caring for patients with chest tubes

through an inlet, causing the excess suction to dissipate. The extra air pulled into the chamber causes vigorous bubbling. If this occurs, lower the suction source setting to reduce noise and evaporation of the fl uid. The absence of bubbling indicates that no suction is be-ing exerted into the system. Raise the suction setting to restore gentle bubbling.

There are two types of commercial drainage systems: the water-seal and the waterless systems.

WATER-SEAL SYSTEMS

NSO Chest Tube Module / Lesson 2

Two-Chamber Water-Seal SystemOn expiration, fl uid or air is forced out of the intrapleural space. Suction pulls air or fl uid through the chest tube into the drainage collection chamber. On entering the drainage collection chamber, this fl uid 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 in order to drain. If the tubing is clamped, there is no mechanism for air to vent. To main-tain the water-seal system, the chest tube system must remain up-right. When it is tipped or overturned, the water seal is disrupted.

Three-Chamber Water-Seal SystemIf suction is used, the three-chamber water-seal system (Fig. 26-6) is set up with the suction control chamber added. A prescribed amount of sterile fl uid (e.g., 20 cm of water) is poured into the suc-tion control chamber, which is then attached to a suction source by tubing. The amount of sterile water added depends on the manufacturer’s recommendations. The chamber is fi lled to the set volume for the prescribed amount of suction. Sterile water is added several times a day because of evaporation. As the fl uid level de-creases, 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).

If the suction source delivers more negative pressure than the suction control chamber water level allows, there is no danger be-cause atmospheric air is pulled into the suction control chamber

SKILL 26-1 Caring for Patients With Chest Tubes Connected to Disposable Drainage SystemsChest Tubes Module / Lessons 1 and 3NSO

FIG 26-6 Disposable waterless chest drainage system with suction.

Ch26_0699-0719-A05289.indd 703Ch26_0699-0719-A05289.indd 703 1/22/09 3:25:10 PM1/22/09 3:25:10 PM

Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

The middle chamber of a traditional chest drainage system is the water seal. The main purpose of the water seal is to allow air to exit from the pleural space on exhalation and prevent air from entering the pleural cavity or mediastinum on inhalation. When the appropriate amount of sterile water is added, a 2-cm water seal is established. To maintain effective water seal the chest drainage unit must remain upright and you must monitor the water level in the water-seal chamber to check for evapora-tion. Bubbling in the water-seal chamber indicates an air leak.

WATERLESS SYSTEMS

Two-Chamber Waterless SystemThe principles of the waterless system are similar to those of the water-seal system except that fl uid is not required for setup. Be-cause water is not used, accidentally tipping over the system does not compromise the patient’s condition.

The water seal is replaced by a one-way valve (Fig. 26-7) lo-cated near the top of the system. Most of the container serves as the drainage chamber. The suction chamber does not depend on water. Instead, it contains a fl oat ball, which is set by a suction control dial after the suction source is turned on. A diagnostic air-leak indicator is located on the face of the unit. It does require the addition of 15 mL of fl uid for visualization. The indicator’s func-tion is to identify one of the following:1 The lung is expanding normally. This is indicated by a gentle

tidaling of the fl uid in the diagnostic indicator.2 The lung is probably reexpanded if after 2 or 3 days the tidaling

has stopped.3 There is an air leak in the system if, when facing the system, the

observer sees the fl uid bubbling left to right. Locate and correct the source of the air leak.

Three-Chamber Waterless SystemWhen suction is ordered, attach the suction chamber port to the suction source by tubing, turn the suction on, and set the fl oat ball to the prescribed setting. If the fl oat ball does not rise to the pre-

scribed level, increase the suction source setting until it does. The system is now functioning with suction.

There are usually two suction settings: one at either the suction control chamber or the fl oat ball setting and the other at the suc-tion source. The chamber or fl oat ball setting is a safety factor to reduce the possibility that the intrapleural tissues receive too much suction, causing injury.

Dry Suction SystemDry suction control systems provide many advantages (Fig. 26-8). Higher suction pressure levels are achieved, set up is easy, and the lack of continuous bubbling provides for quiet operation. There is no fl uid to evaporate, which decreases the amount of suction necessary. A self-compensating regulator controls dry suction units. A dial is set to the prescribed suction control setting. These units are preset to �20 cm of water pressure, but they are adjust-able from �10 to �40 cm of water pressure. However, the dry suction control systems do require sterile water in the water-seal chamber.

