Providing Care of a Chest TubeDefinition Pneumothorax collection of air in the pleura space Hemothorax an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae, usually as the result of trauma Chest tubes a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures

The Mechanics of Breathing

In normal situations, the pressure between the pleura of the lungs is below atmospheric pressure. When air or fluid enters the intrapleural space, the pressure is altered, and this can cause collapse of a portion of the lung. Even with adequate oxygenation and an open airway, a patient with a collapsed portion of the lung will not have adequate oxygen - carbon dioxide exchange. The only treatment for this altered condition is to restore the negative pressure to the intrapleural space. This is accomplished through the use of a chest tube and collection chamber.

Normal Chest Anatomy

Alterations in Normal Status

Indicators for Chest Tube Placement

Nursing Assessment Findings Diminished or absent breath sounds on affected side. Decreased chest wall movement on affected side. Difficulty breathing. Tachycardia Anxiety Restlessness Decreased oxygen saturation Cyanosis Complaints of pleuritic-type chest pain Increased respiratory rate Pain may worsen when attempting to breathe deeply Equipment needed for Chest Tube Setup Chest tube insertion tray Tube (size per M.D.) Local Anesthetic (Xylocaine) Betadine (or other antiseptic) Suturing suppliesSterile gloves 2 1000cc bottles of sterile water 4 x 4s Suction setup Suction tubing Chest tube collection system Vaseline Gauze Silk Tape

Components of the Chest Tube Drainage System

Suction control chamber The use of suction helps overcome an air leak by improving the rate of air and fluid flow out of the patient. The simplest and most cost effective means of controlling suction is by a calibrated water chamber. This is axxomplished with a suction control chamber. By addiing or removing water from the suction control chamber, the chest drain controls the amount of suction imposed on the patient. Lower the water content, lower the suction. Raise the water level, raise the amount of suction. Water Seal Chamber The water seal chamber which is connected to the collection chamber, allows air to pass down through a narrow channel and bubble out through the bottom of the water seal. Since air must not return to the patient, a water seal is considered one of the safest and most cost effective ways for protecting the patient. Also a patient air leak can be rapidly assessed when bubbles go from right to levt in this chamber. Continuous bubbling confirms a persistent air leak.

Collection chamber Fluids drain diirectly from patient into the collection chamber via a 6 patient tube. As drainage fluids collect, the nurse must record the amount of fluid that collects on each shift. This amount must be marked on the unit itself, and documented in ProTouch, along with the characteristics of the fluid being collected. Preparing for Insertion Gather supplies. Prepare patient. Open chest drainage system. As seen at right. Swing out floor stand to stabilize the unit. Close suction control stopcock.Adding Sterile Water to the Unit First, position the funnel as shown on the right, and fill to the top of the funnel. Raise funnel to empty water into water seal to 2cm line marking. NOTE: IF THE TUBING IS NOT CRIMPED AS IT SHOWS IN THE PICTURE, YOU WILL OVERFILL THE CHAMBER. Remove the vent-plug, pour sterile water in to ordered level, and replace vent-plug. As seen at the bottom right. Insertion The patient will need to be positioned according to where the chest tube will be placed. Typically having the patients arms over their head assists the physician. Pre-medicate the patient with sedation & pain medicine as per Physicians order. This is a scary & painful procedure for the patient. The Physician will prep and numb the area, then make a small incision with a scalpel, then using a trocar (a sharp, pointed rod that fits inside a tube) will insert the chest tube. The patient will feel pressure. Once the chest tube is inserted it may be either clamped or connected to the prepared drainage system, while the M.D. is suturing the chest tube in place. Connect tube to drainage system if not done previously, and apply an occlusive vaseline gauze dressing topped with sterile 4x4s to the insertion site. Securely tape all connections.Post-Insertion Documentation Reason for chest tube placement. Patient vital signs. Any medications given. Location & size of chest tube. Patients tolerance of procedure. Drainage received (if any): color, characteristics, volume, etc. Dressing type applied. Connections securely taped. Vital signs during/post procedure. Water level ordered & set for suction control chamber. Post-insertion chest x-ray taken. Maintenance of Chest Tubes Cardiovascular assessments must be performed every 4 hours at least for all patients with chest tubes. Encourage patient to cough & deep breathe. Check insertion site every morning at 0800 and replace dressing at that time. Assess water levels in drainage unit each shift and correct fluid levels if not as ordered. Report to Physician immediately any change or complication with the chest tube.Maintenance of Chest Tubes Check all tubing connections and re-tape as needed EVERY FOUR HOURS. I & O to be completed Monitor for air leaks, chest x-ray results, oxygen saturations, and peak airway pressures. Report any alterations immediately to M.D. Keep tubing coiled on bed, NEVER allow tubing to dangle. Ensure that bedside collection unit NEVER goes above chest level.Potential Complications with Chest Tubes Subcutaneous emphysema - a collection of free air or gas in the tissue under the skin. Can be mild or severe. Needs to be measured, reported to M.D., and documented. Air leak - noted by constant bubbling in the bottom of the water-seal chamber. Potential causes listed on next page.Potential Sources of Air Leaks Poor tubing connections. Tube dislodgement from pleural space. Cracked bedside collection unit. To locate air leak, clamp the tubing momentarily at various points along tubing length. When bubbling stops, the clamp is between the air leak and the water seal. If youve clamped the whole length of tubing, it may be a cracked collection chamber. Safety Concerns Sealed, taped tubing connections Chest tube maintained in pleural space Infection at site Tubing not disconnected or pulled Constant water levels in unit & constant suction (if ordered) Sterile 1000cc bottle of saline and tubing clamps at bedside continuously.What to do if... Chest tube becomes dislodged: cover open insertion site with vaseline gauze at peak of patient inspiration. Cover with 4x4s, tape on three sides only, notify M.D. STAT, chart event. Drainage system breaks: insert the uncontaminated end of tubing into a bottle of sterile water 2cm deep until new unit can be setup. Notify M.D. & document. *Make sure to review the Chest Tube Policies that are attached, and return your completed answer sheet to your nursing manager.

