Care of Patient With Chest-tube Drainage

Care of Patients with

Pleural Disorders and Chest Tube Drainage

Team-Based

Learning

Instructional Activity Sequence for TBL

Preparation(Pre-class)

Readiness AssuranceDiagnosis-Feedback

1hr 50 mins of class time

Application of Course Concepts

2 hours of clinical skills practice

1. Individual

Study

2. Individual

Test (10mins)

3. Team Test

(15mins)

4. Appeals (5mins)

5. Instructor Input (1hr 20 mins)

6. Application Orientated Activities

Team Test

Case Scenario

Peter, 20-year-old man, with no past medical history or involve in any accident,

was admitted to the hospital. He developed SOB and pleuritic chest pain

when having dinner with his family. He has stopped smoking 3 years ago.

His vital signs is BP 112/70mmHg, 89 b/min, RR 28/min, SpO2 95%, T: 36.7. An initial assessment revealed hyperresonance to

percussion

1. The most probable diagnosis

for Peter is:

A: Empyema

B: Hematoma

C: Spontaneous pneumothorax

D: Open pneumothorax

E: Pleural effusion

Blebs are weakened out-pouchings in the upper lung,

which can rupture, causing pneumothorax.

Spontaneous pneumothorax

Pneumothorax

Pneumothorax

Traumatic Spontaneous

Open Close

Tension Pnenumothorax

Mediastinum Shift

SHOCK

DEATH

Air leak into pleural space

during inspiration

Air prevents from leaking out

during expiration

Increased thoracic pressure

2. To determine whether Peter develops

tension pneumothorax, the nurse assesses

the patient specifically for:

A: Pleuritic chest pain

B: Diminished breath sounds on the

affected side

C: Dull percussions on the injured side

D: Decreased chest movement on the

affected side

E: Severe respiratory distress and tracheal

deviation

Traumatic /

Spontaneous

Pneumothorax

Tension

Pneumothorax

Hemothorax

SIMILARITIES

DIFFERENCES

Traumatic /

Spontaneous

Pneumothorax

Tension

Pneumothorax

Hemothorax

SIMILARITIES

•Pleuritic Chest pain

•Absence/Diminished breath sound

•Unequal chest expansion

•SOB

DIFFERENCES

•Hyperresonance to

percussion

•Severe Respiratory

Distress

•Hypotension

•Distended neck vein

•Tracheal deviation

•Dullness to

percussion

•Hypotension

Pleural Effusion

• Excess fluid in the pleural cavity

• Causes

– Increased capillary hydrostatic pressure

– Increased capillary permeability

– Decreased plasma oncotic pressure

– Obstruction of lymphatic drainage

Treatments

ThoracentesisChest-tube insertion

3. The chest tube drainage

system relieves Peter’s

pneumothorax by

A: Enhancing chest wall movement

B: Injecting air into the pleural space

C: Preventing air from entering the cavity

D: Restoring negative pressure in the pleural

space

E: Increasing the amount of pleural fluid

4. Which 3 chambers are found

in a closed chest drainage

system?

• Water seal, pressure, and drainage

collection chambers

• Water seal, suction control, and drainage

collection chambers

• Gravity, suction control, and drainage

collection chambers

• Pressure, water seal, and gravity

chambers

5. The main purpose of the water seal

chamber is to:

A: Prevent air from going into his chest

B: Detects air leaks

C: determines the amount of suction applied

D: Provide high negative pressure

E: Reflect the amount of drainage in the

pleural space

Chest Drainage

System

Collection

Chamber

Water

Seal Chamber

Suction

Control Chamber

Chest Drainage System

Collection Chamber Water Seal Suction Control

•Drain air & fluid from the

pleural space

•Observe & record drainage

Chest Drainage System

Collection Chamber Water Seal Suction Control

• 2 cmH2O

•Act as one-way valve by bubbling out air

•Observe fluctuations in the water level

Chest Drainage System

Collection Chamber Water Seal Suction Control

•Connected to suction wall

• Remove air & fluid more

quickly

Nurses’ Roles

Care of Patient

with Chest Tube

Chest Tube

Removal

Chest Tube

Insertion

6. Which of the following is the most

appropriate position for Peter when

preparing him for chest-tube insertion

A: Prone position with head to the side

B: Lateral supine position with the legs bent

C: Upright seated position, leaning over a

table

D: Semi-Fowler’s position with a pillow

under the back

E: Supine position with the legs straighten

3rd, 4th 5th or 6th intercostal

space in the mid axillary

line

Chest Tube Insertion (Before)

