Transcript File - Samantha Soto`s E

Chest Tubes
Samantha Soto BSN, RN-BC
University of Central Florida
MSN Candidate
Objectives
After participating in this class
the learner will be able to…
 Describe the anatomy and
physiology of the lung
 Identify potential conditions
requiring need for a chest tube
 List equipment and supplies
used to place, maintain, and
remove chest tubes
 Outline the process of
insertion, maintenance, and
removal of chest tubes
Anatomy & Physiology
Thoracic Cavity
 R Lung: 3 lobes
 L Lung: 2 lobes
 Mediastinum: heart, aorta,
esophagus, & trachea
 Diaphram: separates
thoracic cavity from
abdomen
 Visceral Pleura: covers
the lungs
 Parietal Pleura: lines the
chest wall
Left Lung
Right Lung
Mediastinum
Parietal Pleura
Visceral Pleura
Diaphragm
Pleura Anatomy
 area between the pleura is
called the pleural space
 the pressure between the
pleural space is always
negative
 negative pressure is suction
 Normal pleural fluid quantity
is small. There is no set
number or calculation, and it
is based on size.
Breathing
Inhalation
Down
Exhalation
Up
Conditions that require Chest Tubes
Pneumothorax
 A collapsed lung is the collection of air in the space
around the lungs. This buildup of air puts pressure
on the lung so it cannot expand.
Conditions that require Chest Tubes
Open Pneumothorax
 stab wound, gun shot
wound, surgery where
air would leak in to the
thoracic cavity from the
outside; also known as
a “sucking chest
wound”
Conditions that require Chest Tubes
Closed Pneumothorax
 disruption of lung and
visceral pleura
 results when air leaks
from a ruptured bronchus
or a perforated esophagus
and eventually ruptures
into the pleural space.
 Can progress to a tension
pneumothorax
Conditions that require Chest Tubes
Hemothorax
blood in the pleural space
Large Plueral Effusions
transudate or exudate in the
pleural space usually from
CHF and Cancer
Conditions that require Chest Tubes
Tension Pneumothorax
 air can get in, but not
OUT
 there is an obstruction
and an accumulation of
air under pressure in the
pleural space. This
condition develops when
injured tissue forms a 1way valve, allowing air to
enter the pleural space
and preventing the air
from escaping naturally
Conditions that require Chest Tubes
Mediastinal Shift
 a shifting or moving of the
tissues and organs that
comprise the mediastinum
(heart, great vessels,
trachea and esophagus) to
one side of the chest cavity.
The condition occurs when a
severe injury to the chest
causes the entrapment of air
in the pleural space
 Very serious condition and
requires attention
immediately; can lead to
cardiac arrest
 Worsening closed/tension
pneumothorax
Conditions that require Chest Tubes
Thoracic surgery
 Coronary Artery Bypass Graft
(CABG) and Valve
replacements
 Chest tubes are used to drain
the chest cavity of fluid and
blood (which is temporary and
normal) after surgery.
 Occasional placement of tubes
in the left or right pleurae are
used for collapsed lung during
and post procedure
Signs & Symptoms
 Dyspnea
 Tachypnea
 Tachycardia
 Chest pain
 Crepitus
 Decreased breath
sounds on the side
where the
pneumothorax is
 Cough
 Fatigue
 Cyanosis
Diagnostic Tools
 Pulse oximetry
 Ausculatation
 Chest x-ray
 CT scan
Equipment for Chest Tube placement
Chest tube cart
 Clamps
 Pleur Evac
 Vaseline guaze
 Trocar
 Chloraprep
 Chest tube
 Suction set up
 Suture with needles
 Dry sterile 4x4s
 Some medications will
be pulled from pyxis
Drainage Systems
Heimlich Valve
• used primarily to
release air
• Mobile
Pleur Evac
• used for both fluid
and air drainage
PluerX
• used for effusions
that rapidly
reaccumulate
Insertion Diagram
Insertion Diagram
Maintenance of the Chest Tube
Vital Signs
 with O2 sats as per hospital
policy
 q 15min x4, q 30min x2, q 1hr x4,
then q 4hr until removed
Site
 tape securely
 check for bleeding, crepitus
around insertion site,
 mark it with a marker, if its
growing…that’s could be a
problem
 assess color at insertion and for
swelling or bruising
Maintenance of the Chest Tube
Tubing
 Start at the insertion site and
move down towards drainage
system
 You should never see any
holes
 Remove any loops
 Check for patency/clots
 Check color of fluid
 DO NOT CLAMP a chest
tube unless you have been
instructed to or you are
changing the drainage box
 Do not strip or milk your chest
tube
Maintenance of the Chest Tube
Pleur Evac/Drainage System
 Do not touch sterile tip, you will
hand this to the physician during
insertion
 Fill in the H2O chamber with
sterile water
 If air is leaking then you will see
it in this chamber as shown. It is
numbered 1-5 to indicate the
grade of the air leak.
