Care Of Clients With Chest Tube

DEFINITION

• Is a catheter that is inserted into the pleural cavity to reexpand the lung

INDICATIONS

1.Traumatic pneumothorax2.Hemopneumothorax3.Spontaneous pneumothorax4. Latrogenic pneumothorax5.Bronchopleural fistula6. Emphysema7. Malignant8. Pleural effusion

PURPOSE• 1. To permit drainage of air and fluid

from the pleural cavity• 2. To establish normal negative

pressure in the pleural cavity for lung expansion

• 3. To equalize pressure on both sides of the thoracic cavity

• 4. To provide continuous suction to prevent tension pneumothorax

SITES FOR CHEST TUBE INSERTION

1. Thoracic surgery.• 2 chest tube inserted – Anterior chest

tube & Posterior chest tube

2. Anterior chest :• Upper/anterior chest wall• Inserted in the 2nd intercostal space

to remove the air arising from the pleural cavity

CON’T

3.Posterior chest tube :• Placed at the posterior chest in the

8th or 9th intercostal space at the mid-axilllary line.

• Indication to remove serogeneous fluid at the lower area of pleural cavity

• Diameter of tube in the lower section is wider or longer compare to the upper tube.

CON’T

4.Pneumothorax :• Tube placed at

the 2nd or 3rd intercostal space along midclavicle or anterior axillary line.

TYPES OF CHEST DRAINAGE SYSTEM

Chest Drainage System

1 bottle 2 bottles 3 bottles Pleurovac

TYPES OF SYSTEM - 1 BOTTLE DRAINAGE

TYPES OF SYSTEM - 2 BOTTLE DRAINAGE

TYPES OF SYSTEM - 3 BOTTLE DRAINAGE

PLEUROVAC

FUNCTION OF PLEURAL DRAINAGE SYSTEM

Inspiration

Intrapleural pressure

Air and fluid move into bottle

Pleural space becomes negative

Lungs reexpand

PRINCIPLES OF THE CHEST TUBE

1. Gravity

2. Under Water Seal

3. Suction

1. Gravity

• Enhances flow from high to low

• Chest drain is placed below client’s bed

2. Water Seal

• Is a barrier to prevents backflow into pleural space.

• Rod – depth determines the negative pressure

• Air bubbles is released through the rod

• Air vent – to allow drained air to escape to prevent pressure build up

3. Suction

• Is a pull force• MUST be in another bottle• Purpose for the suction when :- Gravity drainage is not enough.- Patient’s respiration and cough are

too weak- Air leak is fast into the pleural space- Need to speed up removal from

pleural space

Nursing Responsibilities

1. Pre procedure.2. During3. Post procedure4. Emergency care

Pre-procedure care

1. Confirm :• Open thoracotomy – during surgery• Closed thoracotomy – at patient’s

bedside.2. Inform patient3. Check for consent4. X-ray – with report to determine the

affected lung

CON’T

5. Prepare equipments (Top shelf) :• T & S set that contains :- Swab cotton wool & gauze- Forceps, sponge holding forceps, dissecting,

toothed Holder, artery forceps, scissors, kidney dish, gallipot,sterile towel.

• Trocar and cannula set FG 33.• Syringe 20 cc,50cc,5cc• Needle – 21G,23G & 25G(2 each)• Suture – Mersilk size 0,2/0 reserve cutting.• Blade size 11

CON’T

6. Prepare equipments (bottom shelf) :• Sterile glove depending dr size.• Mask• Connecting tubing & bottle drainage.• Cleansing lotion – alcohol 70% and povidone.• Op-site spray.• Sterile specimen bottle• Elastoplast• Counter scissors• Local anesthetic lignocaine 2% or 1%.• Low suction pump – if required• Clinical waste.• Regular waste bin

CON’T

7. Position client :- Fowler’s

Insertion of chest tube

DURING – INSERTION OF CHEST TUBE

Procedure :1. Chest tubes can be inserted in the

ER, client’s bedside,or in OT2. In OT the chest tube is inserted via

the thoracotomy insertion.3. In ER, client’s bedside the client is

placed in the sitting position or is lying down with the affected side elevated

CON’T

4. The area is prepared with antiseptic solution, and the site is infiltrated with a local anesthetic agent.

5. After a small incision is made, one or two chest tubes are inserted into the pleural space.

CON’T

6. One catheter is placed anteriorly through the 2nd intercostal space; the other is placed posteriorly through the 8th or 10th space to drain fluid and blood.

7. The tubes are sutured to the chest wall, and the puncture wound is covered with an airtight dressing.

CON’T

8. During insertion, the tubes are kept clamped

9. After the tubes are in place in the pleural space, they are connected to drainage tubing and pleural drainage and clamp is removed.

10. Each tube may be connected to a separate drainage system and suction.

CON’T11. More commonly, a Y connecter is

used to attach both chest tubes to the same drainage system.

