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JM Chest drainage
Pleural chest drainage lab/ppt pgs18-21
| Question | Answer |
|---|---|
| Pleural Chest Drainage/Lab pgs 18-21 Lag | |
| When is a chest drainage system indicated? | if Air, fluid has entered pleural space-must be removed to reestablish begative pressure & re-expand the lung. One way with chest tube. |
| What two tubes are placed? | Anteriorly, 2nd intercostal space (air);Posteriorly, 8th or 9th ICS midaxillary line to drain fluid, blood ( gravity). |
| What does a chest drainage apparatus consist of? | Chest tube attached to valve mechanism;one-way valve;H2O-seal drainage system:collection chamber, H2O seal chamber, suction control chamber. |
| Discuss one- way valve. | One-way valve or H2O-seal drainage w/suction;one-way valve allows the chest tube to collapse on inspiration & opens on expiration (valve opens only when pressure within chest exceeds atmospheric pressure so air & fluid are removed from chest). |
| Discuss H2O-seal drainage system. | Most common;three chambers:collection,H2O-seal, & suction control. |
| Discuss collection chamber function. | Where chest tube from pt connects to the system;drainage from the tube drains into this section (calibrated columns to record output). |
| Discuss H2O-seal chamber function. | Allows air to escape but not reenter the pleura. Acts as one-way valve.If there is a pheumothorax, should be gentle, intermittent bubbling. |
| What should be happening in H2O-seal chamber? | Should be tidaling, oscillation or fluctuation of fluid (rises on inspiration, falls with expiration unless on + pressure ventilator. |
| What does no bubbling in H2O-seal chamber indicate? | INADEQUATE suction or healed pneumothorax, CLOT OR KINK OF TUBING! |
| What does abrupt cessation of bubbling in H2O-water seal chamber indicate? | Inadequate suction, clot, or kink of tube! Should take 48-72 hrs for fairly large pneumothorax to heal. |
| How long should it take a fairly large pneumothorax to heal? | 48-72 hrs. |
| If there is no tidaling in H2O-seal chamber what may that indicate? | Reexpanded lung or kinked/clogged tube especially if abrupt cessation of tidaling. |
| Discuss suction control chamber. | Provides suction,that can be controlled to provide negative pressure to the chest. |
| When is the suction control chamber necessary? | When ther is a large leak or when negative intrathoracic pressure must be re-established. |
| How much H2O is used in suction control chamber for moderate continuous control? | -120-180 cm H2O at the suction control. |
| How is the amount of suction determined? | By either the amount of water in this chamber or by a knob on the chest drainage system, NOT BY WALL SUCTION |
| What is the usual amount of suction ordered? | -20 Cm H2O |
| Discuss general respiratory status assessments Rn should do for pt with chest drainage. | BBS @ least q2hr;V/S @least Q4hr;note quality of resp;observe for abnormal chest movements&cyanosis;anxiety. |
| What complication of chest drainage should RN be alert to? | Possiblity of extended pneumothorax or hemothorax. |
| How would RN assess for extended pneumothorax? | Increased ABSENT breath sounds over the area, hyperresonance, tachycardia, increased respiratory distress, cyanosis, restlessness, sudden sharp chest pain, & confusion. |
| How would Rn assess for extended hemothorax? | Diminished or absent breath sounds, dyspnea, cyanosis. |
| How often should chest drainage system be assessed? | HOURLY! |
| Where should system be located in relation to pt? | Below pt’s chest level and free of kinds, dependent loops or other external obstruction. |
| Discuss drainage assessment. | Note color & amount; if changes from dark sanguineous to bright NOTIFY DR IMMEDIATELY! If drainage exceeds 200 ml/hr for 2 consecutive hrs NOTIFY DR. Usuallydc/d if < 50 ml/day. |
| Discuss dressing for chest drain. | Observe dressing & subQ emphysema (mark on dressing if needed);an occlusive STERILE dressing applied to insertion site; FOR A PNEUMOTHORAX PETROLEUM GUAZE OFTEN USED. |
| What may Rn observe indicating a leak in system? | Tidaling & continous bubbling. |
| Discuss nursing diagnosis. | Ineffective breathing pattern, impaired gas exchange r/t decreased lung expansion: |
| Discuss goals for nursing diagnosis: Ineffective breathing pattern, impaired gas exchange r/t decreased lung expansion. | Breath sounds are equal, clear, RR 16-20/min, even & unlabored; ABGs approaching normal; lung re-expansion noted on CXR, symmetrical expansion |
