ATI: CLOSED CHEST DRAINAGE SYSTEM

the exchange of gases in the alveoli
alveolar ventilation
an increase in pericardial pressure from an accumulation of fluid or blood in the pericardial sac that can lead to cardiac rupture
cardiac tamponade
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pus in the pleural (or other body) cavity
empyema
one of a group of muscles that facilitate respiration by contracting to raise the ribs and rotate them slightly, pushing the sternum forward and enlarging the chest
external intercostal
a one way flutter valve through which air can escape from the chest cavity but cannot re enter it
heimlich valve
an accumulation of blood in the pleural cavity
hemothorax
the pressure within the pleural cavity that is normally negative in relation to ints alveolar pressure
intrapleural pressure
an accumulation of fluid in the pleural cavity as a result of cancer
malignant pleural effusion
a tube inserted into the mediastinal space (the space between the right and left thoracic cavity that contains the heart, the mainstem bronchus, the thymus gland, and large blood vessels) to drain blood and fluid after cardiac surgery
mediastinal chest tube
movement of the tissues and organs of the mediastinum to one side of the chest cavity
mediastinal shift
a flow that changes direction periodically or rhythmically; used to refer to the rise and fall of fluid within a closed-chest drainage system with inhalation and exhalation, also called tidaling
oscillation
serous, lubricating liquid within the pericardial cavity, the space between the layers of the membranes of the pericardium (the fibrous covering that surrounds the heart)
pericardial fluid
the space between the layers of the membranes of the pericardium, the fibrous covering that surrounds the heart
pericardial space
the space between the parietal and visceral pleura
pleural cavity
an accumulation of fluid in the pleural cavity
pleural effusion
a procedure that involves instilling a chemical agent, such as talc, into the pleural space to trigger an inflammatory response that creates scar tissue, improves adhesion between the pleural layers, and reduces the risk of recurrent pneumothorax
pleurodesis
an accumulation of air or gas in the pleural space
pneumothorax
systolic blood pressure that is more than 10 mm Hg higher during exhalation than during inhalation, a finding with pericardial effusion and cardiac tamponade
pulsus paradoxus
an accumulation of air or gas in the pleural space that results from a breach in the visceral or parietal pleura with no apparent external trauma
spontaneous pneumothorax
air in the tissues under the skin that produces a crackling sensation on palpation
subcutaneous emphysema
an accumulation of air or gas in the pleural space that results from a lacerated lung or an opening in the chest wall, often a complication of other types of pneumothorax
tension pneumothorax
the rise and fall of fluid within a closed-chest drainage system with inhalation and exhalation
tidaling
the process of the exchange of air between the lungs and the environment, including inhalation and exhalation
ventilation
serous membrane adjacent to the outer surface of the lungs
visceral pleura
TYPES OF CLOSED CHEST DRAINAGE SYSTEMS
connect the tubing to a sealed drainage system or a one way valve that keeps air from entering the chest cavity to prevent a tension pneumothorax
physcians insert chest tubes to restore a collapsed lung or to drain fluid from the pleural cavity and…
the negative pressure in the chest cavity . as the patient inhales, the water chamber should rise….
without suction, read the negative pressure from the water chamber only..
-if patient has suction, then add the suction reading and the water sealed reading
water seal chamber measures what?
to remove secretions from the chest cavity
why do they add suctions to closed chest drainage system?
directly to the collection chamber port not he very right side.
for a three chamber system, the chest tube connect to what?
1. WATER SEAL OR ONE WAY VALVE
water seal, allows air to exit the pleural space on exhalation and keeps air from entering the pleural or mediastinal space on inspiration.
-usually fill up sterile water up to the 2cm mark.
-water should rise on inhalation called tidaling
-water should fall on exhalation called tidaling
*continuous bubbling in this chamber indicates an air leak
middle chamber is what?
-if the patient is receiving positive pressure, the reverse happens,
the water level drops on inhalation and rises on exhalation
middle chamber continued..
