SKILL 26-1

NSO

Caring for Patients With Chest Tubes Connected to Disposable Drainage Systems
through an inlet, causing the excess suction to dissipate. The extra air pulled into the chamber causes vigorous bubbling. If this occurs, lower the suction source setting to reduce noise and evaporation of the uid. The absence of bubbling indicates that no suction is being exerted into the system. Raise the suction setting to restore gentle bubbling.

Chest Tubes Module / Lessons 1 and 3

There are two types of commercial drainage systems: the water-seal and the waterless systems.

WATER-SEAL SYSTEMS
NSO

Chest Tube Module / Lesson 2

Two-Chamber Water-Seal System

On expiration, uid or air is forced out of the intrapleural space. Suction pulls air or uid through the chest tube into the drainage collection chamber. On entering the drainage collection chamber, this uid or air displaces the air present in the chamber by pushing it through the water seal and out of the system into the atmosphere. The water-seal chamber is left open to air in order to drain. If the tubing is clamped, there is no mechanism for air to vent. To maintain the water-seal system, the chest tube system must remain upright. When it is tipped or overturned, the water seal is disrupted.

Three-Chamber Water-Seal System

If suction is used, the three-chamber water-seal system (Fig. 26-6) is set up with the suction control chamber added. A prescribed amount of sterile uid (e.g., 20 cm of water) is poured into the suction control chamber, which is then attached to a suction source by tubing. The amount of sterile water added depends on the manufacturers recommendations. The chamber is lled to the set volume for the prescribed amount of suction. Sterile water is added several times a day because of evaporation. As the uid level decreases, the amount of suction also declines. The wall or portable suction device is turned up until the water in the suction control bottle exhibits a continuous, gentle bubbling. This provides the prescribed amount of suction (negative pressure). If the suction source delivers more negative pressure than the suction control chamber water level allows, there is no danger because atmospheric air is pulled into the suction control chamber

FIG 26-6

Disposable waterless chest drainage system with suction.

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FLOW PATTERN Negative suction display Fluid Airflow

To suction source

scribed level, increase the suction source setting until it does. The system is now functioning with suction. There are usually two suction settings: one at either the suction control chamber or the oat ball setting and the other at the suction source. The chamber or oat ball setting is a safety factor to reduce the possibility that the intrapleural tissues receive too much suction, causing injury.

Patient chest drainage tubing

Dry Suction System

Dry suction control systems provide many advantages (Fig. 26-8). Higher suction pressure levels are achieved, set up is easy, and the lack of continuous bubbling provides for quiet operation. There is no uid to evaporate, which decreases the amount of suction necessary. A self-compensating regulator controls dry suction units. A dial is set to the prescribed suction control setting. These units are preset to 20 cm of water pressure, but they are adjustable from 10 to 40 cm of water pressure. However, the dry suction control systems do require sterile water in the water-seal chamber.

FIG 26-7

Disposable waterless chest drainage system with suction.

Delegation Considerations
The skill of caring for a patient with a chest tube connected to a disposable drainage system cannot be delegated to nursing assistive personnel (NAP). However, NAP may assist with other aspects of the patients care, such as monitoring vital signs. The nurse directs the NAP about: Proper positioning of the patient with chest tubes to facilitate chest tube drainage and optimal functioning of the system How to ambulate and transfer patient with chest drainage Immediately informing the nurse of any changes in vital signs, chest pain, or sudden shortness of breath, or excessive bubbling in water-seal chamber Immediately informing the nurse if there is disconnection of system, change in type and amount of drainage, sudden bleeding, or sudden cessation of bubbling

The middle chamber of a traditional chest drainage system is the water seal. The main purpose of the water seal is to allow air to exit from the pleural space on exhalation and prevent air from entering the pleural cavity or mediastinum on inhalation. When the appropriate amount of sterile water is added, a 2-cm water seal is established. To maintain effective water seal the chest drainage unit must remain upright and you must monitor the water level in the water-seal chamber to check for evaporation. Bubbling in the water-seal chamber indicates an air leak.

