What parts of the body consist of the thoracic cavity?
-aorta and great vessels
How does breathing work?
Breathing is all about pressure gradients
Air is made up of gas molecules> gas molecules create pressure when it collides in a confined space
Air moves from an area of HIGH PRESSURE to an area of LOW PRESSURE
When does inspiration in a breath occur?
1. Brain signals phrenic never to contract the diaphragm making it go down
2. intercostal muscles contract
3. thoracic cavity expands and intrapulmonary pressure increase and air moves in
MAIN: atmospheric pressure > intrapulmonary pressure>air moves in
When does expiration in a breath occur?
1. phrenic nerve stimulus stops and the diaphragm relaxes
2. intercostal muscles relaxes
3. thoracic cavity contracts and intrapulmonary decrease and air moves out
MAIN: intrapulmonary pressure > atmospheric pressure > air moves out
What is pleural?
thin tissue that surrounds the lungs and is a continuous membrane that folds over itself.
What are the two types of pleural?
Parietal pleura = lines the chest wall (outer layer)
Visceral pleura = covers the lungs (inner layer)
What is considered the pleural space?
potential space that is filled with pleural fluid
what is considered pleural fluid?
Fluid that reduces friction allowing the pleura to slide easily during breathing
holds the two layer together creating NEGATIVE pressure
What type of pressure do we need the lungs to be in at all times?
What will happen if air or fluid enters the pleural space between the parietal and visceral pleural?
The negative pressure that keeps the lungs against the chest wall will disappear and the lung will collapse.
What are conditions that require the need for chest tubes?
Pleural effusion-fluid in the lungs
Pneumothorax-air in the lungs
Hemothorax-blood in the lungs
Post cardiac surgery
What is tension pneumothorax?
air trapped in the lungs that cause a shift in the mediastinal organs d/t the pressure being so high everything shifts to the unaffected side of chest.
If a patient is experiencing either air, fluid, or blood in the lungs what type of signs/symptoms would the patient have?
pleuritic chest pain (pain when taking a deep breath)
asymmetric chest movement
decreased breath sounds on affected side
How would we generally treat a patient with air, fluid, or blood in their lungs?
1. remove the air, fluid, or blood ASAP
2. prevent drained air & fluid from returning to the pleural space
3. restore negative pressure in the pleural space so lungs can re-expand
What is the purpose of having chest tubes?
1. prevent air & fluid from returning to the pleural space with its one-way valve
2. allows air & fluid to leave the chest
What is a complication of post cardiac surgery?
What is cardiac tamponade?
Accumulation of blood or fluid in or around the pericardial sack
Causes compression of the heart muscle which cause cardiac arrhythmias and lead to death
How do we prevent cardiac tamponade and what are we looking for?
Place a mediastinal chest tube during cardiac surgery
drainage should be serosanginous fluid
What are the differences in chest tubes?
Range in size for infants to adults
Small size is for air to be removed
Large size is for fluid to be removed
can be curved or staright
can be made out of PVC or silicone
some have eyelets on the distal end
What is the importance of a tube having eyelets on the distal end?
allows for air and fluid to move in and out
allows for patient to speak
If a patient has a chest tube inserted because of pneumothorax where would the tube be located?
at the top
anterior of chest
between 2nd or 3rd intercostal space
tip of catheter in pleural space
If a patient has a chest tube inserted because of pleural effusion where would the tube be located?
lateral and posterior of chest
between 4th and 9th intercostal space
tip in the pleural space
If a patient has a chest tube because of post cardiac surgery where would the tube be located?
anterior and mediastinal to chest
below epigastric area
How does a WET chest drainage system work?
with the use of bottles and straws to return to negative pressure in the pleural space
How does the 1 bottle system work?
only for removing air
straw is attached to chest tube from client and is placed under 2cm of fluid
air can be pushed from client thru straw, but cant be drawn back up straw = one way valve
How does the 2 bottle system work?
along with the first bottle
a second bottle is added for drainage
the first bottle collects drainage
the second bottle is the water seal
How does a 3 bottle system work?
the third bottle is added as the suction control
the depth of the water in the third bottle determines the amount of negative pressure that can be transmitted to the chest
How does a chest drainage system work?