2. WET OR DRY SUCTION CONTROL
– to set up this, fill the suction chamber with sterile water up to the 20cm mark for adult, which indicates application of a suction pressure of -20cm water tot he pleural cavity
-the water level in the suction chamber regulates the amount of suction transmitted to the pleural cavity
traditional closed chest drainage systems regulate the amount of suction by the height of the water in the suction control chamber, which is located on the left side
-allows for higher suction pressure levels, there is no need to replace fluid
-instead of using the column of water to control the amount of suction, a self compensating regulator balances the force of suction with the atmosphere = allows system to respond to changes in air leaks and fluctuates in the suction source vacuum to deliver accurate suction pressure
dry suction control=?
-pateint with a large hemothorax or those undergoing thoracic surgery with blood loss, some systems have a sump port for continuous collection of autologous blood for auto transfusion
3. MOBILE CHEST DRAINS
-used for patient who need to go home or who require early ambulation
-heimlich valce is a one way flutter that allows air to escape but keeps it from re-entering the chest cavity
-device accommodates a small or parietal pneumothorax and does not collect fluid
-arrow on housing valve should always point away from the patient and the inner valve should move during exhalation= air flow through device
attaches directly to the chest tube to collect fluid
-useful for patients with a pneumothorax who have small amounts of fluid
pneumostat chest drain valve:
INDICATIONS FOR CLOSED CHEST DRAINAGE SYSTEM
During inspiration, the chest wall muscles (the external intercostals) contract, elevating the ribs as the diaphragm also contracts and moves downward. These two actions create negative intrapleural pressure, which causes the lungs to expand. During expiration, the lungs deflate passively because of their elastic recoil, the relaxation of the diaphragm, and the surface tension of the alveoli.
The pleural space, the potential space between the membranes that cover the outside of the lungs (the inner visceral layer) and the inside of the chest wall, the top of the diaphragm, and the mediastinum (the outer parietal layer) normally contains a thin film of serous lubricating fluid that allows the visceral and parietal pleura to move without friction during respiration
Various disease processes can also result in the accumulation of fluid in the pleural cavity. With severe heart failure, transudates and exudates accumulate, while liver cirrhosis and pulmonary malignancies increase the likelihood of pleural effusion. Empyema is a high-protein exudative effusion resulting from infection in the pleural space.
Accumulation of fluid in the pleural cavity can create counterpressure, preventing the lung from expanding fully. Fluid can collect in the pleural cavity due to trauma or as a result of a disease process. For example, chest trauma can cause hemothorax, a collection of blood in the pleural space, or chylothorax, a leakage of lymph fluid from the thoracic duct into the pleural cavity
Air collecting in the pleural space causes a loss of negative intrapleural pressure, resulting in a partially or completely collapsed lung, or pneumothorax. This can occur spontaneously, as a complication of a pre-existing pulmonary disorder, or as result of chest trauma.
Ventilation is severely compromised, and venous return to the heart is impaired. Hypotension and distended neck veins are evident as tension pneumothorax affects venous return and cardiac output. The mediastinal shift also displaces the trachea toward the unaffected side.
Tension pneumothorax develops when injury to the chest wall or lungs allows air to enter the pleural space but keeps it from escaping. Tension pneumothorax is a medical emergency that requires immediate intervention to preserve respiration and cardiac output. Pressure within the pleural space becomes positive in relation to atmospheric pressure as air rapidly accumulates with each breath. The lung on the affected side collapses, and pressure on the mediastinum shifts the thoracic organs to the unaffected side of the chest, placing pressure on the opposite lung as well.
This helps re-establish negative pressure in the pleural space, allowing the lung to re-expand. Applying a low level of suction to the system can also help remove fluid from the pleural space.
Closed-chest drainage removes air and fluid from the pleural space, prevents air or fluid from re-entering the pleural space, and re-establishes the usual intrapleural and intrapulmonic pressures. Clinicians insert a tube into the pleural cavity to remove air and fluid and then connect a Heimlich (one-way flutter) valve or a closed drainage system with a water seal to keep air from entering the chest cavity during inspiration and to allow air to escape during expiration.
Checking the mediastinal tube frequently for the presence of blood clots is imperative, as these tubes are typically small, and if signs of cardiac tamponade develop (such as rapidly dropping systolic pressure and jugular vein distention), surgical intervention is essential.
