• Three-bottle system – water seal, collection

SKILL 10: of drainage, and suction control in separate

CHEST TUBE CARE AND BOTTLE bottles.
• Disposable single units that work the same
CHANGING as a three-bottle system (Pleur-evac,
Atrium, Thora-Seal)
OBJECTIVES
1. To be able to define what is Sitz bath. THREE BOTTLE SYSTEM
2. To know what are the purpose, indications, and
contraindications of this therapeutic procedure.
3. To be able to determine what are the Nursing
Responsibilities in performing Sitz bath.
4. Demonstration of skill# 6 and discuss the rationale
per action done.

Nursing Management of the Client with a Chest Tube

Placement
When suction is turned on, air and fluid out of the
Chest Tubes pleural space and into the drainage collection bottle. Suction
• Inserted in the emergency department, in the is applied through the entire system until it reaches the
operating room via a thoracotomy incision, or at the pressure that will draw atmospheric air into through the open
client’s bedside. tube of the suction control bottle. When the incoming
• Inserted into the pleural space to remove air and atmospheric air reaches the lower end of the tube, it bubbles
fluid and to reestablish negative intrapleural into the bottle. At this point, the desired sction level will be
pressure. maintained as any increase in suction will just draw in mo re
• This procedure allows the lungs to reexpand. atmospheric air.
• Chest drainage, which is collected in the drainage
system, will be measured and sent to the laboratory
for analysis. DISPOSABLE CHEST DRAINAGE UNIT
• The chest tube may be positioned anteriorly through • Air and fluid move from an area of high pressure
the second intercostal space to remove air. (intrapleural space) during expiration to an area of
• A second tube may be positioned posteriorly low pressure (drainage system).
through the 8th or 9th intercostal space to remove • The usual water depth in water seal system is 2cm.
fluid and blood. • Chest tubes are removed when the lungs have re-
• The tubes are sutured to the chest wall, and an expanded and/or there is no more fluid drainage.
airtight dressing is placed over the punctured • It usually takes two to three postoperative days of
wound. chest drainage for lungs to fully expand.

Securing chest drain Risk Factors Necessitating Chest Tubes

Before securing the tube with stitches, look for a respiration- • Blunt, crushing or penetrating chest injuries
related swing in the fluid level of the water seal device to • Tension pneumothorax
confirm correct intra thoracic placement. Secure the chest • Hemothorax
tube to the skin using 0 or 1-0 or nylon stitches, as depicted • Hemopneumothorax
below. • Thoracic surgery
• Invasive thoracic procedures

A pneumothorax can be caused by a blunt or penetrating

chest injury, certain medical procedures, or damage from
underlying lung disease. Or it may occur for no obvious
reason. Symptoms usually include sudden chest pain and
Drainage System shortness of breath. On some occasions, a collapsed lung can
• The tubes are then attached to drainage tubing and be a life-threatening event.
the drainage system.
• 4 types of drainage: Hemothorax is when blood collects between your chest wall
• One-bottle system – water seal and and your lungs. This area where blood can pool is known as
collection of drainage in same bottle the pleural cavity. The buildup of the volume of blood in this
• Two-bottle system – water seal and space can eventually cause your lung to collapse as the blood
collection of drainage is separate bottles. pushes on the outside of the lung.
Hemopneumothorax, or haemopneumothorax is the • Tape tops of bottles.
condition of having air in the chest cavity (pneumothorax) • Re-tape all connections if necessary.
and blood in the chest cavity (hemothorax). A hemothorax, • Milk and strip the chest tubes if necessary to
pneumothorax, or the combination of both can occur due to increase amount of negative pressure to pleural
an injury to the lung or chest. space.
• Take precautions that drainage bottle are never
elevated to level of client’s chest.
Signs and Symptoms Necessitating Chest Tubes • Do not empty drainage bottles unless overflowing.
• Air hunger • Never clamp chest tubes without a physician’s order.
• Agitation • Encourage client to cough and deep breathe, sit up
• Hypotension in bed, and ambulate.
• Tachycardia • Provide pain medications one-half hour before
• Severe diaphoresis removing chest tubes.
• Absence or diminished breath sounds on affected • After removal of chest tubes, apply air tight sterile
side petroleum jelly gauze dressing
• Tracheal deviation (tension pneumothorax) • Order chest-rays as needed following removal of
• Cyanosis chest tubes.
• Mediastinal shift to unaffected side

