If fluid or air accumulates in the pleural space, the negative subatmospheric pressure becomes positive, and the lungs will collapse. Chest tube insertion (thoracostomy) can help drain the pleural space, enable optimal lung expansion, and reestablish negative pressure.
In this article:
- Chest Tube Procedure
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Gas Exchange
- Impaired Spontaneous Ventilation
- Ineffective Breathing Pattern
- Risk for Infection
Chest Tube Procedure
A thoracostomy involves inserting a flexible tube through the chest wall and into the pleural space. Chest tubes vary in size and will depend on the patient’s condition. Small tubes are used to drain air, medium tubes drain fluids, and large tubes drain blood.
After chest tube placement, the tube is attached to a pleur-evac system, which has three chambers: the suction chamber, the water-seal chamber (one-way valve allowing air to escape and not enter the thoracic cavity), and the collection chamber.
Chest tube insertion can take place in the emergency department, operating room, or at the patient’s bedside. The patient is placed in a position with the arm raised above the head on the affected side to expose the midaxillary area and spread the intercostal space.
The chest tube is advanced up or over the top of the rib to avoid intercostal nerves and blood vessels. Once the chest tube is in place, it is secured with sutures and connected to the pleural drainage system.
The wound is covered with an occlusive dressing, sealing it with petroleum gauze. Proper tube placement is then confirmed through a chest x-ray.
Nursing Process
Nursing care for patients with a chest tube includes assessment of the chest tube site to prevent dislodgement and infection, management of effective suction and drainage, pain relief, monitoring the respiratory status, and providing overall supportive care.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to chest tube insertions.
Review of Health History
1. Assess the patient’s indication for chest tube insertion.
Indications for chest tube insertion include the following:
- A collapsed lung (pneumothorax)
- Hemothorax (blood in pleural space)
- Chylothorax (lymphatic fluid in pleural space)
- Empyema (infection in pleural space)
- Fluid buildup
- Post-heart, lung, or esophageal surgery
2. Review the patient’s medical history.
Ensure that the patient is medically fit for chest tube insertion. The following are contraindications for chest tube placement:
- Deficient clotting (coagulopathy)
- Pulmonary adhesions
- Pulmonary abscess
- Diaphragmatic hernias
3. Review the patient’s medications.
Note medications that can cause an increased risk of bleeding. Inform the healthcare provider about the patient’s use of anticoagulants and antiplatelets.
Physical Assessment
1. Ensure that the consent form is signed.
Obtain the patient’s or the patient’s representative’s informed consent. In emergency situations, obtaining consent may not be possible.
2. Perform a respiratory assessment.
The nurse should frequently monitor the respiratory status of the patient, including their respiratory rate, pattern, breath sounds, and oxygen saturation.
3. Perform site marking with the healthcare provider.
Ensure that the healthcare provider marks the location of the chest tube insertion clearly.
4. Assess the insertion site.
Determine the midaxillary line and the fifth intercostal. Assess the skin where the incision is to be made. Insertion is made over a rib below the intercostal level chosen for chest tube insertion (between the midaxillary and anterior axillary lines).
Diagnostic Procedures
1. Review the bleeding tendencies of the patient.
One of the complications of chest tube insertion is bleeding. Review the coagulation profile. Report to the healthcare provider about results that are beyond the normal limits.
2. Use imaging scans.
The chest tube placement can be guided by computed tomography or ultrasound for complex cases. A chest X-ray is obtained following the procedure to verify correct placement.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to chest tube insertions.
Assists With Tube Insertion
1. Place the patient in a comfortable position.
The patient is placed with the arm raised above the head on the affected side to expose the midaxillary area and spread the intercostal space. The client is positioned either supine or with the head of the bed elevated about 45 degrees to lower the diaphragm and prevent misplacement into the abdominal cavity.
2. Prepare the insertion site.
Shave any excess hair. Disinfect the area with an appropriate antimicrobial solution.
3. Maintain sterility before and during the procedure.
Prepare the area with sterile drapes. Don necessary PPE, including:
- Sterile gloves
- Gown
- Hair cover
- Goggles
- Face shield
4. Administer sedation and analgesia as ordered.
Administer sedatives or analgesics (unless contraindicated) as instructed by the healthcare provider. Assess the patient’s level of consciousness, vital signs, and sensation after administration.
5. Administer antibiotics as ordered.
Prophylactic antibiotics should be given before insertion to prevent infection from skin flora.
