Transcript Care of the client with chest tubes

Care of the Client with
Chest Tubes
Matthew D. Byrne, RN, MS, CPAN
7/16/2015
Outline
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Basics
Indications
Insertion
Function
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The Pleural Space
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Space between
ribs and lungs
Filled with small
amount of fluid
Air or fluid in
pleural space
inhibits expansion
and breathing
The Pleural Space
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Physiologically, intrapleural pressure is 4-5
cm H2O below atmospheric pressure during
expiration
Intrapleural pressure is 8-10 cm H2O below
atmospheric pressure during inspiration
If the intrapleural pressure equals the
atmospheric pressure, the lung will collapse,
causing a pneumothorax
Chest Tubes: Basics
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Used when integrity of the pleural space
is lost
Loss of normal intrapleural pressures
Air or fluid may enter with loss of integrity
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Image from Trauma.org
Chest Tubes: Indications
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Surgery
Traumatic chest injuries
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Pneumothorax
Hemothorax
Pleural effusion (build up
of fluid between the
pleura)
Infection (empyema)
Chest Tubes: Insertion
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Placed in the OR/ER/PACU or bedside
Metal trocar used as guide
Generally done with some sedation
Ideally restores negative pressure and allows air
to escape/fluid to drain
Sutured to chest wall
Occlusive dressing applied
Serial chest X-Rays for progress/placement
Free end attached to drainage system
Connections are secured (taped/banded)
Pre and post vital signs and pain assessment
Chest Tubes: Location
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To drain air: Anterior (and laterally) through
2nd intercostal space
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To drain fluid/blood: Posterior through 8 or 9th
intercostal space in midaxillary line
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Chest Tubes: How they function
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Drainage systems:
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One chamber
Two chamber
Three chamber
Two types of suction control chambers:
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1) dry (valve/regulator)
2) wet (water chamber) control
When you breathe…
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When you inhale, negative pressure is
created in your chest that pulls air in through
your mouth/nose
What would happen if there was a hole in
your chest?
A chest tube system can act as a one-way
valve that can remove air/fluid
Can also be set up to create “pull” in the form
of negative pressure
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Chest tube systems
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What do we need to connect to this tube in
the patient’s chest?
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How can what we connect collect drainage,
allow air to escape and create a slight pull?
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We need a three part system to do this…
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One Bottle=One way valve
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Allows air out but not in
Rise and fall of fluid
with breathing (WHY?
HOW?)- Tidaling
Creates no “pull”
Not intended for
collection
The valve is the water
What would happen if
we pulled the tube out
of the water?
Two Bottles=Valve + Drainage
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Water Seal
(Valve)
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Drainage
Allows air out but
not in
Rise and fall of fluid
with breathing
Creates no “pull”
Allows for collection
3 Bottles=Valve + Drainage + Pull
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Allows air out but
not in
Rise and fall of fluid
with breathing
Allows for collection
Creates a “pull” in
the form of negative
pressure
Suction
(Dry or Wet)
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Water Seal
(Valve)
Drainage
Commercial chest tubes
Wet Suction = actual
column of water used
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(usually 20cm)
Dry Suction = pressure
and vacuum internally
regulated
In Clinical…
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The units are connected to wall suction unless
the order is for water seal only
Wall suction creates a vacuum, while the
column of water creates the actual “pull”
Turning up the wall suction, WILL NOT increase
the pull
A column of water creates pressure, much like
when you are diving underwater
Therefore, increasing the column of water WILL
increase the pull
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Nursing Responsibilities
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Standard 1 Assessment
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Patency/functioning of system (kinks, clamps,
atrium, suction, etc)
Dressings
Quantity and quality of drainage
Dependency of collection system
Coiled tubing, not hanging tubing
Pain control
Respiratory status and Vital signs (CDB/IS, lung
sounds, respiratory quality/number)
Nursing Responsibilities
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Standard 5 Implementation
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Note specific orders regarding:
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Suction versus water seal
Amount of acceptable drainage
I&O
X-rays
Administer pain medications regularly
Patient should change positions frequently
(promotes drainage, prevents complications)
BSN Essentials
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Critical thinking and technical skills =
Having the knowledge and skill to handle
problems!
Always have at the ready:
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Extra atrium/set-up
Oxygen
Suction
Occlusive dressings
Chest tube clamps
Bottle of sterile normal saline
Patient Ed: Standard 5B
Reducing anxiety…
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Teach basics of drainage system, frequent checks,
ask for analgesics PRN
Assure that CT is sutured in place
Remind not to kink/compress tubing
Drainage system to be kept below level of chest
Fluctuations in water seal are normal
Prepare for expected amount & type of drainage
May hear bubbling if it is a “wet” suction system
Discuss ambulating and repositioning
Plan of care
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Chest Tubes: Removal
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When “tidaling” ceases and chest Xray/assessments confirm re-expansion of
lung
Pre-medicate for pain
Breath in & hum out (have pt practice)
CT is quickly removed
Occlusive dressing applied over insertion site
Pleura seals itself off
Chest wound heals within a week
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