1
Q
What organs are found in the thoracic cavity?
A
- Lungs
- Heart
- Diaphragm
- Trachea
- Esophagus
- Bronchial tubes
- Lymph nodes
2
Q
How do the pressures inside the thoracic cavity change as a person breathes in and out?
A
- always negative pressure in the pleural cavity
- degree of negativity changes during respiration
- normal inspiration, intrapleural vacuum pressure is approximately - 8cmH2O
- during expiration the vacuum pressure falls to -4cmH2O
3
Q
where are the parietal and visceral pleura?
A
parietal pleura
- membrane that lines the inside of the rib cage
viceral (pulmonary) pleura
- membrane coming the lungs
4
Q
how much fluid is normally found in the pleural space?
A
small amount of lubricating fluid so membranes slide smoothly against each other
5
Q
What is a pneumothorax?
A
- air in the pleural space
- collapsed lung
6
Q
What is a hemothorax?
A
blood in the pleural space
7
Q
what is a pleural effusion?
A
build-up of excess fluid between the layers of the pleura outside the lungs
8
Q
what are the 2 types of pneumothorax?
A
- open
- closed
9
Q
describe a closed pneumothorax
A
- No associated external wound
- Most common form is a spontaneous pneumothorax > accumulation of air in the pleural space without an apparent antecedent event
10
Q
when does a closed pneumothorax occur most commonly?
A
- underweight male cigarette smokes between 20-40 years
- rupture of small bleb
11
Q
describe an open pneumothorax
A
- Occurs when air enters the pleural space through an opening in the chest wall
- Air can freely move in/ out of the pleural space through the hole in the chest wall
- Also known as sucking chest wound
12
Q
When does an open pneumothorax occur most commonly?
A
- gun shot wound
- stabbing
- any empaling in the thoracic cavity
13
Q
What is a tension pneumothorax?
A
- Air in pleural space that does not escape
- Continued increase in amount of air shifts intrathoracic organs and increases intrathoracic pressure
14
Q
Why is a mediastinal shift dangerous to the patient?
A
- causes the entire mediastinal area, including the heart, aorta, bronchial tree and other structures to be pushed toward the unaffected side
- reduce size of the unaffected lung chamber and make breathing very difficult
15
Q
Why is suction often used for patients on chest tube drainage?
A
aids in getting negative pressure back and maintaining it during drainage
16
Q
How is the amount of suction regulated on a chest drain?
A
- Through the amount of suction turned on through the wall mount which is then connected to the drainage system
17
Q
Why should the chest drainage unit be kept below the level of the patient’s chest?
A
Maximize drainage efficiency
18
Q
How would the nurse recognize if a patient has an air leak?
A
bubbles in the water chamber
19
Q
What are the 3 chambers or compartments in a disposable chest drainage system?
A
- Water-seal chamber
- Suction control chamber
- Collection chamber
20
Q
Why would a chest tube be placed in the mediastinal space?
A
prevent cardiac tamponed
21
Q
after thoracic surgery, what type of drainage might the nurse see?
A
- sanguineous
22
Q
what is the purpose of the water seal chamber?
A
- Allows visual detection of air leaks
- Air bubbles passing through the graduated air leak monitor help assess the air leak patterns and patient air leak trends
23
Q
What does it mean if the nurse sees consent bubbling in the water seal chamber?
A
- Air leak in the system somewhere
- Air leak independent of patients breathing
24
Q
What does it mean if there is NO bubbling in the water seal chamber?
A
- No air is being passed through tubing
- Good scenario for fluid drainage
- Bad for pneumothorax
25
what is tidalling or fluctuating?
reflects the pressures in the pleural space
26
What are the 9 assessment steps when caring for a patient with a chest drainage system?
- Check dressing
- Check tubing for NO dependent loops
- Don’t strip or milk the tube
- Check drainage
- Check for bubbling in the system
- Check for tidalling
- Check H2O levels in the seal
- Check tubing patency the full length of the tubing and all connections
- Safety
- Check for air leaks
- Is patient on suction or gravity
- Check for bellows within the window assess proper level of suction
27
Why is a nurse concerned when a patient develops subcutaneous emphysema?
- Indicates a poor seal to the chest tube
- Air is leaking into the subcutaneous tissue
- Feels like rice crispys
28
in regards to chest tube drainage, what assessment data does a nurse need to report to the physician ?
- Air leak
- Subcutaneous emphysema
- Sudden increase or stop in drainage
- Infected area (red, warm, puss)
29
if a chest tube is inadvertently removed, what does a nurse need to do?