Diagnostic and Laboratory Tests Complications

• History and physical exam • Infection
• Pleural fluid analysis • Recurrent or new pneumothorax
• Blood gas analysis • Respiratory failure
• Chest x-rays following removal of chest tube

Therapeutic Nursing Management IMPELMENTATION:

• Assess/Monitor: 1. Informs the patient of the procedure.
• For blockage of drainage system 2. Washes hands.
• For air leaks 3. Prepares needed materials: dressing set with sterile
• For air bubbles in water-seal chamber forceps and kidney basin, sterile gloves, clean gloves,
• For fluctuations in glass tube or chest tube sterile petrolatum gauze, cotton balls with betadine,
• Vitals signs sterile 4 x 4 gauze, adhesive tape, sterile CT bottle
• Breath sounds with sterile water or PNSS (depending on hospital
• Chest wall for unusual chest movements protocol), clamp, bottle guard.
• Oxygen saturation 4. Provides privacy. Closes bed curtains or room
• Chest tube insertion site for redness, pain, curtains.
infection, and crepitus 5. Checks the chest tube for any possible disconnection
• Wound for excessive drainage or signs of and assesses fluid fluctuation during inspiration.
infection following chest tube removal 6. Wears clean gloves.
• Client for signs of recurrent pneumothorax 7. Removes and discards the old dressing on the kidney
basin. Assesses site for any signs of infection.
The insertion site dressing may need to be changed by the 8. Removes used gloves.
surgeon who inserted the chest tube. Development 9. Unwraps sterile pack.
of crepitus can indicate a small air leak into the subcutaneous 10. Puts on sterile gloves.
tissue. Crepitus may indicate a need for the surgeon to adjust 11. Cleans the insertion site using cotton balls with
the chest tube placement. betadine held by forcep at least 3x using one cotton
ball per stroke (starting from the insertion site in a
circular motion going out; then from inside going at
Nursing Activities least 2 inches up the tube).
• Assist physician with insertion of chest tubes and 12. Covers the insertion site with sterile 4 x 4 gauze and
set-up of drainage system if this is am emergency secured using tape (may use petrolatum gauze in the
procedure performed at bedside. inside then dry sterile gauze on top, depending on
• Keep all tubing straight and coil loosely. hospital protocol and availability).
• Prevent client from lying on tubing. 13. Checks the level of the drainage bottle and notes the
• Make certain that connections between the chest total amount of output.
tube, drainage tubing, and drainage collection 14. Clamps the chest tube (if chest tube bottle is
bottles are tight. connected to a suction apparatus, turns off the
• Tape connections securely to prevent air leaks. suction prior to clamping).
15. Detaches the tubing from the bottle by loosening the
rubber stopper.
16. Submerges the end of glass tubing 2-3 cm into the
new sterile CT bottle with sterile water or PNSS.
Secures rubber stopper in place.
17. Places CT bottle in bottle guard to prevent accidental
breakage.
18. Reconnects to suction apparatus (if indicated).
19. Checks tubings for loose connections.
20. Unclamps chest tube. Turns on the suction
apparatus (if indicated).
21. Reassesses for chest tube placement by instructing
patient to take a deep breath and checks for fluid
fluctuation.
22. Discards disposable equipment and
cleansesnondisposable equipment.
23. Removes gloves.
24. Washes hands.
25. Documents the following: any signs of infection,
characteristics of drainage (color, consistency,
transparency), amount, baseline level of fluid in the
drainage bottle and time it was replaced