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.