Flashcards in Chest Tubes Deck (66):
How many sections does the chest have
3 distinct sections sealed from each other, 1 for each lung and the mediastinum
How does P change in the lungs with inspiration
How does disease/damage change this pressure?
• With inspiration the inc negative P pulls lungs out which dec the alveolar P to less than atmospheric P, this inc the negative P within the lungs
• Trauma, disease, sx result in air, blood, pus or lymph fluid leaking into intrapleural space creates positive pressure, leading to lung tissue collapse
Can a leak in the lungs we resolved without a chest tube? How large?
• Small leaks of <24% are sometimes absorbed spontaneously and don’t require a chest tube
What is pleural effusion?
What do we did about it?
abn accum of fluid in the pleural space eg hydrothorax, pyothorax etc. When present the pt usually needs a diagnostic thoracentesis and pleural fluid analysis to find cause of exudates
eg from CA, infect, pancreatitis, connective tissue disease, autoimmune disease, asbestos, drugs etc
Does a traumatic pneumo result from closed or open injuries?
can result from penetrating or closed injuries
Difference between primary + secondary pneumo + causes of each
• Spontaneous or primary pneumo can occur from rupture of sm blister or bleb on lung or invasive procedure like subclavian IV insertion
• Secondary pneumos can occur d/t disease eg emphysema
Signs and symptoms of pneumo?
S+S of tension pneumo?
• Pt with pneumo gen feels sharp chest pain that worsens on inspiration or coughing as atmospheric air irritates the parietal pleura. As it worsens the pt will experience easy fatigue, rapid HR and low BP
• Tension pneumo can lead to tracheal deviation, dec VR, and then dec CO. Pt will have sudden chest pain, dec BP, tachycardia, acute pleuritic pain, diaphoresis, dry cough, and cadiopulm arrest can occur
Causes/risk factors for tension pneumo?
pt w chest trauma, fx ribs, invasive procedures eg central line insertion, high P mechanical ventilation
o Emergent treatment for tension pneumo=
needle decompression with lg gauge needle 14 or 16 gauge inserted into second intercostals space, midclavicular. Hissing sound occurs then rapid stabilization of pts VS and resp status
Causes of hemothorax?
• gen d/t trauma but also from inflm
________ is Tx for most types f effusions, pneumothorax, hemothorax, and postop hest Sx or trauma
Chest tube insertion
How big of chest tubes?
• Sm bore chest tubes 12-20 are sufficient to remove air and lg bore 24-32 french tubes are needed to remove fluid and blood
What is chest tube attached to?
• A closed chest drainage system with or without suction is attached to the chest tube to promote drainage of air and fluid
Location of the chest tube indicates the tye of drainage expected. Where should you see them positioned for air or fluid?
Apical (2nd or 3rd intercostals space) and anterior promotes air removal as air rises. The air goes into atmosphere and little to no drainage in collection chamber
• Low chest tubes gen in 5th or 6th intercostals and posterior or lateral drain fluid or blood. Freq application of suction helps drainage
Mediastinal chest tube placement? Connection used?
When is this used?
is placed in mediastinum just below sternum and connected to drainage system. Used after open heart sx
When is it used?
How does it work?
• In emergent situations sometimes or for small pneumos a catheter is insered through chest wall and rubber flutter one way valve eg Heimlich valve is attached to catheter. Pos P from exhalation opens valve and allows air release but valve closes on inhalation, no air gets in. Not used for drainage as theres no collection device
Smaller pigtail catheters
When not used?
I think also typically in emerg situations...?
are also used and are less traumatic than the lg bore tubes. If they occlude the HCP can irrigate them w sterile water. Not used for chest trauma as theyre too small and don’t promote blood drainage
WHy use Mobile chest drains?
• lighter (decs pts pain) and self contained. Dec risk of DVT or immobility complics. Rely on gravity or dry suction for drainage. Best for pts w persistent drainage or air leaks needing prolonged therapy (theyll need ++teaching)
Disposable systems eg Atrium or Pleur-Evac
Open or closed systems?
How many chambers?
chest drainage system are 1 piece molded plastic units that provide for single or multi chamber closed drainage system. Cost effective.
Can facilitate auto-transfusion
Single chamber system
How does it work?
What do you use it for?
allow air from pneumo to bubble out of water seal and escape tough the air utlet while preventing air from reentering the intrapleural space. Not recommended for evacuation of fluid as dranage would raise the level of the water seal liquid. An inc height of fluid in the water seal inc the resistance to drainage on expiration and eventually stops the drainage
Two or three chamber system
How is it divided?
drains both hemo and pneumo effectively. In both the first chamber is compartment for blood or fluid drainage and the second is for either a water seal or one way valve. In 3 chamber the third is for suction control which may or may not be used
• 2 chamber allows liquid to flow into the collection chamber and air frolws into the water seal chamber
• 3 chamber promotes the drainage of fluid and air w controlled suction
What to do or not do with chest tubes occluded by fibrin + clots?
