Providing Care of a Chest Drainage System Learning Objectives: Provide care of a chest drainage system. Assist with chest tube removal.

What is Chest Tube? A firm plastic tube with drainage holes in the proximal ends that is inserted in the PLEURAL SPACE. It is inserted to drain fluid (PLEURAL EFFUSION), blood (HEMOTHORAX), air (PNEUMOTHORAX) from the pleural space. Secure with a suture and tape and covered with AIRTIGHT DRESSING

Chest Tube Placement

What is Chest Drainage System? Components: Chest tube Collection chamber Closed water-seal drainage- prevents air from reentering the chest Suction control chamber- prevents excess suction pressure from being applied in the pleural cavity (may be water filled or dry chamber) Commonly used in hospitals: molded plastic, three-compartment disposable chest drainage unit

Chest Drainage System

Chest Drainage System

Comparison of Chest Drainage System 1. Traditional water-seal (wet-suction) chamber Has 3 chambers: collection, water-seal, wet-suction chamber sterile fluid be instilled into water seal and suction chambers Intermittent bubbling indicates that the system is functioning properly

Comparison of Chest Drainage System 2. Dry-suction water seal (dry suction) Has 3 chambers: collection chamber, water-seal chamber (middle chamber), and wet suction control sterile fluid be instilled in water seal chamber at 2-cm level. No need to fill suction chamber with fluid. Suction pressure is set with a regulator.

Comparison of Chest Drainage System 3. Dry-suction (one-way valve system) Has one-way mechanical valve that allows air to leave the chest and prevents air from moving back into the chest No need to fill suction chamber with fluid Ideal for ambulatory patient

Providing care of a Chest Drainage System EQUIPMENT Bottle of sterile normal saline or water Two pairs of padded or rubber-tipped Kelly clamps Pair of clean scissors Disposable gloves Additional PPE, as indicated Foam tape or bands Prescribed drainage system, if changing is required

Providing care of a Chest Drainage System ASSESSMENT V/S Respiratory status, oxygen saturation level Lung sounds Pain Knowledge of the patient

Providing care of a Chest Drainage System: IMPLEMENTATION 1. Bring necessary equipment to the bedside stand or overbed table. 2. Perform hand hygiene and put on PPE, if indicated. 3. Identify the patient. 4. Close curtains around bed and close the door to the room, if possible. 5. Explain what you are going to do and the reason for doing it to the patient. 6. Assess the patient’s level of pain. Administer prescribed medication, as needed. 7. Put on clean gloves.

Implementation: Assessing the Drainage System 8. Move the patient’s gown to expose the chest tube insertion site. Keep the patient covered as much as possible, using a bath blanket to drape the patient, if necessary. Observe the dressing around the chest tube insertion site and ensure that it is dry, intact, and occlusive

Implementation: Assessing the Drainage System 9. Check that all connections are securely taped. Gently palpate around the insertion site, feeling for subcutaneous emphysema, a collection of air or gas under the skin. This may feel crunchy or spongy, or like “popping” under your fingers.

Implementation: Assessing the Drainage System 10. Check drainage tubing to ensure that there are no dependent loops or kinks. Position the drainage collection device below the tube insertion site. 11. If the chest tube is ordered to be suctioned, note the fluid level in the suction chamber and check it with the amount of ordered suction. Look for bubbling in the suction chamber. Temporarily disconnect the suction to check the level of water in the chamber. Add sterile water or saline, if necessary, to maintain correct amount of suction.

Implementation: Assessing the Drainage System 12. Observe the water-seal chamber for fluctuations of the water level with the patient’s inspiration and expiration (tidaling). If suction is used, temporarily disconnect the suction to observe for fluctuation. Assess for the presence of bubbling in the water-seal chamber. Add water, if necessary, to maintain the level at the 2-cm mark, or the mark recommended by the manufacturer.

Implementation: Assessing the Drainage System 13. Assess the amount and type of fluid drainage. Measure drainage output at the end of each shift by marking the level on the container or placing a small piece of tape at the drainage level to indicate date and time. The amount should be a running total, because the drainage system is never emptied. If the drainage system fills, it is removed and replaced.

