Chest Tube Drainage System Monitoring and Care
Maintaining and troubleshooting a patient’s chest tube keeps the chest tube functioning properly and prevents infection. As part of this process, the nurse is responsible for making respiratory and thoracic assessments, obtaining vital signs that reflect effectiveness of therapy or impending complications, and knowing the appropriate interventions to perform in response to changes in the patient’s therapy.
Equipment
Sterile gloves ▪ personal protective equipment (gown, gloves, goggles, face shield) ▪ single-use, disposable, sterile chest tube drainage collection unit ▪ sterile water ▪ suction source ▪ suction connection tubing ▪ two sterile 4″ × 4″ drain dressings ▪ sterile 4″ × 4″ or 2″ × 2″ gauze pads ▪ 3″ to 4″ (7.5 to 10 cm) sturdy elastic tape ▪ 1″ adhesive tape for connections ▪ two rubber-tipped clamps for each chest tube inserted ▪ Optional: sterile petroleum gauze, sterile nonadherent gauze, sterile transparent dressing.
Implementation
Review the doctor’s orders regarding chest tube care.
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.1
Explain the procedure to the patient.
Maintain sterile technique whenever you make changes in the system or alter any of the connections to avoid introducing pathogens into the pleural space.5
For All Drainage Systems
Repeatedly note the character, consistency, and amount of drainage in the drainage collection chamber.
Mark the drainage level by writing the time and date at the drainage level on the drainage collection chamber every shift (or more often if there’s a large amount of drainage).
Observe the integrity of the drainage tubing and chest tube every 2 to 4 hours as well as with a change in the patient’s condition to ensure that the system is intact, with no air leaks, and to help prevent kinks or clots from forming.6
Periodically check that the air vent in the system is working properly (if applicable). Occlusion of the air vent results in a buildup of pressure in the system that could cause the patient to develop a tension pneumothorax.
Coil the system’s tubing and secure it to the edge of the bed. Be sure the tubing remains at the level of the patient. Avoid creating dependent loops, kinks, or pressure on the tubing. Avoid lifting the drainage system above the patient’s chest because fluid may flow back into the pleural space.5
Keep two rubber-tipped clamps at the bedside to clamp the chest tube if the commercially prepared system cracks or to help locate an air leak in the system.
Nursing Alert
Never clamp the tube to get the patient out of bed or during transportation of the patient. Whenever the chest tube is clamped, air or fluid can’t escape from the pleural space, which puts the patient at risk for a tension pneumothorax.
Encourage the patient to cough frequently and breathe deeply to help drain the pleural space and expand the lungs.5
Instruct the patient to sit upright for optimal lung expansion and to splint the insertion site while coughing to minimize pain.
Check the rate and quality of the patient’s respirations and auscultate his lungs periodically to assess air exchange in the affected lung.5 Diminished or absent breath sounds may indicate that the lung hasn’t reexpanded.
Tell the patient to report any breathing difficulty immediately. Notify the doctor immediately if the patient develops cyanosis, decreased oxygen saturation, rapid or shallow breathing, subcutaneous emphysema, chest pain, or excessive bleeding.
When clots are visible, after carefully assessing the patient, you may be able to milk the tubing, depending on your facility’s policy. Gently milk the tubing in the direction of the drainage chamber as needed.5
Check the chest tube dressing at least every shift. Palpate the area surrounding the dressing for crepitus or subcutaneous emphysema, which indicates that air is leaking into the subcutaneous tissue surrounding the insertion site. Change the dressing when soiled or according to the doctor’s order or your facility’s policy.5
Encourage active or passive range-of-motion (ROM) exercises for the patient’s arm or the affected side if he has been splinting the arm. Usually, the thoracotomy patient will splint his arm to decrease his discomfort.5
Assess the patient for pain and administer ordered pain medication, using safe medication administration practices, as needed for comfort and to help with deep breathing, coughing, and ROM exercises.6
Remind the ambulatory patient to keep the drainage system below chest level and to be careful not to disconnect the tubing, which would disrupt the water seal.
Troubleshoot the system as needed when problems arise. (See Troubleshooting chest tubes.) Early and prompt attention to system difficulties will minimize the patient’s complications.
Document the procedure.7
Additional Steps for A Water-Seal–Wet Suction System
Check the water-seal level every shift and maintain the proper level to ensure that the system is being used properly and to maintain the patient’s safety.
Check for fluctuations in the water-seal chamber as the patient breathes. Normal fluctuations of 2″ to 4″ (about 5 to 10 cm) reflect pressure changes in the pleural space during respiration. To check for fluctuation when a suction system is being used, momentarily disconnect the suction system so the air vent is opened, and observe for fluctuation.
Check for intermittent bubbling in the water-seal chamber. This bubbling occurs normally when the system is removing air from the pleural cavity. If bubbling isn’t readily apparent during quiet breathing, have the patient take a deep breath or cough. Absence of bubbling indicates that the pleural space has sealed.5
Check the water level in the suction-control chamber. Detach the chamber or bottle from the suction source; when bubbling ceases, observe the water level. If necessary, add sterile water to bring the level to the 20-cm line or to the ordered level.
Check for gentle bubbling in the suction-control chamber, which indicates that the proper suction level has been reached. Vigorous bubbling in this chamber increases the rate of water evaporation.
Additional Steps for A Water-Seal–Dry Suction System
Check the water-seal level every shift and maintain the proper level to ensure that the system is being used properly and to maintain the patient’s safety.
Check for fluctuation in the water-seal chamber as the patient breathes. Normal fluctuations of 2″ to 4″ (about 5 to 10 cm) reflect pressure changes in the pleural space during respiration. To check for fluctuation when a suction system is being used, momentarily disconnect the suction system so the air vent is opened, and observe for fluctuation.
Check for intermittent bubbling in the water-seal chamber. This bubbling occurs normally when the system is removing air from the pleural cavity. If bubbling isn’t readily apparent during quiet breathing, have the patient take a deep breath or cough. Absence of bubbling indicates that the pleural space has sealed.
Check that the rotary dry suction control dial is turned to the ordered suction mark, usually −20 cm suction, and verify that the appropriate indicator is present, indicating the desired amount of suction is applied. In some models, an orange float appears in an indicator window. Other models indicate that the correct amount of suction is being delivered when the bellows reach the calibrated triangular mark in the suction monitor bellows window. Always refer to the manufacturer’s instructions.
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