| A | B |
|---|
| Chest Tubes | (1) inserted (a) following thoracic surgery (b) for tx of a chest trauma that may result in pneumothorax or hemothroax (2) inserted to remove (a) air (b) fluid (c) blood (d) purulent material from the intrapleural space (3) inserted to promote re-expansion of of the lung |
| Chest Tube Purpose | (1) to promote removal of air & fluids from the pleural space (2) to re-establish normal negative pressure in the pleural space promoting lung re-expansion (3) prevent the dev of a tension pneumothorax (4) Loss of normal intrapleural pressures |
| Commercial Drainage System | (1) chest tube attached to first chamber w/use of a one-way valve preventing fluid reflux (2) water placed in the second chamber acts as an underwater seal |
| Commercial Drainage System (Third Chamber) Suction Control Chamber | (1) w/suction applied to the 2nd chamber, H20 in the third chamber will continuously bubble indicating a working system (2) suction gauge sh/be regulated to produce slow, steady bubbling in the 3rd chamber (3) suction controlled by (a) the gauge (gauge alone does not control the amt of suctioning applied to the pt) (b) the amt of water level in the 3rd chamber (the more water in the 3rd chamber, the more suction is created) (4) fill suction control chamber to the level Rx by dr (4) a vent to air room is located in the 3rd chamber |
| Continuous Bubbling | (1) in the water seal chamber indicates presence of air leak (2) air leak (a) can be found at the insertion site in the chest (b) loose tube connections (c) puncture in the tubing or drainage system (3) petroleum gauze sh/be applied to air leaks at the chest tube insertion site (4) if external source of leak cannot be found, a large amount of air could be escaping from the pleural space (notify dr) |
| Coughing & Deep Breathing | (1) help re-expand the lungs (b) remove airway secretions (c) facilitate drainage of fluid & air from the pleural space (2) w/clotting, coughing can cause tidaling to start again (3) notify dr if tidaling not re-established |
| Chest tube Indications | (1) surgery (2) traumatic chest injuries (a) pneumothorax (b) hemothorax (3) pleural effusion (build up of fluid between the pleura) (4) infection (empyema) |
| Drainage Amount | depends on nature of problem |
| Drainage System Chambers | (1) collect drainage (2) creater a water seal (3) apply suction (4) sh/be kept upright at all times (5) sh/not be raised above waiste level |
| Fluid Level Incr | (1) as level incrs w/in drainage bottle, it become increasingly difficult for air & fluids to drain from the pleural space into the bottle (2) apply gentle suction to aid in removal of air & fluids |
| Hemorrhage | (1) may be indicated by (a) bright red drainage from a postsurgical patient (b) drainage approaches 200 cc/hr (2) notify physician |
| Intermittent Bubbling | (1) can be considered normal as air is removed from the pleural space |
| Nurse | (1) observe for tidaling in water seal compartment |
| Pain Control | (1) essential so that pt can breathe deeply & cough at regular intervals |
| Pneumothorax | (1) 3 kinds (a) closed (simple or spontaneous) (b) open (traumatic) (c) tension (2) may produce only a scant amount of fluid as mostly air is removed from the pleural space (3) condition of collapsed lung that develops when the parietal or visceral pleura of the lungs have been punctured allowing atmospheric air to enter the pleural space |
| Replacement (Commercial Drainage System) | (1) replace entire system if leak cannot be found or repaired |
| Single-Bottle System | also called water-seal drainage system |
| Single-Bottle System Setup | (1) end of chest drainage tube is submerged below water in the bottle (2) submerged tube creates (a) negative pressure w/in the pleural space (b) allows air & fluids to drain from the pleural space into the bottle while preventing air re-entry into lungs (c) as fluid drains lung re-inflates d/t to negative pressure |
| Single & Two Bottle System | the effectiveness of both drainage systems depends upon gravity or suction being applied to the system |
| Suction Added To Drainage System | (1) usually 10 - 20 cm H2O (2) dr must Rx amount of suction applied to system (3) suction is usually supplied by a small wall unit |
| Suctiion Applied (Single-Bottle System) | (1) cause water to gently bubble/tidle |
| Suction (Commercial Drainage System) | (1) can be applied to the second chamber to help increase drainage (2) suction amount: 10 - 2- cm/H2O but can range up to 40 cm H2O (3) suction amount of over 50 cm H20 can create lung tissue damage |
| Suction (Single-Bottle System) | provided by a wall suction unit |
