3Definition:*Use of tubes and suction to return negativepressure to the intrapleural space.*To drain air from the intrapleural space, thechest tube is placed in the second or thirdintercostals space, to drain blood or fluid, thecatheter would be placed at a lower site, usuallythe eighth or ninth intercostals space.
9*Nursing Care:-Preparing for chest tube insertion dependingon circumstances, the practitioner may inserta chest tube at the bedside or send thepatient to the operating room.
10*Pre-insertion:-patient consent.-explanation of the procedure with him and his family.-Explain that his breathing will be easier once the tube is inserted and his lung starts to reexpand.-Tell them he'll receive a local anesthetic to reduce discomfort.
11*prepare for the procedure: *obtain tray, which typically includes:-injectable lidocaine,-an antiseptic,-sterile gloves,-a scalpel,-hemostats,-sutures,-dressing material.-obtain the appropriate CDU-sterile water-and suction control chambers.
12Setting up a CDU:*Before the patient's skin is prepared for chest tube insertion,set up the CDU according to the manufacturer's instructions.A traditional water seal system is set up by filling the waterseal chamber to the level specified by the manufacturer(usually the 2-cm mark).*Fill the suction control chamber withsterile water to the -20 cm H2O level, or as prescribed.
13*connect the tubing on the suction control chamber to a suction source and turn up the pressure until you seeGentle bubbling in the chamber.*Avoid higher suction, which causes more vigorous bubblingand faster evaporation.*Monitor the CDU water levels and add sterile water asnecessary.*Momentarily turn off the suction to add water becausebubbling makes the water level appear artificially high.
14*Inserting the chest tube: help position the patient for the procedure. Patientpositioning depends on the site of the air or fluid to bedrained and the patient's clinical status.The practitioner cleans the patient's skin with povidone-iodineor another antiseptic solution,drapes the area,and anesthetizes the skin.
15After inserting the chest tube: -She connects its distal end to the CDU.-She uses suture to fix the tube at the insertion site and prevent displacement.-She applies a 4x4-inch piece of sterile gauze with a slit over the tube,and places an occlusive dressing over the gauze on the chest wall.-She tapes the chest tube to the patient's chest to prevent traction on it when he moves.-All tube connections, from the insertion site to the drainage container, must also be securely taped to prevent air leaks or disconnections.-A chest X-ray confirms tube position and lung expansion.
16Risks and complications: Bleeding is a potential complication of chest tubeinsertion if a vessel is nicked accidentally during theprocedure. Usually it's minor and resolves on its own,but bleeding into or around the lung may require surgery.
17Infection, another risk, becomes more likely the longer the chest tube stays in place.Subcutaneous emphysema can occur if airleaks from the pleural space intosubcutaneous tissues. Notify the practitionerif you notice subcutaneous emphysema,which is characterized by tissue swelling inthe neck, face, and chest and a cracklingsound when the area is palpated.
18Other rare but potential complications include lung trauma and bronchopleural fistula.In both of these complications, you'll noticerespiratory distress, decreased oxygen saturation,altered level of consciousness, tachypnea, andsigns and symptoms of infection.A patient with lung trauma also will have bloodychest tube drainage. In both these conditions,the chest tube remains in place until the patientheals.
19Problems? Check your patient first: Now that your patient's chest tube is in place,your goals are to restore adequateoxygenation, promote lung reexpansion,and prevent complications.Whether giving routine care or managinga complication, always assess the patientbefore the equipment.
20Monitor his vital signs—especially rate, pattern, depth, and ease of respirations—and Spo2 levelevery 2 hours or as necessary.Assess his breath sounds bilaterally, especiallychecking for symmetry of breathe sounds.Assess the insertion site for subcutaneousemphysema.
21taped and that the chest tube is secured to your patient's chest wall. Encourage the patient to cough and coach him indeep breathing to promote drainage and lungexpansion.*Teach him to support a thoracic incision if indicated.Keep all tubing free from kinks.Make sure that the connections are securelytaped and that the chest tube is secured toyour patient's chest wall.
22* Keep the collection apparatus below the patient's chest level. *Frequently check the water seal and suction control chambers.*Keep in mind that the water in either chamber can evaporate, soyou may need to add water to maintain the manufacturer'srecommended level.*The water seal level should fluctuate with respiratory effort; this iscalled tidaling. If it doesn't, the tubing may be kinked or clamped orthe patient may be lying on it.
23*The lack of tidaling may be a good sign indicating that no more air is leaking into the pleural space.*Assess the color of drainage in the drainage tubingas well as the collection chamber.
24Measure drainage every 8 hours, or more frequently depending on your patient's clinicalstatus.*At regular intervals, mark the date and time atthe current fluid level on the drainage chamber.*The chamber isn't replaced until almost full,unless the unit is accidentally broken.
25*Document the amount of drainage and its characteristics in your patient's medical record andfluid intake/output record.*Immediately report more than 70 ml/hour of brightred blood or red free-flowing drainage, which couldindicate hemorrhage.*Frequently reposition the patient and help himambulate or sit in a chair as ordered.
26Clamping: *As a rule, avoid clamping your patient's chest tube. Clamping prevents the escape of air or fluid, which increasesthe risk of tension pneumothorax.*You can clamp the tube momentarily to replace the CDU or tolocate the source of an air leak, but never clamp it whentransporting the patient or for any extended period, except asdirected by the practitioner.
27*For example, she may want to clamp the tube to assess the patient's ability to do without itbefore removing it.*While it's clamped, observe him for any signsof respiratory distress (such as chest pain andtachypnea) that could indicate thedevelopment of a tension pneumothorax.*If this happens, remove the clamp immediatelyto let air escape.
28Removing the tube:The practitioner will remove your patient's chest tubeaccording to these criteria:* The drainage has decreased to little or none.* The air leak has disappeared.* The patient is breathing normally without respiratory distress.* Breath sounds are at baseline.* Fluctuations in the water seal chamber have stopped.*A chest X-ray shows lung reexpansion with no residual air orfluid in the pleural space.
29*Gather the necessary equipment and supplies, including a suture removal kit,-petroleum gauze dressing,-4x4 dressings, and occlusive tape.-Explain the procedure to the patient andanswer his questions.-Administer premedication as ordered toprevent pain and anxiety.
30The practitioner will remove the insertion site dressing, clean the area, and remove the sutures.Then, during peak exhalation, she'll remove the tubein one quick movement.Immediately apply sterile occlusive petroleum gauzeto the wound to prevent air from entering the pleuralspace.
31Arrange for your patient to have a chest X-ray to assess for lung reexpansion.Monitor his respiratory status and Spo2 for 1to 2 hours after removal, or longer if necessary.