Implementation: Assessing the Drainage System 14. Remove gloves. Assist patient to a comfortable position. Raise the bed rail and place the bed in the lowest position, as necessary. 15. Remove additional PPE, if used. Perform hand hygiene.

Implementation: Changing the Drainage System 16. Obtain two padded Kelly clamps, a new drainage system, and a bottle of sterile water. Add water to the water-seal chamber in the new system until it reaches the 2-cm mark or the mark recommended by the manufacturer. Follow manufacturer’s directions to add water to suction system if suction is ordered.

Implementation: Changing the Drainage System 17. Put on clean gloves and additional PPE, as indicated. 18. Apply Kelly clamps 1.5 to 2.5 inches from insertion site and 1 inch apart, going in opposite directions

Implementation: Changing the Drainage System 19. Remove the suction from the current drainage system. Unroll or use scissors to carefully cut away any foam tape on the connection of the chest tube and drainage system. Using a slight twisting motion, remove the drainage system. Do not pull on the chest tube.

Implementation: Changing the Drainage System 20. Keeping the end of the chest tube sterile, insert the end of the new drainage system into the chest tube. Remove Kelly clamps. Reconnect suction, if ordered. Apply plastic bands or foam tape to chest tube/drainage system connection site.

Implementation: Changing the Drainage System 21. Assess the patient and the drainage system as outlined (Steps 5–15). 22. Remove additional PPE, if used. Perform hand hygiene.

Documentation site of the chest tube amount and type of drainage amount of suction applied any bubbling, tidaling, or subcutaneous emphysema noted type of dressing in place patient’s pain level, as well as any measures performed to relieve the patient’s pain. 9/10/12 1805 Chest tube present in right lower portion of rib cage at the axillary line. Draining moderate amount of serosanguineous fluid. Suction at 20 cm H2O noted; gentle bubbling noted in suction chamber. Tidaling present in water-seal chamber, no air leak noted. Small amount of subcutaneous emphysema noted around insertion site, unchanged from previous assessment; patient denies any pain; occlusive dressing remains intact. —C. , RN

Air Leak (Bubbling) An air leak will be characterised by intermittent bubbling in the water seal chamber when the patient with a pneumothorax exhales or coughs. The severity of the leak will be indicated by numerical grading on the UWSD (1-small leak 5-large leak) Continuous bubbling of this chamber indicates large air leak between the drain & the patient. Check drain for disconnection, dislodgement and loose connection, and assess patient condition. Notify medical staff immediately if problem cannot be remedied.

Oscillation (Swing) The water in the water seal chamber will rise and fall (swing) with respirations. This will diminish as the pneumothorax resolves. Watch for unexpected cessation of swing as this may indicate the tube is blocked or kinked. Cardiac surgical patients may have some of their drains in the mediastinum in which case there will be no swing in the water seal chamber.

What will you do if… The chest tube becomes separated from the drainage device: Open the sterile normal saline or water and insert the chest tube into the bottle while not contaminating the chest tube. This creates a water seal until a new drainage unit can be attached. Assess the patient for any signs of respiratory distress. Notify physician. Do not leave the patient. Anticipate the need for a new drainage system and a chest x-ray.

What will you do if… The chest tube becomes dislodged: Put on gloves. Immediately apply an occlusive dressing to the site. There is a controversy in the literature over whether the occlusive dressing should be a sterile Vaseline-impregnated gauze covered with an occlusive tape or a sterile 4 4 gauze folded and covered with an occlusive tape.

What will you do if… While assessing the chest tube, you notice a lack of drainage when there had been drainage previously: Check for kinked tubing or a clot in the tubing. Note the amount of suction that the chest tube is set on. “Milking” of the tubing (squeezing and releasing small segments of tubing between the fingers) and “stripping” of the tubing (squeezing the length of the tube without releasing it) are not recommended. Bruising and trauma of lung tissue can occur as a result, as well as dangerously increased negative pressure in the pleural space. If the suction is not set appropriately, adjust until the ordered amount is achieved. Keeping the tubing horizontal across the bed or chair before dropping vertically into the drain device, and avoiding dependent loops optimize drainage. Notify the physician if the lack of drainage persists.