| Three-Bottle Drainage System | (1) consist of (a) the underwater seal bottle of the single-bottle system or water-seal drainage system (2) an additional bottle to collect fluid (2) the first bottle in the system collects fluids (3) the second bottle creates an underwater seal (4) third bottle (a) controls the amount of suction applied to the drainage system (b) has an outside vent to room air |
| Tidaling or Fluctuation | (1) of fluid in the water seal chamber sh/occur w/the patient's respirations (2) will stop if lung has re-expanded (can be verified by chest x-ray) (3) will stop if there is a clot |
| Tube Clots | (1) stabilize tube close to chest w/one hand (2) other hand sh/move carefully down the drainage tube toward the drainage device |
| Two-Bottle System | (1) consist of (a) the underwater seal bottle of the single-bottle system or water-seal drainage system (2) an additional bottle to collect fluid (2) the first bottle in the system collects fluids (3) the second bottle creates an underwater seal |
| Two-Bottle System Suction | (1) is added to the UNDERWATER SEALED BOTTLE by attaching the suction connection to the VENT STEM of the underwater seal bottle (2) the amount of suction applied is the same as in the single-bottle system (10 -20 cm H2O) |
| Persistent Air Leak | (1) clamping may be necessary to locate such air leaks (2) clamping sh/be ordered specifically by dr (3) can trap air and precipitate lung collapse |
| Underwater Seal (Single-Bottle System) | (1) MUST be air tight (b) prevent (be free of) any air leaks (3) again, no leaks from atmosphere is allowed to flow back into the pleural space (4) re-entry of air back into pleural risks lung re-collapse |
| Underwater Seal (Two-Bottle System) | (1) fluid level in this system remains unaffected by the amount of fluid draining from the pleural space into the first (collection bottle) |
| Underwater Seal (Commercial System) | (1) causes air & fluid to be drained from the pleural space into the FIRST CHAMBER (2) air escapes thru an air vent in the second chamber out into the atmosphere preventing re-entry to the patient's pleural space (3) the air vent MUST NOT BE CLAMPED or the air will not be able to escape |
| Signs & Symptoms of Respiratory Distress (Indications of Dev Tension Pneumothorax) | (1) tachypnea (2) tachycardia (3) hypotension (4) chest pain or pressure (5) dyspnea (6) diminished or absent lung sounds (7) tracheal deviation |
| Removal of Chest Tube | (1) admin pain medication before procedure (2) tell pt to take deep breath & hold (keep air from entering pleural space) (3) place over tube opening & tape securely in place a piece of parolatum gauze & a gauze pad to keep to create an airtight bandage (4) pleura seals itself off after removal of tube |
| Pleural Effusion | (1) accumulation of excess fluid in pleural space/cavity (fluid filled space surrounding lungs) that can dev in pt w/pneumonia (2) 4 types (a) serous fluid (hydrothorax) (b) blood (hemothorax) (c) chyle (chylothorax) (d) pus (pylothorax or empyema (purulent fluid in pleural space d/t complication of pneumonia)) (3) chest pain that incrs upon inspiration cld/be pleuritic pain |
| Closed/Simple/Spontaneous (Pneumothorax) | (1) devs when air enters the pleural space thru an opening in the parietal or visceral pleura (2) d/t i.e. (a) emphysema (b) bronchopleural fistula (c) air blebs on lungs that rupture (3) percussion of chest wall reveal a tympanic (hyperresonance) sound (4) auscultation of lungs reveal diminished or absent breath sounds (5) hypotension devs (6) Tx (a) tube inserted into 2nd intercostals space (b) w/hemothorax another tube inserted posteriorly in 4th or 5th intercostals space (as fluid is removed, pleural space decompresses & lung re-expands) (7) gentle suction is applied to help remove air & fluid |
| Homans’ Sign | (1) calf tenderness when the foot is dorsiflexed, clinical manifestation of deep vein thrombosis (2) (2) majority of pts with DVT do not demonstrate a (+) sign |
| Venting Tube (Three-Bottle System) | (1) the level to which the VT is submerged in the water controls the amount of water suction that is applied to the patient (a) if the tube is submerged to 20 cm below the surface of the water, 20 cm of water suction will be applied to the patient |
| Wall Suction (Three-Bottle System) | (1) is applied to the system to create negative pressure BUT THE AMOUNT OF SUCTION PROVIDED IS CONTROLLED BY THE WATER IN THE THIRD BOTTLE (2) constant ("gentle") bubbling will be seen in the third bottle meaning the system is functioning correctly |