Delegation ConsiderationsThe skill of caring for a patient with a chest tube connected to a dis-posable drainage system cannot be delegated to nursing assistive per-sonnel (NAP). However, NAP may assist with other aspects of the patient’s care, such as monitoring vital signs. The nurse directs the NAP about:• Proper positioning of the patient with chest tubes to facilitate

chest tube drainage and optimal functioning of the system• How to ambulate and transfer patient with chest drainage• Immediately informing the nurse of any changes in vital signs,

chest pain, or sudden shortness of breath, or excessive bubbling in water-seal chamber

• Immediately informing the nurse if there is disconnection of system, change in type and amount of drainage, sudden bleeding, or sudden cessation of bubbling

EQUIPMENT❑ Disposable chest drainage system as ordered❑ Suction source and setup (wall canister or portable)

• Water suction system: Add sterile water or normal saline (NS) solution to cover the lower 2.5 cm (1 inch) of water-seal U tube, sterile water or NS to pour into the suction control chamber if suction is to be used (see manufacturer’s directions)

• Waterless system: Add vial of 30 mL injectable sodium chloride or water, 20-mL syringe, 21-gauge needle, and antiseptic swab

❑ Clean gloves❑ Sterile gauze sponges❑ Local anesthetic, if this is not an emergent procedure❑ Chest tube tray (all items are sterile): Knife handle (1), chest

tube clamp, small sponge forceps, needle holder, knife blade No. 10, 3-0 silk sutures, tray liner (sterile fi eld), curved 8-inch Kelly clamps (2), 4 � 4 inch sponges (10), suture scissors, hand towels (3), sterile gloves

❑ Dressings: Petrolatum gauze, split chest-tube dressings, several 4 � 4 inch gauze dressings, large gauze dressings (2), and 4-inch tape or elastic bandage (Elastoplast)

❑ Head cover❑ Face mask/face shield❑ Sterile gloves❑ Rubber-tipped hemostats for each chest tube (2)❑ 1-inch adhesive tape for taping connections❑ Stethoscope, sphygmomanometer, and pulse oximeter

Tosuctionsource

Negativesuctiondisplay

Patientchestdrainagetubing

Fluid

Airflow

FLOW PATTERN

FIG 26-7 Disposable waterless chest drainage system with suction.



STEP RATIONALE

ASSESSMENT 1 Obtain baseline and serial vital signs, oxygen saturation

(SpO2), and level of orientation.Baseline vital signs are essential for any invasive procedure. Pa-

tients requiring chest tube insertion frequently have respiratory distress. Changes in vital signs and level of orientation may indicate decreased levels of oxygen and/or hypoxia.

2 Know patient’s current hemoglobin and hematocrit levels. Provides measure refl ecting blood loss and subsequent levels of oxygenation.

3 Assess pulmonary status: Patients in need of chest tubes have impaired oxygenation and ven-tilation.

a Signs and symptoms of increased respiratory distress: Dis-placed trachea, decreased breath sounds over the affected and nonaffected lungs, marked cyanosis, asymmetrical chest movements.

The degree of the signs and symptoms associated with respiratory distress is related to the size of the pneumothorax, hemothorax, or preexisting illness of the patient.

b Assess for sharp, stabbing chest pain or chest pain on inspiration, hypotension, and tachycardia (Carroll, 2002). If possible, ask patient to rate 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 a tension pneumothorax. The presence of a 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 the insertion of the tube. As a result of this discomfort, patients tend to not cough or change position in an effort to minimize this pain (Milgrom and others, 2004).

4 Assess patient for known allergies. Ask patients if they have had a problem with medications, latex, or anything applied to the skin.

Povidone-iodine or chlorhexidine are antiseptic solutions used to cleanse the skin during tube insertion (Coughlin and Parchin-sky, 2006). Lidocaine is a local anesthetic administered to re-duce pain. The chest tube will be held in place with tape. Iodine, lidocaine, and tape are common allergens.

SKILL 26-1

Collectionchamber

D

Needlelessaccess port

Water sealchamber

Patienttube clamp

In-lineconnector

Suctionport

Positive pressurevalve release

Dry suctionregulator

B

A

Suctionmonitorbellows

E

Air leakmonitor

Patientpressurefloat ball

Swing outfloor stand

Patientconnector

C

FIG 26-8 Dry suction chest drainage system. (Courtesy Atrium Medical Corp.)