• Informed consent

• Administer pain medication

• Prepare equipment

• Set up drainage system

• Obtain baseline vital signs

• Position patient

Chest Tube Insertion (During)

• Assist Dr with chest tube insertion

• Monitor patient’s condition

• Provide emotional support

• Apply dressing on the insertion site

• Taped all connections

Chest Tube Insertion

(Immediately After)

• Call for chest x ray

• Monitor patient’s vital signs hrly X 6hrs

• Administer pain medications

• Observe complications

• Assess drainage system

Care of Patient

with Chest Tube

Chest Tube

Removal

Chest Tube

Insertion

Care of Patient with Chest-tube

drainage system

I

Assess

Insertion Site

Check

Chest-tube

Drainage System

Monitor & Maintain

Respiratory

Function

Monitor & Maintain

Respiratory Function

• Monitor vital signs & SpO2

• Auscultate breath sounds

• Encourage deep breathing & coughing

• Encourage use of incentive spirometery

• Prop up patient

• Reposition patient

Assess Insertion Site

7. When palpating around Peter’s chest

tube insertion site, you detect crepitation

and tissue swelling, you suspect:

A: Infection

B: Subcutaneous emphysema

C: Tension Pneumothorax

D: Unresolved pneumothorax

E: Bleeding

Assess Insertion Site

• Bleeding

• Infection

• Subcutaneous emphysema

Check Chest Drainage System

• Tubing avoid dependent loops, kinking & clamping

• Connection taped securely

• Drainage bottle below level of patient’s chest

Check Chest Drainage System

• Check water seal

• Level

• Bubbling

• Fluctuations

• Check suction pressure

• Assess drainage

Chest Tube Drainage

8. Peter needs to be transported to the x ray

department. The concern during transport

include assure that:

A: the chest tube is clamped

B: the chest tube bottle is below the

insertion site

C: Suction tubing is open to air

D: B & C

E: A & B

9. At the X ray department, you notice the

drainage tubing was disconnected from the

drain. Your first action is to

A: Re-established connection

B: Clamp Peter’s chest tube immediately

C: Notify doctor immediately

D: Send him back to the ward immediately

and change another drainage system

E: Check Peter’s vital signs

Common Problems

• Disconnection of drainage tubing from drain

– Clamp with artery forceps

– Re-establish connection ASAP

– Notify Dr

– KIV chest x ray

• Lack of Drainage

– check tubing for kinks or obstruction

Common problems

• Collecting bottle fall over

– Re-establish water seal level

• Intrapleural drain fall out

– Tie the purse-string suture

– Cover with gauze and pressure bandage

– Notify Dr

– Monitor Patient

Care of Patient

with Chest Tube

Chest Tube

Removal

Chest Tube

Insertion

10. The doctor plan to remove the Peter’s

chest tube. Which of the following signs

suggests the pneumothorax has resolved?

A: An air leak in the water seal chamber

B: Bubbling in the suction control chamber

C: Clear lung sound that extend to the

periphery

D: More than 100mil of fluid in the collection

chamber

E: C & D

Removal of Chest Tube

(Indicator)• Little to no drainage

• Normal breathing

• Fluctuations in water seal stopped

• Chest X ray shows lung re-expansion with

no residual air or fluid

• Able to tolerate chest tube clamping

• Monitor respiratory status

Removal of Chest Tube

• Administer pain medication

• Prepare equipment

• Patient hold his breath, Dr tie the purse string &

nurse remove the chest tube in one quick

movement

• Apply dressing

• Monitor respiratory status

• Arrange for chest X ray

Care of Patient

with Chest Tube

Chest Tube

Removal

Chest Tube

Insertion

Pleural Conditions

Instructional Activity Sequence for TBL

Preparation(Pre-class)

Readiness AssuranceDiagnosis-Feedback

1hr 50 mins of class time

Application of Course Concepts

2 hours of clinical skills practice

1. Individual

Study

2. Individual

Test (10mins)

3. Team Test

(15mins)

4. Appeals (5mins)

5. Instructor Input (1hr 20 mins)

6. Application Orientated Activities

Clinical Lab Skills

• Prepare Equipment

• Set up drainage system

• Apply dressing on the insertion site

• Taped all connections

• Documentation

Video Show

Mosby’s Chest Tubes and Closed

Chest Drainage SystemRD539Vhe2007