- Don clean gloves
- Place gloved hand over insertion site
- Call for help
- Apply 3-sided dressing
- Call doctor
30
What does it mean if the red/orange bellows is visible in the suction window?
suction is applied
31
Where are the 2 places that a patient might have an air leak if the nurse sees bubbling in the air leak chamber?
- Chest drainage system/ tubing
- In the patient/ dressing
32
What should the nurse do if the chest drainage system accidentally tips over?
- Upright the drain immediately and check the fluid levels
- If required, the air leak monitor level may be adjusted using a Luer lock syringe
- I blood has contaminated the air leak monitor, it may be advisable to replace the chest drain with a new unit
- Fluid drainage can potentially spill from one collection column to another. Gently tip the drain to the right to return fluid back to the correct column and then upright the drain
33
what are the key components to teach a patient during chest tube removal?
- Take a deep breath
- Exhale
- Bear down (Valsalva maneuver)
34
why does the patient need to do special breathing during chest tube removal?
- So they don’t gasp for air and pull air into the open pleural space
35
What are the 2 stitches you will see holding a chest tube? Which one do you cut?
- Purse string suture
- Skin suture (this is the one you cut)
36
What is the purpose of the purse string?
to close the incision site and prevent air from entering the pleural space
37
What type of dressing should be applied after CT removal?
Sterile petroleum jelly gauze dressing
38
When do you clamp the chest tube?
- prior to pulling chest tube out
- while replacing the collection chamber
- when looking for an air leak
39
what signs and symptoms would you watch for post-chest tube removal?
- SOB
- Chest pain
- Restlessness
- Asymmetrical chest wall movement
- Tracheal shift
- Subcutaneous emphysema
- Decreased breath sounds
40
why would the Pneumostat Chest Drain Valve be used for a patient?
- Simple pneumothorax with minimal chest fluid drainage
- Allows for quick discharge from hospital
41
What total volume of drainage can a Pneumostat drain hold?
30mL
42
How can the nurse check to see if there is an air leak in the Pneumostat or chest tube?
- Draw 1mL sterile water in syringe add to air leak well on side of Pneumostat
- Have pt take deep breath/ cough
- If air leak present there will be bubbling in air leak well
- Once test Is done clean 1mL water off with gauze
- Ensure air leak well facing forward
43
What should the nurse do if the Pneumostat drain is full?
- Pneumostat in upright position
- Clean needless sampling port with alcohol swab for 15 seconds/ allow to air dry
- Attach sterile 30mL needleless connector port withdraw fluid
- Discard syringe in sharps
- Clean drainage port again
44
What should the nurse do if the drainage valve on the Pneumostat drain gets clogged with a blood clot?
must change device
45
What are the steps on how to change a Pneumostat?
- Wash hands/ put on PPE
- Clamp chest tube
- Remove tape from connections between proximal end of Pneumostat and distal end of chest tube
- Disconnect Pneumostat from distal end of chest catheter
- Insert proximal end of Pneumostat firmly into distal end of chest tube
- Tape connection lengthwise between proximal end of Pneumostat and distal end of chest tube
- Unclamp chest tube
- Confirm pt air leak is present
- Position device below level of chest tube insertion/ ensure chest tube is taped securely to chest wall
46
Can a patient go home with pneumostat? What teaching might they need?
- Yes
- Educated regarding the purpose, indications and contraindications of use and about their role in management of this device
- Receive clear instructions on emergency care/ treatment
47
What is the main difference between a large bore chest tube and a pigtail catheter?
large bore
- Less kinks
- Larger diameters
- Faster drainage of thick fluids/ hemothorax
- More painful
- More distorting to tissues
pigtail catheter
- Smaller in size
- More flexible
- Less traumatic
- Easier in insertion
48
How do you uncoil the pigtail before removal?
- Position circular section of Merit key device over coloured hub so catheter hub rests between circle/ flat section
- Press until a click is heard
- If no Merit key available use tip of pen> insert tip into hole on back of round section, lock will disengage
- Remove key device, rotate tab clockwise to 3 > makes pigtail straighten
49
is the breathing the same with a pigtail chatheter as it is with a large bore chest tube?
yes
50
A chest tube may be inserted during/ following what?
- lung/ thoracic surgery
- cardiac surgery
- esophageal surgery
- hiatal hernia repair
- kidney surgery
- trauma to thoracic cavity
51
after thoracic surgery, the patient will have what?
- surgical incision
- 1 or more chest tubes
52
What causes a hemothorax?
