TEACHER’S COLLEGE
Patricia Carroll, RN,BC, CEN, RRT, MS
Owner, Educational Medical Consultants
CREATIVE TEACHING
STRATEGIES FOR CHEST DRAINAGE
MMoorree∧∧
CREATIVE TEACHING
STRATEGIES FOR CHEST DRAINAGE
Patricia Carroll, RN,BC, CEN, RRT, MS
Participant ObjectivesAt the end of this session, you should be able to...
...describe three interactive activities used to teach chest drainage content
...develop a plan for using any of these activities in your practice setting
Interactive Activities
Four Facts pages 3-5
Do You Remember? pages 6-9
Chest Drainage Tic Tac Toe pages 10-15
Pop! Goes The Case Study pages 16-24
Question Box pages 25-34
What’s My Problem? pages 35-40
New Product Introduction Worksheets pages 41-46
Resources pages 47-55
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MMoorree∧∧
Interactive Teaching and Learning
Today’s Instructional Environment• Limited resources
• Need to save time
• Tradition - Lectures are traditional
• Results-based education
• Helping learners remember
• Repetition is essential for learning
Keys to Success• Don’t call these activities games! They are interactive activities for
content reinforcement
• Make sure learners know the purpose of the activity
• Help learners see the connection to content
• Use teams to foster healthy competition
• Don’t force people to stand alone
• Help everyone participate
• Be concise, to the point, upbeat
• Use activities to energize
• Don’t forget to have fun!
2
Four Facts
PurposeThis exercise provides an opportunity to discuss stereotypes in a non-threatening
way. Encourages learners to think about how they make judgements about others
— patients, classmates, co-workers. Also a good icebreaker at the beginning of a
course, new employment situation.
How to do itMake a list of four facts about yourself — three should be true and one should be
false. Choose items that are not always obvious, especially those that are
different from typical stereotypes (i.e. a woman being a big sports fan, an unusual
hobby, a special talent.) Share the four “facts” with the group. (Usually best to
show the facts on an overhead projector.) Then, invite the group to share their
own “facts”. You can pair group members, and have them share one-to-one, or, if
you have more time, you can form teams and have each member of the team
share facts with other team members.
Instructions to GroupWrite four facts of your own. Remember, one is false, three are true. After you
write the facts, you’ll share them with a partner [other members of your team].
You will then need to determine which of your partner’s facts is false.
Follow UpSee sample discussion sheet.
Apply the exercise to your practice setting. For example, can be used to
emphasize that you can’t tell who is HIV positive just by looking at them. Can be
used to discuss stereotypes about people who receive Medicare and Medicaid
assistance. Can be used to launch discussion about racial and other cultural
stereotypes.
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Part I On this sheet please list four facts about yourself. Three of them
should be true. One of them should be false.
1.
2.
3.
4.
Part II Now as a group, do the following steps, in order, one at a time.
1. List below the name of each person in your group.
2. Each person reads their four statements aloud.
3. As each person reads the four statements, list next to his or her name the
number of the statement you think is false about them and why.
4. Once each person has completed sharing the statements, take one person
at a time and have each of the remaining people tell which statement is
false and why. Then the person who shared the four statements originally
can reveal which one was really false.
5. Do this for each of the people in your group.
1. Name Statement # is false
because
2. Name Statement # is false
because
3. Name Statement # is false
because
4. Name Statement # is false
because
5. Name Statement # is false
because
6. Name Statement # is false
because
4
Group Leader read:
1. Were you surprised at some of the “facts” that people shared? Which?
Why?
2. How good were you as a group and individually at picking the false
statement? What does this tell you about making assumptions and
judgements about people?
3. Were some of the statements made by different people similar? What
reasons could you give for this?
4. Were some of the “facts” quite different? What reasons could you give for
this?
5
Do You Remember?
PurposeThis exercise makes it easier for learners to remember lists of information by
linking content on the list to common, everyday items.
How to do itLink a list of content to common, everyday items. Collect the items, and lay them
out on a table top. Ask learners to come up and pick up one item each. In
content order, stand beside each learner, describe what the learner is holding, and
then explain how that item represents the content. After each item is described,
review content in order. Next, ask the original participants to go back to the
group, and give their item to another group member. Ask the new team to arrange
themselves in the proper order. Ask the seated group to determine if the standing
team is in the correct order. Then, review each step by linking the content to the
common item one more time. Ask learners holding the items to put them back on
the table and take a seat.
Instructions to GroupI need X people to come up to the front and pick up an item
Follow UpFor additional reinforcement, list the items on paper, and cut the paper so each
item is on a separate strip of paper. Add in three or four items that are not a part
of the content list as distractors. Put the sheets of paper in an envelope, mixed up.
Break the group into teams, and tell them this is a timed exercise. One member is
the timer. They are to take the pieces of paper out of the envelope and arrange
them in order. DO NOT tell learners there are distractors mixed in. Once they
have placed the items in the correct order, ask them to stand and cheer. Once all
teams are done, ask them to check their work against their notes. During this
activity, play loud music as a distraction.
After the exercise, learners will usually complain that there were extra items in
the envelope and the music was distracting. The teaching point is that we learn
information in the classroom where conditions are controlled. Then, when we
apply that information in the clinical setting, there are often a number of
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interfering factors. This helps learners experience distractions in a safe, otherwise
controlled setting, to help prepare them for “real life” in the clinical setting.
When you do the entire exercise, the content list will be reviewed 6 times —
which significantly enhances retention.
Application to Chest Drainage Content
Steps to Assessing the Chest Drainage System Represented by(in order from patient to wall)
Check the dressing A large doll dress
Check tubing for dependent loops A large, loopy straw
Do not strip or milk tubing Playboy magazine with
on cover, or can of
paint stripper
Check drainage Sink drain
Check for bubbling in water seal Bottle of bubbles; have
participants blow bubbles
Check for tidalling in water seal Play tape of waves from
the ocean (tide)
Check the level of water Carpenter’s level
(water seal and suction chambers)
Adjust for gentle bubbling in suction chamber Bubble bath
Make sure tubing is open Open sign (such as you
would see in a business
window)
7
�
The key to this activity is to make it fun and interactive. Ask the participant to
blow the bubbles; have another participant play the audio tape. By using different
types of items, you’ll also involve more of the learner’s senses — tactile,
auditory, visual. The more people are involved with the content, the more they
will remember. Learners will also better remember a fun lesson.
