1. NMH Patient Care Division
Safety
Morbidity & Mortality Study Module
Closed Chest Drainage Policy and Practice
May 2009
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2. What To Expect
An actual NMH case study, slightly edited for anonymity.
It will take approximately 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.

3. 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.

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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.

10. 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

11. 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

12. 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 for an “Airway Emergency” and give your location to the operator.

13. 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.

14. 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.

15. 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 reviews the importance of properly taped chest tube connections.

16. 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.

17. Chest tube

18. 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 for chest tube assistance.

19. Review of Available Resources
Click on the following link below to review the resource:
NCP # 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 or
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.