FUNCTIONS A rigid external immobilizer to secure body part To maintain support To protect realignment of bone To promote healing and early weight bearing To prevent or correct deformity When to cast Indications: Circumferentialcastsmay be used for: Fractures Severe sprains Dislocations Protection of post-operative repairs Gradual correction of a deformity with serial castingContraindications: Circumferential castsshould notgenerallybe usedwith: Open fractures Severe swelling Compartment syndrome Insensate limbs Ulcers or draining wounds assessment History Taking Mechanism of injury Medical history Social background allergies Physical assessment Neurovascular status Skin integrity Presence of wound and drainage Alignment and position Respiratory, abdominal, urologic status Materials needed Stockinette Stockinette is usually the first layer applied over the area to be cast.Its ends can be folded over the cast edges to soften them. It may be omitted in acute fracture treatment as it may restrict swelling. Webril Webril comes in a range of widths from 5-15 cm; the smallest ones are easiest to work with. 5-10 cm webril should be used for the upper extremity and 10-15 cm for the lower extremity. Plaster of Paris Plasteris the most commonly used casting material because of itsease of use. Immersion in water initiates an exothermic reactionin the plaster causing it to harden. Once applied, itwill feel hard within 4 minutes, however, it takes 2-3 days to dry completely. bucket The bucket should be filled with water at or below room temperature.Cooler water decreasesthe risk of burning the patients skin as the plaster setsandalso allows for more working timewith the casting material.

Patient instructions 1. Keep the cast dry!If your cast gets wet, see your doctor.The only exception to this rule is fiberglass casts with gortex linings.2. Plaster casts take 2-3 days to dry completely, thus, they should be left uncovered for at least 2 days to allow for total water evaporation.For walking casts, weight bearing should be avoided for at least the first two days (whether weight bearing is permitted at all is fracture dependent).3. To reduce and minimize swelling, the limb should be elevated above the heart for at least 2 days.4. Fingers and toes should be wiggled often5. DO NOT: put anything down the cast, trim or cut the cast, remove any padding from the cast, drive while in a cast.6. To relieve itch, a blow dryer on a cool air setting may help.7. Seek immediate medical attention if: Pain or swelling increases There is any numbness or tingling There is drainage or an unusual smell The digits distal to the cast are purple There is swelling not relieved by elevation The cast breaksCast removal It is important to remember that removing a cast can be a frightening experience for patients - children and adults alike. A clear explanation of how the cast saw works - that they may feel heat but that it is unlikely to cut their skin, will help improve the patients comfort. It should also be explained that there is a greater risk of skin injury if the cast being cut is wet, if too much pressure is applied, if thepatientsskin is relatively fragile (babies and the elderly), or if the cast has a gortex lining.Both the person removing the cast and the patient should wear ear protection, as the cast saw is loud. Someone who removes casts frequently may also wish to wear a mask to decrease the risk of respiratory complications from the dust of the casts. Removing the cast (equipment) Cast saw The blade of the cast saw oscillates from side to side cutting through the hard cast material without damaging the padding or soft tissue beneath. Cast spreadersCast spreaders are used to split apart the edges of the cast after it is cut with the saw. Bandage scissors Bandage scissors are used to cut through the padding of webril and stockinette.The blunt tip protects the patients skin.