WATERLESS SYSTEMS
Two-Chamber Waterless System
The principles of the waterless system are similar to those of the water-seal system except that uid is not required for setup. Because water is not used, accidentally tipping over the system does not compromise the patients condition. The water seal is replaced by a one-way valve (Fig. 26-7) located near the top of the system. Most of the container serves as the drainage chamber. The suction chamber does not depend on water. Instead, it contains a oat ball, which is set by a suction control dial after the suction source is turned on. A diagnostic airleak indicator is located on the face of the unit. It does require the addition of 15 mL of uid for visualization. The indicators function is to identify one of the following: 1 The lung is expanding normally. This is indicated by a gentle tidaling of the uid in the diagnostic indicator. 2 The lung is probably reexpanded if after 2 or 3 days the tidaling has stopped. 3 There is an air leak in the system if, when facing the system, the observer sees the uid bubbling left to right. Locate and correct the source of the air leak.

EQUIPMENT
Disposable chest drainage system as ordered Suction source and setup (wall canister or portable) Water suction system: Add sterile water or normal saline (NS) solution to cover the lower 2.5 cm (1 inch) of water-seal U tube, sterile water or NS to pour into the suction control chamber if suction is to be used (see manufacturers directions) Waterless system: Add vial of 30 mL injectable sodium chloride or water, 20-mL syringe, 21-gauge needle, and antiseptic swab Clean gloves Sterile gauze sponges Local anesthetic, if this is not an emergent procedure Chest tube tray (all items are sterile): Knife handle (1), chest tube clamp, small sponge forceps, needle holder, knife blade No. 10, 3-0 silk sutures, tray liner (sterile eld), curved 8-inch Kelly clamps (2), 4 4 inch sponges (10), suture scissors, hand towels (3), sterile gloves Dressings: Petrolatum gauze, split chest-tube dressings, several 4 4 inch gauze dressings, large gauze dressings (2), and 4-inch tape or elastic bandage (Elastoplast) Head cover Face mask/face shield Sterile gloves Rubber-tipped hemostats for each chest tube (2) 1-inch adhesive tape for taping connections Stethoscope, sphygmomanometer, and pulse oximeter

Three-Chamber Waterless System

When suction is ordered, attach the suction chamber port to the suction source by tubing, turn the suction on, and set the oat ball to the prescribed setting. If the oat ball does not rise to the pre-

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SKILL 26-1

Positive pressure valve release

In-line connector Suction port

B Water seal chamber

Needleless access port

A Dry suction regulator E Suction monitor bellows C Air leak monitor

D Collection chamber

Patient tube clamp

Patient pressure float ball

Swing out floor stand

Patient connector

FIG 26-8

Dry suction chest drainage system. (Courtesy Atrium Medical Corp.)

STEP
ASSESSMENT 1 Obtain baseline and serial vital signs, oxygen saturation (SpO2), and level of orientation.
2 Know patients current hemoglobin and hematocrit levels. 3 Assess pulmonary status:

RATIONALE
Baseline vital signs are essential for any invasive procedure. Patients requiring chest tube insertion frequently have respiratory distress. Changes in vital signs and level of orientation may indicate decreased levels of oxygen and/or hypoxia. Provides measure reecting blood loss and subsequent levels of oxygenation. Patients in need of chest tubes have impaired oxygenation and ventilation. The degree of the signs and symptoms associated with respiratory distress is related to the size of the pneumothorax, hemothorax, or preexisting illness of the patient. Sharp stabbing chest pain with or without decreased blood pressure and increased heart rate may indicate a tension pneumothorax. The presence of a pneumothorax or hemothorax is painful, frequently causing sharp inspiratory pain. In addition, there is discomfort associated with the presence of a chest tube, not just with the insertion of the tube. As a result of this discomfort, patients tend to not cough or change position in an effort to minimize this pain (Milgrom and others, 2004). Povidone-iodine or chlorhexidine are antiseptic solutions used to cleanse the skin during tube insertion (Coughlin and Parchinsky, 2006). Lidocaine is a local anesthetic administered to reduce pain. The chest tube will be held in place with tape. Iodine, lidocaine, and tape are common allergens.

Signs and symptoms of increased respiratory distress: Displaced trachea, decreased breath sounds over the affected and nonaffected lungs, marked cyanosis, asymmetrical chest movements. b Assess for sharp, stabbing chest pain or chest pain on inspiration, hypotension, and tachycardia (Carroll, 2002). If possible, ask patient to rate level of comfort on a scale of 0 to 10.
a

Assess patient for known allergies. Ask patients if they have had a problem with medications, latex, or anything applied to the skin.

