3. At the end of the lecture/discussion session students will be able to:
1. Define the term chest tube
2. Identify the site for chest tube insertion,
3. Identify indications for the chest tubes,
4. Explain the role of the nurse in monitoring of a patient with a chest tube,
5. Explain considerations in caring for the patient with a chest tube
including chest tube maintenance.
5. What do you understand by the term
chest tubes?
6. • Between the two membranes that surround the lung is a negative
pressure air space called _____.
a. the parietal space
b. the pleural space
c. the pericardial space
d. the peritoneal space
7. Definition of Chest tube
A chest tube is a procedure that insert a flexible, hollow drainage tube
into the chest to remove an abnormal collection of air, blood, or fluid from
the pleural space
15. Nursing management
The nurse is responsible for the managing the chest tube and drainage system
including:
• Caring for the tube and drainage system when transporting patient
• Changing or emptying the drainage container
• Monitoring fluid drainage
• Monitoring chest tube position
• Milking and clamping contraindicated
16. Nursing
management
Patient assessment
• Vitals sign: HR, SPO2 BP,RR
• Btreath sounds
• Pain : Pain rating on pain scale
• Drain insertion site
• Observe for signs of infection and inflammation and document finding
• Check dressing site: clean and intact
• Observer sutures remain intact and secure (long term drains may allow
sutures to erode over time)
17. Nursing management
Chest tube drainage system and tubing
• Drain should never be lift above chest level
• The unit must remain below the patient’s chest level to facilitate
drainage
• Tubing should be free from Kinks and obstructions that would
hinder drainage
• Ensure all connections between chest tubes and drainage unit are
tight and secure
18. Nursing management
Chest tube drainage system and tubing Con'd
• Connections should have cables ties in place
• Tubing should be anchored to the patient’s skin to prevent
pulling of the drain
• Ensure the drainage unit is securely positioned on its stand or
hanging on the bed
• Ensure that the water seal is always maintained at 2cm
19. Nursing management
Drainage
• Milking of chest drains should be avoided
Volume
• Document hourly the amount of fluid in the drainage chamber in the patient
chart
• Document total hourly output if multiple drains
20. Nursing
management
Drainage Con'd
• Notify Doctor if there is a sudden increase in amount of
drainage
• Greater than 5mls/kg in 1hour
• Greater than 3mls/kg consistently for 3hours
• If the drain with ongoing loss suddenly stops draining
21. Nursing management
Drainage Con'd
• Colour and Consistency
• Monitor the colour/type or the drainage fluid. If there is
a change: Haemoserous to bright red or serous to creamy, notify the
patient doctor
22. Nursing management
Air Leak (Bubbling)
• An air leak will be noted by intermittent bubbling in the water seal chamber
when the patients with a pneumothorax exhales or coughs
• Check tubing for disconnection, dislodgement, and loose connection, and assess
patient condition. Notify patient doctor immediately
• Document must be made to patient chart
• Assessing for an air leak: Clamp off suction for one minute. An air leak is
present if there is constant bubbling in the water-seal chamber.
24. Nursing
management
Oscillation
• The water in the water seal chamber will rise
and fall(swing) with respirations. This will
diminish as the pneumothorax resolves.
• Monitor for unexpected cessation of swing as
this may indicate the tube is blocked or kinked
• Documentation of noted oscillation in patient
chart
25. Nursing management
Equipment at the bedside
• Drain clamps: at least 2 drain clamps per drain. This is for emergency
only in case of accidental disconnection.
• Two suction outlets: for the chest drain and one for airway
management
26. Nursing management
Patient positioning
• Patients who are ambulant to prevent fewer complications and short
hospital stay.
• Strict bed rest patients should be repositioned to encourage the
promotion of drainage.
• The patient should be placed in an upright position to
facilitate drainage.
