TEST 3 - Chest Tubes and Ostomy Flashcards by Elaina Pontarelli

Q

Chest Tube

What is it?

A

A catheter inserted through the thorax into the pleural space for:
Removing fluid and/or air
Preventing air or fluid from reentering the pleural space
To reestablish normal intrapleural and intrapulmonic pressures

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Q

Lung _______________occurs as the fluid or air is removed from the ____________ space.

A

reexpansion, intrapleural

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Q

What are five conditions that require a chest drain insertion

A

Pneumothorax
Haemothorax
Pleural effusion
Empyema
After cardiothoracic surgery

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Q

Conditions Requiring Chest Drain Insertion

Pneumothorax

A

Presence of air in the pleural space. Air can come from the lung, trachea or oesophagus or it can be caused by chest trauma.
Pain (sharp and pleuritic) r/t to atmospheric air irritating the parietal pleural
Dyspnea

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Q

Conditions Requiring Chest Drain Insertion

Hemothorax

A

Collapse of the lung caused by an accumulation of blood and fluid in the pleural cavity
Pain
Dyspnea
Shock if severe blood loss

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Q

Conditions Requiring Chest Drain Insertion

Pleural effusion

A

Accumulation of fluid in the intrapleural spaces
Pain
Dyspnea
Adventitious lung sounds
Nonproductive cough
Causes: 
Tumor
Infection (Tb)
Pulmonary infarction
Trauma

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Q

Conditions Requiring Chest Drain Insertion

Empyema

A

Accumulation of pus in the pleural space
Cause
Bacterial infection (pleurisy, Tb)
Pain
Dyspnea
Fever

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Q

Conditions Requiring Chest Drain Insertion

Tension pneumothorax/hemothorax

A

Air/fluid in the pleural space that does not escape
Continued increase in amount of air shifts intrathoracic organs and increases intrathoracic pressure
S & S
Cyanosis, ↓ O2sat, ↓ BP, ↑ HR
Air hunger
Violent agitation
Tracheal deviation 
Subcutaneous emphysema
Neck vein distention
Hyperresonance to percussion
** Medical emergency **

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Q

Location of Chest Tubes

For air

A

Placed high b/c air rises 
Apical
2nd or 3rd intercostal space
Anterior
Allows evacuation of air into atmosphere
Little or no drainage present in collection chamber
Semi-Fowler’s

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Q

Location of Chest Tubes

For fluid

A

Placed low b/c of gravity will localize in the lower portion of the lung cavity when client is sitting upright
Usually 5th or 6th intercostal space
Posterior or lateral to drain fluid
Applying suction assists this drainage
High Fowler’s

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Q

Location of Chest Tubes

Mediastinal

A

Placed in the mediastinum just below the sternum
Drains blood and fluid
Attached to drainage system
There will be no tidling (fluctuations) since tube is not placed in lung cavity
Common with open heart surgery

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Q

Chest Drainage System

1st compartment

A

Receives fluid and air from the chest cavity

Fluid stays in chamber while the air vents to 2nd compartment

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Q

Chest Drainage System

2nd compartment (water–seal chamber)

A

compartment (water–seal chamber)

Contains 2 cm of water (acts as one way valve)

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Q

Chest Drainage System

3rd compartment (suction control chamber)

A

Applies controlled suction to the chest drainage system

Suction pressure ordered usually

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Q

Rubber flutter one-way valve attached to the catheter
Valve opens whenever the pressure is greater than atmospheric pressure
Closes when the reverse occurs
No drainage chamber is used with this device
Used in emergencies and for some transfers

A

Hemlick valve

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Q

Water-Seal System

Collects air or fluid
As it enters the drainage collection chamber, this air/fluid pushes the air present in the chamber through the water seal and into the atmosphere
Chest tube system must remain upright
If tubing clamped, mechanism won’t work

