Hey everyone, it's Sarah with RegisteredNurseRN.com and in this video I'm going to be going over an NCLEX review about chest tubes. What I'm going to do in this video is I'm going to cover the things you need to know exactly for the NCLEX exam. I'm going to cover the anatomy, the different types of drainage systems, the purposes, and the nursing interventions whenever you're maintaining these systems.
And after you watch this lecture, be sure to go to my website RegisteredNurseRN.com and take the free... quiz that will test you on your knowledge about how to take care of chest tubes and a card should be popping up so you can access that. So let's get started. First, let's start out talking about the purpose of a chest tube. What is it and what does it do?
Okay, it is a tube that is inserted into the pleura space of the lungs to remove air or fluid to help re-expand the lung. So let's look at what it does. Okay, we have our lung here.
That is that little red area on the drawing. Then around the lung we have a little protective layer called the visceral pleura. And then we have this small little space and then around that space that attaches to our thoracic cavity is called the parietal pleura and what happens is that whenever you breathe in and out these two layers glide gently over each other because in the pleura space there's a small amount of cirrus fluid that allows them to glide nice and gently to prevent them from rubbing together but while they're gliding they're creating a negative pressure which allows your lungs to work properly and to inflate and deflate.
Now, whenever something gets into this space like air or fluid, the lungs are like, oh no, this is not right. It's messing up our pressure setting because we have a negative pressure and it causes the lung to collapse. So the physician will go in there and insert a chest tube to help drain out that air and that fluid that's causing this.
lung issues. Now there's another type of chest tube which is called a mediastinal chest tube and this is a tube that is inserted into the mediastinum space and it's typically placed under the sternum to drain fluid from around the heart after cardiac surgery because a lot of times after cardiac surgery there can be extra blood or fluid and this can get around the heart and compress it and send the patient into cardiac tamponade. So those are placed as well. Now let's take it a little bit deeper and look at some other reasons why a chest tube might be placed. Okay the first one we hit on this is a pneumothorax and this is just where air enters into this small little space and causes the lungs to collapse.
This can happen because of like trauma or spontaneously happen. I've had patients who've been admitted, the doctor wasn't sure why they had a pneumothorax, it just happened spontaneously. Another thing is called a pleura effusion. There's different types of pleura effusions depending on what type of fluid is in that pleura space.
What it is, it's just fluid in the pleura space. Here's your nice little space and some fluid gets in there, messes up that pressure setting and the lung collapses and they have some major breathing issues. Different types of pleura effusions. You have hemothorax, which is where blood enters into the pleura space.
Hemio means blood. This can be due to a trauma, a disease like tuberculosis, or a blood clotting issue. They're not clotting, so blood is leaking in there. Another thing is called ephema, where they can get an infection in the pleura space.
And the last type of pleura fusion is the xylothorax, which is where lymphatic fluid can get into the pleura space. And of course, another reason for a chest tube is the cardiac surgery. Now let's look at the different types of chest.
Chest tube drainage systems. Whenever you get a job as a nurse, be sure to familiarize yourself with the different types of chest tube drainage systems your facility offers. Make sure you get a good in-service on that because different places have different chest tube drainage systems.
Here are your basic ones. I'm going to be going over, for NCLEX purposes, the wet suction and the dry suction. Let me go over the basic setup of how a typical chest drain is set up and then we'll talk about the differences between the two.
Okay, so you have your little suction device. The tube will be coming from the patient and this tube right here is from the patient and it's draining down into the drainage chamber. These are your drainage chamber where whatever's coming out of that lung is flowing down into there.
Then in the middle you have your water seal chamber and there's blue water in this and as the patient breathes in and breathes out This water will tie will auscultate up and down and sometimes there's a little ball in there that will move as well And then you have a little more an air leak monitor area and in this area You are looking for bubbling because if you see continuous bubbling which will go over in depth whenever I'm covering the nursing interventions and there could be an air leak. And then over here at the very end you have your suction control chamber. Now notice, on the wet suction and the dry suction it looks a little bit differently and that is the biggest difference with these two systems is the suction, how the suction works. So let's cover it. Okay, wet.
