572 SECTION 5 Problems of Oxygenation: Ventilation

effective deep breathing and use of incentive spirometry. If the patient practices these techniques before surgery, the tech-niques will be easier to perform postoperatively. Tell the patient that adequate medication will be given to reduce the pain. Help the patient to splint the incision with a pillow to facilitate deep breathing.

For most types of chest surgery, chest tubes are inserted and connected to water-sealed drainage systems. Explain the

purpose of these tubes to the patient. In addition, supplemental oxygen is frequently given the first 24 hours after surgery. Teach range-of-motion exercises on the surgical side similar to those for the mastectomy patient (see Fig. 52-1).

The thought of losing part of a vital organ is frequently fright-ening. Reassure the patient that the lungs have a large degree of functional reserve. Even after the removal of one lung, there is enough lung tissue to maintain adequate oxygenation.

TABLE 28-23 CLINICAL GUIDELINES FOR CARE OF PATIENT WITH CHEST TUBES AND WATER-SEAL DRAINAGE

Drainage System 1. Keep all tubing loosely coiled below chest level. Tubing should

drop straight from bed or chair to drainage unit. Do not let it be compressed.

2. Keep all connections between chest tubes, drainage tubing, and the drainage collector tight and tape at connections.

3. Observe for air fluctuations (tidaling) and bubbling in the water-seal chamber.

If no tidaling is observed (rising with inspiration and falling with expiration in the spontaneously breathing patient), the drainage system is blocked, the lungs are reexpanded, or the system is attached to suction.

If bubbling increases, there may be an air leak in the drainage system or a leak from the patient (bronchopleural leak).

4. If the chest tube is connected to suction, disconnect from wall suction to check for tidaling.

5. Suspect a system leak when bubbling is continuous. To determine the source of the air leak, momentarily clamp the

tubing successively from the chest tube insertion site to the drainage set, observing for the bubbling to cease. When bubbling ceases, the leak is above the clamp.

Retape tubing connections. If leak continues, notify physician. It may be necessary to replace

the drainage apparatus, or secure the chest tube with air- occlusive dressing.

6. High fluid levels in the water seal indicate residual negative pressure. The chest system may need to be vented by using the high-

negativity release valve available on the drainage system to release residual pressure from the system.

Do not lower water-seal column when wall suction is not operating or when patient is on gravity drainage.

Patients Clinical Status 1. Monitor the patients clinical status. Assess vital signs, lung sounds,

pain. 2. Assess for manifestations of reaccumulation of air and fluid in the

chest ( or absent breath sounds), significant bleeding (>100 mL/hr), chest drainage site infection (drainage, erythema, fever, WBC), or poor wound healing. Notify physician for management plan. Evaluate for subcutaneous emphysema at chest tube site.

3. Encourage the patient to breathe deeply periodically to facilitate lung expansion and encourage range-of-motion exercises to the shoulder on the affected side. Incentive spirometry every hour while awake may be necessary to prevent atelectasis or pneumonia.

4. Chest tubes are not routinely clamped. A physician order is required. A physician may order clamping for 24 hr to evaluate for reaccumulation of fluid or air before discontinuing the chest tube.

Chest Drainage 1. Never elevate the drainage system to the level of the patients chest

because this will cause fluid to drain back into the lungs. Secure the unit to the drainage stand. If the drainage chambers are full, notify the physician and anticipate changing the system. Do not try to empty it.

2. Mark the time of measurement and the fluid level on the drainage unit according to the unit standards. Report any change in the quantity or characteristics of drainage (e.g., clear yellow to bloody) to the physician and record the change. Notify physician if >100 mL/hr drainage.

3. Check the position of the chest drainage container. If the drainage system is overturned and the water seal is disrupted, return it to an upright position and encourage the patient to take a few deep breaths, followed by forced exhalations and cough maneuvers.

4. If the drainage system breaks, place the distal end of the chest tubing connection in a sterile water container at a 2-cm level as an emergency water seal.

5. Do not strip chest tubes. This dangerously increases intrapleural pressures. Drainage tubes may be milked on physician order. Milking: alternately folding or squeezing and then releasing drainage tubing. Milk only if drainage and evidence of clots/obstruction. Take 15-cm strips of the chest tube and squeeze and release starting close to the chest and repeating down the tube distally.

Monitoring Wet vs. Dry Suction Chest Drainage SystemsSuction Control Chamber in Wet Suction System 1. Keep the suction control chamber at the appropriate water level by

adding sterile water as needed to replace water lost to evaporation. 2. Keep the muffler covering the suction control chamber in place to

prevent more rapid evaporation of water and to decrease the noise of the bubbling.

3. After filling the suction control chamber to the ordered suction amount (generally 20 cm water suction), connect the suction tubing to the wall suction.

4. Dial the wall suction regulator until continous gentle bubbling is seen in the suction control chamber (generally 80-120 mm Hg). Vigorous bubbling is not necessary and will increase the rate of evaporation.

5. If no bubbling is seen in the suction control chamber, (1) there is no suction, (2) suction is not high enough, or (3) the pleural air leak is so large that suction is not high enough to evacuate it.

Suction Control Chamber in Dry Suction System (see manufacturers directions) 1. After connecting patient to system, turn the dial on the chest drainage

system to amount ordered (generally 20 cm pressure), connect suction tubing to wall suction source, and increase the suction until the correct amount of negative pressure is indicated. There will be a high negative-pressure release valve in the system.

Chest Tube Dressings 1. Dressings are not routinely changed. If there is visible drainage, notify

physician for instructions. 2. If orders to change dressings, remove old dressing carefully to avoid

removing unsecured chest tube. Assess the site and culture site as indicated.

3. Cleanse the site with sterile normal saline. Apply sterile gauze and tape to secure the dressing. Some physicians may prefer use of petroleum gauze dressing around the tube to prevent air leak. Date the dressing and document dressing change.

Obtaining a Sample from the Chest Tube 1. Form a loop in the tubing in an area to get the most recently drained

fluid. 2. Swab the sampling site of the tubing with antiseptic and allow to air dry. 3. Aspirate from the sampling site with syringe, cap syringe, label with

patient name, date, time, and source of specimen. 4. Send to laboratory.