5 Review patient’s medication record for anticoagulant therapy, including aspirin, warfarin, heparin, or platelet aggregation inhibitors such as ticlopidine or dipyridamole.

Anticoagulation therapy can increase procedure-related blood loss.

6 For patients who have chest tubes, observe: a Chest tube dressing and site surrounding tube insertion Ensures that dressing is intact and occlusive seal remains without

air or fl uid leaks and that area surrounding insertion site is free of drainage or skin irritation (Carroll, 2002).

b Tubing for kinks, dependent loops, or clots Maintains a patent, freely draining system, preventing fl uid accu-mulation in chest cavity. Subcutaneous emphysema can occur if the tubing is blocked or kinked. When the tubing is coiled, looped, or clotted, the drainage is impeded, and there is an in-creased risk for a tension pneumothorax or surgical emphysema. If the drainage is lengthy and the chest tube remains in place for some time, the patient’s risk for infection increases (Allibone, 2003).

c Chest drainage system, which should remain upright and below level of tube insertion

An upright drainage system facilitates drainage and maintains the water seal.

NURSING DIAGNOSES

STEP RATIONALE

• Anxiety • Acute pain • Impaired gas exchange

Individualize related factors based on patient’s condition or needs.

PLANNING 1 Expected outcomes following completion of procedure:

• Patient is oriented and is less anxious. Hypoxia is relieved.• Vital signs are stable. Decreased hypoxia improves vital sign measures.• Patient reports no chest pain. Reexpansion of the lung reduces chest pain.• Breath sounds are auscultated in all lobes. Lung expansion is

symmetrical, SpO2 is stable or improved, and respirations are nonlabored.

Reexpansion of the lung promotes normal respirations.

• Chest tube remains in place, and chest drainage system re-mains airtight.

Indicates correct placement and patency of the chest tube drainage system.

• Gentle tidaling (fl uctuations or rocking) is evident in water seal or diagnostic indicator.

Indicates system is functioning normally. Refl ects changes in intra-pleural pressure.

2 Check agency policy, and determine whether informed con-sent is needed.

In nonemergent situations most institutions require informed, written permission for chest tube insertion.

3 Review health care provider’s role and responsibilities for chest tube placement (Table 26-1, p. 712). The nursing responsibilities and interventions are detailed in the steps of this skill.

Helps differentiate health care provider and nurse roles so that the nurse can function more effectively.

4 Explain procedure to patient. Reduces anxiety and promotes patient cooperation. 5 Perform hand hygiene. Reduces transmission of microorganisms. 6 Set up the prescribed drainage system. Note: Open the system

when health care provider is ready to insert chest tube.Premature opening of the sterile chest drainage system increases

risk for contamination of sterile equipment. a Prepare a water-seal drainage system (check manufacturer’s

guidelines):System permits displaced air to pass into the atmosphere.

(1) Obtain chest drainage system. Remove wrappers, and prepare to set up the system.

Maintains sterility of the system. The system is packaged for use in sterile operating room conditions.

(2) While maintaining sterility of the drainage tubing, stand the system upright, and add sterile water or normal saline to the appropriate compartments.

Reduces possibility of contamination.

(a) For a two-chamber system (without suction): Add 2 cm sterile water to the water-seal chamber (second chamber), which is enough to sub-merge the water-seal tube and create a one-way valve (Roman and Mercado, 2006).

The water seal creates a one-way valve allowing fl uid and air to drain from the patient’s chest and not return (Roman and Mercado, 2006).



(b) For a three-chamber system (with suction): Add 2 cm sterile water to the water-seal chamber (middle chamber). Add amount of sterile solu-tion prescribed by health care provider to the suction control (third chamber), usually 20 cm water pressure (8 inches). Connect tubing from suction control chamber to suction source. (Tailor length of drainage tube to patient.) (See illustration.)

The amount of fl uid in the suction control chamber governs the suction’s intensity, not the amount of suction delivered from an outside suction source, such as a portable or wall suction unit (Roman and Mercado, 2006). For example, 20 cm of water is approximately �20 cm of water pressure.

STEP RATIONALE

SKILL 26-1

Suctioncontrol

Water seal Drainagecollection

Air ventTo suction

Fromclient

Fromclient

To suction

Suctioncontrol

Waterseal

Drainage collectionchamber

Air vent

STEP 6a(2)(b) Top, The Pleur-Evac drainage system, a commercial three-chamber chest drainage device. Bottom, Schematic of the drainage device.



