FLUID, ELECTROLYTES, AND ACID-BASE BALANCE hours, or at least 0.5 mL per kilogram per hour.

− In healthy people, urine output may vary noticeably from day to

What is Fluid? day.
− Means water that contains dissolved or suspended substance
such as glucose, minerals, salts and proteins. Interpreting Intake and Output
− Body fluids are located two distinct compartments; • − If the intake is less than output or if the output is more than the
ECF intake, think DEHYDRATION.
• ICF − If the intake is more than the output or if the output is less than
− Composition of body fluids; the intake, think that the patient may be retaining fluid and
• Fluid in the body compartments contains minerals – is in FLUID OVERLOAD.
Electrolytes. − Fluid I&O measurements are totaled at the end of the shift
• ELECTROLYTES: is a compound that separates into ions (every 8 to 12 hours), and the totals are recorded in a client’s
(charged particles) when it dissolves in water. chart.
• OSMOLALITY: measure of the number of particles per − In intensive care areas, nurses may record I&O hourly. − Usually,
kg of ��2��. the staff on the night shift totals the amounts of I&O recorded for
each shift and records the 24-hour total.

Daily Weight
− Significant changes in weight over a short time are indicative of
Acute Fluid Changes. Each kilogram (2.2 lb) of weight gained or
lost corresponds to 1 L of fluid gained or lost. − Obtain accurate
weight measurements;
• The scale should be balanced before each use, and the
client should be weighed
a. At the same time each day (e.g., before
breakfast and after first void)
b. Wearing the same similar clothing
c. On the same scale. The type of scale (i.e.,
standing, bed, or chair) should be
documented

Intravenous Therapy Fluids

− Fluid balance: 3 Process
1. Fluid Intake − A treatment that infuses intravenous solutions, medications,
2. Fluid Distribution blood, or blood products directly into a vein.
3. Fluid Output − IV therapy fluids will come in sterile plastic bags or glass bottles.
− To maintain fluid balance, fluid intake must be equal to output. − physicians and health care providers order IV fluids and flow
rates.
Clinical Measurements:
− Fluid Intake and Output The most common for IV Therapy include:
− Vital Signs 1. To replace fluids and electrolytes and maintain fluid and
− Daily Weight electrolyte balance.
2. To administer medications, including chemotherapy,
What is Intake? anesthetics, and diagnostic reagents.
− These are fluids taken in the body. 3. To administer blood or blood products.
− It can be via various routes like the mouth, a tube, or 4. To deliver nutrients and nutritional supplements.
intravenous (IV).
− What do you include for the liquids that are consumed? •
Anything that is liquid at room temperature.
− Many times, test questions will give you the amount in ounces
(oz), but we record intake and output in milliliters (mL). • To
convert oz to mL, simply multiply the amount of oz by 30.

What is Output?
− These are fluids that leave the body.
− 4 organs: Skin, Lungs, GI Tract, and Kidneys IV Orders − The prescriber is responsible for writing the order.
− What’s included? − Administering and monitoring an IV = nursing responsibility. −
• Urine output (most of the output calculation) IV order must specify the following:
• Emesis • Name of the IV solution
• Liquid stool (ostomy or diarrhea) • Name of medication to be added if any
• Wound draining (drains, tubes-chest tubes) • Amount (Volume) to be administered
• Suction (gastric, respiratory) • Time period during which the IV is to infuse
− Not included but needs to be considered is Insensible Loss. Review: Types of IV Fluids
− Normal urine output for an adult is 1,400 to 1,500 mL per 24 • D5W = D5%W
 • D5S = D5%0.9NS − Formula for gtt/min.
• D512NS = D5%0.45NS ����/ℎ�� × �������� ������������
• NS = 0.9%NS
60 (��������������)= ������/������.
•12NS = 0.45%NS
• LR = Lactated Ringers IV Fluid Rate
− ��������/������. =������������ ���� ���� ×
Regulating and Monitoring IV Infusions �������� ������������
− The number of drops delivered per milliliter of solution varies with ����.���� ℎ������ × 60 ������
different brands and types of infusion sets. This rate, called the or
drop factor, is printed on the package of the infusion set. − ������/������. =����/ℎ��. × ��������
− Macrodrops commonly have drop factors of 10, 12, 15, or 20 ������������
drops/mL; the drop factor for microdrip sets is always 60 60 ������
drops/mL. − ����/ℎ��. =������������ ���� ����
− Drop factor is number of GTTS = 1 mL ����.���� ℎ������������
��������/������ × 4
IV Drip Factors − ���������������� ���� ℎ��������
− Microdrip = 60 gtt/mL =������������ ���� ����
− Macrodrip need to check the package ����/ℎ��

• 10 gtt/mL
Electronic Volumetric Pumps
• 15 gtt/mL
− Infuse fluids int the vein under pressure and against resistance
• 20 gtt/mL
• Do not depend on gravity
− To calculate IV drip rates, this information must be known.
− Pumps are programmed to deliver a set amount of fluid per hour
• Milliliters per hour (mL/hr)
− Milliliter calculation that results in a decimal fraction – round to a
whole milliliter
• Pumps in ICU may have decimal capability and may use
fractions.

IV Pump Using Controller

− IV pump = rate will be mL/hr
− Formula:
���������� # ���� ���� ��������������

���������� # ���� ℎ��������

�������������� = ����/ℎ��.
Drip Chambers
− IV sets with a small needle in the chamber Determining the Number of Hours an IV will Run
• Microdrip Formula:
������������ ����
• 1 mL = 60 gtts (60 gtts in drip chamber = 1 mL) ����������������������
− IV sets without a small needle ��������������
• Macrodrip
������������ ���� ����������������������
• Baxter tubing macrodrip/1 mL = 10 gtts (10 gtts in drip
chamber = 1 mL) ������ ℎ������= ������������ ���� ℎ�������� ����
������
• Other companies tubing may be 15 gtt/mL or 20 gtt/mL
What does “Priming the IV Tubing” mean?
IVF Rate − This means you will allow the solution in the IV bag to flow
− KVO (keep vein open) or TKO (to keep open = 10 to 25 mL/hr. through the tubing to remove air.

Regulation of IV Drip Rate Manually What does “Spiking the IV Bag” mean?
− Tubing for these sets contain a roller camp − This means you will be penetrating the IV bag with the spike of the
− Can open or close and regulate rate manually IV tubing into the spiking port of the bag so the contents can
− Use a watch with second hand to count number of drops per flow into the IV tubing and then into the patient.
minute in the chamber
When to Change IV Tubing?
Electric Infusion Pumps − Continuous infusion tubing changes occur no more frequently
− IV infusion pumps utilized to deliver IV fluids accurately – set at than every 96 hours unless the tubing has been compromised
mL/hour. or become contaminated, which requires tubing change.
• Need to enter the total number of milliliters to be infused. • − Intermittent infusion every 24 hours because of the increased risk
Need to enter the number of milliliters per hour. of contamination from opening the IV system.
− You leave transparent dressings in place until the IV tubing is
Labelling IV’s
replaced.
− Every IV must be labelled so any professional can check • The
− If a gauze dressing is used, change it every 48 hours. − Both types
fluid infusing is correct. of dressings must be changed when the IV device is removed or
• The rate of infusion is correct. replaced or when the dressing becomes damp, loosened or soiled.
− Label:
− Peripheral IVs are prone to phlebitis and infection, and should be
• Patient Name removed (CDC, 2011) as follows:
• Room/Bed # • Every 72 to 96 hours and p.r.n.
• Date & Time • As soon as the patient is stable and no longer requires IV
• IV Order fluid therapy.
Calculating Basic IV Drip Rates • As soon as the patient is stable following insertion of a
− IV drip rate cannula in an area of flexion.
• No pump: rate will be gtt/min. – also known as gravity • Immediately if tenderness, swelling, redness, or purulent
drip. drainage occurs at the insertion site.
 • When the administration set is changed (IV tubing). − The Piggybacked
CDC.GOV recommends changing IV tubing that is used continuously − As a secondary set into the primary line or as a primary
and not used for blood, blood products, or fat emulsions (TPN, intermittent infusion to be administered over a 30- to 60-
Lipids) every 96 hours. However, IV tubing used for blood, blood minute period.
products, or fat emulsion should be changed every 24 hours. − Injectable medications such as antibiotics are usually added to a
− Many hospitals require you change out tubing that is not used for small IV solution bag.
blood, blood products, or fat emulsions every 3-4 days (again
always follow hospital protocols) and 24 hours for tubing used
for blood, blood products, and fat emulsions.