- trauma
- surgery
- cancer
- complication of anti-coagulants
53
What is a chylothorax?
- build up of lymphatic fluid in the pleural space
- looks milky
54
What causes a chylothorax?
- trauma
- leak
- cancer
55
What causes an empyema?
- TB
- lung abscess
- infection of thoracic surgical wounds
56
What causes a spontaneous closed pneumothorax?
- rupture of bleb
- use of too high pressures in mechanical ventilator
- injury to lung following subclavian central line insertion
- broken ribs
57
What does it mean if you see white areas or black areas on an x-ray
white
- puss
- fluid
- tissues
black
- air
58
what causes a pleural effusion?
- CHF
- liver disease
- cancer
- infection
- pancreatic disease
- esophageal leak
59
Why can congestive heart failure cause a pleural effusion?
increase blood hydrostatic pressure
60
Why can liver disease cause a pleural effusion?
decrease plasma proteins and decrease oncotic pressure
61
Why can pancreatic disease cause a pleural effusion?
leak of enzymes
62
Why can esophageal leaks cause a pleural effusion?
perforation or complication of surgery
63
define transudates
fluids that pass through a membrane or squeeze through tissue or into the extracellular space of tissues
64
define exudates
fluids, cells, or other cellular substances that are slowly discharged from blood vessels usually from inflamed tissues
65
What are examples of transudates?
- CHF
- liver disease
66
What are examples of exudates?
- cancer
- infection
- pancreatic disease
- esophageal leak
67
by knowing what kind of surgery the patient had done, what will this tell you in regards to chest tubes?
- amount of drainage to expect
- type of chest drainage to expect
- how long tube might stay in
68
What are you going to assess on a patient with a chest tube during morning safety check
- breathing depth
- effort
- SOB
- use of O2
- pain
- start at pt work way down
- dressing
- equipement
- suction setting
- safety equipment at bedside
69
if a patient has a chest tube in, how often after your morning assessment do you need to check the system? Why?
- Q2H
- function
- drainage changes
70
What position do you place a patient in following lung surgery or chest tube placement? Why?
- semi or high flowers
- helps promote expansion of diaphragm
- allows air to rise to lung apex
- allows fluid to sink to bases
71
What are some changes in the amount or quality of pleural drainage you do not want to see?
- sudden increase/ decrease in drainage (>100mL)
- increase in frank blood
- change in appearance of drainage
- increased resp distress/ effort
72
What do you do if you find subcutaneous emphysema?
- mark the area with a marker that will not wash off
- date/ time it on patient
73
in a patient with severe subcutaneous emphysema, which complication should be the highest concern for the nurse?
A. decreased cardiac output
B. airway obstruction
C. skin breakdown
D. dysphagia
B. Airway obstruction
74
What is a thoracostomy?
creation of a surgical opening in the chest
75
What is a thoracotomy?
an incision into the chest cavity
76
What is a pleurodesis?
instillation of a sclerosing agent into the pleural space
77
What is a thoracoscopy?
insertion of an endoscope to visually examine the inside of the chest cavity
78
What is a lung biopsy?
taking a tissue sample for diagnostic study
79
What is decortication?
removal of thick, fibrous membrane from the visceral pleura
80
When charting about a chest tube, what do you need to include in your narrative notes?
- bubbling
- fluctuation
- drainage
- any complications
- resp. assessment
81
What do you do if the chest tube gets pulled out?
- don clean gloves
- place gloved hand over insertion site
- call for help
- apply 3-sided dressing
- call doctor
82
what if the chest tube does get disconnected?
- get pt. to exhale/ cough
- clamp chest tube cross-wise with Kelly clamps
- disinfect ends of tubes and reconnect
- tape connections
- unclamp
83
How do you prevent chest tube insertion site problems?
- chest tube sutured in place by doctor
- take chest tube and dressing securely to skin
84
When would you clamp a chest tube?
- reconnecting tubes
- changing drainage system
- checking for air leaks
- checking to see if pt can handle no suction prior to removing chest tubes
85
what can happen if you clamp a chest tube for too long?
tension pneumothorax
86
What is a Heimlich valve?
one way valve used with chest tube to stop air from coming into chest through tube when you breath in
87
What are signs and symptoms of a tension pneumothorax ?
- increased RR
- dyspnea
- pleuritic chest pain
- decreased movement on affected side
- decreased breath sounds
- rising pulse
- subcutaneous emphysema
88
the diameter of the chest tube selected depends on what?
- size of patient
- types of drainage
- expected duration of drainage
NRSG 301
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