1. NUR 232: Laboratory Handout Chest Drainage Skill - Review
For this power point presentation, I will concentrate on the above skill, along with some background information

2. Everyone has a chest cavity
Everyone has a chest cavity. The chest cavity is a closed structure bound by muscle, bone, connective tissue, vascular structures and the diaphragm. The lungs are covered with a membrane called the visceral pleura. The interior chest wall is lined with a membrane called the partial pleura. The space between the visceral and parietal pleura is called the pleural space and is filled with approximately 7 to 20 mL of lubricating fluid to help the pleura slide during respiration

3. Trauma, disease, or surgery can result in air, blood, pus or lymph fluid leaking into the intra-pleural space, creating a positive pressure that collapses lung tissue.

4. PLEURAL EFFUSION: When a number of clinical conditions such as cancer, infection, pancreatitis, connective tissue disease, autoimmune diseases, asbestos exposure, certain drugs or collagen vascular diseases increase pleural fluid entry or decrease fluid exit from the lung.

5. LET’S TALK ABOUT PNEUMOTHORAXES:
A pneumothorax is collapse of the lung caused by a collection of air in the pleural space. The loss of negative intra-pleural pressure causes the lung to collapse. A variety of mechanisms cause a pneumothorax.
A traumatic pneumothorax develops as a result of penetrating chest trauma, such as a stabbing (open) or the chest striking the steering wheel in an automobile accident (closed.)
A spontaneous or primary pneumothorax sometimes occurs from the rupture of a small bleb (blister) on the surface of the lung or an invasive procedure such as insertion of a subclavian intravenous (IV) line.
Secondary pneumothorax occurs because of underlying disease such as emphysema.

6. CONTINUATION OF PNEUMOTHORAX:
A patient with a pneumothorax usually feels sharp chest pain that worsens on inspiration or coughing because atmospheric air irritates the parietal pleura.
As a pneumothorax worsens, a patient will experience easy fatigue, a rapid heart rate and low blood pressure
A tension pneumothorax, a life- threatening situation, occurs from rupture in the pleura when air accumulates in the pleural space more rapidly that it is removed.

7. LET’S TALK ABOUT A HEMOTHORAX! What is a Hemothorax?
A hemothorax is collapse of the lung caused by an accumulation of blood and fluid in the pleural cavity between the chest wall and the lungs, usually as a result of trauma.
It produces a counter-pressure and prevents the full expansion of the lung.
A hemothorax is also caused by rupture of small blood vessels from inflammatory processes such as pneumonia or tuberculosis.
In addition to pain and dyspnea, signs and symptoms of shock can develop If blood loss is severe.

8. WHY IS INSERTION OF A CHEST TUBE NECESSARY?
Chest tube insertion is the treatment for most types of effusions, pneumothorax, hemothorax, and postoperative chest surgery or trauma.
A chest tube is a large catheter inserted through the thorax to remove fluid (effusions), blood (hemothorax), and/or air (pneumothorax).
Small-bore chest tubes (12 to 20Fr) are sufficient to remove air, and large bore (24 to 32 Fr) tubes are needed to remove fluid and blood.
The location of the chest tube indicates the type of drainage expected.

9. CHEST TUBES MODULES: TWO CHAMER WATER SEAL SYSTEM:
There are two types of commercial drainage systems: the water- seal and the waterless systems.
This skill reviews the nursing responsibilities and the interventions related to the safe management of chest tubes.
TWO CHAMER WATER SEAL SYSTEM:
On expiration fluid or air is forced out of the intrapleural space. Suction pulls air or fluid through the chest tube into the drainage collection chamber.
On entering the drainage collection chamber, this fluid or air displaces the air present in the chamber by pushing it through the water seal and out of the system into the atmosphere.
The water-seal chamber is left open to air to drain.

10. THREE-CHAMBER WATER-SEAL SYSTEM:
If suction is used, the three-chamber water-seal system is set up with the suction control chamber added. A prescribed amount of sterile fluid (e.g., 20 cm of water) is poured into the suction control chamber, which is then attached to a suction source by tubing.
The amount of sterile water added depends on the manufacturer recommendations.
The chamber is filled to the set volume for the prescribed amount of suction. Sterile water is added several times a day because of evaporation.
As the fluid level decreases, the amount of suction also declines.
The wall or portable suction device is turned up until the water in the suction control bottle exhibits a continuous, gentle bubbling. This provides the prescribed amount of suction (negative pressure).

