Chest Tube Care and Monitoring

Chest Tube Care and Monitoring

TERMINAL LEARNING OBJECTIVE

Given a scenario in a holding or ward setting, involving a patient with a chest tube, identify procedures for chest tube care and monitoring IAW the Textbook of Basic Nursing, Lippincott

Introduction

Trauma, disease, or surgery can interrupt the closed negative-pressure system of the lungs, causing the lung to collapse. Air or fluid may leak into the pleural cavity. A chest tube is inserted and a closed chest drainage system is attached to promote drainage of air and fluid. Chest tubes are used after chest surgery and chest trauma and for pnuemothorax or hemothorax to promote lung re-expansion

Terms and definitions

a. Pneumothorax – collection of air in the pleura space

b. Hemothorax – an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae, usually as the result of trauma

c. Chest tubes – a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures

Chest Tube Systems

a. Pleur-Evac chest drainage system

(1) One-piece molded plastic unit that duplicates the three-chambered system

(2) Cost effective

(3) There must be bubbles flowing in the suction control portion of the unit to provide suction to the patient

b. Pleur-Evac Set Up

(1) Fill water seal chamber

(2) Fill suction control chamber

(3) Attach tube to suction source

(4) Tape all the connections

(5) Provide sterile tube for connection to patient

c. Procedure for Proper Usage of the Heimlich Valve

(1) Heimlich valve is a plastic, portable one-way valve used for chest drainage, draining into a vented bag

(2) Equipment

(a) Heimlich valve

(b) Kelly clamps - 2 (rubber-tipped)

(d) Ostomy tape or rubber band

(e) Suction setup (if applicable)

(f) Clean scissors

(3) Procedure Steps

(a) Gather equipment and bring to patient area

(b) Wash hands

(c) Don gloves. Nonsterile gloves are acceptable as long as sterile technique is maintained while the connection is being made.

(4) Heimlich Valve To Chest Tube

(a) Place rubber-tipped Kelly clamps in opposite directions on the proximal end of the chest tube as near to the patient as possible

(b) Connect the chest tube to the blue end of the Heimlich valve using sterile technique

CAUTION: Only the blue end of the Heimlich valve can be connected to the chest tube. If the clear end is connected, the one-way valve will be in the wrong position and no drainage will take place.

CAUTION: When two chest tubes are present, two Heimlich valves must be used to ensure proper functioning of chest tubes.

(d) Monitor and record character of drainage and patency of valve in nursing progress notes.

CAUTION: Measure all drainage in a calibrated cylinder for accurate readings.

(e) Record drainage output on I & O graphic every 8 hours. If conditions permit.

Care of patients with chest tubes

a. Assess patient for respiratory distress and chest pain, breath sounds over affected lung area, and stable vital signs

b. Observe for increase respiratory distress

c. Observe the following:

(1) Chest tube dressing, ensure tubing is patent

(2) Tubing kinks, dependent loops or clots

(3) Chest drainage system, which should be upright and below level of tube insertion

d. Provide two shodded hemostats for each chest tube, attached to top of patient’s bed with adhesive tape. Chest tubes are only clamped under specific circumstances:

(1) To assess air leak

(2) To quickly empty or change collection bottle or chamber; performed by soldier medic who has received training in procedure

(3) To change disposable systems; have new system ready to be connected before clamping tube so that transfer can be rapid and drainage system reestablished

(4) To change a broken water-seal bottle in the event that no sterile solution container is available

(5) To assess if patient is ready to have chest tube removed (which is done by physician’s order); the solider medic must monitor patient for recreation of pneumothorax

e. Position the patient to permit optimal drainage

(1) Semi-Flower’s position to evacuate air (pneumothorax)

(2) High Flower’s position to drain fluid (hemothorax)

f. Maintain tube connection between chest and drainage tubes intact and taped

(1) Water-seal vent must be without occlusion

(2) Suction-control chamber vent must be without occlusion when suction is used

g. Coil excess tubing on mattress next to patient. Secure with rubber band and safety pin or system’s clamp

h. Adjust tubing to hang in straight line from top of mattress to drainage chamber. If chest tube is draining fluid, indicate time (e.g., 0900) that drainage was begun on drainage bottle’s adhesive tape or on write-on surface of disposable commercial system

(1) Strip or milk chest tube only per MD/PA orders only

(2) Follow local policy for this procedure

Problems solving with chest tubes

a. Problem: Air leak

(1) Problem: Continuous bubbling is seen in water-seal bottle/chamber, indicating that leak is between patient and water seal

(a) Locate leak

(b) Tighten loose connection between patient and water seal

(d) Leaks are corrected when constant bubbling stops

(2) Problem: Bubbling continues, indicating that air leak has not been corrected

(a) Cross-clamp chest tube close to patient’s chest, if bubbling stops, air leak is inside the patient’s thorax or at chest tube insertion site

(b) Unclamp tube and notify physician immediately!

Warning: Leaving chest tube clamped caused a tension pneumothorax and mediastinal shift

(3) Problem: Bubbling continues, indicating that leak is not in the patient’s chest or at the insertion site

(a) Gradually move clamps down drainage tubing away from patient and toward suction-control chamber, moving one clamp at a time

(b) When bubbling stops, leak is in section of tubing or connection distal to the clamp

(4) Problem: Bubbling continues, indicating that leak is not in tubing

(a) Leak is in drainage system

(b) Change drainage system

b. Problem: Tension pneumothorax is present

(1) Problems: Severe respiratory distress or chest pain

(a) Determine that chest tubes are not clamped, kinked, or occluded. Locate leak

(b) Obstructed chest tubes trap air in intrapleural space when air leak originates within patient

(2) Problem: Absence of breath sounds on affected side

(a) Notify physician immediately

(3) Problems: Hyperresonance on affected side, mediastinal shift to unaffected side, tracheal shift to unaffected side, hypotenstion or tachycardia

(a) Immediately prepare for another chest tube insertion

(b) Obtain a flutter (Heimlich) valve or large-guage needle for short-term emergency release or air in intrapleural space

(4) Problem: Dependent loops of drainage tubing have trapped fluid

(a) Drain tubing contents into drainage bottle

(b) Coil excess tubing on mattress and secure in place

(5) Problem: Water seal is disconnected

(a) Connect water seal

(b) Tape connection

(6) Problem: Water-seal bottle is broken

(a) Insert distal end of water-seal tube into sterile solution so that tip is 2 cm below surface

(b) Set up new water-seal bottle

(7) Problem: Water-seal tube is no longer submerged in sterile fluid

(a) Add sterile solution to water-seal bottle until distal tip is 2 cm under surface

(b) Or set water-seal bottle upright so that tip is submerged

SUMMARY

Caring for a patient with a chest tube requires problem solving and knowledge application. Remember, a chest tubes is a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures. When caring for and maintaining a patient with a chest tube, it is important to note the patency of chest tubes, presence of drainage, presence of fluctuations, patient's vital signs, chest dressing status, type of suction, and level of comfort.