Nursing Care
Respiratory Assessment & Care
• Respiratory Rate & Characteristics, Breath Sounds, SpO2
• Elevate Head of Bead
• Turn every 2 hours; increase activity as ordered
Indications
• Encourage Coughing/Deep Breathing & use of Incentive
Goal of therapy is to remove air or fluid Spirometry
from the pleural space. • Pain Assessment & Management (Very Important!)
• Pneumothorax (Air) Chest Tube & Drainage System
• Hemothorax (Blood) • Palpate the insertion site for subcutaneous emphysema.
• Chylothorax (Chyle/Lympathic Fluid) • Assess if site dressing is occlusive. Do not use petroleum
• Empyema (Pus) gauze at site unless ordered.
• Secure connections between chest tube and drainage
• Pleural Effusion (Fluid)
system with tape.
• Verify suction is set as ordered and that orange float is
visible.
Attach Suction Tubing Tubing attached • With an order, CT may be placed to water seal (d/c
Here to Chest Tube suction) to see if lung remains expanded & the chest tube
is no longer needed.
• Monitor the amount and characteristic of drainage
o Minimal drainage if placed for air removal.
• Keep drainage system upright and below level of chest.
See Orange Float
• Avoid dependent loops in the tubing by loosely coiling the
tube on the bed & allow the rest of tubing to fall in a straight
line to the drainage unit.
• Accumulation of drainage in the tubing impedes suction.
Lift the tubing & empty drainage into the collection chamber
as needed.
• Assess water seal chamber for:
o Fluctuations
Water column will move with inspiration and
with expiration; movement is opposite if patient is on
a ventilator. Presence indicates the system is
Suction Control Chamber properly functioning.
• Dial in the ordered suction level (most May be minimal if system is placed to suction.
commonly it is -20 cm). When suction is o Bubbling
applied an orange float will be visible in the Indicates an air leak;
window beside this chamber. • Check all connections between the chest tube &
Water Seal Chamber drainage system
• This consists of a tube submerged under 2 cm
• Reinforce dressing
of water that functions like a one-way valve:
• Notify physician.
As the patient breathes spontaneously, the air
passes through the water as he exhales. When If chest tube is placed for a pneumothorax, bubbling
he inhales, the water barrier prevents air from may be present until the lung has reexpanded.
going into his chest. This helps reestablish • Never clamp a chest tube.
negative intrapleural pressure. (Bubbling • Never strip a chest tube. If clot is seen, gently squeeze or
indicates an air leak) pinch the tubing between the fingers in the direction of
Drainage Collection Chamber the drainage device.
• This reservoir is where drainage accumulates • If the chest tube becomes dislodged, immediately apply
as it is drained from the chest. Markings an occlusive dressing, and tape three sides. Notify
indicate fluid level. physician.