27. Nursing management
Patient transport
• If the patient needs to be transferred to another department or
is ambulant, the suction should disconnect and be left open to air
28. Nursing management
• Do not clamp the tube
• Clamps must not be used on the patient for transport because of the
risk of tension pneumothorax
• Ensure the chamber is below the patient’s chest level during transport
29. Nursing management
•Dressings should be changed if:
•no longer dry and intact, or signs of infection e.g. redness, swelling,
exudate
•Infected drain sites require daily changing, or when wet or soiled
•No evidence for routine dressing change after 3 or 7 days
•This procedure is a risk for accidental drain removal so avoid
unnecessary dressing changes
30. Nursing management
Changing the chamber:
• The chest drain chamber needs to be replaced when it is ¾ full or
when the chest tube drainage system sterility has been compromised
e.g. Accidental disconnection
• What if the chest tube falls out
32. What if the tubing disconnects for the
site?
• Immediately cover the site with a dry, sterile dressing and notify the
physician.
• If air is heard from the site, place an occlusion dressing to the site to permit
the air out and prevent tension pneumothorax.
• Closely monitor the patient and prep for reinsertion.
33. What if there is bleeding at the site?
• Apply pressure to the insertion site
• Place occlusion dressing over the site
• Immediately notify the physician.
• Check drainage system to ensure no excessive blood loss.
• Closely monitor the patient and prep for reinsertion.
34. What if the chest tube disconnect
from the drainage system?
• If the chest tube and drainage system become disconnected, air can enter the
pleural space, producing a pneumothorax.
• To prevent pneumothorax if the chest tube is inadvertently disconnected from
the drainage system, a temporary water seal can be established by immersing
the chest tube’s open end in a bottle of sterile water.
• Or if possible reconnect to the water seal drainage system!
35. Nursing management
Documentation:
Describe of the drainage (serous, sangineous, serosangeounous).
• Date and time of the drainage amount on the chest drainage unit.
• Total amount of drainage on intake/output flowsheet.
• Type and amount of suction.
36. Nursing management
Documentation:
• Date/time of dressing change. Follow hospital policy on frequency. Note any
redness around the insertion site, any purulent drainage, any odor, or crepitus.
• Air leak presence or absence.
• Respiratory status.
• Patient or family education
38. • A nurse is assessing a patient who has a chest tube in place attached to
a closed-chest water-seal drainage system. When the nurse palpates the
area around the chest-tube insertion site, she is checking for?
a. air emphysema that may be seen after facial fractures.
b. Subcutaneous emphysema.
c. Airway concentration
d. Edema
39. A healthcare provider is providing care for a patient with a chest tube. The chest
tube gets caught between the side rail and the stretcher and is clamped off. What
can occur when a chest tube is accidentally clamped?
A. Atelectasis
B. Tachypnea
C. Hemothorax
D. Tension pneumothorax
40. • While transferring a patient who has a chest tube in place attached to a
closed-chest drainage system, the patient accidentally disconnects the
chest tube from the system. Which of the following should the nurse
do to prevent a serious complication while preparing to reconnect the
system?
a. Submerge the end of the chest tube in 1 inch of sterile water
b. Clamp tubing
c. Notify the physican
d. Remove the chest tube place occulusion dressing
41. • A patient has returned from the operating room with a chest tube in his sixth
intercostal space with orders to connect the patient to wall suction. The patient has a
three-chamber, water-seal system. Eight hours later you find the patient complaining
of increased chest pain, a respiratory rate of 40 breaths per minute, and a pulse of
110. The water-seal chamber is dry. The patient is in obvious distress. What should
you suspect as the primary cause?
a) The patient’s chest tube has become dislodged.
b) There is no water in the water-seal chamber.
c) The wall suction is too low.
d) The patient is breathing shallowly and avoiding coughing.