• Sm chest tubes often get blocked by fibrin and clots. Can be removed by milking or stripping
• Milking-squeeze the chest tube back and forth intermittently with the hands alon the length of the tube. Should only be used in certain cases like acutely occluded by multiple clots
• Stripping causes dangerous inc intrathoracic P that damages lung tissue. It involved using continuous P on the tube while runnin hands own from the site of insertion to the drainage container
**IN class we were told to never do either of these things without dr's order and likely only dr would do it
When you cant avoid loops...what to do?
lift and clear the tube q15
If drainage is impeded it can result in....?
Having chest tube more than ____ days leads to inc risk of infect
Should a pt w chest tube practice deep breathing?
• Encourage deep breathing, early mobility, inc activity and educate
What should be seen coming from the water seal
How does this change if on mechanical ventilation?
• Observe water seal for intermittent bubbling or rise (w inspiration) and fall of fluid synchronous w resps
When pt is on mechanical ventilation the fluids fall during inspiration and rise on expiration
Constant bubbling or sudden stop of water seal activity is normal or abn? Urgent?
WHen is a stop of bubbling expected?
abn and requires immed attention
o Unexpected stoppage may indicate blockage or reexpansion. Needs immed attention. After 2-3days tidaling or bubbling on expiration is expected to stop, indicating that the lung has reexpanded
In waterless system, what should be seen in the diagnostic air leak indicator?
look for rise and fall of fluid in the diagnostic air leak indicator synchronous w resps. Constant L to R bubbling or violent rocking is considered abn and indicates an air leak
How/when to note amount of chest tube drainage?
note amount of chest tube drainage and monitor on reg basis. Q1h then q4h. Make mark at end of shift to indicate fluid level with date and time on side of the drainage collection chamber. Note drainage amount as output
Sudden dec in amount of chest tube drainage can indicate?
possible clot or obstr
What amount increase in drainage warrants notifying physician?
• Notify when sudden inc of more than 250ml drainage over 1hr which can indicate fresh bleed from thorax
Do you see drainage from a pneumo?
Drainage from pneumo is gen limited. Fluid buildup is caused by hest tube insertion trauma
What should you see in a water seal system when connected to suction?
How is suction set in waterless system?
• In water seal system observe for constant gentle bubbling in suction control chamber when connected to suction.
In waterless system a designated amount of suction is maint by setting the suction source and dialing the prescribed suction level in the float ball column
WHat to do if leak present?
- determine if in the pt (by assessing resp status) or in the chest tube system
What does continuous bubbling in the water seal chamber with an absence of bubbles int he suction control chamber indicate?
that theres a leak in the system
Water seal system
-2 chamber gives one way valve for chest drainage
-water seal prevents re-entry of air into lung
-3 chamber adds chamber to aid evacuation of chest drainage
2) easy set up and use and cost effective
3) -Must be kept upright to keep seal
-drainage chamber may fill quicly if pt has lg amount of drainage
-sterile water must be added several times a day to maint suction and water seal because of evaporation
Waterless chest tube system
1) How many chambers?
Also has 3 chambers but no water nec to establish a seal
water seal maint even if sys knocked over
-more space provided for drainage
-sterile water must be added to sys if pt requires eval of air leak
Dry suction system?
Also has 3 chambers but no water nec to establish a seal
-easy set up
-can be used w higher suction
-sterile water must be added to sys if pt requires eval of air leak
Two chamber water seal system
- How does it work?
- How is water seal broken?
• On expiration fluid or air is forced out of the intrapleural space
• Suction pulls air or fluid through the chest tube into the drainage collection chamber which displaces air present in the chamber and pushes it through the water seal and out the system into atmosphere
• Water seal is left open to air to drain
• If clamped cant vent air
• If tipped the water seal is broken
Three chamber water seal system
• If suction used then 3 chamber sys used
• Prescribed amount of sterile fluid eg 20cm of water (based on manufacturer) is poured into suction control chamber which is attached to suction.
• Add water several times a day d/t evaporation
• As fluid level dec the amount of suction dec
• Wall suction turned up until continuous gentle bubbling
• If suction source delivers more neg P than the suction control chamber allows theres no danger as atmospheric air is pulled into suction control chamber through an inlet, causing the excess suction to dissipate
• Extra air pulled into chamber causes vigorous bubbling. If occurring, lower the suction source setting to dec noise and evaporation of fluid
• Middle chamber of traditional chest drainage system is the water seal which allows air to exit from pleural space on exhalation and prevent it from entering the pleural cavity or mediastinum on inhalation
• Bubbling in the water seal chamber indicates air leak
2 chamber waterless sys
• Same principles as water seal but no water nec to set up
• Tipping sys doesn’t affect pt
• Suction chamber contains a float ball, set by a suction control dial after the suction source is turned on
WHat is required for the diagnostic air leak container to work on the waterless sytem?
If lug expanding normally, see what?
When should lung be properly expanded again? And what will you see then?
