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Chest Tubes

Nursing cares, assessment, and interventions

By: Morgan Kraut, Bonnie Glover and Allison Hildebrand

Purpose of Chest Tubes 

The purpose of chest tube therapy is to remove air or fluid from the pleural space and to restore normal intrapleural pressure helping to promote lung reexpansion

Anatomy and Physiology of thoracic cavity 

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The chest is composed of ribs, sternum, vertebrae and inter-costal muscles. The lower border of the thoracic cavity is known as the diaphragm. This muscle contracts with inspiration and expiration. The parietal pleura is a membrane lining the inside of the rib cage. The membrane covering the lungs is called the visceral pleura. The cavity between these two membranes is called the pleural space. This space creates a negative pressure that keeps the lungs expanded. When air or fluid is present in the pleural space, this limits lung expansion and causes the lung to collapse partially or completely

Indications for Chest Tubes  Pneumothorax

– air in pleural

space  Pleural Effusion – fluid in pleural space  Hemothorax – blood in pleural space  Empyema – collection of pus or infection in pleural space  Chylothorax – lymphatic fluid in pleural space

Equipment  Pleuravac

collection system – this is a sterile system and includes a funnel and sterile NS  Tubing connecting chest tube to pleuravac  Tubing connecting pleuravac to wall suction  Hemostats – for clamping flexible tubing before disconnecting patient from pleuravac  Vaseline impregnated gauze – to create seal over insertion site

Pleuravac collection chambers 

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Purpose of this system is to evacuate air or fluid from pleural space to promote adequate re-expansion Collection chamber – for air, blood or other foreign drainage from pleural space Suction control chamber – promotes faster draining than gravity Water seal chamber – Allows air to pass from the collection chamber to water seal chamber where it will leave pleuravac

Active Orders in Healthlink 

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Suction amount – continuous, intermittent, or dependent (water seal) draining Dressing changes – during chest tube therapy and after chest tube is removed I&O Activity allowance – can RN disconnect pt from suction for walking Post-placement chest x-ray

HEALTH LINK Documentation

How to set up a Pleuravac  Fill

water seal chamber to 2 cm  Fill suction control chamber to ordered level  Attach tube to suction source  Tape all the connections  Provide sterile tube for connection to patient

Nursing Assessment and Documentation    

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Assess the pt first - color, respiratory rate/rhythm, lung sounds bilaterally, presence of crepitus Monitor Vital signs Encourage coughing and deep breathing Assess for an air leak – have pt bear down by sealing lips over thumb and blowing, or have patient cough. Chest tube dressing and insertion site – color/presence of drainage, skin color Tubing – free of kinks, tubing is lower than pt, tubing is not clamped, tubing should also be coiled flat on the bed and fall in a straight line to the drainage system. Reposition frequently: drainage is promoted when the pt is sitting in a semi-sitting position, and also by turning the pt to the side of the chest tube and exhaling or coughing.

If this, then what 

What if chest tube accidentally disconnects from tubing? –

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Quickly clamp with hemostat or by kinking and find bottle of sterile NS to put end of tube into. Then reconnect to new tubing/pleuravac system.

What if pleuravac is knocked over? –

Not an emergency, simply tip back up. Reassess for correct fluid levels of each chamber. If mixing of chambers has occurred, change pleuravac system.

If this, then what (cont.) 

What if there is bubbling in water seal chamber? –

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How do I assess for crepitus? Crepitus will sound like rice krispies under the skin around chest tube site. This is trapped air that is incorrectly leaving pleural space. What if drainage is bright red in color and increases output? – If pt (with all types of disruptions to thoracic cavity) starts having large output of blood, especially bright red drainage >70 ml an hour, this may indicate hemorrhage. Assess pt and immediately contact MD. –

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This indicates possible air leak. Attempt to locate air leak (insertion site, tubing connections, etc). Contact MD.

Pleuravac assessment 

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Suction control chamber – should have steady bubbling, should be filled to ordered suction level with water Water seal chamber - Check the fluid level in the water seal and adjust to 2 cm, is the negative pressure indicator visible, potential air leak if bubbling, assess for rise and fall (tidaling) with inspiration and expiration, this is normal Collection chamber – is chamber full, color/amount of drainage, should be no bubbling present

Indications for the removal of a chest tube

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Little to no drainage q shift Patient is breathing normal with no respiratory distress X-ray confirms that the lung is re-expanded.

Removal of chest tube and nursing assessment 

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Physician will order for chest tube removal, this is done at bedside Gather all supplies and explain procedure to patient. During peak exhalation, physician will remove the tube in one quick motion Apply sterile gauze over site to prevent air from entering the chest cavity. Monitor vital signs closely

CS Catalog   

How to order a new pleuravac system: In U-Connect, click on CS catalog: Under Search by item description type in: – –

chest : this will bring up both the chest tube sets, and drainage systems. Most commonly pts will have: 

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DRAINAGE CHEST ADULT/PEDS PLEUREVAC single A7002-08LF item #1216245 Order item that fits your patients specific needs: proceed to check out. Account # specific to orthopedics is 93430 Finalize order.

References 

Albuquerque D, et al. The effect of experimental pleurodesis caused by aluminum hydroxide on lung and chest wall mechanics. Lung. 179(5):292–303, October 2001.

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Anders K. Chest drainage to go. Nursing2004. 34(5):54–55, May 2004.

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Baumann MH. What size chest tube? What drainage system is ideal? And other chest tube management questions. Current Opinion in Pulmonary Medicine. 9(4):276–281, July 2003.

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Brubacher S, Gobel BH. Use of the Pleurx pleural catheter for the management of pleural effusions. Clinical Journal of Oncology Nursing. 7(1):35–38, January/February 2003.

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Carroll P. Mobile chest drainage: Coming soon to a home near you. Home Healthcare Nurse. 20(7):434–441, July 2002.

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Conces DJ Jr, Tarver RD, Gray WC, Pearcy EA. Treatment of pneumothoraces utilizing small caliber chest tubes. Chest. 1988;94:55–57.[Abstract/Free Full Text]

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Coughlin, A.M., Parchinsky, C. “Go with the flow of chest tube therapy.” Journal of Nursing 2006, 36, (37-41).

References (cont.) 

LeMone P, Burke K. Medical-Surgical Nursing. Critical Thinking in Client Care, 3rd edition. Upper Saddle River, N.J., Prentice Hall, 2003.

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Lewis, S. M., Heitkemper, M. M., Dirkson, S. R. Medical and Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis: 2004.

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Morton PG, Fontaine D, eds. Critical Care Nursing. A Holistic Approach, 8th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2005.

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Niemi T, Hannukainen J, Aarnio P. Use of the Heimlich valve for treating pneumothorax. Ann Chir Gynaecol. 1999;88:36–37.[Medline]

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Perlmutt LM, Braun SD, Newman GE, et al. Transthoracic needle aspiration: use of a small chest tube to treat pneumothorax. AJR Am J Roentgenol. 1987;148:849– 851.[Abstract/Free Full Text]

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Rossi A, Ganassini A, Polese G, Grassi V. Pulmonary hyperinflation and ventilator-dependent patients. Eur Respir J. 1997;10: 1663–1674.[Abstract]]

CHEST TUBES A Reference Guide for Nurses

By: Morgan Kraut, Allison Hildebrand and Bonnie Glover