Chapter 28
Respiratory Care
573
“vacuum” necessary to restore the negative pressure within the pleural space. An increase of positive pressure can build up within the pleural space and, if it is not resolved, can cause a tension pneumothorax. This condition can eventually shift the entire mediastinal area, which includes the heart, bron- chial trees, and major blood vessels, from the center to one side, causing compression of the heart. This shift can prevent the previously unaffected lung from optimally exchanging gases, further adding to the problem. If clots are noted, follow your facility’s policy and your health-care provider’s orders. The previous practice of “stripping” the tubes that lead to the drainage unit (pinching the tubing closed and sliding your fi ngers down the tubing to pull clots toward the drainage unit) is not recommended because it increases positive pres- sure within the pleural space. However, a clot that occludes the tubing can have the same result. “Milking” chest tubes refers to pinching the tube above the clot brie fl y and repeat- ing this action to work the clot gently away from the wall of the tube. Safety: Know your facility’s policy for intervening when clots are present in the tubing from the chest tube to the drainage unit. In many situations, the response to a blood clot in chest tubing lies with the physician’s preference. It is also important to know what to do if a chest tube comes out. A special dressing impregnated with petroleum jelly makes an occlusive barrier to cover the opening and prevent air from entering. It is the policy at some hospitals to keep such a dressing at the bedside of the patient with chest tubes. However, if the patient has an unresolved pneumotho- rax, placing petroleum gauze over the opening could cause a tension pneumothorax because of air trapped in the chest. In that case, some researchers recommend placing regular gauze over the opening and preparing for reinsertion. Safety: Notify the physician immediately if a chest tube comes out. Follow facility policy regarding the use of petroleum gauze. If the chest tube becomes disconnected from the drain- age unit, place the end of the tube in a bottle of sterile saline or sterile water so that it is 2 cm below the surface of the
the chest tube drainage unit, notify the physician immediately because this could indicate hemorrhage. DIGITAL CHEST TUBE DRAINAGE SYSTEM. In recent years, digital chest tube drainage systems have become available. These digital systems are designed to detect air leaks and sound an alarm, rather than depending on nursing staff to detect bubbling in the water seal chamber. They also include a drainage container that, when full, can be snapped off and replaced with a new one (Fig. 28.10). In addition, the digi- tal system measures the amount of chest tube output for you and displays it on a screen. One main bene fi t of the digital system over the three- chamber system is that it provides a very consistent level of negative pressure that is not dependent on suction regulators, patient position, or fl uid in the tubing. Another researched bene fi t is that the digital system decreases the length of time that the chest tubes must remain in place and how long the patient must remain in the hospital. The digital system also allows the patient to be more mobile because it can easily be suspended from a strap while the patient is ambulating. Cur- rently both types of drainage systems are being used, so be sure that you follow your facility’s guidelines for chest tube drainage system care. Nursing Interventions for Patients With Chest Tubes Patients with chest tubes may be in critical care units, but they also may be on regular nursing units, which is why it is important for you to know how to care for them. Your responsibilities include assessing the patient’s respiratory status every 2 hours to ensure that no complications occur. The patient should have audible breath sounds in all lung fi elds as the pneumothorax, hemothorax, or both resolve. It is possible that you will hear a friction rub because of the presence of the chest tube in the pleural space. It is important for you to assess for clots that might occlude the tubing, preventing the suction from maintaining the
FIGURE 28.10 A digital chest drainage sys- tem showing the digital readout and the drainage collection container.
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