1. when the patient breaths out, coughs, or valsalva the expiratory positive pressure pushes air and fluid out of the chest
2. gravity helps fluid to drain as long as the chest drainage system is below the level of the chest
What level does the chest tube drainage need to be in order for the fluid to drain correctly?
below the level of the chest
What is the importance of the suction on the chest tube?
It can improve the speed at which air and fluid are pulled from the chest
What is considered the DRY chest tube collection device?
there is no water in the suction control chamber
a dry one way valve is used instead of 20 cm of water
there still will be a water seal chamber that will have 2 cm of water that is used to check for any air leaks
What is the difference between a Heimlich chest drain valve and a Pneumostat?
Heimlich chest drain valve =a flutter or flap valve used to drain AIR only
Pneumostat =used to drain AIR and FLUID
When a client is getting a chest tube inserted how should they be positioned?
Postioned so that the side the chest tube is being inserted is accessible
can be either flat or semi-Fowlers
During the insertion of a chest tube what is important for the nurse to do?
Give emotional support to the patient
Asses client VS-RR (before, during, and after)
give instruments to MD
Apply sterile, occlusive dressing if MD has not done
Before the insertion of the chest tube what should the nurse do?
1. pre medicate patient with narcotics
2. prepare and set up 2 or 3 chamber system
How is a 2 chamber (no suction) wet system prepared?
1.Add sterile solution of 2cm in water seal chamber
2. attach to clients thoracic catheter
3. tape connection between chest and drainage tube with spiral taping method
4. attach to suction system via water level and check for gentle bubbling in suction control chamber
How is a 3 chamber (with suction) wet system prepared?
1. add 2 cm of sterile H2O in water seal chamber
2. add 20 cm of sterile H2O in suction control
3. connect tubing from suction control chamber to suction on wall
4. attach to clients thoracic catheter
5. tape connection between chest and drainage tube with spiral taping method
6. attach to suction system via water level and check for gentle bubbling in suction control chamber
How is a dry system prepared?
1. add 2 cm of sterile H2O to water seal chamber
2. attach to clients thoracic catheter
3. tape connection between chest and drainage tube with spiral taping method
4. attach to suction system and set via dial and confirm BELLOWS is properly placed
What do you want to teach the patient about in order to help improve their condition?
Sit upright to enhance lung expansion
change position at least q 2hr
cough & deep breathing
use incentive spirometry q 1-2hr.
ambulate q shift
If a patient is going to ambulate the halls what should you do?
DC suction from wall
leave the vent open
DO NOT clamp tubing
Every shift as your assessment of the chest tube what are things you need to be checking for?
check the dressing for any drainage (bleeding or foul smelling discharge)
check the tube for no kinks
check the drainage collection chamber
When you are assessing the drainage collection chamber what things will you be assessing?
drainage amount and color
check to see if there is any bubbling in water seal and suction control chamber
check for tidaling
check the levels of the waters
At least every shift you need to assess your patient for what?
depth and ease of respirations
pain q 4hr
If your patient has air leaking out to the tissues and only a small amount what should you tell the patient and what interventions?
this is crepitus emphysema
document and monitor for worsening
If your patient develops Subcutaneous emphysema what is the priority the nurse should do?
expect MD to:
exchange chest tube for a tube with a larger diameter
apply additional suction
return to OR for closure of air leak
If your patient c/o the dressing at the insertion site is damped with drainage what should the nurse do?
if there is blood on the dressing notify MD
reinforce dressing if ordered
If a patient has a chest tube to get rid of air how should the nurse position the patient in bed?
semi to high fowlers
If a patient has a chest tube to get rid of fluid how should the nurse position the patient in bed?
What type of sign would indicate that the tube is not patent?
lack of drainage
what are some interventions the nurse can do if the tube is not patent.
assess for any kinks or clots in the tube
make sure the tube is positioned next to client in bed and that it is not coiled on floor.
If there are clots located in the tub what should the nurse do?
Avoid milking the tube aggressively.
Gentle milking is okay start at the proximal end, gently squeeze and release tube
If your patients chest tube gets dislodged from the chest what is the priority of the nurse?
1.immediately apply pressure over chest tube site with anything that is clean/sterile
2.apply sterile petroleum dressing as patient exhales with a tight seal
If the tube gets disconnected from the drainage system what should the nurse do?