 you will almost always have an
air leak when the tube is
inserted, but is resolves
 Hang drainage box at the foot of
the bed
Maintenance of the Chest Tube
Suction
 You will set the suction dial
on the Pleur Evac as
ordered by the physician
 The wall suction is
increased until the orange
buoy floats
Output
 What does it look like?
 Check for stop cocks
 How much is ok, or not
enough?
 Mark the Pleur Evac at the
beginning of your shift
 Check the amount of
drainage at least every 2
hrs.
Maintenance of the Chest Tube
What is water seal?
 Water seal acts as a one way valve
 Fluid and air can go out, but not back in.
What if your water seal is low?
 You can refill it with a syringe and a bottle of
sterile water
How often does the dressing need to be
changed?
 Daily unless it is saturated and needs to be
changed sooner
 Is this a sterile procedure?
 No, but should be as clean a technique as
possible
Patient Education
 Description of procedure
 IS and cough/deep
breath
 Ambulation/sitting up in
chair(pts can do these
things even with a chest
tube!)
 Pain management
 The pt can expect to
have chest x-rays
performed daily until the
tube is removed
When to call for HELP!
 My patient’s having trouble breathing
 My patient’s sats are below 90% and staying there
 My patient’s chest tube is making whistling noises
 My patient pulled out their chest tube
Chest Tube Removal
 A chest x-ray has confirmed that the
patient’s problem has resolved or well
enough to remove their chest tube
 Your patient should have breath
sounds over the affected area now
 Drainage has also decreased
significantly.
 Sometimes a physician will ask that
the chest tube be clamped for a few
hours prior to removal
 Usually a physician will order for a
chest tube to be removed from wall
suction and placed to water seal for a
day prior to tube removal.
Chest Tube Removal
What will you need?
 Kelly Clamps to clamp the chest tube
 Chloraprep or betadine swab to clean the site
before you remove the chest tube
 Suture removal kit-to remove the sutures
 Vaseline gauze or Adaptic-to help create a seal
 Dry sterile 4x4, that will go over the Vaseline
dressing
 Tegaderm or Occlusive Dressing (at first you
want a dressing that will help make a seal)
 Red Bag for disposal of the chest tube and Pleur
Evac
Chest Tube Removal
Procedure
 make sure you have an order first
 Explain what your going to do to the patient.
 The patient must be in bed, always
 Pre-medicate: some physicians will pre-medicate for
large bore chest tubes 15-30min prior to pull.
 Practice breathing deep. Explain to the pt that on the
third breath they will hold it until you say so, at that
time you will pull the chest tube quickly
 Get your red bag ready and place the Pleur Evac in
the bag prior to pulling the chest tube
 Clamp the chest tube with the Kelly Clamps
Chest Tube Removal
Procedure continued…
 Remove old dressing
 Cleanse the area with chloraprep or betadine prior to
pull and make sure it is dry.
 Remove sutures
 As you pull the chest tube you will place the Vaseline
gauze and dry sterile 4x4s.
 Remind your patient to breath and that IT’S OVER!
 Place Tegaderm over the gauze. Time and date the
dressing.
 Instruct your patient on when to call for help
 Dispose of your waste in the red bin