| Water Level (Commercial Drainage System) | (1) of the second chamber WILL FLUCTUATE WITH THE PATIENT'S RESPIRATION (2) the level witll move up with inspiration & down w/expiration |
| Pleural Space | (1) space between ribs and lungs (2) filled with small amount of fluid (3) air or fluid in pleural space inhibits expansion and breathing (4) Physiologically, intrapleural pressure is 4-5 cm H2O below atmospheric pressure during expiration (5) Intrapleural pressure is 8-10 cm H2O below atmospheric pressure during inspiration (7) If the intrapleural pressure equals the atmospheric pressure, the lung will collapse, causing a pneumothorax |
| To Drain Air (Chest Tube Location) | (1) location (a) Anterior (and laterally) through 2nd intercostal space (2) To drain fluid/blood: Posterior through 8 or 9th intercostal space in midaxillary line |
| Suction Control Chambers | 2 types (a) dry (valve/regulator) (b) wet (water chamber) control |
| When you breathe | (a) w/inhalation, (-)pressure is created in the chest that pulls air in thru the mouth/nose (2) what would happen if there was a hole in your chest? (a) a chest tube system can act as a one-way valve that can remove air/fluid (b) can also be set up to create “pull” in the form of (-)pressure |
| One Bottle=One way valve | (1) valve is the water (2) not intended for collection (3) creates no “pull” (4) Allows air out but not in (5) Rise and fall of fluid with breathing (WHY? HOW?)- Tidaling |
| Two Bottles=Valve + Drainage | (1) Allows air out but not in (2) Allows for collection (3) Rise and fall of fluid with breathing (4) water seal is the valve |
| 3 Bottles=Valve + Drainage + Pull | (1) Allows air out but not in (2) Rise and fall of fluid with breathing (3) Allows for collection (4) Creates a “pull” in the form of negative pressure (4) suction wet or dry (5) water seal is the valve |
| Commercial | (1) wet suction (actual column of water used - usually 20 cm) (2) dry suction: pressure & vacuum internally regulated |
| Commercial Wall Suction | (1) creates a vacuum while the column of water creates the actual pull (2) turning up the wall suction will not increase the pull (3) column of water creates pressure much like diving underwater SO INCREASING THE COLUMN OF WATER WILL INCREASE THE PULL |
| When “tidaling” | ceases and chest X-ray/assessments confirm re-expansion of lung |
| Pleural Space | (1) has negative pressure which maintains lung inflation (2) w/atmospheric air in this space d/t an impaired (no longer intact), the lungs collapse (3) degree of collapse depends upon the extend of damage to the pleura & how much air enters the space (4) lungs may collapse partially or totally |
| Open (Traumatic) | (1) open (traumatic) life-threatening circulatory problems result (2) caused by (a) laceration or puncture of the lung itself allowing air to leave the lung & enter the pleural space (b) penetrating chest wounds (stabs, gunshot), motor vehicle accidents & invasive surgical procedures (c) can lead to a shift in the heart, trachea & great vessels (mediastinal shift) toward the uninjured side w/ea breath taken (3) percussion of chest wall reveal a tympanic (hyperresonance) sound (4) auscultation of lungs reveal diminished or absent breath sounds (5) hypotension devs |
| Open Pneumothorax S/S Same As W/Tension | (1) air hunger, restlessness, agitation, cyanosis, Hypotension & Tachycardia (2) profusely diaphoretic (3) trachea wil deviate from midline toward unaffected side (4) jugular venous distention can occur (5) diminished heart sounds, shock & subcutaneous emphysema (air leakage into surrounding tissue that prodices a crackling sound when the skin is lightly compressed) can dev along w/ineffective ventilation |
| Open & Tension Pneumothorax S/S Difference | (1) w/open there will be a sucking sound at the site of the open w/ea respiration (2) trachea will deviate toward unaffected side w/ea inspiration & shift back to midline w/ea expiration (3) sucking chest wound air moves freely i/o of the wound w/ea expiration (2) cover immediately w/airtight (non-porous) dressing to prevent dev of tension pneumothorax (3) emergency: use anything (waste no time looking for a sterile dressing) (4) ideal dressing is a piece of sterile petrolatum gauze (5) if tension pne devs the dressing must be immediately removed |
| Tension Pneumothorax Types | (1) medical emergency requiring immediate intervention (2) devs when air is drawn into the pleural space thru a small puncture in the chest wall or d/t a lacerated lung (3) can dev from both closed & open pneumothoraces (4) regardless of underlying cause, pathology is same (a) air enters pleural space (b) becomes trapped (c) cannot escape thru the opening (5) w/ea inspiration more air is drawn into lungs incr the intrathoracic pressure (6) lungs collapses & the heart, great vessels & trachea shifts (deviate) toward unaffected side (mediastinal shift) (7) respirations & circulation are greatly compromised |
