07.01 Chest Tube Management

Note:   At 00:22, Nicole mentions that she is filling the water seal chamber with the syringe included in the packaging, but she’s actually filling the suction control chamber on this Atrium model. Always check the model and refer to the manufacturer’s instructions, and the physician’s orders for proper chest tube set up.

Overview

1. Purpose
   1. Chest tubes are placed to:
      1. Drain fluid, blood, or air
      2. Establish negative pressure
      3. Facilitate lung expansion
   2. The system is setup and maintained by the nurse
      1. Chest tube itself – secured with suture – placed by provider
      2. Drainage system
         1. Collection chamber
         2. Tubing
         3. Water seal chamber
         4. Suction port and pressure dial
      3. Occlusive dressing
         1. Usually vaseline gauze covered with dry gauze and tape
      4. MUST remain upright, below patient’s chest

Nursing Points

General

1. Supplies needed
   1. Drainage system
      1. Should include a syringe of water for the water seal chamber
   2. Suction setup
      1. Regulator
      2. Tubing
   3. Vaseline gauze and other dressing supplies
   4. Permanent marker

Assessment

1. When assessing an existing chest tube, follow the mnemonic TWO AA’S
   1. Tidaline
   2. Water Seal Level
   3. Output
   4. Air Leak
   5. Ability to breathe
   6. SpO2
2. See Chest Tube Management lesson in Respiratory Course

Therapeutic Management

1. If an air leak is discovered
   1. Use the cross-clamp technique to identify the source
   2. If the chest tube itself or the site are the source – notify the provider
2. If the tube is accidentally removed
   1. Cover the site with occlusive dressing, taped on 3 sides immediately
   2. Notify provider

Nursing Concepts

1. Steps and Nursing Considerations
   1. Explain procedure to patient
   2. Perform hand hygiene
   3. Don clean gloves
   4. New chest tube placement
      1. Open Pleur-Evac or other drainage system package
      2. Remove the syringe of water from the back
      3. Insert the syringe into the water seal port and inject the water
      4. Set up your suction regulator and tubing
      5. Attach suction tubing to suction port and set dial to ordered pressure
         1. If the provider orders “water seal” – do not attach suction
      6. Open the feet or hangers of drainage system to stabilize below the bed
      7. Remove the tubing from the package
      8. In a sterile fashion, remove the cap and assist the provider to attach the chest tube to the tubing
      9. Tubing should be coiled in bed to prevent dependent loops
      10. Make note of the volume of drainage expelled in the first hour by marking it with a permanent marker
   5. Checking an existing chest tube
      1. Assess your patient
         1. Are they breathing okay?
         2. Lung sounds
         3. SpO2
      2. Check for tidaling in the tubing – should move with respirations
      3. Check for bubbling in the water seal chamber – which would indicate an air leak
         1. Also make sure there is enough water in the chamber (2cm)
      4. Assess the output
         1. Color, character
         2. Quantity – measured every 4-8 hours
         3. Mark level on chamber
   6. For SAFETY
      1. Never clamp except when troubleshooting for an air leak
      2. Never strip the tubing
      3. Keep at the bedside:
         1. 2 hemostat clamps
         2. Sterile water/syringe for water seal
         3. Occlusive dressing and tape
   7. Discard trash and used supplies
   8. Remove gloves
   9. Perform hand hygiene
   10. Document procedure, findings, and patient response

Patient Education

1. Purpose for chest tube drainage system
2. Symptoms to report to the nurse ASAP