6. Connect the tube to the drainage system.
After insertion, connect the tube to the drainage system, which may be connected to suction.
- Wet suction uses water to control the suction pressure as determined by the water height. The nurse will refill the suction control chamber with water as it evaporates.
- Dry suction does not use water and is connected to wall suction that is regulated by a suction monitor bellow.
Chest Tube Care
1. Promote drainage.
Ensure the chest tube remains free from kinks and occlusions. Keep the drainage system below the level of the patient’s chest. Do not let the drainage system tip over, as water can contaminate other chambers.
2. Assess drainage.
Assess drainage in the collection chamber and document the color, characteristics, and amount per facility guidelines. Mark the drainage level with the time and date to reference during the shift.
3. Assess for tidaling.
Tidaling is the rise and fall of water in the water-seal chamber that correlates to inhalation and exhalation and ensures the chest tube is patent.
4. Monitor the insertion site.
Assess for signs of infection, such as redness, bleeding, or purulent drainage. Palpate the area for crepitus, which can indicate subcutaneous emphysema (when air leaks into the subcutaneous tissues).
5. Collaborate with the respiratory therapist.
Collaborate with the respiratory therapist about the care plan for chest tube insertion and monitoring. If you are unsure about abnormalities in the drainage system or chest tube, ask the respiratory therapist for help.
6. Prevent chest tube complications.
Chest tubes can result in the following complications, including:
- Bleeding
- Infection
- Deep organ space infection (empyema)
- Tube dislodgement
- Clogs in the tube
- Re-expansion pulmonary edema
- Intraabdominal organ injury
7. Promote drainage and lung expansion.
Continue to assist the patient in repositioning, ambulation, coughing, and deep breathing techniques to promote fluid drainage and lung re-expansion.
Chest Tube Complications
1. Continuous or intermittent bubbling means an air leak.
If continuous or intermittent bubbling is observed in the water-seal chamber, this indicates an air leak. To assess the location of the leak, clamp the tubing along the tube to evaluate for a leak at the chest wall, the tube, or the drainage system.
2. Dislodgement is an emergency.
It is an emergency if the tube becomes dislodged from the patient. Immediately cover the insertion site with a sterile occlusive dressing and alert the provider so a tube can be reinserted.
3. Assess for bleeding.
Bleeding is normal after insertion, but if a large amount of bright red bleeding is observed in the collection chamber, this can indicate hemorrhage.
4. No drainage could mean clogging.
If no drainage occurs within the first 24 hours of insertion, the tube may be clogged (unless the chest tube is only draining air). First, inspect for kinks, reposition the patient, and assess the drainage system. If unsuccessful, contact the provider.
5. Get a new drainage system if it breaks.
If the drainage system becomes cracked or broken, obtain a new one. In the meantime, insert the tubing 1” into a bottle of sterile water to create a water seal.
6. Do not milk, clamp, or strip the tubing.
Unless directed by the physician, do not milk, strip, or clamp (unless assessing for an air leak) the tubing, as this could cause a tension pneumothorax.
Assist With Tube Removal
1. Review indications for removal.
The chest tube is ready to be removed when the following is observed:
- Improved respiratory status
- Symmetrical rise and fall of the chest
- Bilateral breath sounds
- Decreased chest tube drainage
- Improvement on chest X-ray
2. Educate the patient on removal.
Ensure the patient is aware of what to expect with removal. Premedicate for pain if necessary. Instruct the patient to take a deep breath, hold it, and bear down right before the tube is removed to increase pressure in the chest without allowing air in.
3. Position the patient.
Place the patient in semi-Fowler’s position with a pad under their chest to soak up any drainage.
4. Apply a dressing.
After removal of the chest tube, apply an occlusive dressing with tape to secure the site.
5. Monitor the patient.
Continue to monitor the patient’s respiratory status, vital signs, comfort level, and the site for any drainage.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for a chest tube insertion, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for chest tube insertions.
Acute Pain
Chest tube insertion has been reported to be a very painful procedure, though it can be managed through anesthetics and medications.
Nursing Diagnosis: Acute Pain
Related to:
- Procedural effects
- Inflammatory process
- Surgical intervention
- Impaired pleural integrity
As evidenced by:
- Distraction behavior
- Expressive behavior
- Facial expression of pain
- Guarding behavior
- Positioning to ease pain
- Tachycardia and hypertension
- Rapid, shallow breathing
Expected outcomes:
- Patient will report pain relief and demonstrate effective pain relief interventions.
- Patient will demonstrate controlled pain as evidenced by vital signs within expected limits.