A

Two-chamber water-seal system

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Q

Water-Seal System

Used when suction required
Chamber is filled to the set volume for the prescribed amount of suction i.e. 20 cm of H20 for a suction of – 20 cm of H20 pressure
Sterile water may need to be added (evaporation)
The wall or portable suction device is turned up until the water in the suction control bottle exhibits a continuous, gentle bubbling

A

Three-chamber water-seal system

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Q

Water-Seal System

Fluid is not required for setup
If system tips, does not disrupt
Water seal replaced with a one-way valve
Suction chamber does not depend on water
Contains a float ball which is set by a suction control dial once suction turned on
15 ml of fluid required for the diagnostic air-leak indicator
Gentle tidaling = normal reexpansion of lung
No tidaling x 2-3 days = fully reexpanded
Fluid bubbling left to right = air leak → must locate leak

A

Two-chamber waterless system

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Q

Expected Drainage

Post-op mediastinal chest tube

A

< 50 – 200 ml/hr or ~ 500 ml/24 hrs

Sanguinous initially, then serous over time

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Q

Expected Drainage

Pleural tube

A

Btw 100-300 ml in first 3 hours
500-1000 ml/24 hours
Grossly sanguinous in first several hours post-op to serous

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Q

Expected Drainage

If sudden gush of dark blood =

A

client position change

◦dark it’s ok

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Q

If _____ _____ or > ____ ml/hr = √ client and notify physician

A

bright red or > 100 ml/hr

◦fresh blood is emergent and may require further surgery

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Q

Milking or stripping creates excessive _______ ________ _________

A

negative intrapleural pressure

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Q

Apprehension
Respiratory distress
Subcutaneous emphysema

A

Early Signs of Complications

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What if: | Air leak unrelated to client’s respirations occurs

Locate source using shodded hemostats | Notify physician

What if: | No drainage

√ for kink √ for possible clot in chest drainage system √ mediastinal shift or resp. distress Notify physician

What if: | Chest tube is dislodged

Immediately apply pressure over chest tube insertion site Apply an occlusive gauze dressing and tape three sides Notify physician STAT Prepare for replacement of the tube

What if: | Substantial ↑ in bright red drainage

``` √ VS √ drainage √client’s cardiopulmonary status Notify physician Prepare for the OR ```

What if: | Continuous bubbling in water-sealed chamber indicating leak btw client and water seal

•Bubbling indicates a leak btw client and water seal ``` Tighten loose connections √ agency policy for cross-clamping chest tube Unclamp chest tube Reinforce dressing Notify physician ```

Assessment: Air leak can occur at insertion site, connection between tube and drainage, or within drainage device itself. Determine when the air leak occurs during respiratory cycle (e.g. inspiration or expiration). Continuous bubbling is noted in water-seal chamber, and water seal indicates a leak during the inspiratory and expiratory phases WHAT IS THE INTERVENTION

check all connections between the chest tube and drainage system. Locate leak by clamping tube at different intervals along the tube. Leaks are corrected when constant bubbling stops. If pres- ent on chest drainage system, such as the Sahara S 1100a Pleur-Evac, observe the air leak meter to determine the size of the leak.

Assess for location of leak by clamping chest tube with two rubber- shod or toothless clamps close to the chest wall. If bubbling stops, air leak is inside patient’s thorax or at chest insertion site. WHAT IS THE INTERVENTION?

Unclamp the tube, reinforce chest dressing, and notify health care pro- vider immediately. Leaving chest tube clamped can cause collapse of lung, mediastinal shift, and eventual collapse of other lung from buildup of air pressure within the pleural cavity.

If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down drainage tubing away from pa- tient and toward suction control chamber. When bubbling stops, leak is in section of tubing or connection between the clamps. WHAT IS THE INTERVENTION

Replace tubing, or secure connection and release clamps.

If bubbling still continues, this indicates the leak is in the drainage system. WHAT IS THE INTERVENTION

Change the drainage system. Make sure chest tubes are patent: re- move clamps, eliminate kinks, or eliminate occlusion.

Assess for tension pneumothorax; indicated by: • Severe respiratory distress • Low oxygen saturation • Chest pain • Absence of breath sounds on affected side • Tracheal shift to unaffected side • Hypotension and signs of shock • Tachycardia WHAT IS THE INTERVENTION

Obstructed chest tubes trap air in intrapleural space when air leak originates within the thorax. Notify health care provider immediately, and prepare for another chest tube insertion. A one-way ﬂ utter (Heimlich) valve or large-gauge needle may be used for short-term emergency release of pressure in the intrapleural space. Have emer- gency equipment, oxygen, and code cart available because condi- tion is life threatening.

Water-seal tube is no longer submerged in sterile ﬂuid due to evaporation. WHAT IS THE INTERVENTION

Add sterile water to water-seal chamber until distal tip is 2 cm under surface level.

Removal of Chest Tube | THE FIRST THING TO MANAGE?

PAIN

Removal of Chest Tube

