CHEST TUBES AND DRAINAGE SYSTEMS NURSING COMPETENCY Presented by: Jonna Bobeck BSN, RN, CEN

Objectives Discuss anatomy and physiology of chest Describe mechanics of breathing Explain indications/contraindications Discuss nursing care Describe set up and monitoring Understand water seal

Introduction

Anatomy of the Chest Visceral Pleura Parietal Pleura Lung Ribs Intercostal Muscles

Why are the Lungs Expanded

Mechanics of Breathing

Indications: Pneumothorax/Hemothorax

Indications: Tension Pneumothorax

Indications: Other Conditions

Contraindications and Cautions Be aware of hemodynamic status Use of a trocar Pneumothorax and air transport

How Water Seal Chest Drainage Units Functions

Fluid Collection

WATER SEAL Safe Cost effective Measurement of intrathoracic pressure

Suction Control

Equipment

PREPARATION AND INSERTION IV, O2, Monitor Proper cleansing Place patient supine Administer antibiotics Prepare drainage device Tape or band connections Apply occlusive dressing Obtain CXR Monitor

FOUR STEP SET UP: STEP 1

STEP 2

STEP 3

STEP 4

WHAT TO CHECK DURING SYSTEM OPERATION: SUCTION CONTROL STOPCOCK

WHAT TO CHECK CONTINUED Verifying system operation Placement of unit

PLACEMENT OF UNIT Place below patient’s chest Use floor stand or hangers

OBSERVING FOR AIR LEAKS

SAMPLING PATIENT DRAINAGE

OBSERVING CHANGES IN PATIENT PRESSURE

HIGH NEGATIVITY FLOAT VALVE

MANUAL HIGH NEGATIVITY VENT

WHAT TO CHECK CONTINUED Positive pressure protection Adding water to water seal Adding water to suction control Suction greater than -20cmH20 How to lower suction control pressure setting Recording drainage volume

IN-LINE PATIENT TUBE CONNECTORS

PATIENT TUBE CLAMP-

GRAVITY DRAINAGE AND SYSTEM DISCONNECT Placement Stopcock Close slide clamp

AUTOTRANSFUSION CAPABILITY

WARNINGS AND PRECAUTIONS Colleceted blood should not remain in chest drain for more than 6 hours Keep patient tube clamp open during operation Purge all air/do not administer entire contents Citrate toxicity Use a microemboli filter Use hangers Maximum infusion pressure 150 mmHg

SET UP ATS COLLECTION Close chest drain ATS access line clamp and remove spike port cap. Insert ATS bag spike into access line of chest tube drainage system. Position ATS bag below the base of the chest drain. Open both clamps. Holding ATS bag below base of chest drain, bend ATS bag upward where indicated and it will pop open. Do not activate ATS bag prior to connecting chest drain. When drainage has been collected Close ATS access line and ATS blood bag clamps. Remove spike from ATS access line and recap ATS access line spike port and position access line in the holder located on top of the chest drain. Keep ATS clamp fully closed at all time when not in use.

ATS BAG REINFUSION SET UP Prime I.V. blood administration and microemboli blood filter with sterile saline. Invert ATS bag with spike port pointing upward and remove cap using sterile technique. Insert saline filter spike into ATS bag spike port. Return bag to upright position and place on standard height I.V. pole.

TROUBLESHOOTING GUIDE How to confirm airleak Floatball is at the bottom of water seal column Lowering water seal level Water rises to the top of the water seal float valve Tidaling of pressure ball

TROUBLESHOOTING CONTINUED No bubbling in the suction control chamber Vigorous bubbling noted in the suction control Should suction control valve be turned off for transport? should the manual vent be used during gravity drainage? What to do if drainage system gets knocked over drainage? Should the manual vent be used during gravity during gravity (no suction) drainage. No. It is not recommended to depress the manual vent After a chest drainage system has been knocked over, can I use it and what should I do? If the chest drainage system has been knocked over, volumes. Atrium provides convenient, self-sealing the water seal and suction control chambers for proper set it upright and immediately check the fluid levels of and syringe to adjust the water level in each chamber, if diaphragms for access by a 20 gauge or smaller needle seal or suction control chambers have an inadequate aspirate any overfill that may have occurred. If the water required. Alcohol swab the needle access area and amount of blood has entered the water seal, it may be fluid level, simply replace the lost volume. If a significant advisable to change the system for a new one.

UNEXPECTED OUTCOMES Air leak Mediastainal shift Tube dislodgement Substantial increase in bright red drainage Loss of suction Crepitus

DOCUMENTATION Patient and family education Reason for tube Assessment Presence of fluctuation and bubbling Amount of suction Patient tolerance

OMG! LOOK AT THAT OUTPUT!

References Atrium Medical Corporation, Initials. (2010). A personal guide to managing chest drainage. New Hampshire: Atrium Medical Corporation.