Closed-chest drainage treats patients who have symptoms that result from excessive accumulation of fluid or air in the pleural cavity due to trauma, surgery, or a disease process. It helps manage pleural or thoracic fluid after surgery, such as extensive cardiovascular surgery or a thoracotomy. After cardiac surgery, the surgeon may insert a mediastinal chest tube (or multiple tubes) directly under the sternum to drain blood and fluid from the pericardial sac into a closed-chest drainage system to prevent cardiac tamponade, a life-threatening complication.
APPLYING THE NURSING PROCESS
1. ASSESSMENT
Observe the chest-tube insertion site for redness, swelling, pain, and excessive or unusual drainage. Palpate around the dressing site to check for subcutaneous emphysema (air in the tissues under the skin that produces a crackling sensation on palpation).
Assess and document vital signs and respiratory status, including rate, depth, lung sounds, and oxygen saturation. Ask about chest pain and difficulty breathing. Note the patient’s level of consciousness, skin color and temperature, and the rate of capillary refill in the extremities. Assess for the presence of pain. If the patient reports pain, assess the pain’s severity, location, quality, and any relieving or aggravating factors.
Assess the functioning of the closed-chest drainage system by observing the characteristics and amount of drainage, the patency of the chest tube, tidaling of the fluid in the water-seal chamber, and oscillations within the air leak meter and suction-control chamber. When it is safe for the patient to ambulate, assess his ability to walk unassisted and provide assistive devices to ensure his safety
Enhancing gas exchange and tissue oxygenation are the primary goals of closed-chest drainage. Strategies to optimize ventilation and oxygenation include positioning, pain management, and activity. Unless he cannot tolerate it, position the patient in Fowler’s or high Fowler’s position while he is in bed.
2.PLANNING
The risks for infection and injury are also primary concerns. Planning should include proper care of the chest-tube insertion site and closed-chest drainage system and patient education. Develop a schedule for dressing changes using surgical asepsis.
These positions facilitate lung expansion. Develop a schedule for routine position changes to promote drainage and ventilation. Teach the patient to perform deep-breathing exercises and to use incentive spirometry. Assess his pain frequently and observe his ability to participate in deep breathing, incentive spirometry, and activities of daily living. Encourage him to ambulate or to sit in a chair throughout the day.
Collect the required supplies so that they are readily available when you need them. Maintain a closed system by checking the connections of the closed-chest drainage system routinely and teaching the patient how to avoid disconnecting the tubing. Teach him to keep the drainage system below the level of his chest when sitting or ambulating and to keep the chest tube free of kinks and away from objects or situations that might occlude it.
Keep the head of bed at 30 degrees or higher. Remind or assist the patient to change position at least every 2 hr. Help him ambulate every 4 to 6 hr during the day when allowed to enhance lung expansion and drainage. Administer pain medication so that he can participate in deep breathing, incentive spirometry, and activities of daily living.
3. IMPLEMENT
Replace the dressing on a regular schedule, or when necessary, using surgical asepsis. Maintain a closed system by securing all connections. Secure the chest tube to the chest wall so that it doesn’t dislodge during activity. Prevent kinking or occlusion of the chest tube during activity. Observe the patient during ambulation and activities to ensure that the chest tube remains free of kinks and occlusion.
Respirations should remain unlabored, with a rate within the expected range. Maintain oxygen saturation above 90% and remind the patient to report any chest pain or dyspnea. Expect lung sounds to be clear bilaterally with a symmetric chest rise on inhalation.
4.EVALUATION
The chest tube site should remain free of infection. The chest drainage system should function continuously within the closed system. Chest tube drainage should decrease over time. The patient should be able to ambulate and perform activities without complications, and his level of endurance should increase over time.
The patient’s skin should remain pink and warm and have a quick rate of capillary refill. Decide with the patient on a specific pain level that he finds manageable for performing deep breathing, incentive spirometry, and activities of daily living.
MAINTAINING A CLOSED CHEST DRAINAGE SYSTEM
Diminished or absent lung sounds generally indicate that the lung hasn’t re-expanded. Assess pain and provide analgesia to help optimize the patient’s oxygenation and ability to perform activities. Check the chest tube dressing at least every 4 hours
For patients who have respiratory or cardiovascular instability or copious amounts of chest-tube drainage, monitor vital signs including oxygen saturation and pain level frequently. Auscultate their breath sounds and observe their color and respiratory effort.
