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Need chest tube basics

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by DebbieLynne DebbieLynne (New Member) New Member

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I'm scheduled to take my boards tomorrow afternoon. My weakness seems to be chest tubes. Can someone give me a quick review?

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VickyRN has 16 years experience and works as a Nurse Educator.

15 Likes; 3 Followers; 105 Articles; 130,116 Visitors; 5,348 Posts

Hi DebbieLynne, welcome to the forum :)

Perhaps these sites will be of help to you:

http://www.nursewise.com/courses/chestubes_hour.htm

http://www.nursingcenter.com/prodev/cetest.asp?tid=272440

http://www.icufaqs.org/ChestTubes.doc

http://members.tripod.com/~dgholgate/two.html

http://rnbob.tripod.com/chesttubecare.htm

Best wishes to you for great success on the boards tomorrow :balloons:

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VickyRN has 16 years experience and works as a Nurse Educator.

15 Likes; 3 Followers; 105 Articles; 130,116 Visitors; 5,348 Posts

...from my lecture notes:

Closed chest drainage.

One or more tubes may be inserted to:

1. Restore intrapleural pressure

2. Allow re-expansion of lungs

3. Prevents air and fluid from returning to the chest

Tube to drain air is located near apex (top); to drain fluid is located near base (bottom). A chest tube that allows air to escape from the chest will be placed anterior and superior in the chest because air within the pleural space will rise to the highest point in the chest. A chest tube to drain fluid or blood will be placed posterior and inferior because fluid will collect in the most dependent part of the pleural space.

The insertion site should be covered with airtight dressing--tubes are usually sutured in place. Tape all connections to ensure they do not become loose. The chest drainage system should always be kept below the level of the chest.

Tubing:

1. Should be coiled on the bed.

2. No dependent loops.

3. Avoid kinks in tubing.

4. Do NOT milk clots from line.

Pleurovac --Three chambers.

1. Drainage chamber (look right to left)

2. Water seal

3. Suction

The water seal chamber acts as a one-way valve (air goes out, none goes in). Monitor for continuous bubbling in the water seal chamber. Bubbles on forceful expiration or coughing, not normal otherwise. Intermittent bubbling in water seal chamber with forced expiration or cough is OK. Continuous bubbling in the water seal is abnormal and indicates an air leak. IF the nurse notes that there is CONTINUOUS bubbling in the water seal chamber, check for leaks in the system. With physician's order, RN places padded clamp closest to dressing. If leak stops, air leak is at insertion site. If bubbling continues, leak is between clamp and drainage system.

Water should rise and fall in water seal (undulate) with respirations due to pressure changes in pleural space.

Undulation: increase with inspiration, decrease tidal wave with expiration.

No fluctuations or tidal undulations in water seal:

1. Tube is kinked

2. Pt laying on tube

3. Fluid in the tube

4. Lung fully expanded (blocking the tube eyelets)

Suction chamber: While suction is applied, it is normal to have gentle bubbling in the suction chamber. Suction--can be applied to enhance pressure differences. Very low wall suction: 5-10 mm Hg. There will be gentle bubbling (should not be vigorous bubbling) in the suction chamber.

Drainage collection chamber: Do not empty the contents. Monitor chest tube drainage q 15 minutes for at least 4 hours then at hourly intervals, for the first 24 hours, depending on the amount of drainage. Record hourly drainage. Mark level of drainage with marker on drainage collection chamber. Should NOT be more that 100 ml/hr. Over 100 ml/hr--is excessive--notify physician. After first 24 hours, assess drainage every 8 hours.

Junctions at tube connectors are taped to avoid dislodgement.