DURING THE PROCEDURE – NURSING RESPONSIBILITIES

1. Observe respiration.2. Reduce anxiety3. Monitor saturation4. Prepare the under water seal5. Connect the closed system fast

POST PROCEDURE CARE

1. Respiratory status :- Vital signs (15 min x 1 hour,30 mins x

1 hour,1 hr x 4 hours)- Respiration rate,pattern and rhythm- Color, chest pain, rapid pulse.- Check saturation- Administer oxygen when necessary.

POST PROCEDURE CARE – RESPIRATORY STATUS

2. Auscultate :- Every 2 hours- Listen for breath sound- Listen for increased area of absent

breath sound- Place patient in flowler’s or high

fowler’s.

POST PROCEDURE CARE – ANXIETY

• Due to fear of pain and complication.• Increase the need for oxygen• Explain to the patient – care of tube,

the fluid drained and frequent checks.

• Pay attention to their needs.• Allow relatives to stay.

POST PROCEDURE CARE –WOUND STATUS

• Change the gauze when necessary

• Strict aseptic technique.

• Skin integrity – redness,swelling and loose suture

POST PROCEDURE CARE –TUBING

1. Intact and taped

2. Maintain patency.- Check for obstruction

CON’T

1. Teach the patient on how to care for the tubing.

- Place a pillow between patient and tubing.

- Instruct the patient to cough if tube is blocked

- Milking and stripping of the tube when blocked

POST PROCEDURE CARE –CLAMPS

• Use rubber tips.• Clamped at the bedside.• Clamping :- During transfer- Not > 1 min- Upon doctor’s orders.

POST PROCEDURE CARE –WATER SEAL

• Place below patient’s chest wall

• Fill with sterile water

• Rod must be immersed 2 cm in water

• Observe for the fluctuation of water level.

CON’T

1. Fluctuation (tidaling)• To ensure patency of system.• Stops when :- Lung is fully expanded (36-72 hours)- When there is an obstruction• Check for obstruction.- Tubing – kinked- Patients position- Ask patient to take a deep breath and

cough

CON’T

2. Observe for bubbling :- Intermittent bubbling is normal- Continuous bubbling is abnormal.- Check for• Wound• Tube• Connection- If rapid bubbling without air leak –

inform the doctor immediately

CON’T3. Drainage output :

- 70 – 100 mls/hour

- Observe for change in drainage colour.- Mark the amount.• Mark the time of measurement and the fluid

level on the drainage chamber according to the prescribed orders

• Marking intervals may range from once per hour to every 8 hours.

• Any change in the quantity or characteristics of drainage ( eg. Clear yellow to bloody ) should be reported to Dr.

CON’T

3. Drainage output (con’t)- Document in the I/O chart- Change bottle every 24 hours or

when full

POST PROCEDURE CARE –SUCTION APPARATUS

1. Low suction pump :- Must be controlled- Suction valve / meter is inserted for wall

suction.- Check for bubbling.- If no bubbles :• Clamp the chest tube to check for air

leaks• Check the tubing and connection.• Observe patient’s condition while chest

tube is clamped

POST PROCEDURE CARE –SAFETY

1. Tube :- Prevent kinking- Place a pillow as a barrier- Never clamp unnecessarily.- Assist patient during ambulation the

first time

CON’T2. Bottle :- Bottles must be below chest level - Keep bottle in a basin - Inform relatives and housekeeping

regarding bottles- Bed must be locked- Activity should be limited to avoid

injury

POST PROCEDURE CARE –AMBULATION

- Explain to client- Encourage change of position to

promote drainage.- Can sit up, get in and out of bed.- Stop the suction- No need to clamp the tube.- Maintain chest drain below chest

wall.

POST PROCEDURE CARE –DEEP BREATHING AND ARM

EXERCISE

1. On the 1st post op day.

2. When patient is not in severe pain

3. Enhances lung expansion – expels air and fluid

CON’T

4. Prevents stiffness of the arm

5. Assist patient .- Deep breathing exercise- Support when patient is coughing- Abdominal breathing

POST PROCEDURE CARE - COMFORT

• Administer analgesic in the first 24 hours

• Allow position that is comfortable for the patient.

• Assist patient in providing self-care

REMOVAL OF CHEST TUBE

• The chest tubes are removed when the lungs are reexpanded and fluid drainage.

• Assessment :• - X-ray is done to check the progress• - Clamp for 2 hours

• Chest tube is removed.

EMERGENCY CARE

1. Bleeding Post Chest tube insertion :

- Observe wound dressing- Observe drainage- Inform the surgeon immediately

CON’T

2. Dislodgement :- From insertion site – place a gauze

immediately over the wound

- From connection – clamp the chest tube immediately.

CON’T

3. Bottle breaks :- Identify patient’s problem –

pneumothorax or hemothorax.- Observe patient fortension

pneumothorax - Place the tube in saline immediately.- Unclamp immediately – prevent

respiratory distress

COMPLICATIONS

1. Bleeding

2. Pulmonary Embolus

3. Cardiac Tamponade

4. Atelectasis