Post on 14-Apr-2017
CARE OF INTERCOSTAL DRAINAGE/CHEST TUBES
Terminology
Intercostal - pertaining to the space between the ribs
Milking - Starting at the top of the connecting tubing, squeeze the tube with one hand, grasp just below with other hand and squeeze this area while releasing with the first hand.
Pneumothorax - the collection of air in the intrapleural space
Purulent - making or having pus. Pus is a creamy, thick, pale yellow or yellow-green fluid that comes from dead tissue.
Tension pneumothorax - a medical emergency resulting from an increase in intrathoracic pressure, lung collapse and mediastinal shift toward the opposite side.
Subcutaneous emphysema - The collection of free air or gas in the tissue under the skin, which may occur from the bursting of an airway or small pocket in the lung. This air may move through the mediastinum up into the neck, causing a swollen appearance of the chest, neck and face.
Chest tube insertion
Purposes
– allow drainage of the problem substance– restore normal intrapleural pressure– permit expansion of the lungs– promote adequate gas
• Pneumothorax
• Hemothorax
• Empyema
State of Emergency
Emergency Room - gunshot or stabbed wounds
Operating Room - open heart surgery, Bedside – malignancy, symptomatic pleural
effusion
Chest tube insertion
Chest tube insertion: generally performed by a physician with the
assistance of a nurse consent sterile procedure
Chest tube insertion
The chest tube is inserted between the fourth to sixth intercostal space at the midaxillary line to drain a hemothorax.
-placed in the supine, high-Fowler’s or semi-Fowler’s position
tube will be inserted into the second or third intercostal space in the anterior chest at the midclavicular line.
INSERTION SITES
Materials:
Sterile gloves sterile drapes betadine solution 1 vial of lidocaine alcohol sponge 10 cc syringe 22G 1 inch and 22G5/8 inch needle sterile forcep and scalpel one rubber tipped clamp for each chest tube inserted sterile 4X4 OS elastic tape and scissor chest tube trocar suture kit thoracic drainage system with its collecting tubes
Materials/Equipments
– thoracotomy or chest tube insertion trays– oxygen source, suction and emergency
equipment must be nearby.
– Chest tube sizes: #16 - 20 French catheter is inserted for air or serous
drainage #28 to #40 is inserted for serous, thick or purulent
drainage
Procedure:
informed consent– Provide privacy and emotional support, along
with an explanation of the upcoming procedure at the patient’s level of learning
•Informed consent
•Set up prescribed open system
•Wash hands and apply gloves
•Administer pre-medication as ordered
•Assist physician attach drainage tube to chest tube
•Tape tube connections between the chest and Drainage tubes
•Check patency of air vents
•Coil excess tubing on mattress next to the client
•Adjust to hang in a straight line from the chest tube to the drainage chamber.
•Indicate the TIME, DATE, the drainage begun
•Monitor the chest tube very 15mins for the first 2 hours
•Assist client to a comfortable position
•Remove gloves, dispose of used soiled linens
•Wash hands
•DOCUMENT
one-bottle water-seal system
•100 ml of sterile water• airtight cap with two vent tubes
1st tube (air vent)- patent, prevent pressure within the bottle
2nd tube - extend to 2 cm under the water in the bottle
•More air bubbles will be noted when the patient coughs, sneezes or exhales.
•No bubbling- blockage in the chest tubing- expansion of the patient's lung has occurred- no longer air in the pleural space
two-bottle water-seal system
1st bottle – collect drainage and air
•2 short vents
2nd bottle – water seal
1st vent - longer; 2 cm under 100cc of sterile water2nd vent - open to air to allow air pressure to escape
Nursing Considerations:vertical piece of tape must always be applied to the drainage bottle, so the nurse may observe and document the amount of drainage over time
Advantages:•closely monitor the amount and type of chest drainage•nurse does not have to vigil over the 2 cm level of the water seal•easier to observe the amount of bubbling in the clear water of the second bottle
1st bottle- to collect drainage
2nd bottle - water seal
3rd bottle- suction control - level determines the amount of suction in the system
Advantages:-fairly stable water-seal level, allows for accurate documentation of the drainage and also controlled suction.
Disadvantage:- bulky and does not allow for easy transport or ambulation of this patient
•lightweight, a single unit, portable and doesn’t shatter if broken•fully calibrated drainage compartment •can hold 2500cc of drainage – right•water seal chamber -middle•suction control chamber - left
Pleur –evac
•prep the insertion
•Ensure the patient’s back is properly stretched to allow easier access to the intercostal space
•Remind and assist the patient to avoid movement or coughing during the insertion of the chest tube, in order for the physician to avoid puncturing the visceral pleura or lung
•One surgical clamp for each chest tube must be readily available
•Vaseline gauze may be placed over the chest tube insertion site to ensure an adequate seal. Sterile 4X4s are placed on top of the Vaseline gauze, dressing over the insertion site is completely and securely taped
Immediately after insertion insertion assess for:
A – Assess for amount, color and consistency
B - Breath sounds, heart rate, blood pressure, temperature, respiratory rate and rhythm and Oxygen saturation
C - Comfort level
D - Dressing for occlusiveness and drainage from insertion site
E – subcutaneous EMPHYSEMA at the insertion site
ASSISTING WITH REMOVAL OF CHEST TUBES
Equipments:•Suture set•Sterile scissors•Sterile forcep•Clean glove / sterile glove•Face mask•Sterile dressing•Adhesive tape/ elastic bnadage
•Assess status of lung expansion
•Note trend in water seal fluctuation over last 24 hours
•Clamp chest tube before removal – assess for vital signs
•Administer medications 30 mins before procedure
•Wash hands
•Assist client in sitting on egse of the bed or lying supine
•Physicians prepares for removal
•Support the client physically and emotionally
•Physician ask client to take deep breaths and hold it or exhale completely and hold it
•Aseptically apply sterile prepared dressing over wound and secure it in position
•Assist patient assume comfortable position
•Remove used equipment from bedside
•Hand wash
•Document
Nursing considerations Monitor vital signs
Assess breath sounds bilaterally
Assess the insertion site
Encourage the patient to cough
Make sure connections are taped securely
Keep collection apparatus below the level of the patient’s chest
Check water seal and suction control chambers frequently
Assess drainage for color
Measure drainage every 8 hours or more often depending on patient’s condition
Document assessment
Report immediately bright red blood or red free-flowing drainage >70ml/hour
Reposition patient frequently
Care of chest tube and drainage unit
Tubing: Avoid loops, aggressive manipulation such as “stripping” or “milking”
Patency: To maintain patency, try “gentle” hand-over-hand squeezing of tubing and release
Clamping: Avoid except when replacing CDU, locating air leak, or assessing when tube will be removed
Constant bubbling
•indicate air leak, report to physician assess from the insertion site downward to the collection unit by momentary clamping
•bubbling in the water-seal chamber will cease when the clamp is placed between the air leak and the water seal
•all the connections are tight and there is still an excessive amount of bubbling, the pleural drainage unit may need to be changed
REMEMBER
• small water level• (-) fluctuation
• lungs has re-expand• tubing clotted or kinked, • dependent loopA gentle milking of the chest tube in a downward motion will encourage the movement of stubborn clots.
FLUCTUATIONS
Auscultate bilaterally equal, clear lung sounds will give an indication of lung expansion, however a chest X-ray will confirm it.