Short arm cast The short arm castmay be used for: Distal forearm fractures Wrist sprains and carpal injuries Some metacarpal fracturesThe cast should allow for full elbow movement, and should not extend beyond the distal palmar crease to preserve motion at theMCP joints. The thumb should also maintain full range of motion.The wrist should be in neutral alignment.Thumb spica cast The thumb spica cast may be used for: Scaphoid fractures Some thumb fracturesFor scaphoid fractures, newer materials like polypropylene may be used which will not be visualized on radiographs, so a scaphoid fracture can be monitored with less cast changes.Long arm cast The long arm cast may be used for: Mid to proximal forearm fractures Elbow fractures and dislocations Distal humeral fracturesThe guidelines for casting around the hand are the same as in short arm casts.Below the knee cast The below the knee cast may be used for: Distal tibial fractures Ankle fractures and dislocations Foot fractures Serial/deformity castingThe ankle should be immobilized at a 90angle; patients may inadvertently plantar flex their foot during casting. Because it will rest on the ground, a good foot plate, flat, with extra layers of cast material, is also essential. The cast should not impede range of motion at the knee.Long leg cast The long leg cast may be used for: Tibial fracturesLike the below the knee cast, the long leg cast requires a 90o angle at the ankle and a thick, flat foot plate.Cylinder/stovepipe cast The cylinder/stovepipe cast may be used for: Patellar fractures or dislocations Distal femoral fractures (some)As the inactive leg muscles atrophy and the cast becomes loose, it may slip.Good moulding may help to avoid this, but should loosening occur, the patient should have a new cast applied.ABDUCTION BOOT CAST Applied from upper thighs to the feet. A bar is placed between both legs to keep the legs and hips immobilized Used to hold the hip muscles and tendons in place after surgery to allow time for healing

CLUBFOOT CAST Used to treatclubfoot Applied from upper thighs to toes Usually changed every 5-7 daysUNILATERAL HIP SPICA CAST(ALSO KNOWN AS SINGLE HIP SPICA) Applied from the chest to the foot on one leg Used for thigh fractures Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healingONE AND ONE-HALF SPICA CAST Applied from the chest to the foot on one leg, and to the knee on the other leg. A bar is placed between both legs to keep the hips and legs immobilized Used for thigh fractures Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healingBILATERAL LONG LEG HIP SPICA CAST(ALSO KNOWN AS DOUBLE HIP SPICA) Applied from the chest to the feet. A bar is placed between both legs to keep the hips and legs immobilized Used for pelvis, hip, or thigh fractures Also used to hold the hip or thigh muscles and tendons in place after surgery to allow for healingSHOULDER SPICA CAST Applied around the trunk of the body to the shoulder, arm, and hand Used for shoulder dislocations, or after surgery on the shoulder areaProblems encountered by a patient with cast anxiety Explain the purpose of immobilization and area involved Describe the procedure and sensation patient may experience when applying the castComplication of casting Compartment syndrome Ischemia and neurologic injury Heat injury Pressure sore and skin breakdown Allergy Dermatitis and infection Joint stiffness and muscle atrophy

Compartment syndrome Increased of pressure because of edema within a closed space that compromises blood flow and tissue perfusion; this causes ischemia and reduce capillary flow which leads to more edema. A vicious cycle develops, resulting in potentially irreversible damage to the soft tissues within the space.Signs and symptoms: 5 PsPain- greater than expectedParesthesia- early signParalysis- late signPallor- not reliablePulselessness- not reliable

Passive stretching elicit excessive pain, a reliable early sign!

