Hayek . M Chest tube related to some indications NSG Collage , Medical complex \ Najah university. Chest Tubes: Indication to Removal Chest Tube Care and Monitoring.
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Presenting illness Hayek . M
Past medical history
Auscultation of breath
sounds and quality of voiceAssessment of Respiratory System
Abdominal/Accessory muscles use. Hayek . M
Abnormal breath sounds
Asymmetrical chest wall motion
Decreased oxygen saturation
Decreased urine output
Jugular venous distention
Shortness of breath
Skin color changes
Tachycardia and hypertension
Tracheal shiftThe Patient in Respiratory Distress
Pneumothorax Hayek . M
Symptomatic pleural effusion
Complicated parapneumonic effusion……… ectIndication for Chest Tube Placement
Based on systematic evaluation: Hayek . M
Soft tissues of neck, shoulders, breasts, axillae, diaphragms, and upper abdomen
Skeletal structures such as clavicles, ribs, vertebrae, scapulae, and sternum
Trachea, bronchi, pleural spaces, and lung parenchyma
Tubes, lines, and monitoring devicesNormal Chest Roentgenogram (X-ray)
Normal Chest X-ray Hayek . M
Simple PneumothoraxComparison of Chest Radiographs(Pneumothorax)
Collection Bottle Hayek . M: collects fluid and debris delivered by chest tube. Connected to water seal chamber
Water Seal Bottle: One way valve for air to escape from the pleural space, measures negative pressure in chest, and determines degree of air leak
Suction Control Bottle: Volume of water determines amount of negative pressure in pleural spaceHow Does a Chest Tube Function?
Goal is to remove fluid or air from the pleural space, prevent re-accumulation, and allow for lung re-expansion.
Allergic reaction Hayek . M
Intercostal nerve, artery, or vein injury
Re-expansion pulmonary edema
Subcutaneous emphysemaCommon Complicationsof Chest Tube Insertion
Chest tube inserting Hayek . M
Conduct routine patient assessment Hayek . M
Frequently assess the insertion site, tube, tubing, and drainage unit
Monitor amount, color, and consistency of the drainage
Encourage positioning with head of bed up to 30 degrees
Educate about the benefits of coughing, deep breathing, use of the incentive spirometer, and/or flutter valve every two hours
Advocate ambulation and position changesNursing Responsibilities (care)
A . Assess patient for respiratory distress and chest pain, breath sounds over affected lung area, and stable vital signs.B . Observe for increase respiratory distress
C . Observe the following:
* Chest tube dressing, ensure tubing is patent.
* Tubing kinks, dependent loops or clots.
* Chest drainage system, which should be upright and below level of tube insertion.
F. Maintain tube connection between chest and drainage tube intact and taped* Water-seal vent must be without occlusion * Suction-control chamber vent must be without occlusion when suction is used
G. Coil excess tubing on mattress next to patient. Secure with rubber band and safety pin or system’s clamp
H. Adjust tubing to hang in straight line from top of mattress to drainage chamber. If chest tube is draining fluid, indicate time (e.g., 0900) that drainage was begun on drainage bottle’s adhesive tape or on write-on surface of disposable commercial system.* Strip or milk chest tube only per MD/PA orders only * Follow local policy for this procedure
* To assess if patient is ready to have chest tube removed (which is done by physician’s order
A. Problem: Air leak* Continuous bubbling is seen in water-seal bottle/chamber, indicating that leak is between patient and water seal(a) Locate leak(b) Tighten loose connection between patient and water seal(c) Loose connections cause air to enter system.(d) Leaks are corrected when constant bubbling stops
* Problem: Bubbling continues, indicating that air leak has not been corrected (a) Cross-clamp chest tube close to patient’s chest, if bubbling stops, air leak is inside the patient’s thorax or at chest tube insertion site(b) Unclamp tube and notify physician immediately!(c) Reinforce chest dressing
* Problem: Bubbling continues, indicating that leak is not in the patient’s chest or at the insertion site(a) Gradually move clamps down drainage tubing away from patient and toward suction-control chamber, moving one clamp at a time(b) When bubbling stops, leak is in section of tubing or connection distal to the clamp(c) Replace tubing or secure connection and release clamp
* Problem: Bubbling continues, indicating that leak is not in tubing(a) Leak is in drainage system (b) Change drainage system
* Problem: Tension pneumothorax is present(1) Problems: Severe respiratory distress or chest pain(a) Determine that chest tube are not clamped, kinked, or occluded. Locate leak(b) Obstructed chest tube trap air in intrapleural space when air leak originates within patient
* Problem: Absence of breath sounds on affected side (a) Notify physician immediately
* Problems: Hyper resonance on affected side, mediastinal shift to unaffected side, tracheal shift to unaffected side, hypotension or tachycardia(a) Immediately prepare for another chest tube insertion (b) Obtain a flutter (Heimlich) valve or large-guage needle for short-term emergency release or air in intrapleural space(c) Have emergency equipment (oxygen and code cart) near patient
* Problem: Dependent loops of drainage tubing have trapped fluid(a) Drain tubing contents into drainage bottle(b) Coil excess tubing on mattress and secure in place
* Problem: Water seal is disconnected(a) Connect water seal(b) Tape connection( may mistake happens)
* Problem: Water-seal tube is no longer submerged in sterile fluid(a) Add sterile solution to water-seal bottle until distal tip is 2 cm under surface
* Problem: Water-seal bottle is broken(a) Insert distal end of water-seal tube into sterile solution so that tip is 2 cm below surface
(b) Set up new water-seal bottle(c) If no sterile solution is available, double clamp chest tube while preparing new bottle
What is it? Bubbling seen in the water seal pressure scale. Usually will have some rise and fall with each breath, but constant bubbling is a clue that there could be a problem in:
Chest tube drainage system
Poorly positioned chest tube
Injury to bronchus/esophagus
Continued air leak in the lungAssessing Air Leaks (RE)
To help determine the location of an air leak, the chest tube may be clamped near the chest wall:
If the air leak disappears, then the “leak” is coming
from the patient (i.e. persistent lung injury)
If the air leak continues, the leak is coming from a location distal
to the clamp….i.e. hole in chest tube, loose connection, leak in
the tubing, faulty pleuravac system, etc…
Don’t forget to release the clamp!!!Assessing Air Leaks
. chest tube may be clamped near the chest wall:Bad Things Happen to Good People
hear air leaking, cover site with three sided dressing. If no air is heard, cover with sterile dressing and notify the physician.
When indication for insertion is no longer present (i.e. resolution of pneumothorax, hemothorax, etc…)
No air leak evident the day before considering chest tube removal
Drainage less than 50cc/8 hours or 150cc/day
Patient able to tolerate chest drainage system being brought to water seal from suction
Chest x-ray shows complete re-expansion of the lungWhen is it Time to Come Out?
Assumes supine position with arm above head on side of tube
Chest drainage unit brought to water seal and the dressing is removed
deep inspiration or exhalation ,the tube is removed with one steady movement
Site is dressed and x-ray obtained 24 hours later
Dressing the insertion site & after removing itDiscontinuing the Chest Tube
Caring for a patient with a chest tube requires problem solving and knowledge application. Remember, a chest tubeis a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures. When caring for and maintaining a patient with a chest tube, it is important to note the patency of chest tube, presence of drainage, presence of fluctuations, patient's vital signs, chest dressing status, type of suction, and level of comfort.
1- What are chest tubes used for?
2- Where exactly is a chest placed?
3- How does the three-chamber system work?
4- Can suction be bad for the patient?
5- Can you make care for pt who have chest tube?