12. The following assessment was taken from your book:
Clinical Nursing Skills & Techniques; Perry, Potter & Ostendorf
ASSESSMENT:
1. Measure Vital signs & Pulse Oximetry
2. Perform a complete respiratory assessment:
A. Signs & symptoms of increased respiratory distress and hypoxia (e.g., decreased breath sounds over affected and non-affected lungs, marked cyanosis, asymmetric chest movements, displaced trachea, shortness of breath and confusion).
B. Assess for sharp stabbing chest pain or chest pain on inspiration, hypotension, and tachycardia. If possible ask the patient to rate the level of comfort on a scale of 0 to 10.
Sharp stabbing chest pain with or without decreased blood pressure and increased heart rate may indicate tension pneumothorax. Presence of pneumothorax or hemothorax is painful, frequently causing sharp inspiratory pain. In addition, there is discomfort associated with the presence of a chest tube, not just with its insertion. As a result, patients tend to not cough or change position in an effort to minimize this pain.

13. ASSESSMENT – CONT’D
3. Assess patient for known allergies. Ask patient if they have had a problem with medications, latex, or anything applied to the skin.
4. Review patient’s medication record for anticoagulant therapy, including aspirin, warfarin (Coumadin), heparin, or platelet aggregation inhibitors such as ticlopidine (Ticlid) or dipyridamole (Persantine).
5. Review patient’s hemoglobin & hematocrit levels.

14. 7. Assess patient’s knowledge of the procedure
ASSESSMENT – CONT’D:
6. For patients who have chest tubes observe:
A. *Chest tube dressing and site surrounding tube insertion.
B. *Tubing for kinks, dependent loops, or clots
Maintains patent, freely draining system, preventing fluid accumulation in chest cavity. Subcutaneous emphysema can occur if tubing is blocked or kinked. When tubing is coiled, looped, or clotted, drainage is impeded, and there is an increased risk for a tension pneumothorax or surgical emphysema. If chest tube remains in place for some time, patient’s risk for infection increases
C. *Chest drainage system should remain upright and below level of tube insertion.
7. Assess patient’s knowledge of the procedure

15. VIEW VIDEO DEOMONSTRATION NUV 864 & 865 PLEUR-EVAC
THIS IS THE BEGINNING OF YOUR HANDOUT: 232 Laboratory Handout Chest Drainage Skill – Review.
Prior to reviewing your handout, per the handout, it is recommended that you view the following:
VIEW VIDEO DEOMONSTRATION NUV 864 & 865 PLEUR-EVAC
You would need to ask your faculty instructor how to obtain these videos.

16. Performance CHECKLIST: When demonstrating the use of a water-seal Chest Drainage unit the learner will: 1. Read physician’s orders and check agency policy and procedure manual for directive on care of patient with chest drainage. 2. Make pertinent assessment. 3. Explain the purpose of the procedure and precautions. 4. Wash Hands.

17. 5. Position Patient in Semi-Fowler’s Position.
6. Gather and assemble equipment in clean Utility Room.
7. Inspect water-seal drainage unit for cracks, etc.
8. Check back of unit to make sure plastic adaptor is capped.
9. Maintain sterility of adaptor cap.

18. 10. Fill water-seal chamber with sterile water or saline.
11. Fill the suction control chamber with sterile water or saline, if ordered.
12. Bring equipment to bedside.
13. Apply clean gloves during patient care.
14. Maintain chest tubing in straight drainage.
15. Turn off suction. Disconnect short suction tubing from old Pleur-Evac unit.
16. Connect new suction control chamber tubing to suction.

19. 17. Turn on suction and check setting.
18. Observe for bubbling in suction control chamber.
19. Indicate fluid levels in outside of water-seal drainage units.
20. Have sterile field and hemostat available for use.

20. 21. Double clamp each chest tube no longer than 1 minute (Plastic protectors must cover clamp tips).
22. Attach drainage catheter from chest tube to tubing coming from collection chamber.
23. Tape connection securely without obstructing view of drainage.

21. 24. Remove clamps from chest tubes.
25. State monitoring system hourly.
26. State add sterile water as needed to maintain amount ordered for suction control chamber.
27. Note color, amount and consistency of drainage in collection chamber.
WHAT COLOR IS THE DRAINAGE IN THE COLLECTION CHAMBER? (SEE PICTURE TO THE LEFT)

22. 28. State: MD notified if drainage exceeds 200 mL/per hour or 100 mL/per hour for 3 hours.
29. Record procedure and observations.
30. Reassess patient and equipment prior to leaving room.
31. State nursing action if no fluctuation in water seal chamber when suction applied.

23. 32. State nursing action if air leak.
33. State signs/symptoms of respiratory distress to be reported to the physician.
34. Have thoracentesis tray, clamps, tape, Vaseline gauze, occlusive dressing at bedside for an emergency.
35. Encourage deep breathing and coughing.
36. State nursing action when chest tube (s) are removed.