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Check the dressing
Avoid dependent loops
Do not strip or milk the tubing
Check the drainage
Look for bubbling in water seal
Look for tidalling in water seal
Check the water level in the suction chamber
Turn suction on until gentle bubbling appears
Make sure suction tubing remains open
Chest Drainage Tic Tac Toe
PurposeThis activity provides the opportunity to review content on any topic. Useful at
the end of a unit to wrap up and summarize important content.
How to do itPhotocopy the tic tac toe board on page 10 to make an overhead transparency.
Place the board on the overhead projector, with a plain, clear acetate on top of it.
Choose two teams. One will be X, the other O. Determine which team will go
first. The team chooses a box, and must answer a question about the topic
represented in the box in order to win the box. If the team answers the question
correctly, write their letter on the clear acetate on the game board over the
appropriate box. This will save your game board for future use. If the team
answers incorrectly, the other team has a chance at the question. If the other team
answers correctly, they win the box. (If you’re using true/false questions, choose
another question for the opposing team.)
The first team to get three in a row is the winner. Award prizes to the winning
team.
To make this more interactive, if all participants are not on the teams, have the
“audience” be the judge to determine if the questions were answered correctly and
if the team earned the square.
Instructions to GroupThis activity will review the content about chest drainage. You will form teams.
Each team will, in turn, choose a box and answer a question about the topic
represented by the phrase in the box. If you answer correctly, you win the box. If
you are incorrect, the other team has a chance to answer the question and win the
box. If the question is true/false, another question will be chosen. The first team
to win three boxes in a row will win the game.
Follow UpPlay as many games as needed to adequately review the content. At the end of
the game, you may reveal what topics the phrases represent.
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Chest DrainageTic Tac Toe
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Bubble, bubble,
toil & troubleIt’s a Hoover
... a window to
the soul
The beat goes
onAAA
That thing
that you do
Pressure... it’s
all about
pressure
I’m all shook
up
Vegetable
salad
Questions and Answers
Bubble, bubble, toil & trouble Bubbling in chest drain
Q. What does bubbling in the water seal chamber represent?
A. An air leak; air entering the system
Q. Describe the desired pattern of bubbling in a wet suction control chamber.
A. Gentle, not vigorous bubbling
Q. If a patient receiving mechanical ventilation has an air leak from the lung,
during which part of the respiratory cycle would bubbling be evident?
A. Inspiration; when a patient is on a ventilator, inspiration creates positive
pressure in the chest; this will push air out of the chest tube.
It’s a Hoover Chest drainage suction
Q. How do you set the level of suction in a wet suction chest drain?
A. The water level determines the level of suction.
Q. How do you set the level of suction in a dry-suction chest drain?
A. Dial in the desired level with the regulator on the chest drain.
Q. What is the most common level of suction used for the average patient?
A. 20 cm H2O
... a window to the soul Water seal manometer
Q. What do the numbers on the water seal chamber mean?
A. They reflect pleural pressure; this is a true manometer
Q. What does it mean when the water level rises half way up the water seal
chamber?
A. There is a condition of increased negative pressure in the chest
Q. Describe tidalling and what it reflects physiologically.
A. Tidalling is the rhythmic movement of the water level in the water seal that
follows pressure changes in the chest seen with respirations.
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The beat goes on Mediastinal chest tubes
Q. Define cardiac tamponade.
A. In cardiac tamponade, fluid or air collects between the pericardium and the
heart. As the air or fluid becomes greater, pressure builds, and the heart is
compressed. If the pressure is high enough, the heart cannot expand to accept
venous return and cardiac output will fall.
Q. Name four signs of cardiac tamponade.
A. Muffled / distant heart tones, increased CVP, tachycardia, decreased BP,
decreased cardiac output, jugular venous distension.
Q. Explain why it would be more unusual to see bubbling in the water seal
chamber of the chest drain of a patient with a mediastinal chest tube
compared with a pleural tube.
A. Bubbling in the water seal indicates air entering the system. There shouldn’t
be an air leak from the heart; there can be from the lung.
AAA Autologous transfusion
Q. Why can blood drained from the chest through a chest tube be used for
autologous transfusion?
A. Blood that comes into contact with the pericardium or pleurae is
defibrinogenated and will not clot.
Q. According to American Association of Blood Banks guidelines, what is the
maximum number of hours that can elapse from the beginning of blood
collection to the end of the transfusion?
A. Six hours.
Q. Describe the difference between intermittent and continuous autotransfusion
from a chest tube.
A. Intermittent ATS uses bags to collect blood. The bag is removed from the
system and hung on the IV pole for reinfusion. In continuous ATS, IV tubing
is connected to the collection chamber, and an infusion pump is used to pump
blood from the collection chamber to an IV site. The system is not opened
for reinfusion.
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That thing you do Functions of the parts of the chest drain
Q. Describe the function of the collection chamber.
A. The collection chamber collects fluid drainage from the chest.
Q. Describe the function of the water seal chamber.
A. The water seal chamber creates a one-way valve. Air is allowed to leave the
system, but not re-enter.
Q. Describe the function of the suction control chamber.
A. The suction control chamber limits the amount of negative pressure that can
be transmitted to the pleural or mediastinal space.
Pressure... it’s all about pressure Tension pneumothorax
Q. Define tension pneumothorax
A. A tension pneumothorax describes air collected in the pleural space under
pressure. As the tension increases, the lung collapses and the mediastinum
can shift.