Let's talk about the wet suction. Okay, the wet suction is regulated by the height of the water in the suction control chamber when it's connected to wall suction. So, whenever you're setting up a wet suction, a wet suction chest tube drainage, you will be filling this with the water that it comes with. Depending on what the physician orders, you'll fill it up to whatever they order.
Typically it's negative 20 centimeters of water. This right here, once you connect this tube to the wall suction, will regulate the suction control of the chest tube. You will hear bubbling and see gentle bubbling in this as it's working. that is normal.
Now with dry suction, there is no water column and the suction is controlled and uses a suction monitor bellow that balances the wall suction and you can adjust the wall suction pressure by using a little rotary suction dial on the side of the system. So this area right here, this is where your suction monitor bellow is and it looks like a little orange accordion area and whenever you turn turn on the wall suction to this tube, this little orange accordion will start to expand out. And you have this little triangle there that tells you once it gets to that triangle, it's regulating suction, it's good. And then here, you have your suction control regulator and you have a little dial on the side where you can set the prescribed suction of whatever the physician orders.
And here it said on negative 20, like how it would be over there in the water suction. Now with the dry suction systems, you can get a high, you have high higher suction pressure options. There's no bubbling of water because you don't have a water calm like how you do on wet suction and there's no water evaporation.
With the wet suction, because you have this water, you have to feel it over time that this can evaporate. So you'll have to monitor that, make sure it's at a good level. Here you don't have that so you won't have water evaporation. Now let's look at our nursing interventions of things that you have to do for this patient who has a chest. The biggest thing you want to do whenever you're taking care of a patient with a chest tube is you want to monitor the patient's respiratory status very closely, you want to monitor the drain system itself, and you want to know what to do when things go wrong, like if the chest tube becomes dislodged accidentally, or the system breaks, and how to assist the physician with removing the chest tube.
I'm going to be covering all those things. So first, let's talk about the drainage system and the tubing. The drainage system... The system itself needs to be kept below the patient's chest.
And the tubing, especially the tubing coming from the patient, it tends to be long and bulky and patients roll over on it, it gets caught up in a side rail. So you want to make sure that those connections are secured and that they're draining down into the system and that there's no stagnant fluid collecting in those and clots and that your connections are sealed. Next, while you are taking...
care of this patient with the chest tube you're going to be watching the collection chamber the water seal chamber and the suction control chamber and this is going to tell you a lot about what's going on with the patient but first let's talk about the drainage collection chamber the drainage collection chamber is whenever you're monitoring this you want to note the color of the drainage how much they're putting out typically less than 100 cc's per hour and you want to record it very very well regularly, because physicians are going to ask you, how much is that chest tube putting out? Next, the water seal chamber. This is your water seal chamber on the dry section and on the wet section.
What does the water seal chamber do? It performs an underwater seal to allow air to be removed from the pleura space while preventing outside air from entering into the lungs, because remember, we want to create a negative pressure in there, because that's what the lungs like. So that water seal helps us do that.
Now, one thing you want to know, this is normal. The water will fluctuate in this water seal chamber. It will auscultate up and down.
So that's normal. You want that. And whenever the patient breathes in, the water height will increase and when they have expiration, the water will decrease.
However, it's the opposite if the patient is on positive pressure mechanical ventilation. Whenever the vent breathes in for them, the water will decrease. When the vent breathes out for them, the water will increase. So just commit that to memory. Now NCLEX question.
What if the water and the water seal chamber you notice it's not fluctuating at all what could be the issue well the lung may have re-expanded corrected our problem or there's a kink somewhere so you want to check that out next the air leak monitor area this is part of the water seal chamber and it's at the bottom and what we're looking for in that is bubbling inklex loves to ask questions about bubbling so what's the big thing normally there's should be no bubbling in there because it's monitoring for air leaks. However, if you have excessive bubbling noted in that area, that could mean an air leak. However, if the patient has a pneumothorax, there could be intermittent bubbling in this. Now, let's think back to a pneumothorax.