| Hemorrhage | loss of a large amount of blood (internal or external) in a short period of time |
| Hemorrhage S&S | (1) Hypotension (2) weak (3) rapid pulse (4) cool, clammy skin (5) rapid breathing (6) restless (7) decreased U.O. & vital organ perfusion |
| Hemorrhage Prevention Interventions | difficult to prevent |
| Hemorrhage TX | (1) immed trendelenberg position (head down) (2) notify M.D. immed (stat) (3) get help to (a) monitor VS & client S/S freq (b) start IV & admin IV fluids (c) apply pressure to source of bleeding if possible (d) assess blood & urinary losses |
| Thrombophlebitis | (1) inflammation in a vein that is often accompanied by a clot (2) leg veins are the most common |
| Thrombophlebitis S/S | (1) incl swelling & inflammation of the affected vessel & extremity (2) (+) Homan’s sign (3) pain w/ dorsiflexion (4) vessel hard & sensitive to touch |
| Thrombophlebitis TX | (1) notify M.D. (2) bedrest (3) immobilize affected extremity (4) anticoagulants per INR/PTT results & M.D (5) monitoring SE |
| Thrombus (DVT) | formation of a blood clot, attached to the interior wall of a vein or artery |
| Thrombus (S/S) | (1) depend on the area the clot is formed (LE-DVT, femoral artery) (2) usually pain, swelling, redness, erythema (3) (±) Homan sign on dorsiflexion-? reliable |
| Thrombus Prevention Interventions | (1) leg exercises (2) early ambulation (3) low dose heparin SC/IV until up/walk (4) TEDs, SCDs, PlexiPulse (5) NO Pillows under knees |
| Thrombus TX | (1) notify M.D. (2) bedrest (3) immobilize affected extremity (4) anticoagulants per INR/PTT results & M.D. (5) monitoring SE |
| Embolus | dislodged thrombus (blood clot) that circ until it lodges in a smaller vessel upstream |
| Embolus S/S | (1) depend on the area the clot is lodged (pulmonary embolus, stroke, vision changes, fingers/toes) |
| Embolus Prevention Interventions | (1) leg exercises (2) early ambulation (3) low dose heparin SC/IV until up/walk (4) TEDs, SCDs, PlexiPulse (5) NO Pillows under knees |
| Embolus Tx | (1) notify M.D. (2) admin O2 as indicated (3) CPR if necessary (4) bedrest (5) immobilize affected extremity (6) anticoagulants per INR/PTT results & M.D. (7) monitor SEs |
| Pulmonary Embolus | (1) condition that impedes xportation of oxygenated blood (2) a thrombus (clot) in a vessel breaks loose & travels thru the blood stream until it lodges in a vessel in the lungs obstructing the vessel & impeding the flow of OB beyond the clot location point (4) can be fatal & can lead to dev of pulmonary HTN |
| Pulmonary Embolus S/S | (1) dyspnea (2) sudden chest pain (3) cyanosis (4) tachycardia (5) drop in BP (6) blood-tinged sputum |
| Pulmonary Embolus Prevention Intervention | (1) early ambulation (2) difficult to prevent (3) also see Embolus under circulatory complications |
| Pulmonary Embolus Tx | (1) notify M.D. (2) ABCs (3) admin O2 as indicated (4) bedrest (5) anticoagulants (heparin &/or warfarin) per PTT/INR results (6) monitoring complications (7) CPR if necessary |
| Pleural Friction Rub | (1) pericardial: (a) tell pt to hold breath & if sound continues it's pericardial bc those pleura will rub despite held breath (if it stops it's pleural) (2) pleural rub can be due to pneumonia. HOWEVER, a likely cause is pulmonary infarct 2ndary to PE!(dead lung inflames & rubs against the parietal pleura just like w/pneumonia) (3) rubs (a) harsh, grating, rubbing sounds that can be heard upon inspiration or expiration (b) caused by inflamed pleura rubbing together as pt breathes (2) inflamed pleura usually caused by infection (3) chest pain that incrs upon inspiration could be pleuritic pain |
| Tension Pneumothorax S/S | (1) air hunger, restlessness, agitation, cyanosis, Hypotension & Tachycardia (2) profusely diaphoretic (3) trachea wil deviate from midline toward unaffected side (4) jugular venous distention can occur (5) diminished heart sounds, shock & subcutaneous emphysema (air leakage into surrounding tissue that prodices a crackling sound when the skin is lightly compressed) can dev along w/ineffective ventilation |