What will you do if… Drainage exceeds 100 mL/hr or becomes bright red: Notify physician immediately. This can indicate fresh bleeding. Chest tube drainage suddenly decreases and the water-seal chamber is not tidaling: Notify physician immediately. This could signal that the tube is blocked.

Nursing Responsibilities EQUIPMENT BY THE BEDSIDE: two rubber-tipped clamps and additional dressing material at the bedside for quick access, if needed. a bottle of sterile water or normal saline two suction outlets: One for chest drain & one for airway management

Nursing Responsibilities Never clamp chest tubes except to change the drainage system If the chest tube becomes accidentally disconnected from the drainage system, place the end of the chest tube into the sterile solution. This prevents more air from entering the pleural space through the chest tube, but allows for any air that does enter the pleural space, through respirations, to escape once pressure builds up.

Nursing Responsibilities Maintain the chest drainage system in an upright position and lower than the level of the tube insertion site. This is necessary for proper function of the system and to aid drainage. Encourage the use of an incentive spirometer if ordered and/or frequent deep breathing and coughing by the patient. This helps drain the lungs, promotes lung expansion, and prevents atelectasis.

Nursing Responsibilities Patient  Transport If the patient needs to be transferred to another department or is ambulant, the suction should be disconnected and left open to air. 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 patients chest level during transport Flutter Valve systems (pneumostat, Heimlich) may be used for patient interhospital transfers

Assisting with Removal of a Chest Tube When: if lung is re-expanded and drainage is minimal Who: physician, advance practice nurse, or physician’s assistant EQUIPMENT: Disposable gloves Additional PPE, as indicated Suture removal kit (tweezers and scissors) Sterile Vaseline-impregnated gauze and 4x4 gauze dressings Occlusive tape, such as foam tape

Assisting with Removal of a Chest Tube ASSESSMENT: Assess the patient’s respiratory status, including respiratory rate and oxygen saturation level. Assess the patient’s lung sounds. The lung sounds over the chest tube site may be diminished due to the tube. Assess the patient for pain. Pain medication may be given before the chest tube removal to decrease the pain felt with the procedure.

Assisting with Removal of a Chest Tube Bring necessary equipment to the bedside stand or overbed table. 2. Perform hand hygiene and put on PPE, if indicated. 3. Identify the patient. 4. Administer pain medication, as prescribed. Premedicate patient before the chest tube removal, at a sufficient interval to allow for the medication to take effect, based on the medication prescribed.

Assisting with Removal of a Chest Tube 5. Close curtains around bed and close the door to the room, if possible. 6. Explain what you are going to do and the reason for doing it to the patient. Explain any nonpharmacologic pain interventions the patient may use to decrease discomfort during tube removal. 7. Put on clean gloves. 8. Provide reassurance to the patient while the physician removes the dressing and then the tube.

Assisting with Removal of a Chest Tube 9. After physician has removed chest tube and secured the occlusive dressing, assess patient’s lung sounds, respiratory rate, oxygen saturation, and pain level. 10. Anticipate the physician ordering a chest x-ray. 11. Dispose of equipment appropriately. 12. Remove gloves and additional PPE, if used. Perform hand hygiene.

What will you do if… Patient experiences respiratory distress after chest tube removal: Auscultate lung sounds. Diminished or absent lung sounds could be a sign that the lung has not fully reinflated or that the fluid has returned. Notify physician immediately. Anticipate an order for a chest x-ray and possible reinsertion of a chest tube. Chest tube dressing becomes loosened: Change the chest tube dressing at least every 24 hours or per agency policy in order to assess the site for erythema and drainage. Replace the occlusive dressing using a sterile technique. The dressing should remain occlusive for at least 3 days.

Post Lecture Evaluation

References: Lynn, Pamela (2011). Taylor’s Clinical Nursing Skills A Nursing Process Approach. 3rd Edition. Wolters Kluwer I Lippincott Williams and Wilkins. Gwynedd Valley, Pennsylvania Twomey, Berndette (2012). Chest Drain Management. Retrieved at http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_Drain_Management/