Question

Respiratory Care Modalities

April Long, a 60-year-old patient, is admitted with the diagnosis of small cell carcinoma of the left lower lobe. She had a left lower lobectomy removing the cancerous mass. After surgery, the patient has a chest tube to a closed water-seal drainage system, the Atrium Ocean at 20 cmH₂O.

1.   What are the nursing responsibilities when caring for a patient with a chest tube to a drainage system?

2. How should the nurse reposition the patient in this case study?

3. The chest tube accidently is disconnected from the drainage system and the drainage system is cracked. What should the nurse do?

Answer 1

a) What are the nursing responsibilities when caring for a patient with a chest tube to a drainage system?
The chest tube is connected to a closed chest drainage system, which allows for air or fluid to be drained, and prevents air or fluid from entering the Pleural Space. Here are the steps mentioning that a Nurse should follow when caring the patient in these case:
i. Note the chest tube drainage system which must always be suituated below the drainage site and secured in the upright position to prevent it from being knocked over.
ii. If it is a Traditional Chest Drainage System: Generally, these tubes will have three Chambers named ,
1] Collection Chamber these are connected directly to the chest tube which is caliberated to Measure the Drainage
  2] Water-seal Chamber is a one-way valve that allows air to exit the pleural cavity during exhalation but does not allow re-entering during exhalation, water in these chamber should rise with inhalation and exhalation known as Tidaling
3] Wet or Dry Section Control Chamber this is not required for all patients, but is used to self-control regulator that adjusts the amount of suction for the patient.
On these three chambers, Nurse should notice that all chambers function properly, and if not to change according to the surgican prescription. Should always check the level of water in H2O in both water seal and control suction chamber.
iii. Ensure the safety or Emergency equipment is attached to the bed such as
1] Waterproof Tape
2] Sterile Water
3] Two guarded clamps
4] 4*4 sterile dressing
5] Vaseline gauze (Jelonet)
iv. Should assess the patient for every 15 minutes to 1 hour unless the patient become much stable, following hospital policy for frequency of monitering the patient is much reliable.
v. Normal volume of drainage, location of the test tube, date of the dressing changes, previously recorded air leaks measurements and reviewing reason of the chest tube attachment are major things to be notes frequently during the time period.
vi. Never clamp a chest tube without the Doctor's order, since the tube must remain unobscured and unclamped to drain air or fluid from the pleural space.
vii. Make patient place in semi-fowler position for easier breathing and ensure the measurement of vital sign and respiratory assessment. Check insertion site for subcutaneous emphysema.
These are major nursing responsibilities in this case study.

b) How should the nurse reposition the patient in this case study?
In order of repositioning the patient, informing the patient about the procedure going to be done will be easy and then first the suction should be disconnected and left open to Air. Do not clamp the tube , Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a Tension Pneumothorax. Handle the chest drainage unit carefully and maintain the drainage device below the patient's chest. Ensure it again the chamber is below the patient's chest level during transport and in some cases Flutter Valve Systems (Heimlich) may be used for patient's interhospital transfers. Should be Hygiene and use personal protective equipment to protect from possible body fluid exposure. Look whether its Bleeding at the drain site and ensure it simultaneously. Complications may involve infection, accidental disconnection of system and drian removal and aslo purse sring cut or not present and this should also be noted to prevent the critical circumstances while repositioning. Being much concern on the above mentioned steps would possibly not cause ant trouble and the repositioning wouls be much easier and comfortable for the patient.

c) The chest tube accidently is disconnected from the drainage system and the drainage system is cracked. What should the nurse do?
In this case, Nurse should immedietly seal of the insertion site. Should instruct the person to exhale as much as possible and to cough known as the Valsalva Maneur (that impedes the return of venoud blood to heart and Intrathoracic pressure becomes very positive due to the compression of the thoracic organs by contracting rib cage). At the end of the expiration immediately cover the insertion with vaseline gauze, a dry sterile dressing and occlusive tape. If the chest tube is happened with the contamination, nurse should just submerge the tube 1" to 2" from 2 to 4 cm below the surface if its 250ml bottle of sterile water or saline solution until the new chest tube system is set up, this may establish a water seal and allow air to escape and prevent air renetry, and apply pressure in case of drainage system being cracked. The nurse should also immediately call the physician and prepare for re-inserting the chest tube, if so while informing physician just place oxygen on the patient and ask patient to sit in high-fowlers position. It is also imperative that the nurse evaluates the patient for a life-threatening situation, such as the Tension Pneumothorax also if medically necessary with the physician's order set up the chest drainage unit and gather the thoracotomy tray while monitoring the patient"s vital signs.