Diagnostic air leak indicator is on face of the unit that requires 15ml of fluid for visualization. If lung is expanding normally there is gentle tidaling. After 2-3 days the lung is likely reexpanded if tidaling has stopped. Theres air leak in system when facing the system the nurse sees fluid bubbling L to R
Dry suction sys
• easy set up, quiet d/t no continuous bubbling, can be used w higher suction
• no fluid to evaporate dec the amount of suction nec
• self-compensating regulator controls unit
• dials set to the prescribed suction setting. Adjustable to -10to -40cm water P
• needs pre-sealed sterile water in the water seal chamber
3 chamber waterless system
• Set float ball to prescribed setting when suction is on by adjusting suction. Float ball is safety feat to prevent high P suction
• Gen two suction settings, one at the suction control chamber or the float ball setting and the other at the suction source
abbreviated process of insertion of chest tubes pg 660
• have pain meds ready for before or after
• clean chest wall w antiseptic
• mask and gloves, drape area of chest w sterile towels, inject local anesthetic and let take effect
• make sm incision over rib space where tube is to be inserted. Thread clamped chest tube through. Unclamp when connected to water seal
• suture tube in place and cover site w steile 4x4 gauze and lg drsg to form an occlusive drsg supported w an elastic bandage. Sterile petrolatum gauze is used around the tube
• connect suction or whatever the system necessitates
• add sterile water or NS, unclamp chest tube, HCP orders xray
WHat to assess for pt with pneumo? Additional things to assess when pt has chest tube?
• VS and pulse oximetry, Resp assessment for mnfts of resp distress and hypoxia, sharp stabbing chest pain or chest pain on inspiration, HoTN, tachycardia, pain 0-10,anticoags, hgb and hct,
• If t has chest tube: drsg and site, tubing for kinks loops clots, upright drainage system below site, gentle tidaling in water seal or diagnostic indicator
How to set up 2 chamber w/o sunction?
stand sys upright and add sterile water or NS to 2nd chamber
How to set up 3 chamber sys w suction
add sterile solution to water seal chamber in middle. Add sterile soln prescribed to suction control chamber (third) en 20m water P. Connect tubing from suction chamber to suction source
How to set up dry suction system?
fill water chamber w sterile soln. Adjust suction to prescription (-10 to -40cm water P). Suction control chamber vent is never occluded when suction is used. On dry ssuction sys DONT obstr positive P relief valve as air escapes
How to set up waterless system?
• For 2 chamber (w/o suction), nothing needs be done – just connect to chest tube
• For 3 chamber (w suction), connect to suction to suction control chamber
• Instill 15-45mL SW or NS into diagnostic indicator injection port (allows observ of rise and fall of H2O in diagnostic air leak window)
What in the diagnostic air leak window of waterless system indicates leak?
When is putting H2O in here not necessary?
o Constant left-to-right buubling or rocking = air leak
o No necc for mediastinal drainage – no tidaling
o In emerg, no H2O necessary
How to check system patency of chest tube?
1) clamping drain tube
2) connecting tubing from float ball chamber to suction
3) turing on suction to prescribed level
Before connecting to pt, what should you do with the drainage system after checking patency?
Turn off suction + unclamp before connecting to pt
Why is it important that drain tube is not too long?
if coiled/looped clots tension pneumothorax
**During ct insertion procedure carefully monitor pt for...?
signs in change in consciousness!
Role of nurse during chest tube insertion? What to do immed after insertion?
• Aid in insertion w clean gloves on
• Help attach drainage tube, remove clamp, turn on suction
Steps to take to reduce risk of air leak
Tape or zip-tie all connections b/t chest tube + drainage tube
What will be done after chest tube insertion?
How should pt be positioned following ct insertion?
• Position pt semi or high-fowler if pneumothorax + high-fowler if fluid (hemothorax)
**Drainage tubing may need to be lifted to promote drainage q___min
Chest tubes are double clamped in what 3 scenarios?
1) to assess for air leak 2) empty of quickly change disposal systems 3) assess if pt ready to have tube out
What to do ifchest tube disconnection?
submerge 2-4cm in 250mL bottle SW or NS
What is monitored following chest tube insertion?
• HH + clean gloves
• VS, O2 sats, skin colour, breath sounds, rate, depth + easy of resps, insertion site q 15 min for first 2 hrs, then q shift
• Color, consistency + amount of chest tube drainage q 15 min for 2 hr. Mark on chamber
• Assess drsg for drainage
• Palpate around tube for swelling + crepitus (small amounts common, large amount dangerous)
• Check tubing free of kinks
• Observe for fluctuation of drainage in tubing + water seal chamber during insp + exp
What amount of chest tube drainage should be expected?
o Expect <100mL/hr from mediastinal tube immed after sx and no more than 500mL in first 24hrs
o Expect 100-300mL in first 3hrs post-insertion in posterior chest tube (500-1000mL total in first 24hrs). Bloody first serous
o Expect little to no output from anterior chest tube inserted for pneumothorax