| Pulmonary Embolus Development | (1) clot devs for one of 3 reasons (a) damage to blood vessel walls (b) stasis of blood (c) blood hypercoagulability (2) originate from deep vein thrombosis (DVT) (3) risk factors (a) surgery (esp in pelvic region or orthopedic) (b) immobility (c) obesity (d) myocardial infarction (e) CHF (f) fractures (g) pregnancy & use of estrogen therapy (4) R-sided heart failure can dev d/t incr cardiac workload caused by >pulmonary vascular resistance |
| Chest Tube | (1) remove air, fluid, blood or even purulent material from the intrapleural space following thoracic surgery or treatment of a chest trauma (2) re-establish normal negative pressure in the pleural space promoting re-expansion of lung (3) prevent the dev of tension pneumothorax |
| Chest Tube Closed Drainage System Setup | (1) fill suction control chamber w/sterile water (2) attach chest tube securely to collection chamber & secure w/adhesive tape to chest (3) turn on suction machine & adjust (H2O bubble slowly/steadily) (4) NO Dependent Loops, kinks (lying on tube) bet bed & drainage system (5) mark drainage starting level with tape/monitor increases by marking w/date & time (6) pt in any position comfortable w/but change frequently (semi-fowler’s best) (7) tube clogs: (a) assess system (b) gently squeeze Chest Tube |
| Chest Tube Closed Drainage System assessment | (1) fluctuations or tidaling of fluid in water seal chamber (a) intermittent bubbling is normal as air is removed from pleural space (b) continuous bubbling indicates air leak (c) bubbling in suction control chamber stops the system is not operating correctly or there is an air leak into suctioning apparatus (inspect for air leak) (2) do not clamp chest tube (unless ordered by dr) but reattach if tube is disconnected (3) keep sterile H2O (L) at bedside (system cracks tube can be submerged into bottle to maintain water seal) (4) assess pt for S&S of respiratory distress |
| Closed Chest Tube Drainage System | drainage system that used one, two or three bottles to create a water seal, apply suction, and collect drainage |
| Chest Tube Closed Drainage System Removal | (1) small piece of petrolatum gauze & a gauze pad will be immediately applied (2) tape securely over opening to create an airtight bandage (3) admin pain med about 30 mins prior to removal to decr discomfort of procedure |
| Commercial Drainage Systems | systems that operate upon the same principles of the three-bottle system but combine the three separate bottles into one plastic disposable unit |
| Positive End-Expiratory Pressure (PEEP) Interventions | (1) ensure prescribed settings are maintained (b) monitor functioning of equipment (3) note pt’s response to therapy (4) assess (a) control mode (b) setting for respiratory rate, tidal volume & fraction of inspired oxygen (FiO2) (c) inspiratory pressure reading (d) inspiratory/expiratory ratio (e) minute volume (f) use of PEEP (g) sigh setting (h) sensitivity of ventilator triggering (i) periodic (hrly) checks of ventilator alarms to ensure proper functioning (j) assess humidifier water level; empty accumulated condensation from tubing |
| Positive End-Expiratory Pressure (PEEP) | (1) ventilator mode in which the positive pressure is only applied by the ventilator at the end of expiration (2) use to help decr dev of atelectasis & reduce shunting (3) can result in lung tissue damage if applied at a pressure that is too low or can lead to Hypotension d/t < intrathoracic pressure that impedes blood flow |
| Principles of Drainage (Single-Bottle System) | (1) water-seal drainage system (a) end of chest drainage tube is submerged below water (b)underwater seal creates a (-)pressure w/in pleural space allowing air & fluid to drain from the pleural space into the bottle while preventing air re-entry to pleural space (2) lung expands w/fluid removal (3) gentle suction can be applied to aid in removal of air & fluid |
| Principles of Drainage (Two-Bottle System) | (1) consists of underwater seal bottle (single-bottle system or water-seal drainage system) w/an additional bottle use to collect fluid (2) first bottle in system collects fluids (3) second bottle creates under water seal (4) in this system, the underwater seal fluid level remains unaffected by the amount of drainage coming from the pleural space (5) suction is added to the underwater seal bottle by attaching the suction connection to the vent stem on the underwater seal bottle |
| Principles of Drainage (Three-Bottle System) | (1) third bottle used to control amount of suction applied to drainage system (2) level to which venting tube is submerged in water controls the amount of water suction that is applied to the patient (3) watch constant gentle bubbling (tideling) in third bottle (means system is properly functioning) (4) outside vent to room air in third bottle |
