SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE

Transcription

1 SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE TITLE: ISSUED FOR: CHEST TUBES-- ADULTS Nursing DATE: REVIEWED: PAGES: RESPONSIBILITY: RN, LPN 11/86 12/18 1 of 8 PURPOSE: To provide information and establish guidelines in the care of the adult patient with chest tubes. KNOWLEDGE BASE: 1. The pleural cavity is the potential space between the thin membrane that lines the chest cavity and the thin membrane that covers the lungs. The pleural space normally contains a thin layer of lubricating fluid that allows frictionless movement of the lungs during respiration. An excess of fluid (hemothorax, pleural effusion, or empyema), air (pneumothorax), or both in this space alters intrapleural pressure and causes partial or complete lung collapse. Chest tube insertion permits the evacuation of fluid, blood, and air from the pleural space, mediastinum or both; restores negative pressure to the pleural space and promotes re-expansion of a collapsed lung. 2. Following insertion, the chest tube(s) will be connected to a closed chest drainage system. Closed chest drainage uses gravity and frequently suction is used to restore negative pressure and remove any material collected in the pleural cavity. An underwater seal in the drainage system allows air and fluid to escape from the pleural cavity, preventing air to re-enter. The type of closed drainage system available at SMH is the Pleur-Evac chest drainage system. The physician will order the type of closed chest drainage system preferred. 3. Hand hygiene per policy (01.IFC.67) Hand Hygiene. 4. For patients under the management of Trauma Services, their chest tubes should not be clamped. PATIENT EDUCATION: EQUIPMENT: The physician has primary responsibility for patient education. However, the nurse is responsible for reinforcing the explanation. OBTAIN THE FOLLOWING FROM CS: 1. Chest Tube Tray.

2 2. Central Line Bundle Cart PAGE: 2 of 8 3. Trocar chest tubes, available in sizes 20, 22, 24, 26, 28, 32 and 36, or Thoracic catheters in sizes 20, 28, 32 and Suction Equipment: a. Wall Suction Regulator, Suction Canister, clear tubing, suction tubing, and adaptor 5. Two (2) clamps for each chest tube OBTAIN THE FOLLOWING FROM THE UNIT: 1. Sterile gloves 2. Prep solution usually povidone-iodine solution or chlorhexidine 3. Anesthetic agent a. 1% or 2% Xylocaine without Epinephrine b. 6-ml syringe (1) c. 25-gauge and 21-gauge needles d. Alcohol swabs 4. 2-inch adhesive tape/elastoplast 5. 4x4 dressings Emergency Equipment (to be kept at the patient s bedside) 1. Sterile water 2. Two (2) Kelly clamps (or clamps with rubber teeth) 3. 4 x 4 gauze dressing (in case chest tube is dislodged) 4. Tape PROCEDURE: 1. ASSISTING IN CHEST TUBE INSERTION: a. Obtain informed consent for chest tube insertion. b. Reassure patient, answer questions, and allow him to verbalize feelings. c. Perform hand hygiene. d Assemble and set up equipment (including the Central Line Bundle cart) at patient's bedside prior to the physician s arrival if possible. e. Pre-medicate with pain medication (if ordered). f Perform Time Out to re-verify correct patient, procedure, and site as per Hospital Policy # (01.PAT.09). g h Position patient as physician desires. Have two clamps for each chest tube being inserted available at the bedside. These must be

3 PAGE: 3 of 8 kept at the bedside at all times while chest tubes are in place. Additional 4x4 s and tape should be at the bedside in case of tube dislodgement. i. Open and assemble equipment, maintaining sterility as described below. 2. PLEUR-EVAC CHEST DRAINAGE SYSTEM a. Unwrap Pleur-evac carefully. Place it on its floor stand or hang it from the bed frame, always being careful to keep it below the patient's chest level. b. Follow instructions and measurements printed on the front of unit. c. Fill the water seal chamber through the suction port to the 2 cm level as indicated. Remember to check water level periodically. Refill the chamber as needed via the front rubber stopper with sterile water, syringe needle. Wipe with alcohol. d. If the physician does not want suction used, leave the end of this short tube unclamped. This will allow air to escape from the pleural cavity. e. If the physician does want suction used, dial in the amount of suction ordered using the dial located on the left side of the Pleur-evac. f. To provide suction, the short tubing or clear tubing should be attached to the suction canister and regulator; the long clear tubing or suction tubing should be attached to the Pleur-evac. Increase the suction source until the orange float appears and remains in the window located on the front of the Pleur-evac. g. Suction is determined by what is dialed in and the orange floats appearance in window NOT by amount indicated by source (wall suction). 3. CARE OF THE PATIENT AFTER CHEST TUBE INSERTION a. Patient should be able to breathe easier if previously short of breath. The patient may experience coughing after insertion. 1) Assess lung sounds after chest tube insertion 2) If patient develops symptoms of shortness of breath, increased pulse and respiration, chest pains, or any other signs of respiratory distress check tube connections, status of the system, lung sounds, and