Q. List 3 signs of tension pneumothorax.
A. Decreased breath sounds on the affected side, hyperresonance to percussion
on the affected side, tracheal shift away from the affected side, affected side
does not move with respirations, sustained increase in pressure on the
pressure manometer on a ventilator, difficulty compressing the manual
resuscitation bag.
Q. What is the emergency treatment for tension pneumothorax when the patient’s
condition is rapidly deteriorating?
A. Needle thoracotomy
I’m all shook up Chest trauma
Q. Describe the difference between an open and closed pneumothorax.
A. An open pneumothorax is a penetrating wound; the pneumothorax occurs
because of a hole in the chest wall. A closed pneumothorax occurs when
the chest wall is intact.
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Q. For the three following conditions, identify whether it would cause a closed
or open pneumothorax: A. rib fractures B. knife stab wound C. deceleration
injury
A. rib fractures: closed; stab wound: open; deceleration: closed
Q. Explain why children are less likely to have rib fractures with chest trauma
compared with adults.
A. Children’s ribs are more cartilaginous than adults’. They will bend, but not
break as easily.
Vegetable salad CABG
Q. When two chest tubes are used post-operatively in the mediastinum, where are
they positioned in the chest?
A. Anterior and inferior to the heart.
Q. In which type of CABG surgery is the surgeon more likely to enter the pleural
space?
A. Internal mammary artery grafts.
Q. Name two indications mediastinal chest tubes can be removed following
CABG.
A. Drainage < 100 ml in previous 8 hours; no air leak; patient is weaned from the
ventilator; chest x-ray is normal; coagulation studies are normal.
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POP! Goes the Case Study
PurposeThis activity provides an interactive opportunity for participants to answer
questions about case studies. This activity tests / reviews a higher level of
knowledge than the Tic Tac Toe game in this kit because these questions require
the participant to apply content knowledge to patient situations.
How to do itPhotocopy the questions that appear on pages 21, 22 & 23. Cut them into
individual squares. Each question is assigned a point value; the lower the point
value, the easier the question.
Collect 12 balloons — four each in three different colors. Stuff one question into
each balloon. Choose all of the same color balloons for the same point value (100
point questions pink, 200 point questions blue, 300 point questions yellow, for
example.) Blow up the balloons with the questions inside.
Divide participants into teams. A team will choose the point value they desire,
then pop the proper color balloon and read the question. If they answer the
question correctly, they earn the points. If they answer incorrectly, the other team
can try — if they get it right, they earn the points. Alternate questions back and
forth between teams until all the balloons have been popped. Whichever team has
the most points wins. Award prizes to the winning team.
Instructions to GroupThis activity will help you apply the content you’ve learned about chest drainage.
[break group into teams]
Each balloon has a question in it. The balloon colors represent the point value of
the question [explain which point value is assigned to each color.] Your team will
choose a balloon, pop it, and ask the question contained inside. If you get it right,
you earn the points. If you get it wrong, the other team can try the question.
Whichever team has the most points when the balloons are gone is the winner.
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Follow UpAt the end of the activity, answer any questions from the participants about
applying their knowledge of chest drainage to patient situations. Provide
remediation if there are content areas that need reinforcement.
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Questions and Answers
100 Point Questions
Q. The patient has had coronary artery bypass surgery. Drainage collection for
autotransfusion was begun at 2 pm, when the patient was admitted to the
ICU from the OR. An intermittent ATS system is being used. According
to AABB guidelines, the transfusion should be completed by what time?
A. 8 pm
Q. At the beginning of your shift, you’re caring for a patient with a
spontaneous pneumothorax. You walk into the patient’s room, and you can
hear the suction control chamber’s bubbling sound from the doorway.
When you look at the chamber, you see vigorous bubbling. What would
you do next?
A. Assess the patient; turn vacuum regulator (wall) down until there is only
gentle bubbling in the chamber.
Q. You’re caring for a patient breathing spontaneously following lung volume
reduction surgery. While you’re assessing the water seal chamber, the
patient coughs. You see bubbling in the chamber only during the cough.
What does this mean, and what nursing actions are required?
A. It is common to see bubbling with a cough. A cough generates high
intrapleural pressures, and can push air out through the chest tube and into
the water seal chamber. No nursing actions are required except for regular
assessment of the patient and chest drainage system.
Q. Your patient had a thoracotomy 36 hours ago; a lobectomy was performed.
You turn the patient from supine into a side-lying position, and
approximately 200 cc of dark blood spills into the collection chamber of the
chest drain. What does this mean, and what nursing actions are required?
A. Since blood coming in contact with the pleurae is defibrinogenated, it does
not clot within the chest. It’s not uncommon for drainage to be
inaccessible to the chest tube until the patient is turned. As long as it is
dark in color, there is no indication of fresh bleeding, and no nursing
actions are required other than regular assessment of the patient and chest
drainage system.
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200 Point Questions
Q. A patient was in an auto accident. His car struck a telephone pole. He is
admitted to the ICU because of neurological injuries. On physical exam,
the patient has a reddened area the size of a fist over his sternum, and
marks from the seat belt on his chest. Four hours post injury, you make the
following assessment:
BP 90/60; HR 128 ST; JVD; CVP changed from 7 to 15.
What is your next action? What do you think is going on?
A. Listen to heart tones, notify physician; possible cardiac tamponade from
deceleration injury.
Q. A patient has had a thoracotomy after being stabbed in the chest. He is on
a ventilator and has two pleural chest tubes in place. During the night, the
patient becomes disoriented and pulls out the chest tubes. What key pieces
of information do you need to guide your emergency actions? Besides
calling for help and notifying the physician, what would you do next?
A. The nurse must know whether there was an air leak. If an air leak was
present, a DSD should be applied to the chest, but only secured on three
sides so air can leave the chest through the dressing. If there was no air
leak, an occlusive dressing can be applied.
Q. A patient has had a CABG with the internal mammary artery. During your
assessment of the chest drain, you note new bubbling in the water seal
chamber. Describe what you would do to determine where this air leak is
from.