(c) For a dry suction system: Fill the water-seal chamber with 2 cm sterile water. Adjust the suction control dial to the prescribed level of suction; suction ranges from –10 to –40 cm of water pressure. The suction control chamber vent is never occluded when suction is used.

The automatic control valve on the dry suction control device adjusts to changes in patient air leaks and fl uctuation in suction source and vacuum to deliver the prescribe amount of suction (Roman and Mercado, 2006).

Note: On a dry suction system, DO NOT ob-struct the positive pressure relief valve. This allows air to escape.

Provides a safety factor of releasing excess negative pressure into the atmosphere through the suction control vent. Too little suction prevents lung reexpansion and increases patient’s risk for infection, atelectasis, and tension pneumothorax. Too much suction damages the lung tissue and perpetuates existing air leaks (Allibone, 2003).

b Prepare a waterless drainage system (check manufac-turer’s guidelines):

(1) Remove sterile wrappers, and prepare to set up equipment.

Maintains sterility of the system. The system is packaged in this manner for use in sterile operating room conditions.

(2) For a two-chamber system (without suction) noth-ing is added or needs to be done to the system.

The waterless two-chamber system is ready for connecting to the patient’s chest tube after opening the wrappers.

(3) For a three-chamber waterless system with suction, connect tubing from suction control chamber to the suction source.

The suction source provides additional negative pressure to the system.

(4) Instill 15 mL of sterile water or normal saline into the diagnostic indicator injection port located on top of the system.

Instillation of water into the injection port enables observation of the rise and fall in the diagnostic air-leak window. Constant left-to-right bubbling or rocking is abnormal and may indicate an air leak.

Critical Decision Point This step is not necessary for mediastinal drainage because there will be no tidaling. Also, in an emergency it is not necessary because the system does not require water for setup.

7 Provide two shodded hemostats or approved clamps for each chest tube, attached to top of patient’s bed with adhesive tape. Chest tubes are clamped only under the following specifi c cir-cumstances per health care provider order or nursing policy and procedure:

Shodded hemostats have a covering to prevent hemostat from penetrating chest tube once changed. The application of these shodded hemostats or other clamps to a chest tube prevents air from reentering the pleural space (Allibone, 2003).

a To assess air leak (Table 26-2, p. 713) b To quickly empty or change disposable systems c To assess if patient is ready to have chest tube removed

(which is done by health care provider’s order); monitor the patient for recurrent pneumothorax (Roman and Mercado, 2006)

8 Position the patient: During the chest tube insertion the pa-tient will need to be positioned so the patient’s back or the side in which the tube will be placed is accessible to the health care provider.

Permits optimal drainage of fl uid and/or air.

IMPLEMENTATION 1 Perform hand hygiene, and apply clean gloves. Reduces transmission of microorganisms. 2 Administer premedication, such as sedatives or analgesics, as

ordered.Reduces patient anxiety and pain during procedure.

Critical Decision Point During procedure carefully monitor patient for changes in level of sedation.

3 Assist health care provider in providing psychological support to the patient. (See health care provider’s responsibilities in Table 26-1, p. 712.)

a Reinforce preprocedure explanation. Reduces patient anxiety and assists in effi cient completion of procedure.

b Coach and support patient throughout procedure.

STEP RATIONALE



4 Show local anesthetic to health care provider. Allows health care provider to read label of drug before administer-ing it to patient.

5 Hold anesthetic solution bottle upside down with label facing health care provider. Health care provider will withdraw solu-tion and inject into patient’s skin.

Allows health care provider to withdraw solution properly while maintaining surgical asepsis.

a Health care provider places chest tube. (A standard pro-cedure is detailed in Table 26-1, p. 712.)

6 Help health care provider attach drainage tube to chest tube.

Connects drainage system and suction (if ordered) to the chest tube.

7 After the chest tube is inserted, secure connection between chest tube and chest drainage system with waterproof adhe-sive tape. Tape all connections in a double spiral fashion with 1-inch adhesive tape; be sure not to totally obliterate view of drainage. (Note: Taping of the chest tube is usually done by the health care provider at time of tube placement; check agency policy.) Then:

Secures chest tube to drainage system and reduces risk for air leak causing breaks in airtight system.

a Check systems for proper functioning: (1) Clamp the drainage tubing that will connect the

patient to the system.Provides a chance to ensure an airtight system before connecting

it to the patient. Allows correction or replacement of system if it is defective before connecting it to the patient.

