Date post: | 07-May-2015 |
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Technology |
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Darlene “Cookie” Wilson, MSN, RN
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 ________.◦ aka?
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 pleuraParietal pleura Visceral pleura Visceral pleura
Normal Pleural Fluid Quantity: Approx. 10-20 mL per lung
Normal Pleural Fluid Quantity: Approx. 10-20 mL per lung
LungLung
RibsIntercostal muscles
• The area between the pleura is called the pleural space (sometimes referred to as “potential space”)
• Normally, vacuum (negative pressure) in the pleural space keeps the two pleura together and allows the lung to expand and contract
• If air or fluid enters this space, there is a potential for impaired breathing.
archive.student.bmj.com/.../02/education/52.php
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?◦ A. Operating Room◦ B. Bedside◦ C. Emergency Room◦ D. All of the above◦ E. None of the above
Sterile technique Small incision Tube is sutured Dressing applied
◦ What type?
Choose site
Explore with finger
Place tube with clamp
Suture tube to chest
Photos courtesy trauma.org\
http://www.scielo.br/img/revistas/jbpneu/v34n8/en_a04fig01.gif
and their primary and their primary purposespurposes
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 When?
No dependent loops What is this? Why?
Oxygen therapy Record output
How often? Analgesics ***Incentive Spirometer (IS) and turn,
cough, deep breathe (TCDB)
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
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
If suction is needed, a third bottle is added.
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
Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva)
Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest
Suction can improve the speed at which air and fluid are pulled from the chest
Collection chamber
Water seal chamber
Suction control chamber
from patient
Suction control bottle
Water seal bottle
Collection bottle
From patientTo suction
Chamber A◦ Suction control chamber
How do you know what level the water should be at? Chamber B
◦ Water seal chamber How do you know what level the water should be at? Should the ball be fluctuating in this chamber? What if it isn’t?
Chamber C◦ Air leak monitor
What does bubbling mean? Chamber D
◦ Collection chamber When do you record output?
Be sure you under stand how to set up the system, the function of each chamber and how to troubleshoot issues with each chamber.
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
◦ Amount of drainage◦ Insertion site & dressing
System position Tubing position
◦ What happens when the patient lays on it? Connections to patient and system Assessing the system Monitoring output
What are some common complications?
Chest tube malposition (most common) Subcutaneous emphysema
What is this? What are some nursing interventions related to this
complication? High Fluid in Water Seal Chamber
Chest system may need to be vented Air leak
How do you know? What do you do?
Otherspleural effusion, inc. pneumo
mediastinal shiftDo chest tubes get clotted off?
What can happen when fluid is removed too fast?
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
http://www.youtube.com/watch?v=WVHelcIIee8 (full review chest system – wet)
http://www.youtube.com/watch?v=74H6N-Qxm34&playnext=1&list=PLFCFEACCE12F1D1E0&index=26 (dry suction – start at 5:10)
http://www.youtube.com/watch?v=WVHelcIIee8
http://www.youtube.com/watch?v=74H6N-Qxm34&playnext=1&list=PLFCFEACCE12F1D1E0&index=26
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?
http://www.medicalive.net/186_chest_tube_insertion
If time permits http://www.atriummed.com/Products/Chest_Drains/edu-ocean.asp
Oasis dry suction set uphttp://www.google.com/imgres?imgurl=http://www.atriummed.com/Common/Images/help-oasis.jpg&imgrefurl=http://www.atriummed.com/products/chest_drains/education.asp&usg=__iFwkxjbty1SgU2UOxzHu7gyeorM=&h=100&w=100&sz=6&hl=en&start=2&zoom=1&um=1&itbs=1&tbnid=bjQxSvGWg2AsiM:&tbnh=82&tbnw=82&prev=/images%3Fq%3Doasis%2Bdry%2Bsuction%2Bchest%2Btube%2Bsystem%26um%3D1%26hl%3Den%26tbs%3Disch:1
Thank you, Thank you, Thank you, Thank you, etc.