by Charlotte Cooper RN, MSN, CNS modified by Kelle Howard RN, MSN

 Lungs  Mediastinum Heart Aorta and great vessels Esophagus Trachea

 Diaphragm contracts  Moves down  Increasing the volume of the thoracic cavity  When the volume increases, the pressure inside ________.  Pressure within the lungs is called intrapulmonary pressure

 Phrenic nerve stimulus stops  Diaphragm relaxes  This ______ the volume of the thoracic cavity  Lung volume decreases, intrapulmonary pressure _____

If two areas of different pressure communicate, gas will move from the area of higher pressure to the area of lower pressure

Parietal pleura lines the chest wall Visceral pleura (pulmonary) covers the lung

Parietal pleura Visceral pleura Normal Pleural Fluid Quantity: Approx mL per lung Lung RibsIntercostal muscles

 Area between pleura ----“potential space”  Normally, negative pressure between pleura

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 Diagnostic tests  Client position  Treatment depends on severity Chest tube Heimlich valve on chest tube

 Also called “thoracic catheters”  Different sizes From infants to adults Small for air, larger for fluid  Different configurations Curved or straight  Types of plastic PVC Silicone  Coated/Non-Coated Heparin Decrease friction

 In what setting/environment is a chest tube placed?

 Sterile Tech  Small incision  Tube is sutured  Dressing applied

Chest tube is attached to a drainage device Allows air and fluid to leave the chest Contains a one-way valve to prevent air & fluid returning to the chest Designed so that the device is below the level of the chest tube for gravity drainage

1. Remove fluid & air as promptly as possible 2. Prevent drained air & fluid from returning to the pleural space 3. Restore negative pressure in the pleural space to re-expand the lung

 Dressing changes  No dependent loops  Oxygen therapy  Record output  Analgesics  IS and turn, cough, deep breathe

 Health history-respiratory disease, injury, smoking, progression of symptoms  Physical exam- degree of apparent resp distress, lung sounds, O2 sat, VS, LOC, neck vein distention, position of trachea  All require observation for respiratory symptoms  Pertinent nursing problems Acute pain Ineffective airway clearance Impaired gas exchange Home care

How a chest drainage system works

Tube open to atmosphere vents air Tube from patient

 For drainage, a second bottle was added  The first bottle collects the drainage  The second bottle is the water seal  With an extra bottle for drainage, the water seal will then remain at 2cm

The depth of the water in the suction bottle determines the amount of negative pressure that can be transmitted to the chest, NOT the reading on the vacuum regulator

 Expiratory positive pressure  Gravity  Suction

 Chamber A Suction control chamber  Chamber B Water seal chamber  Chamber C Air leak monitor  Chamber D Collection chamber Be sure you under stand how to set up the system, the function of each chamber and how to troubleshoot issues with each chamber.

Monitoring  Water seal is a window into the pleural space  Not only for pressure  If air is leaving the chest through an air leak, bubbling will be seen here  Air meter (1-5) provides a way to “measure” the air leaving and monitor over time – getting better or worse?

 Focused respiratory assessment Breath sounds Respiratory rate Respiratory depth SpO2 ABG CXR

 Cardiovascular assessment  Level of consciousness  Pain  Chest tube

 System position  Tubing position  Connections to patient and system  Assessing the system  Monitoring output

What are some common complications?

 Chest tube malposition (most common)  Subcutaneous emphysema  High Fluid in Water Seal Chamber Chest system may need to be vented  Air leak Others pleural effusion, inc. pneumo, pulmonary edema mediastinal shift ?

 Check fluid level in suction chamber  Observe water seal chamber fluid level  Assess for tidaling in water seal chamber  Assess for tubing – non dependent  Determine if the unit has been knocked over  Note the amount, color and consistency of drainage

 Monitor your client  Notify MD STAT if Significant drainage Increasing shortness of breath Pain Absence of breath sounds

 Do not remove suction without an order  Manage pain  When full - place in biohazard container  Do not change collection device on client with an air leak without an order  When suction discontinued, must disconnect from suction, not just turn off

 What is the progression of events for discontinuing a chest tube?  Can a patient ambulate with a chest tube?