What are safety considerations when caring for a patient with a chest tube?
Breathing is automatic. We don’t usually think too much about it unless we develop a problem. Lack of adequate ventilation and impairment of our respiratory system can quickly become life-threatening. There are many clinical conditions that may necessitate the use of chest tubes. When there is an accumulation of positive pressure in the chest cavity (where it should normally be negative pressure between pleurae), a patient will require chest drainage. Chest tubes may be inserted to drain body fluids or to facilitate the re-expansion of a lung. It is important for the clinician to determine the most appropriate tube size to use prior to intubation. The position of the chest tube is related to the function that the chest tube performs. When managing the care of patients who have chest tubes it is important to fully understand what to do in case problems arise. It is also important to be able to assess when the chest tube is ready to be discontinued. Nurses and other healthcare professionals who are responsible for the safe delivery of care should be knowledgeable about respiratory pathophysiology, signs of respiratory compromise, and the care and management of interventions that may be utilized to ensure adequate respiration. Show
A chest tube is a hollow plastic tube. Your doctor put the tube into the space around your lungs to help remove air that shouldn't be there. It can also help drain fluid or blood. You may need the drain because of a punctured or collapsed lung (pneumothorax) or because of a surgery you had. A drain can also help remove pus from a serious chest infection, such as pneumonia. The tube will stay in your chest until all or most of the air, fluid, or blood drains out. This usually takes a few days. Your doctor may attach the tube to a device that can help the space around your lungs drain better. The tube may have a one-way valve that lets air and fluid out, but not in. This helps keep the lungs working and allows them time to heal. It may be called a flutter or Heimlich valve, or it may be another type of valve. Your doctor or nurse will show you how to use the valve. If you are at home, you will need to care for the area around the chest tube and empty the container that it drains into. A chest tube, also known as a thoracic catheter, is a sterile tube with a number of drainage holes that is inserted into the pleural space. The pleural space is the space between the parietal and visceral pleura, and is also known as the pleural cavity. A patient may require a chest drainage system any time the negative pressure in the pleural cavity is disrupted, resulting in respiratory distress. Negative pressure is disrupted when air, or fluid and air, enters the pleural space and separates the visceral pleura from the parietal pleura, preventing the lung from collapsing and compressing at the end of exhalation. A small amount of fluid or air may be absorbed by the body without a chest tube. A large amount of fluid or air cannot be absorbed by the body and will require a drainage system (Bauman & Handley, 2011; Perry et al., 2014). The chest tube is connected to a closed chest drainage system, which allows for air or fluid to be drained, and prevents air or fluid from entering the pleural space. The system is airtight to prevent the inflow of atmospheric pressure. Because the pleural cavity normally has negative pressure, which allows for lung expansion, any tube connected to it must be sealed so that air or liquid cannot enter the space where the tube is inserted (Bauman & Handley, 2011; Rajan, 2013). The location of the chest tube depends on what is being drained from the pleural cavity. If air is in the pleural space, the chest tube will be inserted above the second intercostal space at the mid-clavical line. If there is fluid in the pleural space, the chest tube is inserted at the fourth to fifth intercostal space, at the mid-axillary line. A chest tube may also be inserted to drain the pericardial sac after open heart surgery, and may be placed directly under the sternum (Perry et al., 2014). The following are some of the conditions that may require a chest tube drainage system (Bauman & Handley, 2011; Perry et al., 2014):
A chest tube drainage system must always be placed below the drainage site and secured in an upright position (attached to the floor or an IV pole, as in Figure 10.4) to prevent it from being knocked over. Figure 10.4 Chest tube drainage system secured to IV poleFigure 10.5 Chest tube drainage systemFigure 10.6 Chest tube drainage system with labelled partsA chest tube drainage system is a sterile, disposable system that consists of a compartment system that has a one-way valve, with one or multiple chambers, to remove air or fluid and prevent return of the air or fluid back into the patient (see Figures 10.5 and 10.6). The traditional chest drainage system typically has three chambers (Bauman & Handley, 2011; Rajan, 2013). Always review what type of system is used in your agency, and follow the agency’s and the manufacturer’s directions for setup, monitoring, and use. In general, a traditional chest tube drainage system will have these three chambers:
In addition to the three chambers, the drainage system has many safety features to ensure that high negative pressures can be monitored and relieved quickly. To review these safety features and additional information regarding the chambers of a closed chest tube drainage system, visit the Teleflex Medical Incorporated website. When a patient has a closed chest tube drainage system, it is the health care provider’s responsibility to assess the patient and the equipment frequently to ensure the equipment is patent and working effectively. The health care provider should:
Checklist 86 reviews the management of a patient with a chest tube drainage system. Checklist 86: Management of a Chest Tube Drainage System (Pleur-evac)Disclaimer: Always review and follow your hospital policy regarding this specific skill.Safety considerations:
StepsAdditional Information1. Review the patient chart for the reason for the chest tube and location and insertion date.Knowing the reason for the chest tube and location informs the health care provider on the type of expected drainage.2. Perform hand hygiene. identify patient using two identifiers and explain assessment process to patient. Create privacy to assess the patient and drainage system.Hand hygiene reduces the transmission of microorganisms.Proper identification provides patient safety measures for safe care. 3. Complete respiratory assessment, ensure patient has minimal pain, and measure vital signs. Place patient in semi-Fowler’s position for easier breathing.Patient should be in a semi-Fowler’s position, have minimal pain, have no respiratory distress, and have no evidence of an air leak around the insertion site, and no drainage from the insertion site or chest tube equipment.Frequent assessment of the respiratory status is important if the patient’s condition is stable, resolving, or worsening, and ensures that the chest tube is functioning correctly. Assessment should be every 15 minutes to 1 hour until patient is stable. Increase monitoring if patient’s condition worsens. Chest tubes are painful, as the parietal pleura are very sensitive. Ensure patient has adequate pain relief, especially prior to repositioning, sitting, or ambulation. 4. Assess chest tube insertion site to ensure sterile dressing is dry and intact.Check insertion site for subcutaneous emphysema. Dressing should remain dry and intact; no drainage holes should be visible in the chest tube.Dressing is generally changed 24 hours post-insertion, then every 48 hours. Chest tubes are generally sutured in place. There should be no fluid leaking from around the site or sounds of air leaks from insertion site. Chest tube insertion site5. Maintain a closed system. Ensure all connections are taped and secured according to agency policy.These measures are important to keep the system intact and prevent accidental tube removal or disruption of the drainage system.6. Ensure tubing is not kinked or bent under the patient or in the bed rails, or compressed by the bed.Kinked or bent tubing could interfere with the drainage of the pleural fluid.Dependent loops may collect fluid and impede drainage. The long tube may be coiled and secured to a draw sheet with a safety pin (allowing enough tubing so that the patient can move in bed comfortably) to prevent dependent loops. Tubing free from kinks and dependent loops7. Collection chamber (drainage system) is below the level of the chest and secured to prevent it from being accidentally knocked over.The drainage system must remain upright for the water-seal chamber to function correctly.The chest drainage system must be lower than the chest to facilitate drainage and prevent back flow. Chest drainage system lower than insertion site8. Periodically check water-seal chamber to ensure water level is to the dotted line (2 cm) — at least once every shift. Add water as necessary.Adequate water in the water-seal chamber prevents excess suction being placed on the delicate tissue.Water levels should be checked each shift as the water may evaporate. 9. Check water-seal chamber for tidaling (water moving up and down) with respirations. Gentle bubbling is normal as the lungs expand.If the water in the water seal does not move up and down with respirations, the system might not be intact or patent. Periodic bubbling in the water-seal chamber is normal and indicates that air that is trapped is being removed. Frequent assessment of the system is required to ensure proper functioning.Chest tube drainage system with labelled partsExcessive bubbling may cause unnecessary noise and faster evaporation. If there is no tidaling, consider 1) an occlusion somewhere between the pleural cavity and the water seal, or 2) a full expansion of the lung, where suction has drawn the lung up against the holes in the chest tubes. If patient is on positive pressure ventilation, the tidaling will be the opposite: the water will move down with inspiration and up with expiration. 