42. • A teaching plan is done for the education of a patient who has a chest
tube in place attached to a closed-chest drainage system following
surgery after a trauma injury What should the nurse emphasize to the
patient when he is ready to ambulate freely?
a. remain in semi-fowler position.
b. always keep the collection device upright.
c. only ambulate with the nurse assistance.
d. always keep at a 45 angle
43. • What should the suction chamber be refilled with as necessary?
a) Nonsterile water
b) Sterile saline solution
c) Nonsterile saline solution
d) Sterile Water
44. • A 34-year-old man is admitted to the ICU with a chest tube after suffering a blunt
chest wall injury as an unrestrained driver in a motor vehicle accident. The drain
is being monitored for the volume of blood collected from the chest. Which of the
following is the most appropriate indication to clamp the chest tube?
A. Immediately after insertion of the chest tube
B. After the chest tube has been in for 24 hours and on continuous wall suction
C. After 2 stable chest x-rays demonstrating resolution of a space-occupying lesion
D. Only while changing the drainage canister, to prevent re-accumulation of a
pneumothorax
45. • If the chest tube is pulled out of the patient's chest, and the patient had an air leak
from the lung, after asking a colleague to call a physician STAT, emergency
nursing management is to:
a. Cover the opening with a sterile dressing, taped on three sides
b. Cover the opening with sterile Vaseline gauze taped securely on all sides.
c. Leave the opening alone and monitor the patient until a physician can assess the
situation
d. Try to put the tube back in place as quickly as possible.
46. • If the chest tube is pulled out of the patient's chest, and the patient had an air leak
from the lung, after asking a colleague to call a physician STAT, emergency nursing
management is to:
a. Cover the opening with a sterile dressing, taped on three sides
b. Cover the opening with sterile Vaseline gauze taped securely on all sides.
c. Leave the opening alone and monitor the patient until a physician can assess the
situation
d. Try to put the tube back in place as quickly as possible.
47. Reference
Salmon R.Lynch S. Muck K. Chest tube management. [Lecture notes on
internet]. AMN healthcare Education Services 2013 [Cited 2022 Feb 14].
Available from https://lms.rn.com/getpdf.php/1933.pdf
Sasa I.R. Evidence-based update on chest tube management [Internet].
Healthcommedia; 2019[Citedd 2022 Feb 28]. Available
from https://www.myamericannurse.com/evidence-based-update-on-chest-tube-
management/
The eyelets should not be visible after insertion.
This image shows the sites for insertion of the chest tube into the pleural space which is the space or sac surrounding the lung filled with serous fluid and found in the thorax.
In the thoracic cavity, the lungs are surrounded by two thin members. The membrane that wraps tightly against the lungs is called the visceral pleura, and the outer layer is called the parietal pleura. Between these membranes is a thin space filled with air called the pleural space. The pleural space is very important to the function of the lungs. The space is under negative pressure, pressure less than atmospheric air. The difference in pressure between the pleural space, lungs, and outside air is what creates inspiration and expiration. When there is a disruption in the negative pressure either by trauma, surgery, or a pathological process (like a tumor or infection), the negative airspace in the pleural cavity can fill with air or fluid. This upsets normal breathing as the lungs are compressed or collapsed
This image shows the sites for insertion of the chest tube into the pleural space which is the space or sac surrounding the lung filled with serous fluid and found in the thorax.
To drain air: Anterior (and laterally) through 2nd-3rd intercostal space
To drain fluid/blood: Posterior through 8 or 9th intercostal space in midaxillary line
In the lung apex at the second or third intercostal space, mid-clavicular line to drain air.
In the lateral chest area at the lower site, normally the eighth or ninth intercostal space to facilitate drainage of blood or fluid.
In the anterior media sternal beneath the sternum, called retro-sternal tube in case of cardiac surgery
Hemothorax -A small amount of blood (<300) in the pleural space may cause no clinical manifestations and may require no intervention (blood is reabsorbed spontaneously). Massive HTX results from a rapid accumulation of more than 1500cc of blood in the chest cavity. Hemothorax is known as bleeding into the pleural space and is common of thoracic trauma.