A. Clamp the chest tube momentarily, beginning at the patient, where the chest
tube leaves the chest. Clamp and look at the chamber to see whether the
bubbling has stopped. If you clamp at the chest and the bubbling goes
away, the leak is coming from the chest. If you clamp at the chest and the
bubbling persists, the leak is between the clamp and the water seal chamber.
Move the clamp down the tubing toward the chest drain — clamp and
reassess. When the bubbling goes away, the clamp is below the site of the
leak.
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Q. A multiple trauma patient is on a ventilator post op without PEEP. She is
unconscious, and has a left chest tube. You are alerted to the bedside by the
high pressure alarm on the ventilator. When you look at the ventilator’s
manometer, the needle does not go to zero. You disconnect the patient from
the ventilator to bag her, and have a very difficult time squeezing the bag
between your hands. You call for help. What do you think the problem is,
and what should be done next?
A. Tension pneumothorax. Assess to see if the problem is on the side with the
chest tube or the other side. Listen to breath sounds, look at water seal
chamber of chest tube, follow tubing to make sure the tubing is not occluded.
Prepare for needle thoracotomy and possible chest tube placement.
300 Point Questions
Q. A patient has severe ARDS. She is on a ventilator with maximal support,
including 20 cm H2O of PEEP. She has a chest tube to treat a pneumo-
thorax that occurred as a result of barotrauma. When you assess the water
seal chamber, you see continuous bubbling. Explain this assessment finding;
how do you explain it, and do you need to do anything about it?
A. This is to be expected. The PEEP creates positive pressure within the chest,
and pushes air out through the hole in the lung and the chest tube. When
PEEP is that high, the leak can be continuous. No nursing intervention is
required except to carefully monitor the patient.
Q. A trauma patient comes into the Emergency Department. He has been shot
and is bleeding from the chest. The bullet entrance wound is in the right
lower quadrant of the abdomen; the exit wound is from the chest under the
left arm. Is this patient an ideal candidate for autotransfusion from the chest
tube? Why or why not?
A. With that bullet path, bacteria from the bowel could have been carried into
the chest. Bacterial contamination is a contraindication to autotransfusion.
But, it is a relative contraindication. If the patient will bleed to death
without the transfusion, the risk of bacterial contamination may be worth
taking. There’s always antibiotics...
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Q. A patient has had a lung volume reduction surgery. The surgeon wants the
suction level in the suction chamber of the chest drain set at 10 cm H2O.
There is minimal bubbling in the water seal chamber. On chest x-ray, the
lung is not completely expanded. What can be done with the chest drainage
system to enhance evacuation of the chest?
A. The setting on the vacuum regulator can be increased to increase flow rate
through the system without increasing imposed negative pressure. This may
help evacuate the chest and re-expand the lung.
Q. At the beginning of your shift, you assess your patient’s chest drain. The
water level in the water seal chamber is all the way at the top of the chamber.
What does this mean, and what should you do about it?
A. It means a condition of high negativity has occurred in the chest. This can
mean the chest tube was stripped. This can be due to respiratory distress, in
the case of a pleural tube, or it can mean the chest tube was stripped. Vent
the pressure by pressing the manual negative pressure release valve. The
water level should then return to baseline. Continue to monitor the patient,
assessing for conditions that could have caused the high negativity.
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100 Points
The patient has had coronary
artery bypass surgery. Drainage
collection for autotransfusion was
begun at 2 pm, when the patient
was admitted to the ICU from the
OR. An intermittent ATS system
is being used. According to
AABB guidelines, the transfusion
should be completed by what
time?
100 Points
At the beginning of your shift,
you’re caring for a patient with a
spontaneous pneumothorax. You
walk into the patient’s room, and
you can hear the suction control
chamber’s bubbling sound from
the doorway. When you look at
the chamber, you see vigorous
bubbling. What would you do
next?
100 Points
Your patient had a thoracotomy
36 hours ago; a lobectomy was
performed. You turn the patient
from supine into a side-lying
position, and approximately
200 cc of dark blood spills into
the collection chamber of the
chest drain. What does this mean,
and what nursing actions are
required?
100 Points
You’re caring for a patient
breathing spontaneously
following lung volume reduction
surgery. While you’re assessing
the water seal chamber, the
patient coughs. You see bubbling
in the chamber only during the
cough. What does this mean, and
what nursing actions are
required?
23
200 Points
A patient was in an auto accident.
His car struck a telephone pole.
He is admitted to the ICU
because of neurological injuries.
On physical exam, the patient has
a reddened area the size of a fist
over his sternum, and marks from
the seat belt on his chest. Four
hours post injury, you make the
following assessment:
BP 90/60; HR 128 ST; JVD; CVP
changed from 7 to 15
What is your next action? What
do you think is going on?
200 Points
A patient has had a thoracotomy
after being stabbed in the chest.
He is on a ventilator and has two
pleural chest tubes in place.
During the night, the patient
becomes disoriented and pulls out
the chest tubes. What key piece
of information do you need to
guide your emergency actions?
Besides calling for help and
notifying the physician, what
would you do next?
200 Points
A patient has had a CABG with
the internal mammary artery.
During your assessment of the
chest drain, you note new
bubbling in the water seal
chamber. Describe what you
would do to determine where this
air leak is from.
200 Points
A multiple trauma patient is on a
ventilator post op without PEEP.
She is unconscious, and has a left
chest tube. You are alerted to the
bedside by the high pressure
alarm on the ventilator. When
you look at the ventilator’s
manometer, the needle does not
go to zero. You disconnect the
patient from the ventilator to bag
her, and have a very difficult time
squeezing the bag between your
hands. You call for help. What
do you think the problem is, and
what should be done next?
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300 Points
A patient has had lung volume
reduction surgery. The surgeon
wants the suction level in the
suction chamber of the chest
drain set at 10 cm H20. There is
minimal bubbling in the water
seal chamber. On chest x-ray, the
lung is not completely expanded.
What can be done with the chest
drainage system to enhance
evacuation of the chest?
