05.04 Chest Tube Management

Overview

1. Chest tube is inserted through chest wall into pleural space, in order to:
   1. Drain fluid, blood, or air
      1. Pleural Effusion
      2. Hemothorax
      3. Pneumothorax
      4. Post-Op drainage
   2. Establish negative pressure (one-way valve)
   3. Facilitate lung expansion

Nursing Points

General

1. Setup
   1. Chest tube – varying sizes
      1. Holes in end
      2. Secured with suture
   2. Drainage system
      1. Tubing
      2. Collection chamber (2000 mL with markings)
      3. Water seal chamber (should be at 2 cm level)
         1. Port on back to add sterile water
      4. Suction pressure dial
      5. Suction port
         1. Will need suction tubing
      6. Foot to prevent tipping
      7. Hangers to keep off floor
   3. Occlusive Dressing
   4. Must remain upright, below chest

Assessment

TWO AA’S

1. Tidaling
   1. Movement of fluid with breaths
      1. Rise with inspiration
      2. Fall with expiration
   2. Could be normal
   3. NO tidaling = re-expansion or obstruction (assess)
2. Water seal level
   1. Should be at 2 cm at all times
   2. Add more sterile water if needed
3. Output
   1. Quantity
      1. Measure every 4 or 8 hours (per facility policy)
      2. Mark on chamber
      3. Report increased volume (per provider orders)
   2. Quality
      1. Color
         1. Sanguineous
         2. Serosanguinous
         3. Serous
      2. Character
         1. Purulent
         2. Clots
      3. Report unexpected finding to provider
4. Air leak
   1. Continuous bubbling in water seal chamber
   2. May indicate:
      1. Pneumothorax
      2. Dislodgment
      3. Disconnection
      4. Equipment failure
5. Ability to breathe
   1. Always assess the patient (not just the system).
   2. Shortness of breath? Pain?
6. SpO2
   1. Determine oxygenation status

Therapeutic Management

1. Complications
   1. Air Leak
      1. Indicates air getting into the system
      2. Cross-Clamp technique to find the leak
      3. May have to change whole system
      4. If chest tube or site are source — call provider
   2. Dislodged/Removed (accidentally)
      1. Apply 3-sided occlusive dressing immediately
      2. Call provider

Nursing Care

1. Coil tubing in bed
   1. NO dependent loops
2. Do NOT clamp except:
   1. Troubleshooting air leak
   2. Specific instructions from provider
   3. Could cause Tension Pneumo
3. Do NOT strip (pull fingers along tube to move drainage down)
   1. Causes increased negative pressure
   2. Could cause tissue damage
   3. Squeeze gently, instead
4. Keep system upright and below chest
5. Keep at bedside:
   1. 2 hemostat clamps (for cross-clamping)
   2. Sterile water / syringe for water seal
   3. Occlusive dressing & tape

Patient Education

1. Importance of not pulling on chest tube
   1. Also not to get out of bed without help
2. Purpose for chest tube
3. Explanation of procedures (NOT informed consent)
4. Splinting with deep breaths or coughing.