Safety Alert!
− Several electronic devices are on the market for infusing IV
solutions.
− Always familiarize yourself with the equipment before use. −
Follow the institution’s protocol for IV administration. − Nurses have
the primary responsibility for monitoring the client during IV
therapy.
− Nurses are responsible for any errors that occur in administration
of IV fluids (e.g., inadequate dilution, too rapid infusion)
− Pay close attention to IV abbreviations.

Vascular Access Devices

− Are catheters of infusion ports designed for repeated access to the
vascular system.
− Peripheral catheters are for short-term use.
− Devices for long-term use: central catheters and implanted ports,
which empty into a central vein.
− Remember that the term central applies to the location of the
catheter tip, not to the insertion site.
− Peripherally inserted central catheters (PICC lines) enter peripheral
arm vein and extend through the venous system to the superior
vena cava where they terminate.
− Other central lines enter a central vein such as the subclavian or
jugular vein or are tunneled through subcutaneous tissue
before entering a central vein.
− Central lines are more effective than peripheral catheters for
administering large volume of fluid, PN, and medications or
fluids that irritate veins. Proper care of central line insertion
sites is critical for the prevention of catheter-related
bloodstream.
− VADs that are short, peripheral IV catheters are available in a
variety of gauges such as the commonly used 20 and 22 gauges.
− A larger gauge indicates a smaller-diameter catheter. − A
peripheral VAD is called an over-the-needle catheter; it consists of a
small plastic tube or catheter threaded over a sharp stylet (needle).
− Risk of needlestick injury
Primary Line
− Main IV fluid used in a continuous infusion flows through
tubing.
− Connects to the IV catheter.
Venipuncture
− A technique in which a vein is punctured through the skin by
a sharp rigid stylet (e.g., metal needle).
− General purposes of venipuncture are to collect a blood
specimen, start an IV infusion, provide vascular access for
later use, instill a medication, or inject a radiopaque or other
tracer for special diagnostic examinations.
− Most common IV sites = inner arm
− Do not use hand veins on older adults or ambulatory patients.
− IV insertion in a foot vein is common with children, but avoid
these sites in adults because of the risk of thrombophlebitis.
− Contraindicated in a site: signs of infection, infiltration, or
thrombosis.
• An infected site is red, tender, swollen, and possibly
warm to the touch.
• Exudate may be present.
• Avoid using an extremity with a vascular (dialysis)
graft/fistula or on the same side as a mastectomy.
• Avoid areas of flexion if possible.

Maintaining the System

1. Keeping the system sterile and intact.
2. Changing IV fluid containers, tubing, and contaminated site
dressings.
3. Assisting a patient with self-care activities so as not to disrupt
the system.
4. Monitoring for complications of IV therapy.
BLOOD TRANSFUSION − Children with small veins use a smaller catheter. Prime the
tubing with 0.9% sodium chloride (normal saline) to prevent
Purposes
hemolysis or breakdown of RBCs. Initiate a transfusion slowly
− To administer required blood components by the patient. −
to allow for the early detection of a transfusion reaction.
To restore the blood volume.
− The transfusion rate usually is specified in the health care
− To improve oxygen-carrying capacity of the blood. provider’s orders.
− Notify the blood bank immediately to prevent infusion errors
− Ideally,
when administering.
• Whole blood or packed RBCs = 2 hours
− Appropriate size IV catheter and blood administration tubing
that has a special in-line filter. • This time can be lengthened to 4 hours if the patient is
at risk for ECV excess. Beyond 4 hours there is a
− Adults require a large catheter (e.g., 18- or 20-gauge) because
blood is more viscous than crystalloid IV fluids. risk for bacterial contamination of the blood.