300 Points
At the beginning of your shift,
you assess your patient’s chest
drain. The water level in the
water seal chamber is all the way
at the top of the chamber. What
does this mean, and what should
you do about it?
300 Points
A patient has severe ARDS. She
is on a ventilator with maximal
support, including 20 cm H20 of
PEEP. She has a chest tube to
treat a pneumothorax that
occurred as a result of
barotrauma. When you assess the
water seal chamber, you see
continuous bubbling. Explain this
assessment finding; how do you
explain it, and do you need to do
anything about it?
300 Points
A trauma patient comes into the
Emergency Department. He has
been shot and is bleeding from
the chest. The bullet entrance
wound is in the right lower
quadrant of the abdomen; the exit
wound is from the chest under the
left arm. Is this patient an ideal
candidate for autotransfusion
from the chest tube? Why or why
not?
Question Box
PurposeThis activity provides learners with an interactive opportunity to answer questions
and earn points while reviewing their knowledge of chest drainage and related
conditions. This activity is designed as an end-of-course, comprehensive review.
How to do itPhotocopy the game board on page 33 on an acetate so it can be used as an
overhead transparency. Place the transparency on the overhead projector.
Divide learners into teams. The number of teams and the number of learners per
team will depend on the total number of learners. Have a member of each team
draw a numbered piece of paper (from a box or paper bag) to determine the order
in which the teams will ask and answer questions.
The team that chose the number one will go first; number two will go second and
so on. The first team will choose a category and point value. The facilitator asks
the question (questions and answers listed by category and point value begin on
page 26.) If the team answers correctly, they are awarded the points assigned to
the question. If the team answers incorrectly, the next team in order has the
chance to answer the question. This continues until the correct answer is given. If
none of the teams answers correctly, the facilitator provides the correct answer,
discusses the rationale, and no points are awarded. The first team then starts over,
selecting another question. Once a correct answer is given, the next team chooses
a category and point value and another question is asked.
Teaching TipOnce a question has been asked and correctly answered, the facilitator covers the
game board box corresponding to that question with a 2" x 1.5" self-stick note.
This will black out the box on the overhead, indicating the question is "gone."
The game board is specially designed to accommodate the notes of this size.
The game continues until all questions are asked and answered. The team with the
most points at the end of the game wins. Award small prizes to the winning team.
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Instructions to GroupThis activity will allow you to review your knowledge of chest drainage and
related conditions.
[break group into teams]
You will draw lots to determine the order in which your teams will be able to
choose questions and answer them. If your team answers correctly, your team will
win the corresponding number of points. If you answer incorrectly, the next team
will get the chance to answer the question. The lower the point value, the easier
the question. At the end of the game, the team with the most points will win a
prize.
Follow UpProvide rationales for answers when learners have trouble mastering a subject.
Provide any remediation for content as indicated by learners' responses to
questions. Relate questions and answers to hospital policy / procedure /
competencies whenever possible.
26
Questions and Answers
Mediastinal Drainage
100 Points
Q. Chest tubes placed after coronary artery bypass surgery are positioned in
this sac.
A. Pericardial
200 Points
Q. This complication is characterized by muffled heart tones, decreased
cardiac output and increased right atrial pressure.
A. Pericardial / cardiac tamponade
300 Points
Q. This action can create negative pressures as high as -400 cm H2O in the
chest and is no longer recommended for routine postoperative nursing care
of patients with mediastinal chest tubes.
A. Stripping the tubing
400 Points
Q. This type of coronary artery bypass surgery grafting may require a pleural
chest tube postoperatively if the pleural space is entered.
A. Left internal mammary artery graft (LIMA)
500 Points
Q. This substance, covalently bonded to some chest tubes, decreases the
incidence of catheter thrombosis.
A. Heparin.
27
Pleural Drainage
100 Points
Q. This condition is characterized by an accumulation of air between the
visceral and parietal pleurae.
A. Pneumothorax
200 Points
Q. This condition is characterized by diminished or absent breath sounds on
the affected side, a shift of the trachea away from the affected side, and
hyperresonance to percussion.
A. Tension pneumothorax.
300 Points
Q. Using anatomical directional terms, describe the position a chest tube is
ideally located in when placed in the chest to drain fluid alone.
A. Inferior and posterior
400 Points
Q. Using anatomical directional terms, describe the position a chest tube is
ideally located in when placed in the chest to evacuate air alone.
A. Anterior and superior
500 Points
Q. This amount of fluid (in cc or mL) is required for a pleural effusion to be
seen on an upright chest radiograph.
A. 300 to 500
28
Water Seal Chamber
100 Points
Q. Seeing these in the water seal chamber indicates an air leak in the chest
drainage system.
A. Bubbles
200 Points
Q. This is the name for the up and down motion of the water in the water seal
chamber that corresponds to the intrathoracic pressure changes associated
with a patient's respirations.
A. Tidalling
300 Points
Q. When a patient takes in a very deep breath before a cough, and creates high
negative intrathoracic pressure, what will happen to the water level in the
water seal chamber?
A. It will rise.
400 Points
Q. Describe what the numbers on the long arm of the water seal chamber
mean.
A. The water seal chamber is a U-tube manometer. The numbers are
measurements of negative pressure in cm H2O
500 Points
Q. If the level of water in the water seal chamber is halfway up the long arm
of the chamber, the nurse should perform this action to return the water
back down to the baseline level in the chamber after the patient's condition
has been assessed.
A. Depress the manual high negativity vent on the top of the chest drain.
29
Managing Chest Tubes
100 Points
Q. What is the time interval for routinely changing a chest tube dressing?
A. A chest tube dressing should not be changed routinely; only when it is
soiled, loose or otherwise compromised.
200 Points
Q. A patient with a chest tube is scheduled to go to the radiology department
for a chest radiograph. What would you do with the drain and the tubing
when the patient is on the stretcher, ready for transport?