A tension pneumothorax occurs when air is drawn into the pleural space from a lacerated lung or through a small hole in the chest wall. It my be a complication of other types of pneumothorax. In contrast to open pneumothorax, the air that enters the chest cavity with each inspiration is trapped; it cannot be expelled during expiration through the air passages or the hole in the chest wall. With each breath tension is increased within the affected pleural space.
Chest tubes are painful as the parietal pleura is very sensitive. Patients require regular pain relief for comfort and to encourage mobility.
Focus your assessment on the patient, not the equipment. Every 2 hours (or as needed), assess and document the patient’s level of consciousness, orientation, vital signs (especially respiratory rate, depth, and effort), breath sounds, and oxygen saturation. Every 8 hours (or as needed), inspect the CTT insertion site for drainage, subcutaneous emphysema, and tube migration. Signs of respiratory distress include tachypnea, dyspnea, shortness of breath, tachycardia, decreased or absent breath sounds, and use of accessory muscles of respiration. Assessment of chest tube and system tubing should occur at the beginning of the shift and every hour throughout the shift
The insertion site should be regularly checked for any skin breakdown or subcutaneous emphysema (SCE). SCE can occur when air or CO2 is trapped in the subcutaneous tissues, and frequently occurs on the face, neck, or chest. A physical assessment will reveal edema of the affected area along with subcutaneous crepitus (crackling sensation under the skin during palpation). While palpating the involved area, use a skin marker to identify its borders. This will help you determine whether the SCE is progressing or resolving (Moye, 2010). In most cases, the affected tissues slowly absorb the SCE after the underlying cause is identified and treated. When reabsorption occurs, air can move from the insertion site into the face, chest or neck and may displaced the chest tube (Moye, 2010). Air under the skin is usually painless, and feels spongy; some people describe it as feeling "Rice Krispies" under the skin. If it becomes painful, the physician should be notified
Subcutaneous emphysemia is also known as crepitus or Sub Q Air.
Remember that the CTT system will work only if it’s intact. Any breach in the system—even a loose connection—can allow atmospheric air to get sucked into the thoracic cavity, causing patient harm. Secure and monitor all points of connection. Activities of daily living (ADLs) such as bathing, repositioning and turning, and ambulating can loosen or dislodge CTT connections. Assist patients during any of these activities.
Milking of chest drains should be avoided as this creates a high negative pressure that can cause pain, tissue trauma and bleeding
Depending on the hospital, the nursing unit, and the patient’s condition, it is necessary to monitor and document chest drainage every four to eight hours minimally or as condition warrants:
• Closely monitoring the output will enable the nurse to notify the physician if there is excessive output.
• To assess drainage level, mark the drainage level on the outside of the drainage collection chamber in hourly or shift increments with the date and time. Record the output information on the flowsheet to provide a reference point for future measurements.
• In the nurse’s note or flowsheet, a description of the drainage color will also help healthcare providers to guide their care. For example, with a hemothorax, the color should change from bloody to straw color (sanguinous to sero-sanguinous to serous). Accurate documentation will facilitate early identification of any changes in the patient’s condition related to the chest tube. • Significant changes should be reported to the physician. Examples of this are: the drainage color changed from serous to bloody or drainage output was greater than 100 ml in one hour when the Material Protected by Copyright output was normally 10 ml in 12 hours or there is increasing bloody drainage greater than 100 ml in one hour. (Coughlin & Parfchinsky, 2006). If there is no drainage inform the physician and anticipate an order for a chest x-ray to see if the lung has re-expanded. If it has not re-expanded, the chest tube may be displaced or it may be clogged. The physician should be notified so that the patient can be reassessed. The physician may order a CT scan of the chest to check placement or may decide to place a new chest tube
This may indicate an active bleed. Monitor the amount of drainage and vital signs, and notify the primary health care provider.