4 PAGE: 4 of 8 notify the physician at once. 3) Check for fluctuation of drainage in tubes or drainage bottle to ascertain patency. NOTE: When air leak from lung is finally sealed off, no bubbling will be present. b. A chest x-ray is usually ordered to check the reexpansion of the lung and to check placement of the chest tube. Check with the physician to ascertain if he wants a portable x-ray or wants it to be done in Radiology. c. Monitor output from chest tube every shift and PRN, unless otherwise ordered. Notify the physician if the patient has a drainage rate that is increasing progressively (or 200 ml/hr). d. Turn, cough, and deep breathe the patient at least every two (2) hours (or per MD order) while awake. Splint the chest when coughing. Place patient in semi-fowler s position to facilitate the air to rise and make sure tubes are not kinked or pulled on. e. Note the pressure of suction every time the patient is assessed. f. The dressing should be occlusive. If dressing becomes soiled, check with the physician before changing. Note hematomas and amount and consistency of the drainage, and chart specifically. g. When assisting the patient to a chair or stretcher, keep chest tube system lower than patient's chest at all times. If the patient needs to be transported via stretcher, make sure the chest tube system stays below the level of the chest. h. If the chest tube is to suction, and there is an order to ambulate the patient or to go to another department, ascertain if the physician has ordered in SCM (in the Chest Tube insertion order set) for the patient to go to water seal. If no order present, contact physician to obtain an order to remove the patient from suction and put them to water seal. i. Portable Suction Device: 1. Should NOT be used in place of calling physician for water seal order. 2. Should be used if physician specifically orders the patient to remain on suction for transport. Trauma Service patients are to travel with chest tubes to portable suction unless an order for water seal. a. Obtain portable suction device from Respiratory Services or from the Respiratory Progressive Unit (10ET). b. Power on portable suction device c. Short clear tubing should connect from the top of the suction canister to the top of the portable suction device. Connect the long tubing from the Pleur-evac to the suction canister on the portable

5 PAGE: 5 of 8 suction device. d. Increase the suction regulator on the portable suction device until the orange float appears and remains in the window located on the front of the Pleur-evac e. A nurse should be present if the physician orders the chest tube to remain on suction and the portable suction device is used for transport. i. To change the Pleur-evac, gather new equipment and assemble as previously stated. Clamp each chest tubes with two (2) clamps and quickly change the system. NOTE: Clamp for 10 seconds or less and no longer than one minute to prevent a tension pneumothorax. 2) Change system at clamp closest to system approximately six (6) inches from Pleurevac. j. Any dependent loop of tubing containing fluid will obstruct flow and create back pressure, especially to an air leak. Simply coil the tubing flat on the bed and let it run directly down to the Pleur-evac. k. The open air vent must be either open to room air or connected to working suction machine. l. Assess patient for pain and medicate as needed. Encourage deep breathing, range of motion exercising and comfort. m. If alert, enlist patient's cooperation to call if short of breath, bleeding, or other changes appear. 4. TO PUT PATIENT TO WATER SEAL: When gravity drainage is ordered, or when suction is discontinued for transport or prior to removal, the suction tube or port should remain uncapped and free of obstructions to allow air to exit and minimize the possibility of a tension pneumothorax. 5. REMOVAL OF CHEST TUBE: Equipment: Assemble the following for physician s use. a. Suture removal set b. Petroleum gauze (per MD preference) c. 4x4 s (4) d. tape e. gloves f. Protective equipment