10. Ensure suction control dial is set to ordered level (usually 20 cm).The amount of suction in the chamber is regulated by the suction control dial, not the suction source.11. If suction is ordered, a “float” (or equivalent) must be visible clearly in the window.In wet suction control, gentle bubbling is normal. If there is no bubbling, ensure the connections are tight and turn the suction higher.Suction pressure set at – 20 cm12. If suction is not ordered, ensure the suction port is left open to air. Suction window will appear blank if suction is not in use or not working.The suction port must be left open to the air and free of obstruction to prevent a tension pneumonthorax.Suction port on the top of a chest tube drainage systemSuction control window (white rectangle)13. In wet suction systems, expect gentle bubbling in the chamber.Gentle bubbling is normal. Vigorous bubbling is noisy and can be disturbing to the patient. Periodically check the air vent to ensure it is not blocked or occluded.14. Assess air leak meter to determine progress of patient’s internal air level, measured as level 1 to 7. On every shift, document the level of air leak, and if the air leak occurs at rest or with coughing.Bubbling in the air leak meter indicates an air leak. Measure and monitor.The source of the leak may be identified by:
Notify doctor of any new, increased, or unexpected air leaks that are not corrected by the above actions. To document the air leak, note the numbered column through which the bubbling occurs. If bubbling is present in first three columns of the air leak meter, document “air leak 3.” Air leak meter15. Check that the clamp is open.The chest tube should not be clamped unless for specific reasons. See special considerations below.Blue clamp is open16. Measure date and time, and the amount of drainage, and mark on the outside of the chamber. Record amount and characteristics of the drainage on the fluid balance sheet and patient chart.Drainage that is red and free-flowing indicates a hemorrhage. A large amount of drainage, or drainage that changes in colour, should be recorded and reported to the primary health care provider.Drainage that suddenly decreases may indicate a blood clot or obstruction in the chest tube drainage system. Drainage in collection chamber17. Encourage frequent position changes as well as deep-breathing and coughing exercises.Deep-breathing and coughing exercises promote lung expansion and promote fluid drainage.18. The following should be documented and assessed according to agency policy:
Special considerations:
Video 10.10Video 10.11Table 10.3 provides a list of potential complications and interventions related to chest tube drainage systems. Table 10.3 Complications and Interventions Related to Chest Tube Drainage SystemsComplications Interventions Potential pneumothorax/respiratory distressThis is the primary concern for a patient with a chest tube drainage system.
Assess the drainage system and the patient and notify primary health care provider if required. Sudden increase in bright red drainageThis may indicate an active bleed. Monitor amount of drainage and vital signs, and notify the primary health care provider.Data source: ATI, 2015c; BCIT, 2015c; Perry et al., 2014; Teleflex Medical Incorporated, 2009Heimlich ValveA Heimlich valve (see Figures 10.7 and 10.8) is a small, specially designed flutter valve that is portable and mobile, allowing the patient to ambulate with ease. It attaches to the chest tube at one end and a drainage bag at the other. The drainage bag allows air and fluid to escape but prevents their re-entering the pleural space. The valve can be worn under clothing. The valve functions in any position, never needs to be clamped, and can be hooked up to suction if required (Gogakos et al., 2015). What is the nurse's responsibility when managing a patient's chest tube?Chest tubes nursing care staff (most nurses) are responsible for ensuring the chest tube is properly packed up and stowed away for every adventure. This includes removing the chest tube from suction if suction is ordered and leaving the drainage system lower than the patient's chest.
What is a priority in caring for a patient with a chest tube?Finally, the tube placement should be confirmed with an X-ray. Okay, let's look at the nursing care you'll provide to a client with a wet-suction chest tube. Your priority goals of care are to assist with chest tube insertion, promote lung expansion, and monitor for complications.
What are the things you need to consider when transporting the patient with a chest tube drainage?Ensure that all connections are secure, either using tape or wire banding. Make sure the bandage over the incision is securely taped and occlusive. Mark the depth of the tube using a felt-tip marker and continually monitor during transport. If a drainage unit is used, be sure to keep it below the level of the chest.
What should be at the bedside of a patient with a chest tube?2.4 A bottle of sterile water must be located at the bedside to use in case of accidental disconnection of chest tube from drainage unit.
|