(2) Connect tubing from the fl oat ball chamber to the suction source.

Note: Bubbling will be seen at fi rst because there is air in the tub-ing and system initially. This usually stops after a few minutes unless there are other sources of air entering the system.

(3) Turn on the suction to the prescribed level.

Critical Decision Point If bubbling continues, check connections and locate source of the air leak, as described in Table 26-2 (p. 713).

b Check chest tube placement with x-ray fi lm. Verifi es chest tube placement. 8 Turn off suction source, and unclamp drainage tubing before

connecting patient to the system.Having the patient connected to suction when it is being inserted

has the potential to damage pleural tissues from sudden increase in negative pressure. The suction source is turned on again after the patient is connected to the three-chamber system.

9 Check patency of air vents in system: a Confi rm that water-seal vent is not occluded. Permits the displaced air to pass into the atmosphere. b Confi rm that suction control chamber vent is not oc-

cluded when suction is used.Provides safety factor of releasing excess negative pressure into the

atmosphere. c Confi rm that valves are unobstructed. Provides safety factor of releasing excess negative pressure. Note: Waterless systems have relief valves without caps.

For dry suction systems, the positive pressure relief valve must remain unobstructed.

10 Lay excess tubing horizontally on mattress next to patient. Secure with a rubber band and safety pin or the system’s clamp.

Prevents excess tubing from hanging over the edge of the mattress in a dependent loop. Drainage collected in the loop can occlude the drainage system, which predisposes patient to a tension pneumothorax (Roman and Mercado, 2006).

11 Adjust tubing to hang in a straight line from the chest tube to the drainage chamber.

Promotes drainage and prevents fl uid or blood from accumulating in the pleural cavity.

Critical Decision Point Frequent gentle lifting of sections of the drain allows gravity to assist blood and other viscous material to move to the drainage bottle. Patients with recent chest surgery or trauma need to have the chest drain lifted based on assessment of the amount of drainage; some patients might need chest tube drains lifted every 5 to 10 minutes until drainage volume decreases (Lehwaldt and Timmins, 2005). However, when coiled or dependent looping of tubing is unavoidable, the tubing is lifted every 15 minutes at a minimum to promote drainage (Allibone, 2003).

Critical Decision Point Check institutional policy before stripping or milking chest tubes (see Evidence-Based Practice section). This practice is being discontinued at most institutions because it is believed that stripping the tube greatly increases intrathoracic pressure, which damages the pleural tissue and causes or worsens an existing pneumothorax. However, even though the literature is contradictory, milking may be done in selected patients (e.g., fresh postoperative thoracic surgery in presence of multiple clots). The rationale for this selective use of stripping or milking is that the presence of clotted tube drainage causes decreased rate of reexpansion and increases risk for ten-sion pneumothorax (Allibone, 2003). In these selected cases the benefi ts outweigh the risks.

STEP RATIONALE

SKILL 26-1



12 Gently lift sections of the postoperative mediastinal chest tubes. Observe drainage for clots or debris in the tubing.

Maintains tubing in dependent position and facilitates drainage (Roman and Mercado, 2006).

13 After the tube is placed, assist patient to a comfortable position:

Reduces patient anxiety and promotes cooperation.

a Semi-Fowler’s to high-Fowler’s position to evacuate air (pneumothorax)

Air rises to the highest point in the chest. Pneumothorax tubes are usually placed on the anterior aspect at the mid-clavicular line, second or third intercostal space (Allibone, 2003).

b High-Fowler’s position to drain fl uid (hemothorax, pleural effusion)

Permits optimal drainage of fl uid. Posterior tubes are placed on the mid-axillary line, fi fth or sixth intercostal space.

14 Remove gloves, and dispose of used soiled equipment. Prevents accidents involving contaminated equipment. 15 Perform hand hygiene. Reduces spread of microorganisms.

EVALUATION 1 Monitor vital signs, oxygen saturation, and insertion site every

15 minutes for the fi rst 2 hours.Provides immediate information about procedure-related compli-

cations such as respiratory distress and leakage. 2 Monitor chest tube drainage: a Assessment after chest tube insertion is done every 15 minutes

for the fi rst 2 hours. This assessment interval then changes on the basis of patient’s status. Mark the time and level of drainage on the calibrated write-on strip periodically.