If chest tube becomes dislodged:

5. Cover area with sterile (preferably Vaseline or another occlusive type) gauze.

6. Clamps are kept at bedside is system is disrupted or to facilitate device change.

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5 Likes; 3 Articles; 99,130 Visitors; 14,602 Posts

here are two more sites addressing chest tubes and chest tube placement in addition to the ones that vickyrn gave you:

http://flightline.highline.edu/drydberg/balckboard/chest_tube_insertion.htm - chest tube insertion with emphasis on the nurses role in assisting. includes photos.

http://www.thoracic.org/sections/education/patient-education/patient-education-materials/patient-information-series/chest-tube-thoracostomy.html - a 2-page patient information sheet on chest tube insertion, why it is done, the risks and simplistic explanation of how it is helping the patient. by the american thoracic society patient information series.

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2,455 Visitors; 45 Posts

I know this post is really old and I hope you passed the NCLEX and are now happily practicing nursing!

Thank you for sharing your notes - they are very clear and simple.

As a student, I had a really hard time comprehending how the chest tube system functions without a good visualization. Our teacher showed us this video and it really helped me make sense of what I am assessing and why. Thought I'd share it for anyone else out there struggling with chest tube systems!

http://www.youtube.com/watch?v=y1gaC3yfhvw

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2,020 Visitors; 73 Posts

Thank you all! This really helped. Taking NCLEX tomorrow. Please pray!

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6,302 Visitors; 232 Posts

Why do the manuals tell us to monitor for continuous bubbling as it may mean a leak within the system? It is supposed to bubble. It's driving me crazy. I already cannot understand the language these books use.

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5 Likes; 3 Articles; 99,130 Visitors; 14,602 Posts

Why do the manuals tell us to monitor for continuous bubbling as it may mean a leak within the system? It is supposed to bubble. It's driving me crazy. I already cannot understand the language these books use.

Because continuous bubbling means there is a leak in the system and therefore the chest tube is not able to do its job. Yes, it is supposed to bubble, but only on expiration when the lung is releasing air from the pleural space.

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6,302 Visitors; 232 Posts

Now i have been really confused. The tubes i see are always bubbling. This is absolute nonsense.

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juan de la cruz has 27 years experience as a MSN, RN, NP and works as a Adult Critical Care Nurse Practitioner.

522 Likes; 3 Followers; 8 Articles; 57,349 Visitors; 3,744 Posts

In the older chest tube drainage systems (Pleur-evac, for example) there are three chambers where fluid is contained. The larger chamber towards the far right of the device is the collection chamber where blood, pleural fluid, or air empties out into. You will never see any bubbling in this chamber.

The middle chamber is the water seal meter. Water is added to this chamber when prepping the device prior to chest tube placement. There may be bubbling in this chamber depending on what's going on with the patient. Any bubbling in this chamber is caused by an air leak. A continuous bubbling can signify a break in the tubing's integrity or a loose connection between the tubing and the patient's chest tube. Bubbling that corresponds with expiration or coughing is an air leak caused by air entering through the device coming from anywhere inside the patient's respiratory anatomy. It is typical after initial chest tube placement or after chest surgery but does disappear after a while. The key is to let the physician know of any bubbling in this chamber that wasn't there before after you have checked for any break or loose tubing connections.

The suction chamber located in the far left of the device determines the amount of suction applied. During the prepping of the chest drainage device, the nurse fills this chamber with water from a point somewhere between 10-20 cm depending on the physician's order. Once the device is attached to suction, this chamber has continuous bubbling signifying that suction is on. If the device is not attached to suction, there is no bubbling in this chamber whatsoever.

I attached a picture of the chest tube drainage system. In the picture, D is the collection chamber, E is the patient air leak meter (bubbles at times), and H is the suction control chamber that should have continuous bubbling.

There are newer Pleur-evacs that are in use now that doesn't have water in the suction chamber (dry suction). Instead there is an accordion-type device inside and a dial that points to the amount of suction applied to the device.

figure13top.gif

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6,302 Visitors; 232 Posts

OK. So maybe when I read these books, they are speaking about the older systems. Thank you.

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712 Visitors; 2 Posts

Thanks so much VickyRN. I've always been confused about chest tubes and your notes were great! I am taking my boards in a couple days, so I'm glad I finally have some idea! :)

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