What is a pneumothorax? Remember we talked about at the beginning of the lecture. It's where air enters into the pleural space. As that patient is recovering, air will escape and leak from the lungs into the water seal chamber. You could see a little bit of intermittent bubbling.
That could be normal for them, but the excessive continuous bubbling is not. That can indicate an air leak. Next part of it is the suction control chamber. Remember on the wet section, we have the water column, and on the dry section, we have the suction bellow little regulator. that works with that.
Biggest thing you need to know is that with wet suction you're going to hear a continuous bubbling noise and you're going to see gentle bubbling in this. That is normal because it's connected to wall suction and that's telling us it's working. The water can evaporate over time so you want to make sure that you're adding water if it does evaporate to keep it at the prescribed amount of suction. With the dry suction there's no water column and it's regulated by that section. monitor bellow, that little orange accordion thing.
Other thing you want to do is you want to monitor your patient's lung sounds, how fast they're breathing, if they're having any complaints of difficulty breathing like dyspnea. Watch the insertion site, look at it, make sure it's free from infection, and also check for any subcu crepitus or subcu emphysema, also called that. This is where carbon dioxide escapes into the tissues, and whenever you feel it, it'll be puffy, and you'll never forget it if you ever feel it. It feels like a crackling sensation underneath the skin. And also you're going to be having the patient cough and deep breathe.
That helps move fluid and keeps their lungs nice and functioning. And you're going to be repositioning them. Okay, what to do if the chest tube becomes dislodged.
If this happens, cover the site with a sterile dressing and tape it on three sides. Doing this will allow air to escape and prevent a tension pneumothorax and notify the physician immediately. Okay what happens if this system breaks?
You walk into the room it's fell over, cracked, you need to get a new one. While you're waiting on your new one to arrive, order a new one, you'll take the tubing and insert it one inch into sterile water to make that water seal and get a new system. Okay, what about milking or stripping the tubing?
This used to be done a long time ago, however, it's not really recommended anymore due to increasing pressure. So always follow your hospital... protocols with this.
Another thing, clamping. Another issue, always follow your hospital protocols. What do they say to do with that? Because there's an increased risk of increasing the patient's chances of developing a tension pneumothorax. never do it without a physician's order.
Okay, so removal of a chest tube. Typically, the physicians will do this. In some facilities, nurses have been checked off through competencies to do this, but typically, for NCLEX purposes, you will be assisting the physician, usually done at the bedside. What you will do is you will gather the supplies. Typically, it varies on physician preference, so always make sure you know what your physician's like.
Serial gloves, dressing supplies, This could be occlusive, petroleum based, teflon, whatever, a mask, gloves, a suture removal kit, and rubber tipped hemostats. One thing you're going to be doing prior to removal, you're going to teach the patient how to do what's called the valsalva maneuver. This is where you will have the patient take a deep breath, exhale, and bear down.
They will do this during removal. The reasoning for this is to prevent air from from entering that pleural space during removal. So that helps decrease that from happening. Then if ordered, you'll premedicate the patient for pain because this can be painful. Position the patient in semi-fowler's position.
And afterwards, you're gonna monitor the respiratory status. Listen to those lung sounds. Watch for equal chest rise and fall. Make sure it's not unequal. Any drainage.
Is the patient breathing okay? Are they complaining it's hard to breathe? And typically after a removal. When removal is done, the physician will order a chest x-ray to assess lung expansion.
So that is an NCLEX review about chest tubes. Now go to my website, RegisteredNurseRN.com and take the free quiz to test your knowledge. And be sure to check out my other NCLEX review videos. And thank you so much for watching and please consider subscribing to this YouTube channel.