6 PAGE: 6 of 8 1) Prepare patient and medicate for pain if indicated. 2) Note amount of drainage. 3) Place the patient in semi-fowler s position or on his unaffected side. 4) Apply clean gloves and protective equipment, remove the chest tube dressings and discard them. 5) Instruct the patient to perform Valsalva Maneuver by exhaling fully and bearing down once the physician has the chest tube securely clamped. 6) The physician will hold the petroleum gauze (if used) so he can cover the insertion site with it immediately after removing the tube. Place 4x4 s over petroleum gauze and cover the entire dressing completely with tape to make it as airtight as possible. 7) Place fluid-filled drainage system in a red bag in the patient s room and then transport the sealed red bag to the soiled utility room. Place the sealed red bag in the large biohazardous waste bin. 8. POTENTIAL PROBLEMS: 1) Excessive bubbling: Check all connections and re-tape connections as necessary. Check insertion site and tape securely to skin if necessary. Apply occlusive dry sterile dressing to insertion site. If the above is not successful, the nurse can assess for an air leak by clamping and unclamping the chest tube for a few seconds at intervals along the tube, beginning at the patient. If the bubbling stops, then the air leak is in the patient. If the bubbling persists, the leak is in the tubing. Clamp at intervals along the length of the tubing to determine the exact location of the leak, (i.e., it may be a loose connections, a cracked tube, etc.) Notify physician if leak is new and determined to be in chest. Otherwise, change whatever part of set-up is leaking. 1) Chest tube becomes disconnected: Clamp chest tube. Quickly cleanse connecting tubes with alcohol, reconnect, and tape securely with adhesive tape. Remove clamps. Notify physician. If the chest tube cannot be reconnected right away, DO NOT clamp the chest tube. Place the chest tube in sterile water (emergency equipment at the bedside) to create an automatic water seal. 2) Chest tube falls out: Immediately cover the site

7 PAGE: 7 of 8 with gauze pads and tape three of the pads sides to allow air to escape. Stay with the patient and have the physician notified at once. (Lippincott, 2013). 3) Subcutaneous emphysema: Check skin area around and above insertion sites for crepitus (crackling puffy areas) with every assessment. If it appears to be increasing, notify physician. Always outline in marker the area of subcutaneous emphysema that was assessed. 4) Tension pneumothorax: This can occur if tubes are clamped for more than a few seconds or if the chest tube system is improperly assembled. Symptoms are severe dyspnea, cyanosis, tachycardia, absent breath sounds on affected side, increasingly diminished breath sounds on unaffected side, tracheal deviation, shift of mediastinum to unaffected side, cardiac arrhythmias, and decreased cardiac output (decreased peripheral circulation and distended neck veins.) Page, Any surgeon STAT, and attending physician. Be ready to assist with insertion of large bore needle (12-to 14-gauge) to relieve distress and then a regular chest tube insertion. DOCUMENTATION: Critical Care: Respiratory Assessment Flowsheet Nursing Reassessment Flowsheet: Intake an Output Flowsheet Pre-procedural Checklist: 1. Document the procedure and the initial amount and type of drainage; date and time drainage began; type of system; amount of suction used; absence or presence of bubbling and/or fluctuation; Respiratory assessment to include rate, quality, any area of crepitus and patient response to procedure. 2. Mark drainage at end of shift (0600/1800) using a black marker, indicate date and time. 3. Every shift, document the amount of drainage from chest tube on Intake and Output Flowsheet. 4. Every shift, or as indicated by patient condition, document the type and amount of drainage, fluctuation, presence or absence of an air leak and its severity and resolution, dressing condition, presence of any crepitus, and cardiopulmonary status.,

8 PAGE: 8 of 8 5. On removal, document the procedure, amount of drainage in drainage system, patient response, and any other pertinent information. 6. Any patient going to a procedure with a chest tube needs to have it documented on the Pre-procedural checklist. REFERENCE: Lippincott. (2015). Lippincott s Nursing Procedures. 7th Edition. (pp ). Philadelphia: PA. Lippincott Williams and Wilkins. Perry & Potter. (2018). Clinical Nursing Skills and Techniques- 8 th edition. (pp ). Mosby Elsevier. St. Louis: MO. SMH Policy (01.PAT.18). Correct Patient, Procedure, and Site Verification. SMH: Author. http;// php. Wiegand, L-H., D. (2017). AACN Procedure Manual for Critical Care, (7 th ed.). St. Louis, MO: Elsevier Saunders REVIEWING AUTHOR (S): Krista Byler, MSN, RN,CCRN, NPD Specialist, Trauma Tammy Toft, BSN, RN, CCRN, NPD, Critical care Kimberly Gray, BSN, RN, NPD, CVICU Amy Alexander, BSN, RN, NPD, Respiratory Jennifer Sorensen, MS, RN, CNE, NPD, Respiratory APPROVAL: Clinical Practice Council 12/6/18