Permits timely and effi cient account of the amount of drainage from the chest tube. Drainage is marked at specifi ed periods of time and documented in the nurses’ notes and intake and out-put (I&O) sheet. Ensures early detection of complications.

b Observe type and amount of fl uid drainage: Note color and amount of drainage, patient’s vital signs, and skin color. Look at the fl uid in the collection tubing, not just the fl uid in the collection chamber. Is the drainage bright red, dark red, or pink? Is it opaque, or can you see through it?

c Expected drainage in the adult: Less than 50 to 200 mL/hr immediately after surgery in a mediastinal chest tube. Ap-proximately 500 mL in the fi rst 24 hours.

Dark-red drainage is expected only during the immediate postop-erative period. This drainage turns serous over time.

d Expected drainage in the adult: Between 100 and 300 mL of fl uid may drain from a pleural tube during the fi rst 3 hours after insertion. The 24-hour rate is 500 to 1000 mL. Drain-age is grossly bloody during the fi rst several hours after surgery and then changes to serous. Remember that a sud-den gush of drainage may be retained (dark) blood and not active (bright red) bleeding. This increased drainage can result from patient position changes.

Reexpansion of the lungs forces drainage into the tube. Coughing can also cause large gushes of drainage or air. Acute bleeding indicates hemorrhage.

Critical Decision Point If drainage suddenly increases, is bright red, or there is more than 100 mL/hr of bloody drainage (except for the fi rst 3 hours postoperatively), the nurse notifi es the health care provider, remains with the patient, and assesses vital signs and cardiopulmonary status.

3 Evaluate patient for decreased respiratory distress and chest pain, breath sounds over affected lung area, and change in oxygen saturation.

Increase in respiratory distress and/or chest pain, decrease in breath sounds over the affected and nonaffected lungs, marked cyano-sis, asymmetrical chest movements, presence of subcutaneous emphysema around tube insertion site or neck, hypotension, tachycardia, and/or mediastinal shift are critical and indicate a severe change in patient status, such as excessive blood loss or tension pneumothorax (Allibone, 2003; Roman and others, 2003). Notify health care provider immediately.

4 Ask patient to rate level of comfort on a scale of 0 to 10. Indicates need for analgesia. Patient with chest tube discomfort hesitates to take deep breaths and as a result is at risk for pneu-monia and atelectasis.

5 Observe the drainage system: a Inspect chest tube dressing and drainage. Ensures that dressing is occlusive.

Critical Decision Point Check the dressing carefully. It can come loose from the skin, although this may not be readily apparent.

b Inspect tubing for kinks and dependent loops. Straight and coiled drainage tube positions are optimal for pleural drainage. However, when dependent loop is unavoidable, peri-odic lifting and draining of the tube will also promote pleural drainage (Allibone, 2003; Lehwaldt and Timmons, 2005).

STEP RATIONALE



c The chest drainage system remains upright and below level of tube insertion. Note presence of clots or debris in tubing.

Maintains proper functioning, facilitates drainage, and maintains the water seal.

Critical Decision Point Monitor the position of the system relative to the chest tube carefully, especially during patient transport.

d Inspect water seal for fl uctuations with patient’s inspiration and expiration.

(1) Waterless system: Diagnostic indicator for fl uctuations with patient’s inspirations and expirations.

In the non–mechanically ventilated patient, fl uid rises in the water seal or diagnostic indicator with inspiration and falls with expi-ration. The opposite occurs in the patient who is mechanically ventilated. This indicates that the system is functioning prop-erly (Lewis and others, 2008).

(2) Water-seal system: Bubbling in the water-seal chamber (see Table 26-2, p. 713).

When system is initially connected to the patient, bubbles are ex-pected from the chamber. These are from air that was present in the system and in the patient’s intrapleural space. After a short time the bubbling stops. Fluid continues to fl uctuate in the water seal on inspiration and expiration until the lung is reex-panded or the system becomes occluded.

(3) Water-seal system: Bubbling in the suction control chamber (when suction is being used) (see Table 26-2, p. 713).

Suction control chamber has constant, gentle bubbling. Tubing to the suction source remains free of obstruction, and the suction source is turned to the appropriate setting.

e Waterless system: Bubbling in diagnostic indicator. Mechanism to observe for the presence of tidaling. Character of drainage indicates if normal or if infection or hemorrhage is developing.

f Waterless system: The suction control (fl oat ball) indicates the amount of suction the patient’s intrapleural space is receiving.

