Care of Client with under water seal drainage

Chest tube is a flexible plastic tube that is inserted through the side of the chest into the pleural space to reexpand the lung.

Purpose It is used to remove air , fluid or pus. To establish normal negative

pressure in the pleural cavity for lung expansion.

To equalize pressure on both sides of the thoracic cavity.

To provide continuous suction to prevent tension pneumothorax.

Indication Pneumothorax: accumulation of air Pleural effusion: accumulation of fluid Chylothorax: a collection of lymphatic

fluid Empyema: a pyogenic infection of the

pleural spaceHemothorax: accumulation of blood Hydrothorax: accumulation of serous

fluid

Contraindication

Bleeding diathesisCoagulopathy

Pre Procedure

1. Confirm the procedure2. Inform patient3. Check for the consent4. Prepare the equipments5. X-ray (with the report to

determine the affected lung)6. Position patient

During the procedureObserve/monitor patient’s

RespirationSaturation

Reduce patient’s anxietyPrepare the under water sealConnect the closed system fast

Post procedureMonitor vital signs

15min x 1 hour30mins x 1 hour1 hour x 4 hours and until stable

Take note of the respirationRatePatternRhythm

Check saturationAdminister oxygen when necessary

Post procedure1. Care of patient

Respiratory statusAuscultates lungs to assess air exchange in the affected lung

Place patient in fowler’s position

2. Care of the wound

Change the gauze when necessary

Strict aseptic technique when performing dressing

Check skin integrityoRednessoSwellingoLoose suture

3. Care of the Tubing Intact and taped Maintain patency

Check for obstruction Teach patient on how to take care of the

tubing Place a pillow between patient and tubingCoil the tubeAvoid dependent loop Instruct patient to cough if tube is blockedMilking and stripping of the tube when

blocked

4. Clamps Use rubber tipsClamped at the bedsideClamping

During transferNot more than 1 minuteUpon doctor’s order

Note: clamping chest tube will accumulate in the pleural cavity since the air has no means of escape. This can rapidly lead to tension pneumothorax.

3 principles of under water seal

GravityWater sealSuction

5. Water sealEnhances flow from high to low.Place below patient’s chest wall

(gravity)Fill with sterile water.Rod must be immersed 2cm in

water.Observe for the fluctuation of water

level.

5(a) Fluctuation

To ensure the patency of the system

It will stop when : lung fully expanded an obstruction

Check for obstructionTubing –kinkedPatient’s positionAsk patient to take a deep

breath and cough

5(b) Bubbling Intermittent bubbling : normal Continous bubbling : abnormal

Check : WoundTubeConnection

If rapid bubbling without air leak : inform doctor immediately

5(c) Drainage output70-100 mls per hour observe for any change in drainage colourMark the amountDocument in I/O chartChange bottle every 24hours

or when full

6. Suction apparatus1. Low suction pump

Must be controlled Suction valve / meter is inserted for

wall suction Check for bubbling If no bubbling

Clamp chest tube to check for air leaks

Check tubing and connection Observe patient’s condition while

chest tube is clamped.

7. Safety 1. Tube

Prevent kinking Place a pillow as barrier Never clamp unnecessarily

2. Bottle Must be below chest Keep bottle in basin Inform relatives and housekeeping

8. Ambulation Encourage patient to change position to promote drainage

No need to clamp the tubeMaintain chest tube below chest wall

9. Exercise Encourage deep breathing and arm exercise.

On the first post op day.When patient not in severe pain.Assist patient.

To enhance the lung expansionPrevent stiffness of the arm

10. Comfort

Administer analgesic in the first 24hours.

Allow position that comfortable to the patient .

Assist patient in daily living activity Hygiene

Removal of chest tubeAssessment

X-ray done to check the progress

Clamp for 2 hours

Chest tube removed

Emergency careBleeding

Observe wound dressingObserve drainage

DislodgementFrom insertion site : place a

gauze immediatelyFrom connection : clamp

chest tube immediately

Emergency care…Bottle breaks

Identify either patient having pneumothorax or hemothorax.

Observe patient for tension pneumothorax.

Place tube in saline immediately.Unclamped immediately. (prevent

respiratory distress)Elevation of bottle

Immediately inform doctor

Complication

BleedingPulmonary embolusCardiac tamponadeAtelectasis