Assessment:
1. Assess the level of pain and pain characteristics.
Chest tube insertion is painful due to the rich innervation of the pleural space. Pain assessments can help determine the trend and effectiveness of the treatment regimen.
2. Assess for the psychological causes of pain.
Several factors, other than the procedure or medical condition, can precipitate pain. Fear, anxiety, and distress can impair the patient’s ability to cope and make the patient’s pain experience worse.
Interventions:
1. Administer medications as indicated.
After sterilizing the area, a local anesthetic is often injected. An IV opioid may also be given in instances of trauma or severe pain. A nerve block can also be administered and can help reduce the need for postoperative opioids.
2. Teach the patient about splinting.
Coughing and breathing use accessory respiratory and abdominal muscles, which can cause excessive pain after chest tube placement. Splinting the area where the chest tube is inserted can help reduce discomfort.
3. Allow adequate rest periods in between interventions.
Adequate rest periods promote recovery, decrease oxygen demand, reduce discomfort, and conserve energy.
4. Reposition the patient while ensuring the chest tube is secure.
Proper repositioning of the patient may reduce discomfort and facilitate drainage.
Impaired Gas Exchange
Chest tube insertion is often indicated for patients with pneumothorax. When air, blood, or fluid enters the pleural space, this causes positive intrapleural pressure, lung compression, and gas exchange impairment.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Underlying cause or medical condition
- Alveolar-capillary membrane changes
- Ineffective airway clearance
- Ineffective breathing pattern
- Ventilation-perfusion mismatch
- Pain or discomfort when breathing
- Inflammatory process
As evidenced by:
- Altered respiratory depth
- Altered respiratory rhythm
- Hypoxemia
- Hypoxia
- Bradypnea
- Nasal flaring
- Dyspnea
- Tachycardia
- Confusion
Expected outcomes:
- Patient will demonstrate improved ventilation and adequate oxygenation as evidenced by ABGs within expected limits.
- Patient will maintain clear lung fields and remain free from any signs and symptoms of respiratory distress.
Assessment:
1. Assess respiratory rate, rhythm, depth, and ease of respiration.
Alterations in these parameters can indicate respiratory distress and reduced gas exchange.
2. Assess for any signs of hypoxia.
Indicators of hypoxia include anxiety, restlessness, tachycardia, and a decreased level of consciousness. Hypoxia can signal the possibility of respiratory complications and must be corrected immediately.
3. Assess chest tube drainage and positioning.
Frequent monitoring of patients with chest tubes enables prompt detection of issues such as dislodgement, air leaks, or abnormalities in drainage.
Interventions:
1. Position the patient with the head of the bed elevated.
Semi-Fowlers position can help facilitate drainage and promote comfort in patients with a chest tube. It can enable full expansion of the unaffected lung, promote adequate chest wall expansion, and descent of the diaphragm.
2. Encourage deep breathing and other exercises.
Deep breathing exercises decrease the risk of atelectasis, enhance gas exchange, and promote lung expansion. Encourage the patient to use an incentive spirometer hourly while awake.
3. Administer oxygen supplementation as needed.
Providing supplemental oxygen ensures adequate oxygenation as the lung heals.
4. Monitor blood gas values and x-rays.
Monitoring is an essential part of the recovery process for patients with a chest tube. Blood gas values can indicate the effectiveness of the treatment regimen and signal the need for interventions such as a chest x-ray if complications arise.
5. Encourage ambulation.
Patients who are able to should be assisted in ambulating. The chest tube drainage system can be attached to a walker or IV pole below the level of insertion to allow for movement. Ambulation allows for lung expansion and prevents atelectasis.
Impaired Spontaneous Ventilation
Traumatic injuries to the chest, diaphragm, or airway may require assistance in breathing to support life.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Related to:
- Worsening in respiratory status
- Respiratory muscle fatigue
- Chest trauma
- Hypoxemia
As evidenced by:
- Dyspnea
- Increased restlessness
- Increased accessory muscle use
- Decreased partial pressure of oxygen
- Decreased oxygen saturation
Expected outcomes:
- Patient will maintain an effective airway.
- Patient will not demonstrate signs of respiratory distress, such as restlessness or confusion.
Assessment:
1. Observe changes in the level of consciousness.
Early signs of hypoxia include disorientation, irritability, and restlessness. Late signs are lethargy, stupor and somnolence. Mechanical ventilation may be indicated if any of these signs appear.
