Post on 24-Dec-2015
transcript
Chest TubesSamantha 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 tubeList equipment and supplies
used to place, maintain, and remove chest tubes
Outline the process of insertion, maintenance, and removal of chest tubes
Anatomy & PhysiologyThoracic CavityR Lung: 3 lobesL Lung: 2 lobesMediastinum: heart, aorta,
esophagus, & tracheaDiaphram: separates
thoracic cavity from abdomen
Visceral Pleura: covers the lungs
Parietal Pleura: lines the chest wall
Right Lung Left Lung
Parietal Pleura
Mediastinum
Diaphragm
Visceral Pleura
Pleura Anatomy
area between the pleura is called the pleural space
the pressure between the pleural space is always negative
negative pressure is suctionNormal pleural fluid quantity is
small. There is no set number or calculation, and it is based on size.
Inhalation Exhalation
Breathing
DownUp
Conditions that require Chest TubesPneumothoraxA 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 Pneumothoraxstab 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
Hemothorax Large Plueral Effusions
Conditions that require Chest Tubes
blood in the pleural spacetransudate or exudate in the pleural space usually from CHF and Cancer
Conditions that require Chest Tubes
Tension Pneumothoraxair 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 1-way valve, allowing air to enter the pleural space and preventing the air from escaping naturally
Conditions that require Chest TubesMediastinal Shifta 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 TubesThoracic surgeryCoronary 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 & SymptomsDyspneaTachypneaTachycardiaChest painCrepitusDecreased breath
sounds on the side where the pneumothorax is
CoughFatigueCyanosis
Diagnostic Tools
Pulse oximetryAusculatationChest x-rayCT scan
Equipment for Chest Tube placement
Chest tube cartClampsPleur EvacVaseline guazeTrocarChloraprepChest tubeSuction set upSuture with needlesDry sterile 4x4sSome medications will
be pulled from pyxis
Drainage Systems
Heimlich Valve• used primarily to
release air• MobilePleur Evac• used for both fluid
and air drainagePluerX• 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 TubeTubing 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 TubePleur Evac/Drainage SystemDo 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 TubeSuction 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 valveFluid 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 EducationDescription of procedure IS and cough/deep
breathAmbulation/sitting up in
chair(pts can do these things even with a chest tube!)
Pain managementThe 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 breathingMy patient’s sats are below 90% and staying thereMy patient’s chest tube is making whistling noisesMy 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 tubeChloraprep or betadine swab to clean the site
before you remove the chest tubeSuture removal kit-to remove the suturesVaseline gauze or Adaptic-to help create a seal Dry sterile 4x4, that will go over the Vaseline
dressingTegaderm 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
Proceduremake sure you have an order firstExplain what your going to do to the patient.The patient must be in bed, alwaysPre-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 RemovalProcedure continued…Remove old dressingCleanse the area with chloraprep or betadine prior to
pull and make sure it is dry.Remove suturesAs 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 helpDispose of your waste in the red bin