A. Disconnect from suction; if stopcock is present on suction tubing, check to
see that the stopcock is in the completely open position; assure that the
drain remains below the patient's chest level to allow for gravity drainage;
check to see that there are no dependent loops in the tubing [Teaching
point: key aspect is that the chest tube should NOT be clamped for
transport]
300 Points
Q. Describe how the wall vacuum regulator should be adjusted for a patient
with routine chest drainage with a water-filled suction control chamber.
A. Turn suction regulator down until bubbling just stops. Then, increase the
wall vacuum source until gentle bubbling just begins in the suction control
chamber.
400 Points
Q. There has been no evidence of an air leak in the water seal chamber, the
lung is fully re-expanded on a chest radiograph, and fluid drainage has been
less than 50 cc in the past 24 hours. What procedure can you expect to
prepare the patient for?
A. Chest tube removal.
30
500 Points
Q. A mechanically ventilated patient's chest tube has become disconnected
from the tubing leading to the drain, and the drain is cracked. Prior to this
event, there was bubbling in the water seal chamber. While a colleague is
getting another drain, what immediate nursing action would be best for this
patient?
A. Stick the end of the chest tube into a bottle of sterile saline or sterile water
to a depth of approximately 2 cm. [the bubbling in the water seal indicates
an air leak. DO NOT clamp the tube, because a tension pneumothorax
could result. Placing the chest tube under water creates a water seal,
allowing air to leave and not re-enter the chest. This action will best protect
the patient until a new chest drain is set up and available to be connected to
the chest tube.]
31
Potpourri
100 Points
Q. Describe, specifically, the emergency treatment for a patient with a tension
pneumothorax whose condition is rapidly deteriorating while equipment is
being set up for chest tube insertion.
A. Needle decompression in the second intercostal space, in the mid-clavicular
line.
200 Points
Q. What is the difference between an open pneumothorax and a closed
pneumothorax?
A. In an open pneumothorax, the chest wall is penetrated (such as a stab
wound or gunshot); this is often called a sucking chest wound. In a closed
pneumothorax, the chest wall is intact (such as injury to the lung from a
broken rib, or barotrauma during mechanical ventilation.)
[Teaching point: a closed pneumothorax is potentially more dangerous
because it can lead to tension pneumothorax. An open pneumothorax
naturally vents pressure through the opening in the chest, so tension
pneumothorax will not occur unless a pressure / occlusive dressing is
applied. A dressing should only be taped on three sides to allow pressure to
be relieved through the open side of the dressing for safety until a chest
tube can be inserted.]
300 Points
Q. Describe how you would check for the source of an air leak in a chest
drainage system when bubbles are present in the water seal chamber.
A. Momentarily clamp the chest tube, with a padded clamp or special flat
tubing clamp (without teeth that could damage the tubing) starting at the
place where the tube leaves the chest. When the tube is clamped, look at
the water seal chamber. When the clamp is placed distal to the leak, the
bubbling will stop. Work your way down the tubing with the clamp to
determine the location of the leak. [Teaching point: if the chest tube is
clamped as it leaves the chest and the bubbling stops immediately, the leak
is from the lung. If the tubing is clamped as it enters the drain, and the
bubbling continues, the leak is in the drain itself.]
32
400 Points
Q. What would you do if you inadvertently overfilled the water seal chamber
above the 2 cm AFill to here@ line?
A. Use a needle and syringe and withdraw the extra fluid through the rubber
grommet on the front of the drain.
500 Points
Q. How does PEEP on a ventilator affect bubbling in the water seal chamber
when a patient has an air leak from a pneumothorax?
A. Bubbling will be continuous when PEEP is used. [The positive pressure
from the PEEP during exhalation will continue to push the air through the
hole in the lung.]
33
110000
2200
00
3300
00
4400
00
5500
00
110000
2200
00
3300
00
4400
00
5500
00
110000
2200
00
3300
00
4400
00
5500
00
110000
2200
00
3300
00
4400
00
5500
00
110000
2200
00
3300
00
4400
00
5500
00
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What's My Problem?
PurposeThis activity provides an interactive opportunity for learners to review the
assessment findings of patients with a variety of conditions related to chest
drainage.
How to do itPhotocopy the list of thoracic disorders on page 37. Cut the copy into sections, so
that each section contains a single disorder.
Tape a different disorder on each learner's back. Each learner's task is to
determine what disorder is taped on his or her back by asking other learners
questions related to how he or she would assess a patient with a disorder related
to chest drainage.
This activity can be carried out in a number of ways to vary the level of difficulty
and evaluate learning at different cognitive levels. For example:
• You may copy the list of disorders on acetate to make an overhead
learners can refer to as they are trying to determine which disorder is "theirs"
to make the exercise a bit easier
• You can provide a list of assessment questions to direct learners, such as:
breath sounds, percussion findings, degree of dyspnea, assessment of chest
drain, heart sounds, and so on.
This is a particularly effective learning activity because not only do the people
with the disorders on their backs have to determine what "their" disorder is, based
on the assessment data they collect, but they must know about other disorders in
order to answer other learners' questions.
Instructions to GroupThis activity will allow you to review your knowledge of the assessment of
patients with a variety of conditions relating to chest drainage and pleural
disorders.
35
Each of you will have a disorder taped to your back. You will ask other members
of the group to look at your back to see "what your problem is," and then you will
ask one assessment question of each of your colleagues. You might ask about
breath sounds, heart tones, vital signs, the chest drainage system and so forth. You
should be collecting assessment data to answer the question "What's my
Problem?"
[Note: if the group is small, people may ask multiple questions of other learners,
or the facilitator may choose to pair up learners to ask each other questions.]
When you wish to name your problem, tell another learner of your diagnosis, and
the other learner will tell you whether you are correct. If you are incorrect,
continue to collect assessment data until you reach the correct answer.
[The facilitator may provide the list of disorders or sample assessment questions
as noted above; the use of these tools should also be explained to the learners.]
An abbreviated listing of assessment findings related to the eight conditions listed
on page 37 is on pages 38-39.
Teaching TipThis technique can be applied to many different aspects of content in a critical
care nursing course.