The suction fl oat ball dictates the amount of suction in the system. The fl oat ball allows no more suction than dictated by its set-ting. If the suction source is set too low, the suction fl oat ball cannot reach the prescribed setting. In this case the suction is increased for the fl oat ball to reach the prescribed setting.

6 After fi rst 2 hours, assess patient’s physical and psychological status at least every 4 hours or according to agency policy.

Detects early signs and symptoms of complications:Apprehension: Increase in patient anxiety, restlessness, and in-

ability to concentrateRespiratory distress: Alteration in rate and/or depth of respira-

tions, diffi culty breathing, and breath soundsSubcutaneous emphysema: Air that is being trapped in the sub-

cutaneous tissue

STEP RATIONALE

SKILL 26-1

Unexpected Outcomes Related Interventions1 Air leak unrelated to patient’s respirations occurs. • Locate source (see Table 26-2, p. 713).

• Notify health care provider.

2 There is no chest tube drainage. • Observe for kink in chest drainage system.• Observe for possible clot in chest drainage system.• Observe for mediastinal shift or respiratory distress (medical

emergency).• Notify health care provider.

3 Chest tube is dislodged. • Immediately apply pressure over chest tube insertion site.• Have assistant apply occlusive gauze dressing, and tape three sides.• Notify health care provider.

4 Substantial increase in bright red drainage occurs. • Obtain vital signs.• Monitor drainage.• Assess patient’s cardiopulmonary status.• Notify health care provider.

5 Continuous bubbling is seen in water-sealed chamber, indicating leak between patient and water seal.

• Tighten loose connections.• Check agency policy, and if instructed, cross-clamp chest tube closer

to patient’s chest. If bubbling stops, air leak is inside patient’s thorax or at chest tube insertion site.

• Unclamp chest tube.• Reinforce dressing.• Notify health care provider.



Recording and Reporting• Record level of patient comfort, baseline vital signs, including

oxygen saturation. If postoperative patient, record vital signs and oxygen saturation every 15 minutes for at least 2 hours postoperatively. Record chest drainage output hourly for at least 2 hours, and then record as patient status indicates. Document time, type, and amount of drainage. Record integrity of chest suction system (e.g., record the amount of bubbling in the water-seal suction control chamber, level of suction, intactness of system).

• Report patient response to chest tube insertion or continuation, noting level of comfort, drainage, and intactness of the system.

Teaching Considerations• Instruct patient and family regarding proper functioning of

chest tube and drainage system.• Instruct patient to immediately report any changes in chest

comfort.

Pediatric Considerations• If possible, using pictures and special dolls, familiarize child and

family with equipment before inserting chest drainage system (Hockenberry and Wilson, 2007).

• Allow child to play with equipment and special dolls before inserting chest drainage system.

• Chest tube drainage greater than 3 mL/kg/hr for more than 2 consecutive hours is excessive and may indicate postoperative hemorrhage (Hockenberry and Wilson, 2007).

Gerontological Considerations• Fragility of the older adult’s skin requires special care and plan-

ning for management of chest tube dressing. Frequently assess surrounding skin for signs of skin breakdown (Meiner and Lueckenotte, 2006).

Home Care Considerations• Patients with chronic conditions (e.g., uncomplicated pneumo-

thorax, effusions, empyema) that require long-term chest tube may be discharged with smaller mobile drains (Carroll, 2002, 2005).

• Instruct patient in how to ambulate and remain active with a mobile chest tube drainage system.

• Instruct patient and caregivers in when to contact health care professionals regarding changes in the drainage system (e.g., chest pain, breathlessness, change in color or amount of drain-age, leakage on the dressing around the chest tube).

• Provide patient and caregiver information specifi c to the type of drain, and when possible have patient demonstrate proper maintenance of the mobile drainage system. Most of these sys-tems do not have a suction control chamber and use a me-chanical one-way valve instead of a water-seal chamber. For example, if a one-way fl utter valve is used, the arrow on the housing must always point away from the patient. Otherwise there is a risk for air trapping and a recurrent pneumothorax. The Pneumostat and Express Mini mobile devices have built-in collection chambers, and the Express Mini uses dry suction set at �20 cm H2O (Carroll, 2005).



caring for patients with chest tubes

Documents

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