/gloves.
c. Drapes the area with sterile drapes.
d. Applies local anesthetic to the insertion site.
e. Inserts and sutures the chest tube.
f. Connects the chest tube to Pleur-Evac system. Be sure both the connectors –
chest tube to Pleur-Evac tubing-are firmly pushed together in place as securely
as possible. Ensure that these connections are securely taped (see below).
g. Connects Pleur-Evac to suction/adjust settings according to order.
h. Applies dressing to chest tube site and covers area using paper or silk tape.
Cloth or waterproof tape is to be avoided (except to secure chest tube
connections – see below). Vaseline gauze is NO longer used unless the
MD/provider feels it is necessary to decrease air from around the chest tube
(adding a chest tube stitch is ideal/preferred).
i. Tape all connections securely using waterproof tape (see picture below for ideal
taping method – try to avoid wrapping tape repeatedly around tubing). Tape
does not create an air tight seal. This is accomplished by firmly pushing the
connectors into the chest tube and Pleur-Evac tubing.
j. The Provider will write further specific orders for chest tube - i.e. – settings,
STAT chest x-ray.
6. The Nurse – At time of insertion:
a. Assesses the patient’s vital signs before, during and after procedure.
b. Ensures STAT CXR is ordered.
c. Places the chest tube to suction or water seal, according to the provider’s order;
d. Observes and documents if an air leak is present in the water seal chamber of
the Pleur-Evac system.
e. Checks all connections to ensure they are tight, secure and taped (see picture
below);
Title:
CHEST DRAINAGE (PLEUR-EVAC® SAHARA SYSTEM)
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14.01 NCP
f. Places a dressing over the chest tube site – the dressing is dry 4x4 or a drainage
sponge. Cover dressing using paper or silk tape. Cloth or waterproof tape is to
be avoided (except to secure chest tube connections – see above). Vaseline
gauze is NO longer used unless the MD/provider feels it is necessary to
decrease air from around the chest tube (adding a chest tube stitch is
ideal/preferred).
g. Initial, Date and time dressing after each change.
B. Ongoing Nursing Care:
1. Daily Nursing Assessment of the Patient
a. Vital signs at least every 8 hours while the patient has a chest tube in place.
b. Daily CXR to evaluate chest tube placement and status of lungs.
c. SpO2 at least every 8hours and assess for the first hour post-placement of chest
tube for any signs of respiratory distress.
d. Assess for the presence of subcutaneous (subq) emphysema and monitor for any
extension of this subq air. Notify service if extension occurs, especially in the
presence of respiratory distress. Order stat CXR.
e. Pain Assessment and Reassessment: Sufficient analgesics should be available
to the patient to allow for adequate pulmonary hygiene, including cough/deep
breathing, sitting in chair and ambulation, according to MD’s activity orders.
f. Variation of fluid movement in the tubing with the patient’s respirations is
called tidaling. This is not an air leak. It can be considered a normal finding. It
is indicative of a functional tube in the pleural space and the movement reflects
pleural pressure changes during normal respiration.
Suction indicator
2. Pleur-evac system Maintenance
a. Suction
i. Review order for amount of suction and set the Pleur-Evac. Note
that the amount of suction is regulated by the Pleurevac not wall
suction manometer. The goal is to adjust wall manometer to allow
floating of red indicator as noted in picture.
ii. Note: Low-Intermittent Wall suction is not used for chest tubes.
Suction on the wall regulator is always on continuous. Wall
suction must be at least sufficient to maintain the floating red
indicator in the window throughout the patient respiratory cycle
(see picture). This is usually on Low to Medium on the wall
suction regulator. In some instances, the provider may request a
higher wall suction setting to ensure the red device is continuously
floating – this usually occurs during a large air leak.
b. Drainage
i. Observe color (serous, seroussangionous) and amount.
ii. Mark the level of drainage every 8 hours – on the Pleur-Evac and in
Powerchart.
Title:
CHEST DRAINAGE (PLEUR-EVAC® SAHARA SYSTEM)
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Policy #
14.01 NCP
iii. Notify service if amount of drainage in Pleur-Evac is over 200ml/hour or if
fluid changes in appearance especially observed bloody drainage of
>100ml/hr; there are special circumstances to the amount of acceptable
drainage:
1. Unit –specific: i.e. CTICU has a different threshold
2. Clamping to control amount of drainage from a large pleural effusion
(typically allows 500ml every 30minutes)– see above.
c. Air leak
i. Observe for an air leak – bubbling in water seal chamber (note: the air leak
should improve over time and NOT worsen).
ii. If a continuous air leak is observed (both inspiratory and expiratory) assess
for a possible mechanical air leak (connections loose or eyelets on chest
tube exposed). Notify service if a continuous air leak is observed.
