Advice on Chest Tube & mistakes by colleague

[Magsulfate, BSN, RN]

I have been searching the web and this site for about an hour trying to get confirmation that we still use petroleum gauze around a chest tube site... .. Is this true?

I was always taught to dress the site with petroleum gauze, 4x4's and medipore or a very good surgical tape and then ancher the tube to the patient with two more pieces of tape.

Most posts on this topic at AN are several years old and I need a current answer/opinion/knowledge base a little more specific to my issue. I had a patient the other night, upon assessment I found that the dressing was intact,, HOWEVER-- it was below the chest tube site and the insertion point was open to air. I also found the pleurevac must have been turned over at some point because each chamber had an inch or two of drainage in it. The previous nurse had timed, dated and initialed each chamber. (I found this quite interesting). Also the drainage system was not set up correctly to the 20cm wall suction.. wall suction was turned off . The patient was stable with no signs of distress and a normal respiration rate and pattern.

The patient had been in our facility for a little more than a day, had been seen by our nursing wound care team ( initial wound care assessment done on sacrum stage 2 wound) and had care from at least two different nurses before I took over care.... once again...HOWEVER---the tape used for this dressing was not tape that we have at our facility. It was surgical foam tape. I know for a fact we do not keep this tape there.

This dressing didn't even look like it had slid down. It just looked like there was a big part of it missing. It was intact,, but completely NOT ON THE SITE. The chest tube was inserted about two weeks before this, and it was not a dressing that I can imagine was put on by the physician or during surgery.

Anyway, I cleaned the site with choraprep, dressed it with petroleum gauze, 4x4's and an abd pad, topped off with 3inch wide medipore tape to cover and anchored it with silk tape. I also had to replace the pleurevac.

Can someone please give me their educated opinion regarding how I should deal with this?? Am I over reacting? I have already written two other incident reports on the nurse that I recieved this patient from. That's two incident reports out of three that I have written in my almost 8 year nursing career. These are major life ending mistakes. Granted, this OTA chest tube probably wouldn't have killed my patient, but there are some nasty bugs in our facility including multiple drug resistant bacteria, VRE, Acinetobactor and other bacteria that should NEVER be near a chest tube insertion site.

I don't want to make this post about this other nurse, but I have a gut feeling that he will continue to make mistakes. I have already talked with management (and typed incident reports twice regarding nurse not acting on order to help correct a critical blood lab value and titrating an anticoagulant drug grossly incorrect) in educating or reorienting him to practice. However, he has the "I KNOW EVERYTHING AND I'M THE SMARTEST NURSE EVER" attitude and management is focused on other issues not pertaining to our unit or nursing at our facility in general. He would be an outstanding nurse, I am sure of it, but he needs to quit believing that he already knows everything and maybe just once try to listen to his peers. He show's great focus on certain nursing aspects, but great ignorance on other very important aspects.

I realize that this incident has several broken processes. But the only common denominator is this one nurse. I just seemed to have gotten more upset than usual because I am now thinking that it is only a matter of time before he really messes something/someone up. Then I will be left feeling guitly, or worse, have my license in jeopardy because I didn't pursue the issues. As a witness to these mistakes, it leaves me feeling like I have an obligation to report. Like the Nurse Practice Act tells us, we are just as much at fault if we do not report.

But then again, I resent our management for not taking my reports seriously, and it leaves me to not even want to report this to them. However, I did document everything in the chart. Very factual and professional, just like I would any other nursing note.

Thanks in advance :)

Magsulfate

[fiveofpeep]

I also found the pleurevac must have been turned over at some point because each chamber had an inch or two of drainage in it. The previous nurse had timed, dated and initialed each chamber. (I found this quite interesting).

I dont have much advice to give because Im a new grad, but I just wanted to let you know that the above made me chuckle.

But in all seriousness, it shows that he just kinda winged it. He didnt bother to ask what he needed to do, and really he should have known that if it tips it needs a new device. It also shows he doesnt understand the basic concepts of the three-chamber system or he would have known that it makes no sense at all to chart the three different new levels and continue to monitor all three. Its definitely dangerous that he just willy nilly does what he thinks is best without any research or seeking of help.