1. Submerge the tube 1-2in below the surface of a 250 ml bottle of sterile water or saline solution
2. set up a new drainage system
this allows for their to still be a water seal, allowing for air to escape, and prevent air from reentering
If the chest drainage system gets knocked over what should the nurse do?
1. immediately return it to the upright position
2. check the water levels in the water seal and suction chambers and check drainage
3. have client take several DEEP breaths to force air out of the pleural cavity that might have entered when water seal not intact
4. monitor client for signs of increasing pneumothorax
5. change collection device
-this is the only time you can clamp the chest tube with two rubber-tipped clamps and disconnect from old collection chamber and IMMEDIATELY connect to newly prepared collection chamber then unclamp chest tube
6. notify md
When and how do you check for drainage in the tube system?
Drainage should be checked every 15 mins for first 2 hours
then every 4 hours
then every shift
mark volume of drainage with pen at start of shift with date and time
How much drainage should you expect with a mediastinal tube?
immediately post surgery: <100 mls/hr
first 24 hours: < 500 mls/hr
How much drainage should you expect with a lateral/posterior tube?
first 3 hours: 100-300 mls/hr
first 24 hours: 500-1000 mls/hr
How much drainage should you expect with a anterior tube?
little to none this tube is mainly for air
If you see a change in color of drainage from clear to red or milky what is the likely cause? What should the nurse do?
Monitor client then notify MD
If you see a change in amount of drainage from a sudden increase to a sudden decrease what could be the cause of it? What should the nurse do?
sudden increase =hemorrhaging
sudden decrease =tube is possibly kinked
monitor client then notify MD
What is the purpose of bubbling in the water seal chamber?
Bubbling indicates an air leak from the pleural space
a small amount of bubbling right after tube has been inserted or intermittent when the client exhales or cough is NORMAL
bubbling should go away once lung has reexpands
If there is a large amount or continuous bubbling what could be reason and what should the nurse do?
there is a persistent air leak in the system or chest.
1st the nurse needs to asses for location of the leak
2nd notify the md
If there is intermittent bubbling what does this suggest and what should the nurse do?
confirms the presence of intermittent air leak
1st notify MD
2nd continue to monitor and it should resolve over time
How is bubbling measured?
How does the nurse check for where the air is leaking from?
1st-check all the tubing connection sites and tighten/retape any connection that seems loose
-if the bubbling stops there is nothing else to do. if it continues..
2nd-clamp chest tube near chest wall for a few seconds with a big clamp
-if bubbling stops air leak is inside client's thorax or at chest insertion site
-apply pressure to insertion site dressing
-if bubbling stops the leak is at the insertion site apply occlusive dressing and nothing else to do
-if bubbling continues after applying pressure leak is inside thorax notify MD
3rd-move clamp down tubing away from client several inches at a time until bubbling stops
-if it stops along the length of tubing seal leak in tubing with tape
-if it doesn't stop by the time get to the collection chamber need to change the collection chamber the leak is in the chamber
What is the purpose of tidaling?
fluctuation in fluid level of water-seal chamber during inspiration and expiration
What is the purpose of tidaling and is it normal or a complication?
Tiadling reflects the changes in intrapleural pressure that occur with breathing
it is normal
If tiadling ever stops what could be the reason for it stopping?
1. tube may be kinked, has a dependent loop, blood clot, or outside pressure on tubing
2. full lung expansion has occurred (good sign)
what are the appropriate water levels for the water seal and suction chambers?
water seal=2 cm
suction chamber=20 cm
When using a dry chamber and connecting it to suction what are the steps?
1. connect the drain to the vacuum suction
2. slowly increase vacuum suction until gentle bubbling appears in the suction chamber
3. if there is vigorous bubbling it will be loud and disturbing to patient and cause water to quickly evaporate.
4. lower suction until bubbling disappears and turn back up to they reappear gently
What is the minimum the suction should be set at with a dry suction chamber?
-80 mm/hg or greater
When is it okay for a chest tube to be removed?
1. drainage has decreased<10 ml/hr for 6 hr or <100 ml/hr for 24 hours
2. no air leaksfor 24-48 hours
3. client breathing normally
4. patient showing no signs of respiratory distress
5. breath sounds return to baseline
6. Tidaling has stop
7. CXR shows lung re-expansion with no residual air or fluid