Blood Gas InterpretationNames of blood gas interpretations are taped to learners' backs; for example:
• Compensated metabolic acidosis
• Partially compensated respiratory alkalosis
Instruct learners to ask questions that can only be answered yes or no, such as "Is
my pH high?" Instead of using numerical values, yes and no questions that refer
to high, normal or low values reinforce the concept of how the different values
change in different conditions; specific numbers are not as important as knowing,
for example, that the PaCO2 level would be high, low or normal for a given
condition.
ECG InterpretationLearners' understanding of concepts relating to rhythm strip interpretation can be
tested on two cognitive levels. At the lower level, the name of the rhythm in
words is used, such as atrial fibrillation, sinus bradycardia and so forth.
36
To evaluate at a higher level, simply tape rhythm strips on the learners' backs.
Then, the other learners must be able to interpret the rhythm in order to provide
accurate information as they are asked questions.
In this case, questions would relate to ECG configuration such as: Is my PR
interval prolonged? Does a P wave come before every QRS complex? Is my rate
above 60? and so forth.
37
My Chest Drainage Problems
Tension pneumothorax without a chest tube
15% pneumothoraxpatient came to the ER with pleuritic chest painno intervention yet
1000cc right sided pleural effusionno intervention yet
Routine postoperative thoracotomy patientmechanical ventilation without PEEPair leak from the lung through the chest tube
Postoperative trauma patient with flail chest and pneumothoraxARDSmechanical ventilation with 12 cm H2O PEEP
Postoperative coronary artery bypass graftmedian sternotomyleft internal mammary artery graftpleural space entered during surgery; pleural tube in place
Postoperative coronary artery bypass graftmedian sternotomy, saphenous vein graftcardiac tamponade
Postoperative coronary artery bypass graftmedian sternotomy, saphenous vein graftroutine
38
Condition
Tension pneumothorax without a chesttube
15% pneumothoraxpatient came to the ER with pleuriticchest painno intervention yet
1000 cc right sided pleural effusionno intervention yet
Routine postop thoracotomy patientmechanical ventilation without PEEPair leak from lung through chest tube
39
Assessment
Decreased or absent breath sounds on
affected side
Trachea deviated away from affected
side
Hyperresonance to percussion
Decreased blood pressure
Increased heart rate
Increased right sided heart pressures
Jugular venous distension
May or may not have decreased breath
sounds
No tracheal shift
Pleuritic chest pain on affected side
Vital signs normal; may have slightly
increased respiratory rate
Typically adolescent male, may have
had this before
Typically treated with watchful waiting
& repeat chest radiograph; perhaps 23
hour admission for observation
Diminished breath sounds on affected
side
May have pleuritic chest pain on
affected side
Dyspnea due to lung compression
Increased respiratory rate
Dullness to percussion
History of CHF, cancer or other
condition that could lead to pleural
effusion
Should have normal vital signs
One or two chest tubes in place
Bubbling in water seal chamber with
ventilator breath
Chest drain on suction
Postoperative trauma patient with flailchest and pneumothoraxARDSMechanical ventilation with 12 cmH2OPEEP
Postoperative coronary artery bypassgraft via median sternotomyLeft internal mammary artery graftPleural space entered during surgeryPleural chest tubes in place
Postoperative coronary artery bypassgraftMedian sternotomy, saphenous vein graftRoutine postoperative course
Postoperative coronary artery bypassgraftMedian sternotomy, saphenous vein graftCardiac tamponade
40
May have decreased breath sounds on
affected side
May have one or multiple chest tubes
Poor oxygenation
High levels of mechanical ventilatory
support
Continuous bubbling in water seal
chamber due to PEEP
Chest drain on suction
Vital signs should be stable
Patient’s condition overall should be
stable
Mediastinal chest tubes in place
Pleural chest tube in place
May have more than one chest drain
May or may not have bubbling in water
seal, depending if there is an air leak
from the lung where the pleural space
was entered
Bloody to serosanguinous drainage in
collection chamber
Vital signs should be stable
Patient’s condition overall should be
stable
Mediastinal chest tubes in place
Should not have bubbling in water seal
Bloody to serosanguinous drainage in
collection chamber
Muffled heart tones
Reduced drainage from mediastinal
chest tubes
Decreased BP, increased HR, decreased
cardiac output, increased right heart
pressure
Jugular venous distention
41
New Product Introduction Worksheet
1. Specifically, what is being introduced? Pneumostat chest drain valve
2. Why is this product being introduced?
Innovation, regulatory requirement, better
product, standardization?
Innovation, better product than current one-way valve
3. What does the learner already know that
can be used as a foundation for learning
about this product? (It's similar to X)
Relate to water seal of chest drain system,relate to current one-way valve used forpneumothorax
4. How can learners "play" with the new
product to validate it based on past
experience?
Product inexpensive, able to unwrap sterileunits for handling for teaching purposes ,learners can hold
5. What information is the "need to know"
that will be immediately useful to the
learners in their "real world"?
How to hook up, how to assess air leak,how to drain fluid, when to change device,not to tape to chest, use clip to attach toclothing
6. How will this product solve a problem or
fill a need the learner has? Make their job
easier?
No need to jury-rig one -way valve for fluiddrainage, self-contained, no risk of spillage& violating standard precautions, lighter forpatient
7. How can learners be actively involved in
learning about this new product?
Let them handle device, refer to CreativeTraining Strategies Handbook for ideas
8. How will the information you provide
apply to everyday practice? (Relate content
to practice)
One-way valve already in use, no theoryneeded - purely practical info on how deviceworks & how to monitor
9. What are the likely perceptions of
patients/families the nurse should be ready
for?
Patients should be pleased, device muchlighter than drainage tubing, allowsmobility
42
Notes to Users:
Items 2 - 8 focus on adult learning principles
Items 1, 9 - 13 focus on product introduction principles
References:
Impact of self-instructional module for the nurses on nursing-management of the patients
having chest tube drainage. Nursing Journal of India 2002; 94(2):33-34.
