NMH Patient Care Division Safety Morbidity & Mortality Study Module Closed Chest Drainage Policy and Practice May 2009 Click the next arrow to begin

What To Expect An actual NMH case study, slightly edited for anonymity. It will take approximately 10-15 minutes to read and complete. Upon completion, you will be able to identify key nursing actions to respond to an adverse event related to chest tubes.

Problem solving and critical thinking are also required. Introduction Trauma, disease, or surgery can interrupt the closed negative pressure system of the lungs, causing the lung to collapse. Air or fluid may leak into the pleural cavity. A chest tube is inserted and a closed chest drainage system is attached to drain air and fluid. When caring for a patient with a chest tube, it is important to monitor the following: Patency of the chest tube Amount and appearance of drainage Patient's vital signs Patient's comfort level Problem solving and critical thinking are also required.

Indications for Chest Tube Use: To Remove Air or Fluid From Pleural Space Definitions: Pneumothorax- Air in the pleural space Hemothorax- Blood in the pleural space Pleural effusion- Fluid in the pleural space The most common reason for placing a chest tube is to treat a pneumothorax. Possible causes of a pneumothorax: Chest trauma Thoracic surgery CPR Central line insertion Positive pressure ventilation

Daily Nursing Assessment of the Patient with a Chest Tube Vital signs--including SpO2--at least every 8 hours. Appearance of site, dressing (is it intact?), & drainage around site Dressing change every 48 hours or earlier if needed. – Use a dry 4 X 4 or drainage sponge covered with paper or silk tape Pain assessment and reassessment. Sufficient analgesics should be ordered to allow for pulmonary hygiene activities: Cough/deep breathing Sitting in chair Ambulation

Daily Nursing Assessment of the Patient with a Chest Tube (continued) Lung sounds Presence of subcutaneous emphysema Fluid variations (tidaling) Water seal or wall suction (how much) Drainage color & amount (output) Presence (and degree) or absence of an air leak Location and number of chest tubes Daily chest X-ray to evaluate placement of tube and status of lungs

Normal Occurrence: Tidaling Daily Nursing Assessment of the Drainage Tubing and Chest Tube Drainage Unit Normal Occurrence: Tidaling Tidaling is the variation of fluid movement in tubing with patient’s respirations. Absence of tidaling indicates a re-expanded lung or an obstructed chest tube. Abnormal Occurrence: Air Leak An air leak causes bubbling in the water seal chamber during inspiration and expiration. The nurse should assess if this patient should have an air leak by remembering why this patient has a chest tube. If the lung was touched/injured then an air leak can be expected (i.e. pneumothorax or VATS/lung biopsy). On the other hand, a chest tube to drain a pleural effusion should NOT cause an air leak.

Notify Physicians for Any of the Following Circumstances… Chest tube drainage is greater than 200 ml/hr Drainage changes in appearance especially if bloody and greater than 100 ml/hr A new air leak is present Chest tube eyelets/holes are out of the patient’s chest Excessive drainage from chest tube insertion site Changes in vital signs, esp. SpO2 Patient’s pain becomes difficult to control

What to Document in PowerChart Under Respiratory Assessment Document amount of drainage during each shift under I & O’s and mark level on the chest tube drainage unit.

Possible Causes for a Pneumothorax with a Closed Chest Drainage System A pneumothorax can also occur after chest tube placement if there is a break in the closed drainage system: Tube becomes disconnected from the device Tube holes are out of patient’s skin Tube becomes dislodged from the patient Respiratory Care Policy 14.01: Closed Chest Drainage

Nursing Assessment Patients with a disconnected chest tube present similarly as a patient with a pneumothorax clinically: Increased heart rate Decreased blood pressure Increased respiratory rate Decreased breath sounds on the affected lung’s side Decreased chest excursion on the affected lung’s side Shortness of breath Additional symptoms may include: Anxiety Chest pain Tracheal deviation Mediastinal shift

Nursing Actions when a Chest Tube is Disconnected Call for assistance. Assess airway, breathing, and circulation (ABCs). Reconnect the chest tube to the Pleur-Evac system IMMEDIATELY. Notify a physician/mid-level provider STAT. Assess the need for a STAT chest X-ray. DO NOT LEAVE THE PATIENT’S SIDE!! If patient continues to decompensate, call 5-5555 for an “Airway Emergency” and give your location to the operator.

Things You Should Never Do… Never clamp/milk/or strip a chest tube without an MD order. Never tape the chest drainage unit to the floor. Never place chest tube collection system above the level of the patient’s chest. Never place the chest tube to water seal without an MD order. Never place the chest tube to low intermittent wall suction – always use continuous suction. Never increase wall suction to promote vigorous bubbling in the suction chamber. Never use Vaseline gauze for the dressing without an MD order.

To Prevent Accidental Disconnections The recommended method to secure all closed-chest drainage system tubing connections is to use waterproof tape in the manner pictured above. First ensure that the connector is firmly pushed into the chest tube and Pleur- Evac tubing (creech tube). Next, place a long length of waterproof tape to extend from the chest tube to the Pleur-Evac tubing over the connector site. Finally, secure the tape to the tube by wrapping a small piece of tape around each end of the tape, ensuring that the connector is visible at all times.

The Recommended Method of Taping Avoid wrapping tape repeatedly around the tubing. Tape does not create an air tight seal! An air tight seal is accomplished by firmly pushing the connectors into the chest tube and Pleur-Evac tubing. Large amounts of tape placed around the tubing and/or the connector site can cover the source of an air leak due to a disconnected tube. Chest Tube Policy 14.01 reviews the importance of properly taped chest tube connections.

Based on an Actual NMH Case: A Chest Tube was Placed for a Pneumothorax Upon entering the room you find your patient sitting in a chair. The patient states that since getting in the chair he is short of breath and is having extreme difficulty breathing. He states this while gasping for breath.

Chest tube

Summary of Key Nursing Actions Conduct a complete nursing assessment every 8 hours which includes checking the entire Pleur-Evac system, esp. connections. Recognize signs & symptoms of a pneumothorax. Ensure that all chest tube connections are taped properly. If a patient with a chest tube is an infrequent occurrence on your nursing unit, please contact Sue Collazo, Thoracic Surgery APN, at 5-4241 for chest tube assistance.

Review of Available Resources Click on the following link below to review the resource: NCP # 14.01 Closed Chest Drainage (Pleur-Evac Sahara system) NETS Online Reporting Events that result in injury to patients or visitors (including complications or unexpected outcomes) Near misses Events that reflect a variation from policy or practice that affect patient care We welcome your input. For comments, suggestions, or questions, please call Patient Safety at 6-2034 or 6-2195. Congratulations! You have completed this month’s M&M training. Now you may click the ‘X’ button on the upper right corner of this window to exit the course and have it marked as Complete in ELM.