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STEP
5 Review patients medication record for anticoagulant therapy,

RATIONALE
Anticoagulation therapy can increase procedure-related blood loss.

including aspirin, warfarin, heparin, or platelet aggregation inhibitors such as ticlopidine or dipyridamole. 6 For patients who have chest tubes, observe: a Chest tube dressing and site surrounding tube insertion

Tubing for kinks, dependent loops, or clots

Chest drainage system, which should remain upright and below level of tube insertion

Ensures that dressing is intact and occlusive seal remains without air or uid leaks and that area surrounding insertion site is free of drainage or skin irritation (Carroll, 2002). Maintains a patent, freely draining system, preventing uid accumulation in chest cavity. Subcutaneous emphysema can occur if the tubing is blocked or kinked. When the tubing is coiled, looped, or clotted, the drainage is impeded, and there is an increased risk for a tension pneumothorax or surgical emphysema. If the drainage is lengthy and the chest tube remains in place for some time, the patients risk for infection increases (Allibone, 2003). An upright drainage system facilitates drainage and maintains the water seal.

NURSING DIAGNOSES Anxiety

Acute pain

Impaired gas exchange

Individualize related factors based on patients condition or needs.

PLANNING 1 Expected outcomes following completion of procedure: Patient is oriented and is less anxious. Vital signs are stable. Patient reports no chest pain. Breath sounds are auscultated in all lobes. Lung expansion is symmetrical, SpO2 is stable or improved, and respirations are nonlabored. Chest tube remains in place, and chest drainage system remains airtight. Gentle tidaling (uctuations or rocking) is evident in water seal or diagnostic indicator. 2 Check agency policy, and determine whether informed consent is needed. 3 Review health care providers role and responsibilities for chest tube placement (Table 26-1, p. 712). The nursing responsibilities and interventions are detailed in the steps of this skill. 4 Explain procedure to patient. 5 Perform hand hygiene. 6 Set up the prescribed drainage system. Note: Open the system when health care provider is ready to insert chest tube. a Prepare a water-seal drainage system (check manufacturers guidelines): (1) Obtain chest drainage system. Remove wrappers, and prepare to set up the system. (2) While maintaining sterility of the drainage tubing, stand the system upright, and add sterile water or normal saline to the appropriate compartments. (a) For a two-chamber system (without suction): Add 2 cm sterile water to the water-seal chamber (second chamber), which is enough to submerge the water-seal tube and create a one-way valve (Roman and Mercado, 2006).

Hypoxia is relieved. Decreased hypoxia improves vital sign measures. Reexpansion of the lung reduces chest pain. Reexpansion of the lung promotes normal respirations.

Indicates correct placement and patency of the chest tube drainage system. Indicates system is functioning normally. Reects changes in intrapleural pressure. In nonemergent situations most institutions require informed, written permission for chest tube insertion. Helps differentiate health care provider and nurse roles so that the nurse can function more effectively.

Reduces anxiety and promotes patient cooperation. Reduces transmission of microorganisms. Premature opening of the sterile chest drainage system increases risk for contamination of sterile equipment. System permits displaced air to pass into the atmosphere. Maintains sterility of the system. The system is packaged for use in sterile operating room conditions. Reduces possibility of contamination.

The water seal creates a one-way valve allowing uid and air to drain from the patients chest and not return (Roman and Mercado, 2006).

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

SKILL 26-1

STEP
(b) For a three-chamber system (with suction): Add 2 cm sterile water to the water-seal chamber (middle chamber). Add amount of sterile solution prescribed by health care provider to the suction control (third chamber), usually 20 cm water pressure (8 inches). Connect tubing from suction control chamber to suction source. (Tailor length of drainage tube to patient.) (See illustration.)

RATIONALE
The amount of uid in the suction control chamber governs the suctions intensity, not the amount of suction delivered from an outside suction source, such as a portable or wall suction unit (Roman and Mercado, 2006). For example, 20 cm of water is approximately 20 cm of water pressure.

