Chest tubes NCLEX review on how to care for a patient with chest tube drainage systems. The nurse is responsible for monitoring the patient and chest tube drainage system while maintaining the chest tube system.
Therefore, the nurse must know for the NCLEX exam how a chest tube system works, what to do in you note bubbling, what to do if something goes wrong, and the nurse’s role during chest tube removal.
After you watch the lecture below and review the NCLEX notes, be sure to take the chest tube care NCLEX quiz.
This material details the following:
- Purpose of chest tubes
- Reasons for chest tube insertions
- Difference between a wet suction and dry suction drainage system
- Information about the drainage collection chamber, water seal chamber, and suction control chamber
- Normal versus abnormal findings while monitoring a chest tube drainage system
- Nursing interventions for chest tube care
- Nurse’s role during chest tube removal
Lecture on Nursing Chest Tube Care for NCLEX
NCLEX Review for Chest Tubes
Purpose of Chest Tubes: a tube inserted into the pleural space of the lungs to remove air or fluid and to help the lung re-expand OR it is a tube placed in the mediastinum space to help drain blood or fluid from around the heart after cardiac surgery.
- Mediastinal chest tubes are usually placed after cardiac surgery to help drain blood from the pericardial space (placed under the sternum) which prevents fluid from compressing the heart which can lead to cardiac tamponade.
Pleural space: a small space that surrounds the lungs that contains a small amount of serous fluid. This small space is surrounded by the parietal and visceral pleurae. These two layers glide over each other which creates a negative pressure. Therefore, if air or extra fluid enters into the pleural space the lungs are severely affected and can collapse.
Reasons for a chest tube:
- Cardiovascular surgery
- Pneumothorax: air enters into the pleural space and causes the lung to collapse (trauma to the chest or spontaneous)
- Pleural Effusion: fluid in the pleural space
- Types of Pleural Effusions:
- Hemothorax: blood enters in the pleural space and causes lung to collapse (trauma to the chest, disease TB, blood clotting issue)
- Empyema (infection in the pleural space)
- Chylothorax (lymphatic fluid in pleural space),
- Types of Pleural Effusions:
Type of Chest Tubes Drainage Systems
*Always familiarize yourself with what your facility uses and be sure to receive the proper training because each hospital uses different drainage systems.
Wet Suction (water seal suction) or Dry Suction
Wet: suction regulated by the height of water in the suction control chamber when connected to wall suction…some have stop-cocks to help regulate to amount of bubbling (you will hear bubbling while it’s working….water evaporates overtime so you will have to re-add it)…physician determines the suction level (usually -20cmH2O).
Dry Suction: This chest drainage system has no water column to control suction but uses a suction monitor bellow (looks like an orange accordion) that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems.
Nursing Management of a Chest Tube:
Drainage system itself: keep system below patient’s chest
Tubing: Keep it free from kinks and make sure it is draining freely (not clots or stagnate fluid) and that all connections are sealed
Drainage Collection Chamber: Monitor drainage (color, amount…..should drain no more than 100 cc/hr and record routinely)
Water Seal Chamber: performs an underwater seal on the tube to allow air to be removed from pleural space while preventing outside air from entering lungs
- NCLEX: Water in the water seal chamber fluctuates as the patient breathes in and out. If the patient is breathing on their own the water will increase during inspiration and decrease during expiration (it will be the opposite if the patient is on positive pressure mechanical ventilation). There may be intermittent bubbling, which is expected as air is drained from the pleural space, especially for treatment of a pneumothorax. Remember that a pneumothorax is an AIR leak between the lung and chest wall….therefore air can escape into the water seal chamber causing intermittent bubbles.
- What if it doesn’t fluctuate at all? The lung could have re-expanded or there is a kink somewhere.
- Excessive bubbling? There is an air leak somewhere.
Suction Control Chamber:
Dry: suction controlled by a dial on the side and is regulated by suction monitor bellow (orange accordion). There is no water column.
Wet: remember watch the amount of water because it evaporates over time and it should gently bubble due to the suction working.
- *Water in the water seal and suction control can evaporate over time so watch the water and add as needed.
Patient Assessment: Note lung sounds, rate, any dyspnea? Worsening pneumothorax or hemothorax
- Note skin around insertion site for any subcutaneous crepitus (crackling sensation felt on palpitation) that is due to carbon dioxide escaping into the tissues.
- Keep patient moving by turning frequently, coughing, and deep breathing…helps move fluid and improve lung function
Mishaps with a Chest Tube and What to Do?
- What to do if chest tube becomes dislodged? Cover the site with a sterile dressing, and tape on three sides (this allows air to escape and prevent tension pneumothorax) and notify physician immediately.
- System breaks? Insert the tube 1 inch into a bottle of sterile water or sterile normal saline and obtain a new system.
- Milking or stripping tubing? Not recommended anymore because it creates too much negative pressure (always follow hospital policies)
- Clamping tubing? Increase risk of patient developing a tension pneumothorax. Never do it without an order and follow hospital policies.
Chest tube removal:
Nurse’s role: assisting physician (done at beside)…some facilities allow nurses to do this if they’ve completed proper training and competencies.
- Gather supplies: sterile gloves, dressing supplies (occlusive, petroleum gauze, Telfa….every physician varies on their preference), mask, goggles, suture removal kit, tape, rubber tipped hemostats)
- Educate patient prior to remove and how to do the Valsalva’s maneuver. This is performed by having the patient take a deep breath, exhale, and bear down (prevents air for going back into pleural space). This will be performed by the patient when tube is removed.
- Pre-medicate for pain if ordered by physician.
- Position patient in Semi-Fowler’s for removal.
- Monitor respiratory status, lung sounds, drainage, assess chest for unequal chest rising, and dyspnea.
- Note: the patient will have chest x-ray (ordered by the physician) to assess lung expansion after removal.
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