``` Reassure client Assist physician Dispose of equipment Assess client post removal Lung sounds Subcutaneous emphysema Resp. distress VS Comfort level Dressing Prepare for x-rays ```

A patient is resting quietly after a chest tube insertion, and gentle tidaling is seen in the water seal chamber. What action should the nurse take? A) Check the functioning of the chest tube system B) Perform a complete respiratory assessment C) Document the observation D) Increase the setting on the suction control chamber

C) Document the observation

. The nurse is assessing a patient 8 hours after open heart surgery and notes the following findings: T99, P104, R24, BP 106/68, SpO2 96 on 2 L/min of oxygen via nasal cannula, urine output 36 mL/hour, and mediastinal chest drainage averaging 120 mL/hour. Based on the assessment findings, what would the nurse anticipate doing within the next few hours? A) Reinfusing the blood drained through the mediastinal tube B) Increasing the amount of pain medication received via the PCA machine C) Giving a bolus of intravenous (IV) fluid through a new 22-gauge catheter D) Increasing the amount of oxygen by changing the nasal cannula to a mask

A) Reinfusing the blood drained through the mediastinal tube

The nurse is preparing a patient to have her chest tube removed. What information needs to be included in the preprocedural patient education provided by the nurse? A) The patient needs to take a deep breath in as the tube is removed. B) A radiograph will be obtained as soon as the tube has been removed. C) The procedure is painful, and a higher dose of medication will be given. D) The patient needs to hold her breath while the tube is being removed.

D) The patient needs to hold her breath while the tube is being removed.

``` A patient is being readied to have a chest tube inserted. Special care needs to be taken if the patient currently is taking medication from which drug classification? A) Antibiotic B) Antiviral C) Antispasmodic D) Anticoagulant ```

D) Anticoagulant

A patient with a chest tube has a history of confusion and erratic behavior. The nurse should make certain that what supplies are at the patient's bedside? A) Extremity restraints and rubber-tipped (shodded) hemostats B) Petroleum gauze and Elastoplast C) Suction catheters and a new chest drainage set D) An incentive spirometer and a jacket restraint

B) Petroleum gauze and Elastoplast

Surgical opening into the abdominal wall for fecal or urinary elimination

stoma

A stoma can be _______________ or ___________

*Temporary When healing is required i.e. trauma, diverticulitis *Permanent Cancer

Various segments of the colon

Colostomy

Ileum of the small intestine

Ileostomy

Ureter diversion

Urostomy

Only with a ________ ________ the stool consistency can be formed

Sigmoid Colostomy

Types of Stomas

End Loop Double barrel ostomy

Characteristics of Stomas Colour - Rose to brick red

Viable stoma mucosa

Characteristics of Stomas Colour - Pale

May indicate anemia

Characteristics of Stomas Colour - Blanching, dark red to purple

Inadequate blood supply to stoma or excessive tension on the bowel at time of construction

Characteristics of Stomas Colour - Black

Necrotic stoma

Characteristics of Stomas Edema Mild to moderate

Normal in the initial post op period Trauma to the stoma Any medical condition that results in edema

Characteristics of Stomas Edema Moderate to severe

Obstruction of the stoma Allergic reaction to food gastroenteritis

Characteristics of Stomas Bleeding Small amount

Oozing from the stoma mucosa when touched is normal b/c of its high vascularity

Characteristics of Stomas Bleeding Moderate to large amount

Could indicate coagulation factor deficiency Stomal varices 2o portal hypertension Lower GI bleed

Things to consider when a client has a ostomy | 7