− Blood typing only determines the presence of the ABO and

RH antigens, crossmatching is also necessary prior to
 transfusion to identify possible interactions of minor antigens
with their corresponding antibodies.
BLOOD SET OR BLOOD ADMINISTRATION SET

Transfusion of Blood
− OR blood components are a nursing procedure that requires an
order from a health care provider.
− Patient safety is a nursing priority, and patient assessment,
verification of health care provider’s order, and verification of
correct blood products for the correct patient are imperative. −
Assessment before initiating.
− Monitor carefully during and after transfusion. −
Risk for transfusion reactions.
− Pretransfusion assessment (baseline vital signs, done the
transfusion before)
− Before beginning:
• Explain the procedure and instruct the patient to
report any side effect (e.g., chills, dizziness, or
fever) once the transfusion begins.
• Signed an informed consent. (Cultural backgrounds)
Transfusion Reactions and other Adverse Effects
− An immune reaction to the transfusion that ranges from a mild
response to severe anaphylactic shock or acute intravascular
hemolysis, both of which are life threatening.
− Prompt intervention when a transfusion reaction occurs
maintains or restores the patient’s physiological stability.

When you suspect Acute Intravascular Hemolysis, do the following:

1. Stop the transfusion immediately.
2. Keep the IV line open by replacing the IV tubing down to the
catheter hub with new tubing and running 0.9% Sodium
− For patients’ safety, always verify three things:
1. That blood components delivered are the ones that Chloride (normal saline).
were ordered. 3. Do not turn off the blood and simply turn on the 0.9% Sodium
2. That blood delivered to the patient is compatible with Chloride (normal saline) that is connected to the Y-tubing
the blood type listed in the medical record. infusion set. This would cause blood remaining in the IV
3. That the right patient receives the blood. tubing to infuse into the patient. Even a small amount of
mismatched blood can cause a major reaction.
− Together two RNs and one RN and an LPN (check agency policy
and procedures) = check the label on the blood product 4. Immediately notify the health care provider or emergency
against the medical record and against the patient’s response team.
identification number, blood group, and complete name. 5. Remain with the patient, observing signs and symptoms, and
monitoring vital signs as often as every 5 minutes.
− If ever minor discrepancy exists, do not give the blood.
6. Prepare to administer emergency drugs such as antihistamines,
vasopressors, fluids, and corticosteroids per health care
provider order or protocol.
7. Prepare to perform cardiopulmonary resuscitation. 8. Save the
blood container, tubing, attached labels, and transfusion record
for return to the blood bank.
9. Obtain blood and urine specimens per health care provider’s
order or protocol.

Complications of Infusion Therapy

1. Infiltration is the unintended administration of a non-vesicant
drug or fluid into the subcutaneous tissue. Infiltration can be
caused by puncture of the vein during venipuncture,
dislodgement of the catheter, or a poorly secured infusion
device.
2. Extravasation is similar to infiltration with the difference
between the two being the solution. That is, extravasation is
the unintended administration of vesicant drugs or fluids
into the subcutaneous tissue.
− Five measures can help prevent infiltration and
extravasation:
i. Selection of the venipuncture.
ii. Areas of joint flexion such as
the hand, wrist, and antecubital
fossa should be avoided.
iii. The gauge of the catheter
should be the smallest
that can deliver the
prescribed
therapy in an appropriate
size vein. Using a
manufactured catheter
 stabilization device
prevents unnecessary movement of the
catheter in the vein.
iv. Assessing patency of the catheter and vein
frequently.
3. Phlebitis is an inflammation of the vein of which there are
three types.
a. Mechanical phlebitis is caused by too large of a
catheter in a small vein causing irritation of the
vein.
b. Chemical phlebitis occurs when a vein become
inflamed by irritating or vesicant solutions or
medications.
c. Bacterial phlebitis is an inflammation of the vein
and a bacterial infection, which can be caused by
poor aseptic technique during insertion of the IV
catheter and/or breaks in the integrity of the IV
equipment.
− Prevention Strategies: Practicing good hand hygiene,
assessing the length of time needed for the infusion
therapy, and considering alternatives (e.g., midline
catheter or PICC) for long-term therapy, choosing the
smallest catheter, stabilizing the catheter, infusing
solutions at the prescribed rate, avoiding insertion of a
peripheral IV catheter in an area of flexion, and
assessing the IV site at least every 4 hours.
ABDOMINAL PARACENTESIS • Explain the indication, risks, benefits, and alternatives. •
Prepare the appropriate equipment.
Paracentesis
• Ask the patient to urinate before the procedure to empty the
− A procedure involves the aspiration of the fluid from the
bladder.
peritoneal space through a needle, trocar or cannula
• Position the patient in an upright position on the edge of the
inserted in the abdominal wall.
bed or in a chair with feet resting on a stool. Tilt the patient
Purposes: toward the site of paracentesis (allow fluid to accumulate in
1. For relieving pressure in peritoneal cavity. lower abdomen and air-filled loops of bowel tend to float to
2. For drainage fluid from abdominal cavity in Ascites condition. the other site, this will minimize trauma to bowel.
3. For pressure relieving on the organs of chest and abdomen. 4. • Can be done also while in a supine position.
Cirrhosis of liver with Ascites. • Ultrasound scan
5. For lab diagnosis (Histopathology e.g., cancer, Biochemistry − To identify the presence of encysted ascites.
values e.g., Albumin) − To avoid distended bladder, small bowel adhesions, large
veins.
Indications:
− How deep the needle
1. New onset Ascites. could go in.
2. Ascites of unknown origin.
3. Suspecting infection.
4. Symptomatic treatment of large Ascites.