Air vent To suction

From client

Suction Water control seal

Drainage collection chamber From client

To suction Air vent

Suction control

Water seal

Drainage collection

STEP 6a(2)(b) Top, The Pleur-Evac drainage system, a commercial three-chamber chest drainage device. Bottom, Schematic of the drainage device.
Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

STEP
(c) For a dry suction system: Fill the water-seal chamber with 2 cm sterile water. Adjust the suction control dial to the prescribed level of suction; suction ranges from 10 to 40 cm of water pressure. The suction control chamber vent is never occluded when suction is used. Note: On a dry suction system, DO NOT obstruct the positive pressure relief valve. This allows air to escape.

RATIONALE
The automatic control valve on the dry suction control device adjusts to changes in patient air leaks and uctuation in suction source and vacuum to deliver the prescribe amount of suction (Roman and Mercado, 2006).

Provides a safety factor of releasing excess negative pressure into the atmosphere through the suction control vent. Too little suction prevents lung reexpansion and increases patients risk for infection, atelectasis, and tension pneumothorax. Too much suction damages the lung tissue and perpetuates existing air leaks (Allibone, 2003).

b Prepare a waterless drainage system (check manufacturers guidelines):

(1) (2) (3)

(4)

Remove sterile wrappers, and prepare to set up equipment. For a two-chamber system (without suction) nothing is added or needs to be done to the system. For a three-chamber waterless system with suction, connect tubing from suction control chamber to the suction source. Instill 15 mL of sterile water or normal saline into the diagnostic indicator injection port located on top of the system.

Maintains sterility of the system. The system is packaged in this manner for use in sterile operating room conditions. The waterless two-chamber system is ready for connecting to the patients chest tube after opening the wrappers. The suction source provides additional negative pressure to the system. Instillation of water into the injection port enables observation of the rise and fall in the diagnostic air-leak window. Constant left-to-right bubbling or rocking is abnormal and may indicate an air leak.

Critical Decision Point

This step is not necessary for mediastinal drainage because there will be no tidaling. Also, in an emergency it is not necessary because the system does not require water for setup.

7 Provide two shodded hemostats or approved clamps for each

chest tube, attached to top of patients bed with adhesive tape. Chest tubes are clamped only under the following specic circumstances per health care provider order or nursing policy and procedure: a To assess air leak (Table 26-2, p. 713) b To quickly empty or change disposable systems c To assess if patient is ready to have chest tube removed (which is done by health care providers order); monitor the patient for recurrent pneumothorax (Roman and Mercado, 2006) 8 Position the patient: During the chest tube insertion the patient will need to be positioned so the patients back or the side in which the tube will be placed is accessible to the health care provider. IMPLEMENTATION 1 Perform hand hygiene, and apply clean gloves. 2 Administer premedication, such as sedatives or analgesics, as ordered.

Shodded hemostats have a covering to prevent hemostat from penetrating chest tube once changed. The application of these shodded hemostats or other clamps to a chest tube prevents air from reentering the pleural space (Allibone, 2003).

Permits optimal drainage of uid and/or air.

Reduces transmission of microorganisms. Reduces patient anxiety and pain during procedure.

Critical Decision Point During procedure carefully monitor patient for changes in level of sedation.
3

Assist health care provider in providing psychological support to the patient. (See health care providers responsibilities in Table 26-1, p. 712.) a Reinforce preprocedure explanation.
b

Reduces patient anxiety and assists in efcient completion of procedure.

Coach and support patient throughout procedure.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

SKILL 26-1

STEP
4 Show local anesthetic to health care provider.

RATIONALE
Allows health care provider to read label of drug before administering it to patient. Allows health care provider to withdraw solution properly while maintaining surgical asepsis.

Hold anesthetic solution bottle upside down with label facing health care provider. Health care provider will withdraw solution and inject into patients skin. a Health care provider places chest tube. (A standard procedure is detailed in Table 26-1, p. 712.) 6 Help health care provider attach drainage tube to chest tube. 7 After the chest tube is inserted, secure connection between chest tube and chest drainage system with waterproof adhesive tape. Tape all connections in a double spiral fashion with 1-inch adhesive tape; be sure not to totally obliterate view of drainage. (Note: Taping of the chest tube is usually done by the health care provider at time of tube placement; check agency policy.) Then: a Check systems for proper functioning: (1) Clamp the drainage tubing that will connect the patient to the system.
5

Connects drainage system and suction (if ordered) to the chest tube. Secures chest tube to drainage system and reduces risk for air leak causing breaks in airtight system.