Risk of peripheral neurovascular dysfunction Causes Unexpected excessive swelling Cast being applied too tightly Insufficient padding to allow more expected swelling Local pressure on areas where the blood vessels or nerves closed to the skin Elevation (above the heart level) Check tightness of the cast Encouragement movement of the extremities Check neurovascular status Ulnar nerve Sensation distal fat pad of the small finger Motion abduct all fingers Radial nerve Sensation web space between the thumb and index finger. Motion hyperextend finger or wrist Peroneal nerve Sensation web space between the big toe and 2nd toe Motion dorsiflex ankle and extend toes Tibial nerve Sensation medial and lateral surfaces of the sole Motion plantar flex ankle and flex the toesRisk of peripheral neurovascular dysfunction Instruct patient to report any abnormality. E.g. Numbness, tingling or increased in pain. Have cast cutter, spreader ready for use. Altered comfort; pain Elevation Check tightness of the cast Well padded the involved bony prominence Careful handling of the affected part Adequate analgesics Impaired skin integrity Clean and dry skin prior to cast Dress wound properly Ensure smooth surfaces Adequate padding Ensure the edges of the cast are well padded Clean and remove excessive plaster from the skin with warm water. Handle the cast with the palms of the hands instead of the fingers to prevent indentations in the soft plaster Aware of plaster sore Plaster sore Causes Uneven bandaging technique Insufficient padding over bony areas Cast is too tight or too loose Foreign body inside the cast s/s Itching Burning sensation Fever Sleep disturbance Foul smell discharge Impaired mobility Exercise joints above and elbow the affected limb to prevent stiffness of the joints Perform muscle strengthening exercises Encourage self-help. Provide appropriate mobilization aids. Assist in reposition of patient. Adopt fall prevention measures. Weight bearing is not allowed until cast is dry/instructed by surgeon. Cast boot Walking heelRisk of loss alignment Maintain the reduction and keep the affected part in a desired position during cast application. Promote drying of the unconsolidated cast. Use pillow to support the cast Support the cast with palms Check for cracks/softening/loosening Allergic reaction Check for allergy history before apply cast Excessive irritation remove the cast, cleanse the skin thoroughly and reapply other materials Body image disturbance Allow to choose the preferable color esp. in adolescence Discuss expectation of activity and appearance of castKnowledge deficit Assess concern and knowledge of POP care Provide education and pamphlet in care of POP cast and discuss in adaptation of daily activities Patient education Stay in a well-ventilated environment to promote drying up of the cast. Keep the cast away from heat. Never put the cast on hard surface. Elevate your limb at heart level to help reduce pain and swelling. Support the arm with arm sling and use pillows to elevate the lower limb. Move your fingers and toes frequently to prevent swelling and joint stiffness. Avoid pumping and knocking your cast against hard surfaces Do not walk on a walking cast until it is completely dry and hard, and instructed by doctor. Do not push anything down the plaster. Do not use device (e.g. Stick) to scratch underneath the cast. If itching persists, contact your doctor. Keep the cast dry and prevent it from getting wet. To avoid getting your cast wet when taking a shower, cover it with plastic bag and secure the bag to your skin with waterproof tape, making sure that it does not allow water to leak in. Report immediately if: There is any pain, offensive smell or discharge from the plaster. The fingers or toes become blue, swollen or tingling sensation. Any hard objects drop into the plaster. The plaster becomes too tight, loose, soft, or cracked. The child become irritable and is crying with no obvious reason.Advice on diet Calcium and vitamin C aid in bone healing A balance diet: milk product, fish, fruit, vegetables Care after cast removal The skin may become dry and scaly. Wash skin with mild soap and water daily and use moisturizing lotion helps the dead skin to slough off and soften the new skin. Inform patient that it is expected the affected limb will be smaller than the other limb. Once patient start to use the muscle again, the muscles will build back up. It is normal to have some joint stiffness following cast removal. The joint stiffness is caused by lack of motion of the joint while in the cast. It will improve with time.

ConditionPossible CausesTube Placement Location

Hemothorax Open chest procedures

Blunt or penetrating traumaTwo chest tubes may be inserted, one at the apex and one at the base of the lung

Pleural Effusion Heart failure, surgery, malignancyPosteriorly into the fifth or sixth ICS

ConditionPossible CausesTube Placement Location

Pneumothorax Trauma, surgery, invasive pulmonary procedures, bronchoscopy,

Forceful coughing or rupture of a bleb on the lung: spontaneous pneumothorax

Procedures such as central line insertion: iatrogenic pneumothoraxAnteriorly near the apex of the affected lung at the second intercostal space, mid-clavicular line