| Discuss nursing intervention for pt with chest drainage. | Maintain patent system, retape all connection, C.T. (chest tube) dressing management, tubing free of kinks,loops, external pressure, TCDB w/pillow, pain mgt. |
| Discuss “milking” tube. | Perform gently per protocol if clots are obstructing. Ck with MD esp if existing air leak since this increases negative pressure. |
| In regards to milking chest tube, when should MD be notified? | If no fluctuation after gently milking. |
| What should RN do if chest drainage system breaks? | Place end of tube in bottle sterile H2O or saline &AND HOLD BELOW CHEST LEVEL; IMMEDIATLEY REPLACE SYSTEM;Can clamp MOMENTARILY if air entering pleural cavity. |
| Discuss risks of clamping chest drainage tube. What should Rn watch for? | Clamping may result in tension pneumothorax (as air enters it has no way of escaping, collapsing lung-look for tracheal deviation & other signs of pneumothorax. |
| What should RN do if CT accidentally is removed? | C over wound with occlusive dressing (TAPE 3 SIDES@ 4TH UNTAPED SO AIR CAN ESCAPE-AVOIDS TENSION PNEUMO). |
| What could be used in an emergency if an occlusive dressing is not available when CT is accidentally removed? | Gloved hand! |
| Discuss nursing diagnoses for CT being accidentally removed. | Anxiety r/t perceived risk of CT dislodgement, system disruption, inability to breathe; goals: pt realistically describes precautions necessary;pt describes expected drainage in terms of color amount … |
| Discuss nursing interventions for CT pt. | Prepare pt for type/amount of drainage (after chest sugery bright red gradually decreasing after 72 hrs), bubbling, tidaling; mark amount of drainage 1-4 hr intervals;NOTIFY MD IF CONSTANT BUBBLING IN WATER-SEAL-CHAMBER;compare sttus w/expected outcomes. |
| What pt education should RN do for chest tube? | Provide basic info,explain care(avoid pulling or rolling on tube);prepare for type/amt of drainage;explain frequent cks by staff;allow time for question,reassure staff nearby,call bell. |
| When might RN notify MD in regards to CT? | If dark sanguineous chngs to bright;if drainage exceeds 200ml/hr for 2 consec hrs;if no fluctuation after milking;if constant bubbling in water-seal. |
| When might chest tube be removed? | CXR confirms full re-expansion, when no fluctuation of fluid & cessation of bubbling in H2O-seal, adequate gas exchange. |
| Dexcribe method of chest tube removal. | Usually medicat 30 min prior;petroleum gauze &sterile dressing place over site;instruct pt to bear down,cough&tube quickly with drawn (gen done by MD);wound gen heals in 1 wk;MONITOR FOR RESP DISTRESS AFTER TUBE DC/D! |
| What is the goal when removing CT? | to facilitate the removal w/o th intro of air into pleural/mediastinal space, and w/o contamination and development of infection; D/C an invasive intervention that is no longer necessary |
| What criteria must be assessed PRIOR TO REMOVAL OF CT? | Minimal drainage;less than a total of 10 mml/hr/tube for six hours prior; absence of air leak documented: by having pt take deep breath&cough(if bubbling is seen, ct not removed/MD notified/stable resp status;coagulation status. |
| What amount of drainage should be present prior to removal of CT? | Less than a total of 10 ml/hr/tube for six hours prior to removal. |
| Describe assessments present with stable respiratory status. | Non-laboured resp,absence of SOB,decreased use of accessory muscle,symmetrical resp excursion, resp rate LESS THAN 30/min;breath sounds audilbe bilaterally, type/amount of ventilator support has stabilized. |
| Discuss coagulation status. | If current coags are NOT within norm range-THIS SHOULD BE REPORTED to MD PRIOR TO TUBES PULLED! Removal of tubes when coags are high may increase the risk of bleeding. |
| What is a Heimlich valve? | Sterile/single use; rubber flutter one-way valve in rigid plastic tube, attached to external end of CT; opens when pressure is >atmospherepress /closes w/reverse. Functions likewater seal. |
| What is a Heimlich valve used for? | For emergency transport in an emergency pneumothorax kit, when placing small-bore chest drains (pigtail cath);home care or long-term nursing units. |
| Where is the proximal end of the Heimlich valve attached? The distal end? | Proximal to most chest catheters and distal to tubing that empties into a plastic bag;if desired, distal end can be connected to regulated suction. |
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