Contradictions:
1. Uncooperative patient.
2. Uncorrected bleeding.
3. Distended bowel. The two recommended areas of abdominal wall entry for paracentesis
4. Distended urinary bladder. are as follows:
5. Abdominal wall cellulitis at the side of puncture. − 2 cm below the umbilicus in the midline
6. Pregnancy. − 5 cm superior and medial to the anterior superior iliac spines on
either side
Equipment
Abdominal Paracentesis Procedure and Nursing Management
− Commercial paracentesis kits are pre-assembled. −
• Check for the physician’s order.
If not available, you will need:
• Explain the procedure to patient and patient’s relatives what’s
1. 16 G catheter
going to be done.
2. 10 cc syringe
• Take written consent from patient and patient’s relatives. •
3. Lidocaine 1%
Measure abdominal girth before and after procedure. • Shave
4. One-liter vacuum bottle
and skin prepare should be done.
5. Thoracentesis kit tubing
6. Sterile drapes • Record the patient’s vital e.g., Temperature, B.P, Pulse Spo2. •
7. Sterile gloves Provide privacy.
8. Antiseptic • Maintain IV line, if any emergency to give fluids and
9. Sterile gauze medications.
10. Plaster • Paint abdomen with betadine.
11. Specimen container • Assist the doctor, giving needed articles, such as cotton swabs,
sterile towels, etc.
Before the Procedure: • Needle should be inserted z-track technique.
• Identify your patient, introduce yourself. • Monitor patient during the procedure.
• Explain the procedure to the patient and obtain a written • Observe for fluid color.
informed consent, if possible. • Measure fluid quantity.
 • Send test tube for diagnostic tests. 3. Spontaneous pneumothorax
• After finishing the procedure, seal the punctured wound with 4. Pleural effusion
sterile dressing.
Contraindications
• Fasten the abdominal binder tightly, from the top to bottom.
1. An uncooperative patient
Post Procedure 2. Coagulation disorder
• Remove the catheter after the desired amount of ascitic fluid 3. Atelectasis
has been drained. 4. Only one functioning lung
• Apply firm pressure. 5. Emphysema (pulmonary enlargement)
• Place sterile gauze a bandage over the skin puncture site. • Ask 6. Severe cough or hiccups
the patient to lie for 4 hours and the nurse to check vital signs Equipment
every hour for 4 hours to avoid hypotension. − Thoracocentesis set
• Give 25 cc of albumin (25% solution) for every 2 liters of ascitic − If not available assemble the following:
fluid removed. 1. Syringe - 10 mL
Write a procedure note which documents the following: 2. Syringe - 5 mL
3. Syringe - 60 mL
• Patient consent • Indications for the procedure.
4. Tubing set with aspiration/discharge device
• Relevant labs, e.g., INR/PTT, platelet count.
5. Antiseptic solution
• Procedure technique, sterile prep, anesthetic, amount of fluid
6. Lidocaine1% solution
obtained, character of fluid, estimated blood loss.
7. Specimen cap for 60-mL syringe
• Any complications
8. Specimen vials or blood tubes
• Lab tests requested. Color, pH, Protein, albumin, specific gravity,
9. Drainage bag or vacuum bottle
glucose, bilirubin, amylase, lipase, triglyceride, LDH, Cell
10. Sterile drapes
count total and differential, Culture &Sensitivity, Gram stain,
11. Sterile towels
AFB, Cytology
12. Scalpel
Complications 13. Adhesive plaster
• Persistent leak from the puncture site. 14. Sterile gauze
15. Surgical gloves
• Abdominal wall hematoma
• Introduction of infection Before the Procedure
• Hypotension after a large-volume paracentesis • Identify your patient, introduce yourself
• Catheter fragment left in the abdominal wall or cavity • • Assess patient to know allergies, especially to local anesthesia •
Oliguria Explain the procedure to the patient and obtain a written
• Hyponatremia informed consent.
• Explain the indication, risks, benefits and alternatives. •
Documentation
Prepare the appropriate equipment.
• Record the date and time of the procedure, puncture site and
• Give the patient anxiolytics (IV midazolam or lorazepam). •
whether the wound was sutured.
Check the platelet count, to prevent complication such as
• Document amount, color, viscosity and odor of aspirated fluid as
bleeding during procedure.
well as the intake and output.
• Place the patient in a seated position, leaning slightly forward
• Record patient’s vital signs, wt, and abdominal girth before and
and resting the head on the arms or hands or on a pillow,
after the procedure.
which is placed on an adjustable bedside table. This position
• Note pt’s tolerance of the procedure and any sign and
facilitates access to the posterior axillary space, which is the
symptoms of complications.
most dependent part of the thorax.
• Document number of specimens sent to the lab.
• Explain that patient will receive a local anesthesia. •
Nursing Diagnosis Clean patient with an antiseptic soap.
• Imbalanced Nutrition: Less Than Body Requirements •
Excess Fluid Volume
• Risk for Impaired Skin Integrity
• Ineffective Breathing Pattern
• Risk for Injury
• Disturbed Body Image
• Deficient Knowledge
THORACENTESIS