2. Assess changes in the client’s respiratory status.
Monitor for changes in the patient’s respiratory status, such as worsening dyspnea, respiratory rate outside of normal parameters, accessory muscle use, and decreasing oxygen saturation.
Interventions:
1. Inspect the chest tube system if respiratory distress occurs.
If respiratory distress develops, inspect the drainage system for leaks, blockages, or disconnection. A lack of drainage may signal a kink or blockage, while too much bloody drainage is a sign of hemorrhage.
2. Apply oxygen.
Noninvasive positive-pressure ventilation is considered the first choice for cooperative and stable patients with chest trauma. If the respiratory status worsens or the patient has a traumatic injury, invasive ventilation may be necessary.
3. Administered analgesics and sedatives as needed.
Pain relievers and sedatives may promote proper rest and comfort and will help reduce anxiety, especially if mechanical ventilation is required.
4. Consult and collaborate with a respiratory therapist.
Collaborate with the respiratory therapist on managing the chest tube system, oxygen, or ventilation devices.
Ineffective Breathing Pattern
As pressure is placed on the lung due to the accumulation of fluid or air, this causes a decrease in vital capacity and partial pressure of oxygen.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Decreased lung expansion
- Inflammatory process
- Fluid in the pleural space
- Trauma
As evidenced by:
- Dyspnea
- Tachypnea
- Altered chest excursion
- Cyanosis
- Use of accessory muscles
- Nasal flaring
- Abnormal ABGs
Expected outcomes:
- Patient will establish an effective respiratory pattern with respiratory rate and depth within normal limits.
- Patient will be free of cyanosis or any other signs and symptoms of hypoxia.
Assessment:
1. Assess the patient’s respiratory function.
Note rapid or shallow respirations, dyspnea, cyanosis, asymmetric chest expansion, or hyperresonance as signs that signal a pneumothorax or other complications that indicate the need for a chest tube. Monitor these symptoms for resolution or worsening.
2. Auscultate breath sounds regularly.
Breath sounds may be diminished or absent in affected lobes. Frequently auscultate the lungs to evaluate for resolution of the patient’s condition.
Interventions:
1. Assist the patient to a position of comfort, usually with the head of the bed elevated.
Encourage sitting in semi-Fowler’s position to facilitate better lung expansion and ventilation and reduce the work of breathing.
2. Promote drainage and lung expansion.
Encourage ambulation, repositioning, deep breathing exercises, and coughing to promote drainage from the lungs and re-expansion.
3. Monitor for bubbling in the water-seal chamber.
Tidaling should be observed in the water-seal chamber if wet suction is ordered. The water level increases with the patient’s inspiration and drops during expiration. If bubbling is continuous or intermittent, this signals a leak anywhere from the chest wall to the collection system.
4. Monitor ABGs and oxygen saturation.
Oxygen saturation and ABGs are monitored for progress or deterioration, therefore aiding in determining the need to continue or alter therapy.
Risk for Infection
Chest tube insertion is a minimally invasive procedure that requires making an incision and inserting a thin plastic tube into the pleural space. Infection increases with the duration of the chest tube placement.
Nursing Diagnosis: Risk for Infection
Related to:
- Invasive procedure
- Compromised tissue
- Increased duration of chest tube placement
- Insufficient primary defenses
- Underlying infectious process
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at the prevention of signs and symptoms.
Expected outcomes:
- Patient will remain free from infection.
- Patient will not display signs of infection, such as bloody drainage; an increase in drainage; redness, warmth, or pus at the insertion site.
Assessment:
1. Assess the chest tube insertion site.
Signs of infection like redness, warmth, bleeding, inflammation, drainage, and abscess can occur in the chest tube insertion site.
2. Assess and monitor laboratory values.
An elevated white blood cell count can indicate a systemic infection.
3. Monitor vital signs.
Tachycardia, dropping oxygen saturation, tachypnea, fever, and changes in blood pressure signal an infectious process.
Interventions:
1. Maintain sterile technique.
Sterile technique is required when inserting and removing a chest tube, as well as performing dressing changes to reduce the transmission of pathogens.
2. Consider a swab or blood cultures.
If the insertion site shows redness, swelling, or drainage, consider obtaining a swab of the area for culturing. Blood cultures can also be obtained to assess for a systemic infection.
3. Practice handwashing before and after patient interventions.
Handwashing is an effective infection control intervention that reduces the risk of pathogen transmission.
4. Administer antibiotics.
IV antibiotics can be administered to prevent or treat an infection.
References
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