Darlene “Cookie” Wilson, MSN, RN

Lungs Mediastinum

◦ Heart◦ Aorta and great

vessels◦ Esophagus◦ Trachea

Diaphragm contracts Moves down Increasing the volume of the

thoracic cavity When the volume increases,

the pressure inside ________.◦ aka?

Pressure within the lungs is called intrapulmonary pressure

Phrenic nerve stimulus stops

Diaphragm relaxes This ______ the volume of

the thoracic cavity Lung volume decreases,

intrapulmonary pressure _____.

If two areas of different pressure communicate, gas will move from the area of higher pressure to the area of lower pressure

◦ Parietal pleura ◦ lines the chest wall

◦ Visceral pleura (pulmonary) ◦ covers the lung

Parietal pleuraParietal pleura Visceral pleura Visceral pleura

Normal Pleural Fluid Quantity: Approx. 10-20 mL per lung

Normal Pleural Fluid Quantity: Approx. 10-20 mL per lung

LungLung

RibsIntercostal muscles

• The area between the pleura is called the pleural space (sometimes referred to as “potential space”)

• Normally, vacuum (negative pressure) in the pleural space keeps the two pleura together and allows the lung to expand and contract

• If air or fluid enters this space, there is a potential for impaired breathing.

archive.student.bmj.com/.../02/education/52.php

Diagnostic tests Client position Treatment depends on severity

◦ Chest tube◦ Heimlich valve on chest tube

Also called “thoracic catheters” Different sizes

From infants to adults Small for air, larger for fluid

Different configurations Curved or straight

Types of plastic PVC Silicone

Coated/Non-Coated Heparin Decrease friction

In what setting/environment is a chest tube placed?◦ A. Operating Room◦ B. Bedside◦ C. Emergency Room◦ D. All of the above◦ E. None of the above

Sterile technique Small incision Tube is sutured Dressing applied

◦ What type?

Choose site

Explore with finger

Place tube with clamp

Suture tube to chest

Photos courtesy trauma.org\

http://www.scielo.br/img/revistas/jbpneu/v34n8/en_a04fig01.gif

and their primary and their primary purposespurposes

Chest tube is attached to a drainage device ◦ Allows air and fluid to leave the chest◦ Contains a one-way valve to prevent air & fluid

returning to the chest◦ Designed so that the device is below the level

of the chest tube for gravity drainage.

1. Remove fluid & air as promptly as possible.2. Prevent drained air & fluid from returning

to the pleural space.3. Restore negative pressure in the pleural

space to re-expand the lung.

Dressing changes When?

No dependent loops What is this? Why?

Oxygen therapy Record output

How often? Analgesics ***Incentive Spirometer (IS) and turn,

cough, deep breathe (TCDB)

Health history-respiratory disease, injury, smoking, progression of symptoms

Physical exam- degree of apparent resp distress, lung sounds, O2 sat, VS, LOC, neck vein distention, position of trachea

All require observation for respiratory symptoms Pertinent nursing problems

◦ Acute pain◦ Ineffective airway clearance◦ Impaired gas exchange

How a chest drainage system

works

Tube open to atmosphere vents air Tube from patient

For drainage, a second bottle was added

The first bottle collects the drainage

The second bottle is the water seal

With an extra bottle for drainage, the water seal will then remain at 2cm

If suction is needed, a third bottle is added.

The depth of the water in the suction bottle determines the amount of negative pressure that can be transmitted to the chest, NOT the reading on the vacuum regulator

Expiratory positive pressure

Gravity

Suction

Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva)

Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest

Suction can improve the speed at which air and fluid are pulled from the chest

Collection chamber

Water seal chamber

Suction control chamber

from patient

Suction control bottle

Water seal bottle

Collection bottle

From patientTo suction

Chamber A◦ Suction control chamber

How do you know what level the water should be at? Chamber B

◦ Water seal chamber How do you know what level the water should be at? Should the ball be fluctuating in this chamber? What if it isn’t?

Chamber C◦ Air leak monitor

What does bubbling mean? Chamber D

◦ Collection chamber When do you record output?

Be sure you under stand how to set up the system, the function of each chamber and how to troubleshoot issues with each chamber.

Water seal is a window into the pleural space

Not only for pressure If air is leaving the chest

through an air leak, bubbling will be seen here

Air meter (1-5) provides a way to “measure” the air leaving and monitor over time – getting better or worse?

Focused respiratory assessment◦ Breath sounds◦ Respiratory rate◦ Respiratory depth ◦ SpO2◦ ABG◦ CXR

Cardiovascular assessment Level of consciousness Pain Chest tube

◦ Amount of drainage◦ Insertion site & dressing

System position Tubing position

◦ What happens when the patient lays on it? Connections to patient and system Assessing the system Monitoring output

What are some common complications?

Chest tube malposition (most common) Subcutaneous emphysema

What is this? What are some nursing interventions related to this

complication? High Fluid in Water Seal Chamber

Chest system may need to be vented Air leak

How do you know? What do you do?

Otherspleural effusion, inc. pneumo

mediastinal shiftDo chest tubes get clotted off?

What can happen when fluid is removed too fast?

Check fluid level in suction chamber Observe water seal chamber fluid level Assess for tidaling in water seal chamber Assess for tubing – non dependent Determine if the unit has been knocked

over Note the amount, color and consistency of

drainage

http://www.youtube.com/watch?v=WVHelcIIee8 (full review chest system – wet)

http://www.youtube.com/watch?v=74H6N-Qxm34&playnext=1&list=PLFCFEACCE12F1D1E0&index=26 (dry suction – start at 5:10)

http://www.youtube.com/watch?v=WVHelcIIee8

http://www.youtube.com/watch?v=74H6N-Qxm34&playnext=1&list=PLFCFEACCE12F1D1E0&index=26

Monitor your client Notify MD STAT if

◦ Significant drainage◦ Increasing shortness of breath◦ Pain◦ Absence of breath sounds

Do not remove suction without an order Manage pain When full - place in biohazard container Do not change collection device on client

with an air leak without an order When suction discontinued, must

disconnect from suction, not just turn off

What is the progression of events for discontinuing a chest tube?

Can a patient ambulate with a chest tube?

http://www.medicalive.net/186_chest_tube_insertion

If time permits http://www.atriummed.com/Products/Chest_Drains/edu-ocean.asp

Oasis dry suction set uphttp://www.google.com/imgres?imgurl=http://www.atriummed.com/Common/Images/help-oasis.jpg&imgrefurl=http://www.atriummed.com/products/chest_drains/education.asp&usg=__iFwkxjbty1SgU2UOxzHu7gyeorM=&h=100&w=100&sz=6&hl=en&start=2&zoom=1&um=1&itbs=1&tbnid=bjQxSvGWg2AsiM:&tbnh=82&tbnw=82&prev=/images%3Fq%3Doasis%2Bdry%2Bsuction%2Bchest%2Btube%2Bsystem%26um%3D1%26hl%3Den%26tbs%3Disch:1

Thank you, Thank you, Thank you, Thank you, etc.