``` Body image and self-esteem Leakage Odour Social activities Resources for support Self-care Complications ```

``` S = T = O= M = A = ```

``` S = set up your equipment T = take off old equipment O = observe stoma and peristomal skin M = measure stoma A = assemble and apply new system ```

ABCDs of Stoma Assessment and Pouching A = Assessment (7)

``` # of stoma(s) location type shape viability drainage size ```

ABCDs of Stoma Assessment and Pouching B=Certification Boards C= Complications

``` Bleeding Necrosis Prolapse Laceration Retraction Stenosis Hernia Irritation ```

ABCDs of Stoma Assessment and Pouching D = Different and determining pouching systems

Differences ``` Fecal vs urinary Adhesive vs nonadhesive One piece vs two piece Precut vs cut to fit Disposable vs reusable Drainable vs closed end ``` Determining pouching systems ``` Correct skin barrier and pouch Fit of skin barrier and pouch Correct measurement of stoma Skin barrier intact Any peristomal skin problems that will alter system needed How often system needs changing When should pouch be emptied ```

Empty the ostomy bad when it's ___ ____

1/3 full

Chewing food is essential to avoid a _________ ___________

Potential obstruction

Drink at least ______ ml/day to prevent ________ unless on fluid restrictions

3000, dehydration

ADL's | When doing health teaching, inform the client to avoid foods that increase _____, ______, _______

gas, odour, stool formation

Unexpected Outcomes

``` Peristomal skin is irritated, reddened, tender, burning sensation or has overgrowth Necrotic stoma No urinary output Thick stools Leakage ```

``` A patient who had a urinary diversion done yesterday just had his drainage bag emptied of 250 mL of yellow urine with mucus, which was his output for the past 6 hours. What is the appropriate action for the nurse to take? A) Record the output and description B) Notify the physician of low output C) Palpate the patient's abdomen D) Assess the patient's pain level ```

A) Record the output and description

A patient asks about what to expect regarding the consistency of stool after his transverse colostomy to be performed tomorrow. Which response by the nurse best addresses this? A) "What is your major concern about having the surgery tomorrow?" B) "The stool will be thin and watery after you establish your eating pattern." C) "The consistency of the stool will vary from thick liquid to semiformed stool." D) "We'll talk about this at length after you have recovered from the anesthesia."

C) "The consistency of the stool will vary from thick liquid to semiformed stool."

A male Amish patient is recovering from surgery 2 days ago when a colostomy was performed. Which approach by the nurse is most important? A) Allowing the patient to do as much of his care as he wishes B) Assigning a male caregiver to him for his hygiene and toileting C) Asking the family to stay with him as much as possible for support D) Pulling the curtain whenever anything is being done with the patient

B) Assigning a male caregiver to him for his hygiene and toileting

The patient calls the surgeon's office 4 weeks after her colostomy was performed, stating that the stoma seems to be shrinking. Which statement by the nurse is most appropriate? A) "A slight decrease in the size of the stoma is expected." B) "Don't worry about the size of the stoma." C) "Because that's unusual, I'll let the doctor know." D) "As long as the stoma isn't purple or black, it's okay."

A) "A slight decrease in the size of the stoma is expected."

The fecal ostomy pouch is leaking, but it's several hours too soon to change the skin barrier wafer. What is the appropriate action for the nurse to take? A) Perform a full abdominal assessment B) Ask the patient what he wants to do C) Change the wafer now D) Pad the skin around the stoma until it is time to change the wafer

C) Change the wafer now