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.

IntroductionTrauma, 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.

Indications for Chest Tube Use: To Remove Air or Fluid From Pleural Space

Definitions:Pneumothorax- Air in the pleural spaceHemothorax- Blood in the pleural spacePleural 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

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

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

Abnormal Occurrence: Air LeakAn 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.

Normal Occurrence: Tidaling

Tidaling is the variation of fluid movement in tubing with patient’s respirations.Absence of tidaling indicates a re-expanded lung or an obstructed chest tube.

Daily Nursing Assessment of the Drainage Tubing and Chest Tube Drainage Unit

Notify Physicians for Any of the Following Circumstances…

A new air leak is present

Chest tube drainage is greater than

200 ml/hr

Drainage changes in appearance

especially if bloody and greater than 100 ml/hr

Changes in vital signs, esp. SpO2 Patient’s pain becomes

difficult to control

Excessive drainage from chest tube

insertion site

Chest tube eyelets/holesare out of the patient’s

chest

What to Document in PowerChart Under Respiratory Assessment

Document amount of drainage during each shift under I & O’s andmark level on the chest tube drainage unit.

Possible Causes for a Pneumothorax with a Closed Chest Drainage System

Respiratory Care Policy 14.01: Closed Chest Drainage

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 patient’s skin• Tube becomes dislodged from the patient

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 lung’s side• Decreased chest excursion on the affected lung’s side• Shortness of breath

Nursing Assessment

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

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.

If patient continues to decompensate, call 5-5555 for an “Airway Emergency” and give your location to the operator.

DO NOT LEAVE THE PATIENT’S SIDE!!

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 patient’s 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.

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.

1. First ensure that the connector is firmly pushed into the chest tube and Pleur- Evac tubing (creech tube).

2. Next, place a long length of waterproof tape to extend from the chest tube to the Pleur-Evac tubing over the connector site.

3. 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.

• 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.

The Recommended Method of Taping

Chest Tube Policy 14.01 reviews the importance of properly taped chest tube connections.

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.

Based on an Actual NMH Case: A Chest Tube was Placed for a Pneumothorax

Summary of Key Nursing Actions

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.

• 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.

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.

Congratulations! You have completed this month’s M&M training. Now you may click the ‘X’ button on the upper right corner of this window to exit the course and have it marked as Complete in ELM.