After your initial assessment of the patient and the closed-chest drainage system, note the character, consistency, and amount of drainage in the collection chamber at regular intervals, generally every hour during the first few hours and then at least every 4 hours. Mark the drainage level in the collection chamber by noting the time and date at the drainage level on the outside of the chamber or on tape affixed to the outside of the chamber every 8 hours or more often if the drainage is continuous or copious.
Palpate the area surrounding the dressing for crepitus or subcutaneous emphysema, which indicates that air is leaking into the subcutaneous tissue surrounding the insertion site. If you see drainage on the dressing, note the dimensions of the stain so that you can monitor for additional drainage. Using surgical asepsis, change the dressing over the chest tube site as necessary or according to your facility’s policies and procedures.
Fluctuation stops when the lung has re-expanded, but it can also stop when the tubing is obstructed or a dependent loop hangs below the rest of the tubing. It can also stop when the suction source is not functioning. Expect continuous bubbling in the water-seal chamber initially and occasional bubbling after that. If you again see constant bubbling, there is probably an air leak
f the system includes a water-seal chamber, check the fluid level regularly because water can evaporate. If necessary, add sterile fluid until the level reaches the 2-cm mark or the level the water-seal chamber gradations indicate. Check for tidaling in the water-seal chamber as the patient breathes. Expect to see 5 to 10 cm (2 to 4 inches) of fluctuation, reflecting pressure changes in the pleural space during respiration.
Periodically check that the air vent in the system is working properly and is not wet or blocked. Occlusion of the air vent prevents drainage and results in a buildup of pressure in the system that could cause a tension pneumothorax
For closed-chest drainage systems with a wet-suction control chamber, aim for gentle bubbling in the suction-control chamber, and be sure to keep the fluid in that chamber at the prescribed level (usually 20 cm). Vigorous bubbling in this chamber can disturb the patient, and it also increases the rate of water evaporation.
Coil the system’s tubing, or lay it horizontally across the chair or bed before it drops vertically into the collection chamber and secure it to avoid dislodgement. Be sure the tubing remains below the level of the insertion site. Avoid creating dependent loops, kinks, or pressure on the tubing. Avoid lifting the drainage system above the patient’s chest because fluid could flow back into the pleural space.
For systems with dry-suction control, check to verify the correct placement of the dial and the presence of the float ball at the appropriate level in the suction control indicator window. If necessary, adjust the suction source so that the float ball is at the correct level.
Encourage the patient to cough frequently and breathe deeply to help drain the pleural space and expand the lungs. Sitting upright promotes optimal lung expansion and splinting the insertion site while coughing can help minimize pain. Patients who undergo thoracotomy often splint the arm of the affected side to decrease discomfort. Assess pain frequently and administer analgesia to help the patient tolerate deep breathing, coughing, and range-of-motion exercises. Encourage active or provide passive range-of-motion exercises for the patient’s arm on the affected side.
If you see clots in the chest tube, check with the physician about milking the tube. Some facilities discourage this practice, however. Milking the tube involves intermittently compressing it in the area of the clot for 1 to 2 seconds. Do not strip the tubing, as this increases negative pressure within the system to a level that can damage the pleural tissue. Some sources caution that milking can also have this effect.
Be sure to keep two rubber-tipped clamps at the bedside to clamp the chest tube if the system cracks or to locate an air leak in the system. Tell the patient to report breathing difficulty immediately. Notify the physician if the patient develops cyanosis, rapid or shallow breathing, subcutaneous emphysema, chest pain, or excessive bleeding.
This allows the drainage unit to remain vented without suction. Be sure the exit vent is open. Other systems allow air to exit through the suction-control tubing. With these systems, keep the suction-control tubing uncapped and free from occlusion to prevent a buildup of air inside the pleural cavity. Disconnect systems without an exit vent from the suction source before turning it off to prevent a tension pneumothorax.
When transporting the patient, keep the drainage device below the patient’s chest and disconnect the system from the suction source. Check your facility’s policies to see if the physician must first prescribe discontinuing suction for transport. Some closed-chest drainage systems and suction devices contain a vent from the water-seal chamber.