McClellan M, Henson RHS: Introducing new technology: confusion or order? NursingManagement 1994;25(7):38-41.
Padberg RM, Padberg LF: Strengthening the effectiveness of patient education: applying the
principles of adult education. Oncology Nursing Forum 1990;17(1):65-69.
10. Does the nurses need to know a lot of
information to use the product safely, or
does the nurse need to know about the
product, but the primary user will be
someone else?
Nurses will need to be experts, monitor thedevice and perform pulmonary assessmentsas with any patient with a chest tube
11. What support is available to nurses
using the product? (24 hour telephone
support, learning guides, internal support)
24/7 toll free number from manufacturer
12. How will this product affect the nursing
role? Simplify or make more complex?
Should make nursing role easier - self-contained unit eliminates need to rig updrainage collection - no risk of spillage
13. Is this product introduction an
organization priority? Can it be delayed?
Who benefits from successful introduction?
Priority for fast-track program, do not wantto delay, benefits: patient, hospital withreduced LOS, surgeons, pulmonaryphysicians, interventional radiologists, ER,nurses
43
New Product Introduction Worksheet
1. Specifically, what is being introduced? Express Mini 500 Chest Drain
2. Why is this product being introduced?
Innovation, regulatory requirement, better
product, standardization?
Innovation, key to fast-track program tofacilitate early ambulation in effort toreduce LOS
3. What does the learner already know that
can be used as a foundation for learning
about this product? (It's similar to X)
Same principles as traditional chest drain:collection chamber, mechanical one-wayvalve instead of water seal, preset suctionlevel -20cmH2O
4. How can learners "play" with the new
product to validate it based on past
experience?
Small compact drain, able to unwrap sterileunits - can demo negative pressure indicatorby inhaling through patient tube
5. What information is the "need to know"
that will be immediately useful to the
learners in their "real world"?
How to hook up, how to assess air leak ornegative intrapleural pressure, how toapply straps so patient can ambulate easily
6. How will this product solve a problem or
fill a need the learner has? Make their job
easier?
Lighter weight, less pain for patient, mucheasier for patient to get out of bed; patientcan walk independently
7. How can learners be actively involved in
learning about this new product?
Handle device, refer to strategies inCreative Training Strategies Handbook
8. How will the information you provide
apply to everyday practice? (Relate content
to practice)
Chest drains already standard practice,emphasize organizational goals of earlyambulation and shorter LOS
9. What are the likely perceptions of
patients/families the nurse should be ready
for?
Patients should be pleased, device is muchlighter than traditional drain, less pullingon chest tube; may be apprehensive aboutwalking soon after surgery
44
Notes to Users:
Items 2 - 8 focus on adult learning principles
Items 1, 9 - 13 focus on product introduction principles
References:
Impact of self-instructional module for the nurses on nursing-management of the patients
having chest tube drainage. Nursing Journal of India 2002; 94(2):33-34.
McClellan M, Henson RHS: Introducing new technology: confusion or order? NursingManagement 1994;25(7):38-41.
Padberg RM, Padberg LF: Strengthening the effectiveness of patient education: applying the
principles of adult education. Oncology Nursing Forum 1990;17(1):65-69.
10. Does the nurses need to know a lot of
information to use the product safely, or
does the nurse need to know about the
product, but the primary user will be
someone else?
Nurses will be the experts, monitor thedevice and perform assessments as with anypatient with a chest tube
11. What support is available to nurses
using the product? (24 hour telephone
support, learning guides, internal support)
24/7 toll-free support from manufacturer,self-study CE program from manufacturer
12. How will this product affect the nursing
role? Simplify or make more complex?
Should simplify nursing care becausepatients will be able to walk moreindependently
13. Is this product introduction an
organization priority? Can it be delayed?
Who benefits from successful introduction?
Priority for fast-track programs in cardio-thoracic surgery and to enhance safety fortransportation on LifeFlight; want toimplement ASAP, patients, staff andorganization all benefit
45
New Product Introduction Worksheet
1. Specifically, what is being introduced?
2. Why is this product being introduced?
Innovation, regulatory requirement, better
product, standardization?
3. What does the learner already know that
can be used as a foundation for learning
about this product? (It's similar to X)
4. How can learners "play" with the new
product to validate it based on past
experience?
5. What information is the "need to know"
that will be immediately useful to the
learners in their "real world"?
6. How will this product solve a problem or
fill a need the learner has? Make their job
easier?
7. How can learners be actively involved in
learning about this new product?
8. How will the information you provide
apply to everyday practice? (Relate content
to practice)
9. What are the likely perceptions of
patients/families the nurse should be ready
for?
46
Notes to Users:
Items 2 - 8 focus on adult learning principles
Items 1, 9 - 13 focus on product introduction principles
References:
McClellan M, Henson RHS: Introducing new technology: confusion or order? NursingManagement 1994;25(7):38-41.
Padberg RM, Padberg LF: Strengthening the effectiveness of patient education: applying the
principles of adult education. Oncology Nursing Forum 1990;17(1):65-69.
10. Does the nurses need to know a lot of
information to use the product safely, or
does the nurse need to know about the
product, but the primary user will be
someone else?
11. What support is available to nurses
using the product? (24 hour telephone
support, learning guides, internal support)
12. How will this product affect the nursing
role? Simplify or make more complex?
13. Is this product introduction an
organization priority? Can it be delayed?
Who benefits from successful introduction?
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Kroehnert G: 100 Training Games. 1992 McGraw-Hill Book Company. Sydney
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Pike RW: Creative training techniques handbook ed 2. 1994 Lakewood Books.
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Pike RW: Creative training techniques workbook. 1990 Creative Training
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Zielinski D ed: The best of creative training techniques newsletter. 1990
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Chest Drainage
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47
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Carroll P: The surgical nurse's managed care manual. Total Learning Concepts,
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Carson MM, Barton DM, Morrison CC et al: Managing pain during mediastinal
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48
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49
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