NMH Patient Care Division

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NMH Patient Care Division

• Morbidity Mortality Study Module
• Closed Chest Drainage Policy and Practice
• May 2009

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What To Expect

• An actual NMH case study, slightly edited for
  anonymity.
• It will take approximately 10-15 minutes to read
  and complete.
• Upon completion, you will be able to identify key
  nursing actions to respond to an adverse event
  related to chest tubes.

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Introduction

• Trauma, disease, or surgery can interrupt the
  closed negative pressure system of the lungs,
  causing the lung to collapse. Air or fluid may
  leak into the pleural cavity. A chest tube is
  inserted and a closed chest drainage system is
  attached to drain air and fluid.
• When caring for a patient with a chest tube, it
  is important to monitor the following
• Patency of the chest tube
• Amount and appearance of drainage
• Patient's vital signs
• Patient's comfort level
• Problem solving and critical thinking are also
  required.

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Indications for Chest Tube Use To Remove Air
or Fluid From Pleural Space
Definitions Pneumothorax- Air in the pleural
space Hemothorax- Blood in the pleural
space Pleural effusion- Fluid in the pleural space

• The most common reason for placing a chest tube
  is to treat a pneumothorax.
• Possible causes of a pneumothorax
• Chest trauma
• Thoracic surgery
• CPR

• Central line insertion
• Positive pressure ventilation

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Daily Nursing Assessment of the Patient with a
Chest Tube

• Vital signs--including SpO2--at least every 8
  hours.
• Appearance of site, dressing (is it intact?),
  drainage around site
• Dressing change every 48 hours or earlier if
  needed.
• Use a dry 4 X 4 or drainage sponge covered with
  paper or silk tape
• Pain assessment and reassessment.
• Sufficient analgesics should be ordered to allow
  for pulmonary hygiene activities
• Cough/deep breathing
• Sitting in chair
• Ambulation

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Daily Nursing Assessment of the Patient with a
Chest Tube (continued)

• Lung sounds
• Presence of subcutaneous emphysema
• Fluid variations (tidaling)
• Water seal or wall suction (how much)
• Drainage color amount (output)
• Presence (and degree) or absence of an air leak
• Location and number of chest tubes
• Daily chest X-ray to evaluate placement of tube
  and status of lungs

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Daily Nursing Assessment of the Drainage Tubing
and Chest Tube Drainage Unit
Normal Occurrence Tidaling Tidaling is the
variation of fluid movement in tubing with
patients respirations. Absence of tidaling
indicates a re-expanded lung or an obstructed
chest tube.

• Abnormal Occurrence Air Leak
• An air leak causes bubbling in the water seal
  chamber during inspiration and expiration.
• The nurse should assess if this patient should
  have an air leak by remembering why
• this patient has a chest tube.
• If the lung was touched/injured then an air
  leak can be expected (i.e. pneumothorax or
• VATS/lung biopsy).
• On the other hand, a chest tube to drain a
  pleural effusion should NOT cause an air
• leak.

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Notify Physicians for Any of the Following
Circumstances
Chest tube drainage is greater than 200 ml/hr
Drainage changes in appearance especially if
bloody and greater than 100 ml/hr
A new air leak is present
Chest tube eyelets/holes are out of the
patients chest
Excessive drainage from chest tube insertion
site
Changes in vital signs, esp. SpO2
Patients pain becomes difficult to control
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What to Document in PowerChart Under Respiratory
Assessment
Document amount of drainage during each shift
under I Os andmark level on the chest tube
drainage unit.
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Possible Causes for a Pneumothorax with a Closed
Chest Drainage System

• A pneumothorax can also occur after chest tube
  placement if there is a break
• in the closed drainage system
• Tube becomes disconnected from the device
• Tube holes are out of patients skin
• Tube becomes dislodged from the patient

Respiratory Care Policy 14.01 Closed Chest
Drainage
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Nursing Assessment

• Patients with a disconnected chest tube present
  similarly as a patient with a pneumothorax
  clinically
• Increased heart rate
• Decreased blood pressure
• Increased respiratory rate
• Decreased breath sounds on the affected lungs
  side
• Decreased chest excursion on the affected lungs
  side
• Shortness of breath

• Additional symptoms may include
• Anxiety
• Chest pain
• Tracheal deviation
• Mediastinal shift

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Nursing Actions when a Chest Tube is Disconnected

• Call for assistance.
• Assess airway, breathing, and circulation
  (ABCs).
• Reconnect the chest tube to the Pleur-Evac
  system IMMEDIATELY.
• Notify a physician/mid-level provider STAT.
• Assess the need for a STAT chest X-ray.

DO NOT LEAVE THE PATIENTS SIDE!!
If patient continues to decompensate, call 5-5555
for an Airway Emergency and give your location
to the operator.
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Things You Should Never Do
Never clamp/milk/or strip a chest tube without
an MD order. Never tape the chest drainage unit
to the floor. Never place chest tube collection
system above the level of the patients
chest. Never place the chest tube to water seal
without an MD order. Never place the chest tube
to low intermittent wall suction always use
continuous suction. Never increase wall suction
to promote vigorous bubbling in the suction
chamber. Never use Vaseline gauze for the
dressing without an MD order.
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To Prevent Accidental Disconnections

• The recommended method to secure all closed-chest
  drainage system tubing connections is to use
  waterproof tape in the manner pictured above.
• First ensure that the connector is firmly pushed
  into the chest tube and Pleur- Evac tubing
  (creech tube).
• Next, place a long length of waterproof tape to
  extend from the chest tube to the Pleur-Evac
  tubing over the connector site.
• Finally, secure the tape to the tube by wrapping
  a small piece of tape around each end of the
  tape, ensuring that the connector is visible at
  all times.

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The Recommended Method of Taping

• Avoid wrapping tape repeatedly around the
  tubing.
• Tape does not create an air tight seal! An air
  tight seal is accomplished by
• firmly pushing the connectors into the chest
  tube and Pleur-Evac tubing.
• Large amounts of tape placed around the tubing
  and/or the connector site can
• cover the source of an air leak due to a
  disconnected tube.

Chest Tube Policy 14.01 reviews the importance of
properly taped chest tube connections.
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Based on an Actual NMH Case A Chest Tube was
Placed for a Pneumothorax
Upon entering the room you find your patient
sitting in a chair. The patient states that
since getting in the chair he is short of breath
and is having extreme difficulty breathing. He
states this while gasping for breath.
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Chest tube
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Summary of Key Nursing Actions

• Conduct a complete nursing assessment every 8
  hours which includes checking the entire
  Pleur-Evac system, esp. connections.
• Recognize signs symptoms of a pneumothorax.
• Ensure that all chest tube connections are taped
  properly.

If a patient with a chest tube is an infrequent
occurrence on your nursing unit, please contact
Sue Collazo, Thoracic Surgery APN, at 5-4241 for
chest tube assistance.
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Review of Available Resources

• Click on the following link below to review the
  resource
• NCP 14.01 Closed Chest Drainage (Pleur-Evac
  Sahara system)
• NETS Online Reporting
• Events that result in injury to patients or
  visitors (including complications or unexpected
  outcomes)
• Near misses
• Events that reflect a variation from policy or
  practice that affect patient care
• We welcome your input. For comments,
  suggestions, or questions, please call Patient
  Safety at 6-2034 or 6-2195.

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