After the lung has re-expanded and drainage is minimal, the physician may prescribe clamping the tube or disconnecting the suction with the tube left to water seal for several hours before removing the chest tube. This allows time to observe for respiratory distress, an indication that air or fluid remains trapped in the pleural space. The physician might also request a chest x-ray prior to chest-tube removal to verify re-expansion of the lung.
Remind patients who are ambulatory to keep the drainage system below chest level and not to disconnect the tubing. With a suction system, they must stay within range of the length of tubing attached to a wall outlet or portable pump. Typically, the physician will allow patients to disconnect from suction briefly for ambulation; however, check your facility’s policies to see if you need a prescription for this.
MANAGING COMPLICATIONS
Start by checking the patency of the chest tube and looking for loose connections between the patient and drainage system. Determine if the chest tube is clamped, kinked, or occluded by following the length of the entire tubing. If the tubing has disconnected from the drainage unit, instruct the patient to exhale and cough. This rids the pleural space of as much air as possible. Submerge the end of the chest tube in 1 inch of sterile water until you can cleanse the tips of the tubing and reconnect them quickly. Tighten any loose connections and tape them securely or use a locking plastic tie.
The primary goal of closed-chest drainage is to optimize ventilation and gas exchange by draining the air or fluid from the pleural cavity. When the closed-chest drainage system is not working properly, patients may show early signs of altered oxygenation, such as restlessness, hyperventilation, and tachycardia. They may also report increased pain on the affected side. At this point, it is essential to troubleshoot the equipment, quickly identify the problem, and provide effective interventions.
Look at the water-seal/air-leak meter chamber. If the bubbling stops, the air leak is at the chest-tube insertion site or inside the chest. Examine the chest-tube insertion site quickly to see if the dressing is loose or the tube is dislodged. If the dressing is loose, air may be entering around the tube as the patient inhales. Palpate around the chest tube site and listen for a crackling sound indicating subcutaneous emphysema, which can result from a poor seal at the chest-tube insertion site.
Next, determine whether or not there is an air leak. If you see excessive and continuous bubbling in the water-seal chamber or the air-leak meter, especially if the system is connected to a suction source, look for a leak in the drainage system. Using rubber-tipped clamps, try to locate the leak by clamping the tube momentarily at various points along its length. Begin at the tube’s proximal end, near the dressing.
Notify the physician immediately and prepare for another chest-tube insertion. Have emergency equipment (oxygen, resuscitation cart, chest- tube insertion kit) nearby including a flutter (Heimlich) valve or a large-gauge needle for an emergency thoracostomy.
Ask the patient to cough to rid the pleural space of as much air as possible, apply an occlusive dressing or reinforce the dressing if it is intact, and monitor the patient to see if oxygenation improves. The sound of hissing air, a large amount of new drainage at the insertion site, or visibility of the drainage holes at the proximal end of the chest tube suggest that the tube has dislodged.
When you place a clamp between the source of the air leak and the water-seal/air-leak meter, the bubbling will stop. That indicates a leak in the tubing distal to the clamp. Replace the tubing or secure the connection and release the clamp. If you clamp along the tube’s entire length and the bubbling doesn’t stop, the drainage unit might be cracked and you will have to replace it.
If the bubbling continues after you clamp the tube momentarily near the insertion site, place another clamp a little further down the tube about 20 to 30 cm (8 to 12 inches) toward the drainage system and remove the first clamp. Each time you clamp at the more distal location, check the water-seal/air-leak meter chamber.
If there is bubbling in the water-seal/air-leak meter and your assessment has determined that there is an air leak from the chest, do not clamp the chest tube as this will cause air to accumulate in the pleural cavity with no means of escape. This can rapidly lead to a collapsed lung and tension pneumothorax, a potentially life-threatening event. Instead of clamping the tube, submerge the distal end of the tube in 1 inch of sterile water to create a temporary water seal while you prepare the system for reattachment or replacement.
When a chest tube disconnects from a closed-chest drainage system, quickly clamp the tube as long as there is no bubbling in the water-seal/air-leak meter. Use a disinfectant to clean the end of the chest tube and the reattachment site and re-establish the connection.