3. Dressing Change
a. Change the initial chest tube dressing (clean technique) after 48hours and then
every 48hours (as a minimum) while the chest tube is in place. There may be a
unit-specific policy on the frequency of CT dressing changes.
b. If the dressing is saturated, dressing changes may occur more frequently. If
excessive, whereby dressing requires reinforcement every ½ hour to 1hours, the
MD/mid-level provider should be informed.
c. Observe condition of site, surrounding skin, assess chest tube security (all chest
tubes are sutured to the patient’s skin) and the presence of any exposed chest
tube holes.
d. Apply clean split sponge or 4x4s. Cover site with a dry dressing and use paper
or silk tape. Cloth or waterproof tape is to be avoided (except to secure chest
tube connections – see below). Vaseline gauze is NO longer used unless the
MD/provider feels it is necessary to decrease air from around the chest tube
(adding a chest tube stitch is ideal/preferred).
e. Initial, Date and time dressing after each change.
4. Pleural Fluid Specimen Collection
a. A sample of drainage fluid may be obtained from the resealable connecting
tube. If drainage is minimal, a dependent loop in the tubing will allow fluid
to collect for sampling. When sufficient fluid has collected, the nurse should
wipe the tubing with a chloroprep wipe. The fluid sample can be aspirated
with a 20-gauge or smaller needle at a 45-degree angle. Try to avoid a 90degree angle needle entry as this may cause a permanent hole in the tubing.
Angles entry into the tubing will create a track which will close when needle
is removed.
b. Specimen collection can also be obtained from specimen port.
c. Collected pleural fluid may be placed in appropriate containers for analysis
and ordered from powerchart.
Title:
CHEST DRAINAGE (PLEUR-EVAC® SAHARA SYSTEM)
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Policy #
14.01 NCP
D. Chest tube removal
1. Criteria for removal of chest tube typically includes:
a. No air leak
b. Radiographic inflation of lung and/or removal of fluid
c. Chest tube output amount over the last 24hours according to service assessment
and criteria.
2. Chest tubes are removed by a MD or midlevel provider, except where permitted by
unit policy (i.e. CTICU unit protocol).
3. The occlusive dressing applied at the time of chest tube removal must stay in place
for at least 48 hours.
4. If the chest tube has been sutured, the suture remains in place after chest tube
removal. It is usually removed 7-10 days since removal of the chest tube.
VII. NURSING DOCUMENTATION
A. When caring for a patient with a chest tube, in addition to standard respiratory
assessment (e.g. VS, lung sounds) the following should be documented every shift in
Powerchart under Respiratory Assessment:
1. Location and number of chest tube(s)
2. Presence and degree of air leak
3. Appearance of drainage
4. Appearance of CT site and CT dressing
5. Presence of drainage around the CT site
6. Presence of subcutaneous emphysema
7. Whether CT is to water seal or suction (if on suction, document amount of suction)
8. Document amount of drainage during each shift under I&O
B. Upon insertion or removal of a chest tube, document in Powerchart under Respiratory
Assessment:
1. All of the above
2. Date and time tube was inserted/removed
3. How patient tolerated procedure
4. Any medications that were given during insertion procedure
C. PRN chest tube documentation:
1. Clamping of chest tube
2. Change in collection system (new Pleur-Evac, change from water seal to suction,
change in the amount of suction, or change to bulb suction, Pneumo-stat or other
collection device)
3. Dressing changes
4. Changes in assessment during shift (new air leak, change in type of drainage)
Title:
CHEST DRAINAGE (PLEUR-EVAC® SAHARA SYSTEM)
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Policy #
14.01 NCP
TROUBLESHOOTING A PLEUR-EVAC SYSTEM:
Area
RESPIRATORY
STATUS
Assessment
Patient is in respiratory
distress
CARDIAC STATUS
(mediastinal tubes)
CHEST TUBE Insertion
Site
Are there signs of cardiac
tamponade?
Is dressing clean? intact?
Is there crepitus upon
palpation around the site?
(subcutaneous emphysema)
Eyelets of chest tube noted to
be out of skin/ accidental
removal of tube.
PATIENT CHEST
TUBES
System becomes
disconnected
Patient requires transport
while on suction
Patient requires transport
on water seal
Air leak Meter bubbles
Is the suction set at prescribed
setting?
Orange float is not in
indicator window while on
suction.