Assess the patient for an air leak. It is important to rectify any air leaks because an airtight system reestablishes negative pressure and permits the lungs to expand effectively.
An air leak alerts the nurse that he or she must assess for the location of the leak by checking the connections from the chest drainage unit to the insertion site. If there is excessive, continuous bubbling in the water-seal chamber, there is most likely a large air leak. Starting from away from the patient and going towards the patient, check all connections. Lastly, change the dressing and make sure there is good seal with the dressing around the insertion site. If it is the pleural space that is leaking, intermittent bubbling with respiration is normal. This will resolve as the lung re-expands. Therefore, when a pneumothorax is the indication for the chest tube, an air leak is to be expected; yet, should decrease with patient improvement
Assess the patient for an air leak. It is important to rectify any air leaks because an airtight system reestablishes negative pressure and permits the lungs to expand effectively.
An air leak alerts the nurse that he or she must assess for the location of the leak by checking the connections from the chest drainage unit to the insertion site. If there is excessive, continuous bubbling in the water-seal chamber, there is most likely a large air leak. Starting from away from the patient and going towards the patient, check all connections. Lastly, change the dressing and make sure there is good seal with the dressing around the insertion site. If it is the pleural space that is leaking, intermittent bubbling with respiration is normal. This will resolve as the lung re-expands. Therefore, when a pneumothorax is the indication for the chest tube, an air leak is to be expected; yet, should decrease with patient improvement
With a chest tube in the pleural space, the water level should fluctuate in the water seal chamber. This is known as tidaling, and should correspond with respiration. so with each inhalation and exhalation the water should have and forward and backward movement. When there is no air leak, the water level in the water seal chamber should rise and fall with the patient's respiration. During spontaneous respiration, the water level will rise during inhalation and fall during exhalation. If the patient is receiving positive pressure ventilation, the oscillation will be just the opposite. If the lung is re-expanded, tidaling may not be present
Clamping the Chest Tube Never clamp the chest tube unless the physician orders it or when a nurse is changing the chest drainage unit. If the patient on water suction is going off the unit for a procedure/diagnostic test or being transferred, put the chest drainage unit to underwater seal (UWS), which is a one-way valve which allows air to exit the chest and prevents air returning to the patient under normal conditions. When ambulating a patient, ensure that the drainage unit is carried at a level below the patient’s chest. Ensure that the tube is functioning & the connections are secure. Also ensure that the UWS is at least 20cmH2O below the patient's fluid level.
When it is medically necessary to clamp the chest tube, clamp for no longer than one minute, to prevent increased pressure within the lung.
If the chest tube accidentally falls out, instruct the patient to perform the Valsalva maneuver. At end-expiration immediately cover the insertion site with vaseline gauze (if indicated by your hospital), a dry sterile dressing, and occlusive tape. In the event of chest-tube disconnection with contamination, you can submerge the tube 1" to 2" (2 to 4 cm) below the surface of a 250-mL bottle of sterile water or saline solution until a new CDU is set up. This establishes a water seal, allows air to escape, and prevents air reentry.
The nurse should immediately call the physician and prepare for re-inserting of the chest tube. While informing the physician, place oxygen on the patient and sit patient in high-Fowlers. It is imperative that the nurse evaluate the patient for a life threatening situation, such as a tension pneumothorax. If medically necessary per the physician’s orders, set up the chest drainage unit and gather the thoracotomy tray while monitoring the patient's vital signs.
Apply dressing when patient exhales. If patient goes into respiratory distress, call a code. Notify primary health care provider to reinsert new chest tube drainage system.
.
Subcutaneous emphysema.
D
A.Submerge the end of the chest tube in 1 inch of sterile water.
Correct answer: b
Rationale: The water seal is dry allowing air to enter the chest and preventing the lung from expanding. The level of water in the suction control chamber maintains the level of suction
Keep the collection device upright at all times.
D.
D. Only while changing the drainage canister, to prevent re-accumulation of a pneumothorax