24. CHEST DRAINAGE:
A crucial intervention for improving gas exchange and breathing is the proper management of chest drainage.
After thoracic surgery, chest tubes and a closed drainage system are used to re-expand the involved lung and to remove excess air and fluid (or blood).
The normal breathing mechanisms operates on the principle of negative pressure (the pressure in the chest cavity is lower than the pressure of the atmosphere, causing air to move into the lungs during inspiration).

25. Whenever the chest is opened, from any cause, there is a loss of negative pressure, which can result in the collapse of the lung.
The collection of air, fluid or other substances in the chest can compromise cardiopulmonary function and even cause collapse of the lung.
Pathologic substances that collect in the pleural space include fibrin, or clotted blood, liquids (serous fluids, blood, pus, chyle) and gases (air from the lung, tracheobronchial tree, or esophagus).

26. Surgical incision of the chest wall almost always causes some degree of pneumothorax.
Air and fluid collect in the intrapleural space, restricting lung expansion and reducing air exchange.
It is necessary to keep the pleural space evacuated post-operatively and to maintain negative pressure within this potential space.
This results in the re-expansion of the remaining lung tissue.

27. A chest drainage system must be capable of removing whatever collects in the pleural space so that a normal pleural space and normal cardiopulmonary function may be restored and maintained.
Commercially available systems (e.g., Pleur- Evac) are the most common methods currently in use to provide water-seal drainage; these systems use the same principles as a three-bottle water seal system.
The chest tube or catheter is attached to the drainage system, using a one-way valve.

28. Water in the second chamber acts as a seal and allows air and fluid to drain from the chest into the first chamber, but air cannot reenter the chest tube.
Drainage accumulates in the first chamber and air exits from the second chamber.
The water level fluctuates the patient breathes; it moves up when the patient inhales and it moves down when the patient exhales.
Suction may be added to the second chamber to create a negative pressure to promote drainage of fluid and removal of air.
The addition of suction creates constant bubbling in the third chamber, if constant bubbling occurs in the absence of suction, there may be leakage of air from the lung or a leak in the system.

29. TROUBLESHOOTING EQUIPMENT:
A. State that no bubbling in suction control chamber means no suction to chest.
1. Check suction control tubing for kink, obstruction or disconnection.
2. Check that suction gauge is on.

30. B. State that bubbling in water-seal chamber indicates an air leak.
1. For patient with no incision and a single chest tube, briefly squeeze tube near insertion point; if bubbling stops, leak is at insertion site.
2. Tape around base of tube and notify physician.
3. For patient with thoracotomy, press hands along length of incision; if bubbling stops, the leak is at the incision.
4. Reinforce dressing with adhesive tape and notify physician.
5. If bubbling still continues, check equipment: connection between chest tubes, and drainage tube.
6. Reinforce all connections with tape;: do not remove any tape.
7. If still bubbling, tape suction tubing connection at unit.
8. If this fails, notify physician: stat that unit with its tubing must be replace.

31. C. State that if after level in water-seal chamber does not fluctuate a little with respiration when suction is applied, it can indicate an obstruction within the system or lung re-expansion.
1. Check drainage tubing between patient and drainage unit for kinks.
2. Check that patient is not lying on tubing.
3. Check for hanging loops where fluid has collected.

32. D. Observe entire length of tubing for clots:
1. If no draining, squeeze and release along length of tubing.
2. If still not draining, call physician and observe patient for a tension pneumothorax.
3. Listen for reduction in chest sounds.
4. Check patient’s trachea for deviation.
5. Report immediately any symptoms of tension pneumothorax and place thoracentesis tray at bedside.
6. State that only a chest X-Ray can confirm lung re- expansion.

33. CHEST DRAINAGE SYSTEM:
A. Strategic placement of a chest catheter in the pleural space.
B. Three types of mechanical drainage systems.
C. A Pleur-Evac operating system:
1. The collection chamber.
2. The water seal chamber
3. The suction control chamber.
The Pleur-Evac is a single unit with all three bottles identified as chambers.

34. The planning information was taken from your book, Clinical Nursing Skills & Techniques. Perry, Potter & Ostendorf.
PLANNING:
1. Expected outcomes following completion of the procedure:
Patient is oriented and less anxious
Vital signs are stable
Patient reports no chest pain
Breath sounds are auscultated in all lobes. Lung expansion is symmetric, pulse oximetery (SpO2) is stable or improved, and respirations are non-labored.
Chest tube remains in place and chest drainage system remains airtight.
Gentle tidaling (fluctuations or rocking) is evident in water- seal or diagnostic indicator.

35. This is not an easy skill and there is a lot to learn, but just keep practicing and have your friends quiz you in the skill lab!
Good Luck!

36. END OF SKILL
Practice this skill in the skills lab & review the video that is needed in order to pass this skill~