(2) Connect tubing from the oat ball chamber to the suction source. (3) Turn on the suction to the prescribed level.

Provides a chance to ensure an airtight system before connecting it to the patient. Allows correction or replacement of system if it is defective before connecting it to the patient. Note: Bubbling will be seen at rst because there is air in the tubing and system initially. This usually stops after a few minutes unless there are other sources of air entering the system.

Critical Decision Point If bubbling continues, check connections and locate source of the air leak, as described in Table 26-2 (p. 713).
b Check chest tube placement with x-ray lm. 8 Turn off suction source, and unclamp drainage tubing before

connecting patient to the system.

Veries chest tube placement. Having the patient connected to suction when it is being inserted has the potential to damage pleural tissues from sudden increase in negative pressure. The suction source is turned on again after the patient is connected to the three-chamber system. Permits the displaced air to pass into the atmosphere. Provides safety factor of releasing excess negative pressure into the atmosphere. Provides safety factor of releasing excess negative pressure.

Check patency of air vents in system: a Conrm that water-seal vent is not occluded. b Conrm that suction control chamber vent is not occluded when suction is used. c Conrm that valves are unobstructed. Note: Waterless systems have relief valves without caps. For dry suction systems, the positive pressure relief valve must remain unobstructed. 10 Lay excess tubing horizontally on mattress next to patient. Secure with a rubber band and safety pin or the systems clamp.
9 11 Adjust tubing to hang in a straight line from the chest tube to

the drainage chamber.

Prevents excess tubing from hanging over the edge of the mattress in a dependent loop. Drainage collected in the loop can occlude the drainage system, which predisposes patient to a tension pneumothorax (Roman and Mercado, 2006). Promotes drainage and prevents uid or blood from accumulating in the pleural cavity.

Critical Decision Point Frequent gentle lifting of sections of the drain allows gravity to assist blood and other viscous material to move to the drainage bottle. Patients with recent chest surgery or trauma need to have the chest drain lifted based on assessment of the amount of drainage; some patients might need chest tube drains lifted every 5 to 10 minutes until drainage volume decreases (Lehwaldt and Timmins, 2005). However, when coiled or dependent looping of tubing is unavoidable, the tubing is lifted every 15 minutes at a minimum to promote drainage (Allibone, 2003).

Critical Decision Point Check institutional policy before stripping or milking chest tubes (see Evidence-Based Practice section). This practice is being discontinued at most institutions because it is believed that stripping the tube greatly increases intrathoracic pressure, which damages the pleural tissue and causes or worsens an existing pneumothorax. However, even though the literature is contradictory, milking may be done in selected patients (e.g., fresh postoperative thoracic surgery in presence of multiple clots). The rationale for this selective use of stripping or milking is that the presence of clotted tube drainage causes decreased rate of reexpansion and increases risk for tension pneumothorax (Allibone, 2003). In these selected cases the benets outweigh the risks.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

STEP
12 Gently lift sections of the postoperative mediastinal chest

RATIONALE
Maintains tubing in dependent position and facilitates drainage (Roman and Mercado, 2006). Reduces patient anxiety and promotes cooperation. Air rises to the highest point in the chest. Pneumothorax tubes are usually placed on the anterior aspect at the mid-clavicular line, second or third intercostal space (Allibone, 2003). Permits optimal drainage of uid. Posterior tubes are placed on the mid-axillary line, fth or sixth intercostal space. Prevents accidents involving contaminated equipment. Reduces spread of microorganisms.

tubes. Observe drainage for clots or debris in the tubing. 13 After the tube is placed, assist patient to a comfortable position: a Semi-Fowlers to high-Fowlers position to evacuate air (pneumothorax) High-Fowlers position to drain uid (hemothorax, pleural effusion) 14 Remove gloves, and dispose of used soiled equipment. 15 Perform hand hygiene.
b

