What are the priority nursing interventions for the management of a patient with a chest tube?
Chapter 10. Tubes and Attachments Show
A chest tube, also known as a thoracic catheter, is a sterile tube with a number of drainage holes that is inserted into the pleural space. The pleural space is the space between the parietal and visceral pleura, and is also known as the pleural cavity. A patient may require a chest drainage system any time the negative pressure in the pleural cavity is disrupted, resulting in respiratory distress. Negative pressure is disrupted when air, or fluid and air, enters the pleural space and separates the visceral pleura from the parietal pleura, preventing the lung from collapsing and compressing at the end of exhalation. A small amount of fluid or air may be absorbed by the body without a chest tube. A large amount of fluid or air cannot be absorbed by the body and will require a drainage system (Bauman & Handley, 2011; Perry et al., 2014). The chest tube is connected to a closed chest drainage system, which allows for air or fluid to be drained, and prevents air or fluid from entering the pleural space. The system is airtight to prevent the inflow of atmospheric pressure. Because the pleural cavity normally has negative pressure, which allows for lung expansion, any tube connected to it must be sealed so that air or liquid cannot enter the space where the tube is inserted (Bauman & Handley, 2011; Rajan, 2013). The location of the chest tube depends on what is being drained from the pleural cavity. If air is in the pleural space, the chest tube will be inserted above the second intercostal space at the mid-clavical line. If there is fluid in the pleural space, the chest tube is inserted at the fourth to fifth intercostal space, at the mid-axillary line. A chest tube may also be inserted to drain the pericardial sac after open heart surgery, and may be placed directly under the sternum (Perry et al., 2014). The following are some of the conditions that may require a chest tube drainage system (Bauman & Handley, 2011; Perry et al., 2014):
A chest tube drainage system must always be placed below the drainage site and secured in an upright position (attached to the floor or an IV pole, as in Figure 10.4) to prevent it from being knocked over. Figure 10.4 Chest tube drainage system secured to IV poleFigure 10.5 Chest tube drainage systemFigure 10.6 Chest tube drainage system with labelled partsA chest tube drainage system is a sterile, disposable system that consists of a compartment system that has a one-way valve, with one or multiple chambers, to remove air or fluid and prevent return of the air or fluid back into the patient (see Figures 10.5 and 10.6). The traditional chest drainage system typically has three chambers (Bauman & Handley, 2011; Rajan, 2013). Always review what type of system is used in your agency, and follow the agency’s and the manufacturer’s directions for setup, monitoring, and use. In general, a traditional chest tube drainage system will have these three chambers:
In addition to the three chambers, the drainage system has many safety features to ensure that high negative pressures can be monitored and relieved quickly. To review these safety features and additional information regarding the chambers of a closed chest tube drainage system, visit the Teleflex Medical Incorporated website. When a patient has a closed chest tube drainage system, it is the health care provider’s responsibility to assess the patient and the equipment frequently to ensure the equipment is patent and working effectively. The health care provider should:
Checklist 86 reviews the management of a patient with a chest tube drainage system. Checklist 86: Management of a Chest Tube Drainage System (Pleur-evac)
Special considerations:
Video 10.10Video 10.11Table 10.3 provides a list of potential complications and interventions related to chest tube drainage systems. Table 10.3 Complications and Interventions Related to Chest Tube Drainage Systems
Heimlich ValveA Heimlich valve (see Figures 10.7 and 10.8) is a small, specially designed flutter valve that is portable and mobile, allowing the patient to ambulate with ease. It attaches to the chest tube at one end and a drainage bag at the other. The drainage bag allows air and fluid to escape but prevents their re-entering the pleural space. The valve can be worn under clothing. The valve functions in any position, never needs to be clamped, and can be hooked up to suction if required (Gogakos et al., 2015). Figure 10.7 Heimlich valveFigure 10.8 Blue end connects to chest tube; other end may be left open to air or attach to a small drainage bag
What are priority nursing interventions for a client with a chest tube?Chest tube.
The priority is to maintain the airway, breathing, and circulation. The most important interventions focus on reinflating the lung by evacuating the pleural air. Patients with a primary spontaneous pneumothorax that is small with minimal symptoms may have spontaneous sealing and lung re-expansion.
What will the nurse include when assessing a patient with a chest tube?Once the chest tube is in place, verified by x-ray, and attached to a drainage device, nurses are tasked with monitoring the patient and the drainage device. This would include monitoring vital signs as directed, observing for pain and signs of infection, and assessing the tube and drain system (5).
What should you do if a patient has a chest tube?A chest tube falling out is an emergency. Immediately apply pressure to chest tube insertion site and apply sterile gauze or place a sterile Jelonet gauze and dry dressing over insertion site and ensure tight seal. Apply dressing when patient exhales. If patient goes into respiratory distress, call a code.
Which nursing action is of highest priority when a client's chest tube has accidentally dislodged?If the chest tube accidentally falls out, instruct the patient to perform the Valsalva maneuver. At end-expiration immediately cover the insertion site with vaseline gauze (if indicated by your hospital), a dry sterile dressing, and occlusive tape (Pruitt, 2008).
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