If the drainage system has tipped over or is disrupted or damaged, or the drainage collection chamber is filled to its maximum capacity, replace it. Prepare a new closed-chest drainage system so that you can attach it as quickly as possible. Clamp the chest tube but only for the brief time it takes to re-establish drainage.
Observe for signs of a tension pneumothorax, hypotension, distended jugular veins, absent or decreased breath sounds, tracheal shift, hypoxemia, weak and rapid pulse, dyspnea, tachypnea, diaphoresis, and chest pain. Make sure the equipment for chest-tube insertion and emergency equipment are nearby.
If a chest tube is completely dislodged, cover the site immediately with a sterile gauze dressing. If you can hear air leaking out of the site, make sure the dressing is not occlusive. If it is, it can cause a tension pneumothorax. Stay with the patient and monitor his vital signs while another staff member notifies the physician.
However, it may also make subsequent surgery more difficult. For this procedure, the physician will instill the chemical agent or talc slurry into the chest tube and allow it to flow into the pleural cavity. The chest tube must remain clamped for a period of time to allow the chemicals to work. Closely monitor the patient during this time to detect any changes that could indicate a tension pneumothorax. If you see them, notify the physician immediately and unclamp the tubing.
When a patient has a recurrent pneumothorax, the physician may perform pleurodesis, a procedure that involves instilling a chemical agent, such as talc, into the pleural space. The subsequent inflammatory response creates scar tissue and adhesion between the pleural layers and reduces the risk of recurrent pneumothorax.
STEP BYS TEP VIEWING
REPLACING A CLOSED CHEST DRAINAGE SYSTEM
4. if unit includes, an air leak meter, fill with solution until you reach the indicated mark.
5. have patient to turn to the opposite side of tubing
6. unwrap the tape of orginal tubing
7. don new gloves
8. put appropriate mask
9. clamp tubing close to the insertion site and place clamps in opposite direction
10. now disconnect old system and reconnect to new system and remove the clamps
1. make sure that the drainage system does not have an air leak, if it does, do not clamp the system.
2. use the funnel to put sterile water into the water sealed chamber until it reaches the 2 cm mark or the mark the manufacture specifies.
3. remove the cap from suction control cap and fill with NS to the 20 cm mark or until what the manufacture suggests. when done recap.
15. have patient lean forward and take deep breaths
16. look at fluctuations within the fluid chambers of system
17. ask patient how he/she is breathing
11. use tape to secure the attachment of tubing to the chest tube
12. remove suction tubing from old system and reconnect it to the new system
13. dispose of waist material in red biohazard bag (check with facility)
14. have patient turn back on back
REPLACING A CHEST TUBE INSERTION SITE DRESSING
6. place facility approved type of dressing around the chest tube
7. place drain pad across the chest tube
8. place tape firmly across the chest wall on the opposite side of chest tube
9. repeat until the entire dressing is sealed
10. check respiratory status, pain etc
1. have patient turn to the opposite side of his chest tube
put a mask on
2. remove old dressing
3. note the color, consistency and amount of drainage on the dressing
4. perform hand hygiene and don sterile gloves
5. clean around chest tube with facility approved antiseptic
DOCUMENTATION
informed consent
date and time of insertion
anatomical location of insertion
size of the tube
reason for insertion
breath sounds, respiratory rate and depth, and oxygen saturation before and after insertion
characteristics and amount of chest tube drainage
dressing application and status
any complications
for patients going home with a mobile drainage device: instructions, contact information, and follow-up appointments
1. chest tube insertion
schedule for drainage checks and dressing changes
status of the insertion site and surrounding skin
type of dressing
drainage on the dressing
dressing change time and date
respiratory assessment
characteristics and amount of chest tube output
functioning of the closed-chest drainage system
any procedural changes (reduction in suction, open to water seal)
strategies to promote ventilation and oxygenation (head of bed elevation, incentive spirometry, positional changes, ambulation)
pain level and interventions for pain management
2. chest tube and drainage system maintenance
date and time of removal
breath sounds, respiratory rate and depth, and oxygen saturation before and after removal
characteristics and amount of chest tube drainage
dressing application and status
any complications
chest tube removal
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