EVALUATION 1 Monitor vital signs, oxygen saturation, and insertion site every 15 minutes for the rst 2 hours. 2 Monitor chest tube drainage: a Assessment after chest tube insertion is done every 15 minutes for the rst 2 hours. This assessment interval then changes on the basis of patients status. Mark the time and level of drainage on the calibrated write-on strip periodically. b Observe type and amount of uid drainage: Note color and amount of drainage, patients vital signs, and skin color. Look at the uid in the collection tubing, not just the uid in the collection chamber. Is the drainage bright red, dark red, or pink? Is it opaque, or can you see through it? c Expected drainage in the adult: Less than 50 to 200 mL/hr immediately after surgery in a mediastinal chest tube. Approximately 500 mL in the rst 24 hours. d Expected drainage in the adult: Between 100 and 300 mL of uid may drain from a pleural tube during the rst 3 hours after insertion. The 24-hour rate is 500 to 1000 mL. Drainage is grossly bloody during the rst several hours after surgery and then changes to serous. Remember that a sudden gush of drainage may be retained (dark) blood and not active (bright red) bleeding. This increased drainage can result from patient position changes.

Provides immediate information about procedure-related complications such as respiratory distress and leakage. Permits timely and efcient account of the amount of drainage from the chest tube. Drainage is marked at specied periods of time and documented in the nurses notes and intake and output (I&O) sheet. Ensures early detection of complications.

Dark-red drainage is expected only during the immediate postoperative period. This drainage turns serous over time. Reexpansion of the lungs forces drainage into the tube. Coughing can also cause large gushes of drainage or air. Acute bleeding indicates hemorrhage.

Critical Decision Point If drainage suddenly increases, is bright red, or there is more than 100 mL/hr of bloody drainage (except for the rst 3 hours postoperatively), the nurse noties the health care provider, remains with the patient, and assesses vital signs and cardiopulmonary status.
3 Evaluate patient for decreased respiratory distress and chest

pain, breath sounds over affected lung area, and change in oxygen saturation.

4 Ask patient to rate level of comfort on a scale of 0 to 10.

Increase in respiratory distress and/or chest pain, decrease in breath sounds over the affected and nonaffected lungs, marked cyanosis, asymmetrical chest movements, presence of subcutaneous emphysema around tube insertion site or neck, hypotension, tachycardia, and/or mediastinal shift are critical and indicate a severe change in patient status, such as excessive blood loss or tension pneumothorax (Allibone, 2003; Roman and others, 2003). Notify health care provider immediately. Indicates need for analgesia. Patient with chest tube discomfort hesitates to take deep breaths and as a result is at risk for pneumonia and atelectasis. Ensures that dressing is occlusive.

5 Observe the drainage system: a Inspect chest tube dressing and drainage.

Critical Decision Point Check the dressing carefully. It can come loose from the skin, although this may not be readily apparent.
b

Inspect tubing for kinks and dependent loops.

Straight and coiled drainage tube positions are optimal for pleural drainage. However, when dependent loop is unavoidable, periodic lifting and draining of the tube will also promote pleural drainage (Allibone, 2003; Lehwaldt and Timmons, 2005).

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

SKILL 26-1

STEP
c

RATIONALE
Maintains proper functioning, facilitates drainage, and maintains the water seal.

The chest drainage system remains upright and below level of tube insertion. Note presence of clots or debris in tubing.

Critical Decision Point Monitor the position of the system relative to the chest tube carefully, especially during patient transport.
d

Inspect water seal for uctuations with patients inspiration and expiration. (1) Waterless system: Diagnostic indicator for uctuations with patients inspirations and expirations.

(2) Water-seal system: Bubbling in the water-seal chamber (see Table 26-2, p. 713).

(3) Water-seal system: Bubbling in the suction control chamber (when suction is being used) (see Table 26-2, p. 713). Waterless system: Bubbling in diagnostic indicator.

Waterless system: The suction control (oat ball) indicates the amount of suction the patients intrapleural space is receiving.

6 After rst 2 hours, assess patients physical and psychological

status at least every 4 hours or according to agency policy.