Orange float
device in window
Nursing Action
Assess the patient. With pleural chest drainage
systems, the major hazard is a tension pneumothorax.
The most likely cause is a secondary etiology.
Quickly, assess the tubing’s patency and observe
tubing for a possible obstruction and notify service
immediately.
If yes, notify surgeon immediately and follow unit
protocol.
Dressings are to be changed every 48hours. When
the dressing is oversaturated, dressing changes may
occur more frequently. If excessive, whereby
dressing requires reinforcement every ½ hour to
1hours, the MD/mid-level provider should be
informed promptly. Assess tube patency.
Obtain vital signs - note for desaturation. Change
dressing and note extent of crepitus. Mark borders
and reassess frequently for any increase in size.
Notify service of its presence. A CXR may be
ordered STAT
Apply occlusive dressing immediately and notify
service STAT. Stay with patient. Assess pt’s vital
signs. Order STAT CXR. If patient decompensates,
an airway emergency should be called.
Wipe ends of tubing with chloroprep wipe, if able to
do so quickly. Reattach the system and notify the
physician. Tape connections securely as noted
above. DO NOT clamp tubing due to the high risk
for a tension pneumothorax. Observe water seal
chamber for an air leak.
Discuss with the service the need for the use of a
portable suction machine vs portable x-ray.
DO NOT clamp chest tube for transport. Keep the
chest tube collection system below the level of the
chest at all times. Maintain chest tube connected to
Pleur-Evac system.
This signifies an air leak. Check all the connections
for tightness/secure. If the air leak is new and all
connections are tight, notify service immediately.
Turn the dial to click to correct prescribed Setting –
20cm suction is most common for adults.
Orange float device should be floating while on
suction. Review order for amount of suction and
apply to Pleur-Evac. Note that the amount of suction
is regulated by Pleurevac not wall suction
manometer. The goal in to adjust wall manometer to
allow floating of red indicator as noted in picture.
Title:
CHEST DRAINAGE (PLEUR-EVAC® SAHARA SYSTEM)
Patient changed from suction
to water seal
Fluid moves up and down in
CT tubing with respirations
Collection chamber spill over
to other columns
Pleur-Evac is full
Locking
connector
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Policy #
14.01 NCP
Disconnect suction from pleue-evac system.
Observe the patient for any changes and Notify
service.
In a patient with a pleural chest tube, tidaling is
normal. If no tidaling is present, consider: 1) an
occlusion somewhere between pleural space and the
water seal; 2) a full expansion of lung where suction
has drawn the lung against the holes of the chest tube
or; 3) PEEP or suction is on, thus hindering tidaling.
Patients with mediastinal chest tubes have no
tidaling.
Assure all connections are intact. Mark each
column’s level with the date/time.
Change the Pleur-Evac system
a.
To change the system a nurse can clamp the
chest tube with the blue clamp and chloraprep
the Locking Connector.
b.
Squeeze the clamp to unlock the “old”
Pleur-Evac while squeezing the Locking
Connector port on the new Pleur-Evac system
and connect the patient’s chest tube tubing to the
new Pleur-Evac. Unclamp the chest tube and
ensure functionality by watching for tidaling.
VIII. REFERENCES
A. Halm, M.A. To Strip or not to strip? Physiological effects of chest tube manipulation.
AJCC. 2007;16(6): 609-612.
B. Allibone, L. Nursing Management of chest drains. Nrsg Standands, 2003; 17(22): 4554.
C. Sullivan, Ben. Nursing Management of patients with a chest drain. BJN 2008; 17(6):
388-393.
D. Couglin, A, et al. Go with the flow of chest tube therapy. Nursing 2006; 36(3); 36-42.
E. Deknatel Product Group. Pleur-Evac Sahara chest drainage system. Genzyme 1999.
Product insert.
F. Teleflex Medical. Nursing Considerations and troubleshooting. 2005.
www.telflexmedical.com.
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CHEST DRAINAGE (PLEUR-EVAC® SAHARA SYSTEM)
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Policy #
14.01 NCP
IX. APPROVAL
Responsible Party:
Carol Payson
Director, Surgical Patient Care
Electronic approval: 12/15/08
Reviewers:
Advanced Practice Nurse, Trauma Surgery
Nursing Professional Practice Committee
Approval Party:
Michelle A. Janney
Senior Vice President and Chief Nurse Executive
Electronic approval: 1/19/2010
X.
REVIEW HISTORY
WRITTEN:
REVISED:
REVISED:
REVISED:
REVISED:
August, 1972
March, 2002
November, 2002
March, 2006
December, 2008