[Magsulfate, BSN, RN]

If it wasn't so pathetic,, it would have been funny.. haha.

I remember thinking. Oh.. my.... what? hmmm .. how?... ohh myyyy.

[medicrn13]

We use petroleum gauze for our chest tubes, at least if the tube becomes dislodged. We keep a couple of them in every room of a patient who has a chest tube, as a just in case.

[meandragonbrett]

We do not use xeroform unless if there is an airleak

[SWEnfermera]

Check out these two excellent sources on chest tubes

The 1st is ICUFAQs- Click on the Chest Tubes link

http://www.icufaqs.org/

This second link is from Atrium- Check out the PPT

http://www.atriummed.com/EN/chest_drainage/education.asp

[livistarr]

Petroleum gauze is usually facility/physician specific. The pleuravac probably tipped in transport and with minimal drainage, labeling both chambers is standard practice. As far as the dim bulb you took report from, I say keep up with the paper trail if it is causing patient harm. I have only written 4 incidents up ever and 3 were on the same nurse that mistook dopamine for nitro (huh??), hung blood on a wrong patient and bagged a patient with a face mask...who was INTUBATED. It took mine and 4 other charge nurses reports before they finally disciplined her but it eventually happened. And remember, crap rolls downhill so CYA...

[cherrybreeze, ADN, RN]

Labeling both chambers isn't necessarily out of line. By marking all 3, it indicates when it was noticed that there was drainiage in all 3. Obviously in increase will only be noticed in the far right one, and you can then go from there. It will be certainly EASIER to just get a new one, but if the tube will be coming out soon, OR if the drainage is at none or minimal, it isn't a necessity.

I can't say for sure we use xeroform or petroleum gauze on all of out chest tubes any more, either.

[Reno1978, BSN, RN]

Petroleum gauze is solely physician preference where I work. I usually redress chest tubes the way I found them since physicians that want it there want it there, but the ones that don't definitely don't, if that makes any sense.

I was always taught that if you knock over your collection unit, it's time to change the collection unit.

About the wall suction being off, I would definitely check through the orders and make sure there was no order to leave it at water seal before turning it back on.

[cardiacmadeline, RN]

We don't use vaseline gauze on our chest tubes either, but of course there is always the exception. I too redress them the way I found them. As far as labeling the chest tube the way he did, we would have done the same thing on our floor. As long as you can still measure it and the drainage did not get in to the water chamber when it tipped, you don't need a new pleurovac. Why charge the patient for another pleurovac if the other one still works?

[fiveofpeep]

We don't use vaseline gauze on our chest tubes either, but of course there is always the exception. I too redress them the way I found them. As far as labeling the chest tube the way he did, we would have done the same thing on our floor. As long as you can still measure it and the drainage did not get in to the water chamber when it tipped, you don't need a new pleurovac. Why charge the patient for another pleurovac if the other one still works?

my apologies. at my nursing school and where I precepted and now work it was a big no-no. I really dont remember the reasoning behind it though. can anyone enlighten me? It does make financial sense but there must be a reason (Im thinking it breaks the water seal or affects the accuracy of the suction) that other hospitals mandate it to be changed.

[Magsulfate, BSN, RN]

Alright, so maybe I did over react a little, but in light of the situation and the constant aggravation from this nurse, I really can expect to find ANYTHING next time.

So does anyone think that the chest tube should have been open to air at a facility that has numerous isolation patients and MDR bacteria swimming around??

I am a little glad that I waited a few days before I reacted but am going to continue my paper trail and continue to hold my own integrety to a high standard, whether he does or not. Hopefully no patients will get hurt.

To answer the question earlier about the wall suction, yes the order remained about the 20cm wall suction.

In the end, it is all about taking care of myself, the patients and making sure that none of this falls back on me. Thanks you all for the help :)