In the nonmechanically ventilated patient, uid rises in the water seal or diagnostic indicator with inspiration and falls with expiration. The opposite occurs in the patient who is mechanically ventilated. This indicates that the system is functioning properly (Lewis and others, 2008). When system is initially connected to the patient, bubbles are expected from the chamber. These are from air that was present in the system and in the patients intrapleural space. After a short time the bubbling stops. Fluid continues to uctuate in the water seal on inspiration and expiration until the lung is reexpanded or the system becomes occluded. Suction control chamber has constant, gentle bubbling. Tubing to the suction source remains free of obstruction, and the suction source is turned to the appropriate setting. Mechanism to observe for the presence of tidaling. Character of drainage indicates if normal or if infection or hemorrhage is developing. The suction oat ball dictates the amount of suction in the system. The oat ball allows no more suction than dictated by its setting. If the suction source is set too low, the suction oat ball cannot reach the prescribed setting. In this case the suction is increased for the oat ball to reach the prescribed setting. Detects early signs and symptoms of complications: Apprehension: Increase in patient anxiety, restlessness, and inability to concentrate Respiratory distress: Alteration in rate and/or depth of respirations, difculty breathing, and breath sounds Subcutaneous emphysema: Air that is being trapped in the subcutaneous tissue

Unexpected Outcomes
1 Air leak unrelated to patients respirations occurs. 2 There is no chest tube drainage.

Related Interventions
Locate source (see Table 26-2, p. 713). Notify health care provider. Observe for kink in chest drainage system. Observe for possible clot in chest drainage system. Observe for mediastinal shift or respiratory distress (medical emergency). Notify health care provider. Immediately apply pressure over chest tube insertion site. Have assistant apply occlusive gauze dressing, and tape three sides. Notify health care provider. Obtain vital signs. Monitor drainage. Assess patients cardiopulmonary status. Notify health care provider.

3 Chest tube is dislodged.

4 Substantial increase in bright red drainage occurs.

5 Continuous bubbling is seen in water-sealed chamber, indicating leak between patient and water seal.

Tighten loose connections. Check agency policy, and if instructed, cross-clamp chest tube closer to patients chest. If bubbling stops, air leak is inside patients thorax or at chest tube insertion site. Unclamp chest tube. Reinforce dressing. Notify health care provider.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Recording and Reporting

Record level of patient comfort, baseline vital signs, including oxygen saturation. If postoperative patient, record vital signs and oxygen saturation every 15 minutes for at least 2 hours postoperatively. Record chest drainage output hourly for at least 2 hours, and then record as patient status indicates. Document time, type, and amount of drainage. Record integrity of chest suction system (e.g., record the amount of bubbling in the waterseal suction control chamber, level of suction, intactness of system). Report patient response to chest tube insertion or continuation, noting level of comfort, drainage, and intactness of the system.

Gerontological Considerations
Fragility of the older adults skin requires special care and planning for management of chest tube dressing. Frequently assess surrounding skin for signs of skin breakdown (Meiner and Lueckenotte, 2006).

Home Care Considerations

Patients with chronic conditions (e.g., uncomplicated pneumothorax, effusions, empyema) that require long-term chest tube may be discharged with smaller mobile drains (Carroll, 2002, 2005). Instruct patient in how to ambulate and remain active with a mobile chest tube drainage system. Instruct patient and caregivers in when to contact health care professionals regarding changes in the drainage system (e.g., chest pain, breathlessness, change in color or amount of drainage, leakage on the dressing around the chest tube). Provide patient and caregiver information specic to the type of drain, and when possible have patient demonstrate proper maintenance of the mobile drainage system. Most of these systems do not have a suction control chamber and use a mechanical one-way valve instead of a water-seal chamber. For example, if a one-way utter valve is used, the arrow on the housing must always point away from the patient. Otherwise there is a risk for air trapping and a recurrent pneumothorax. The Pneumostat and Express Mini mobile devices have built-in collection chambers, and the Express Mini uses dry suction set at 20 cm H2O (Carroll, 2005).

Teaching Considerations
Instruct patient and family regarding proper functioning of chest tube and drainage system. Instruct patient to immediately report any changes in chest comfort.

Pediatric Considerations
If possible, using pictures and special dolls, familiarize child and family with equipment before inserting chest drainage system (Hockenberry and Wilson, 2007). Allow child to play with equipment and special dolls before inserting chest drainage system. Chest tube drainage greater than 3 mL/kg/hr for more than 2 consecutive hours is excessive and may indicate postoperative hemorrhage (Hockenberry and Wilson, 2007).

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.