Thoracentesis During the Procedure

− A procedure to remove fluid from the space between the lungs • Explain what is going on while performing the procedure • After
and the chest wall called the pleural space. positioning ultrasonography is performed to confirm the pleural
− it is a procedure that removes abnormal accumulation of fluid effusion, assess its size, look for loculations, determine the
or air from the chest through a needle or tube. optimal puncture site and minimize complications • The optimal
puncture site may be determined by searching for the largest
Purpose pocket of fluid superficial to the lung.
1. To determine the cause of abnormal accumulation of fluid in • Wash with antiseptic solution.
the pleural space.
• Placed sterile drape over the puncture site.
2. Relieve shortness of breath and pain.
• The skin, subcutaneous tissue, rib periosteum, intercostal
3. As a diagnosis or treatment procedure.
muscles, and parietal pleura should be well infiltrated with
4. To drain large amount of pleural fluid.
anesthetic lidocaine.
5. To equalize pressure on both sides of the thoracic cavity.
• Use scalpel blade to make a small nick in the skin to allow an
Indication easier catheter passage.
1. Traumatic pneumothorax • The device is advanced over the superior aspect of the rib
2. Hemopneumothorax while applying negative pressure until pleural fluid is
 obtained.
• At 5 cm depth (mark on the device), the hemithorax is usually
entered, and the needle don't need be advanced any
further.
• Advance the catheter over the needle and into the pleural
cavity all the way to the skin (if possible).
• Connect the catheter to syringe or vacuum bottle, the pleural
effusion is drained until the desired volume has been
removed for symptomatic relief or diagnostic analysis.

Post Procedure
• Remove the catheter after the desired amount of pleural
fluid has been drained.
• Apply firm pressure and place sterile gauze and bandage
over the skin puncture site.
• Position the patient on the unaffected side for 1 hour. This
allows the pleural puncture to heal.
• Provide post-procedural analgesic as needed.
• Frequently check vital signs, oxygen saturation and breath
sound to detect complications. level.
• Send sample for analysis.
• Request CXR to check for pneumothorax. Pleural Space
• Check each bottle is correctly labelled by checking patient − Normally, 10 to 20 mL of pleural fluid.
identifiers (name, DOB, medical record number then send to − It is the cavity between the membrane lining of the lungs
the lab). (visceral or pulmonary line).
• Document the procedure, patient’s tolerance to the − The lining of the chest cavity (parietal pleura).
procedure, the characteristics of fluid and its
amount.
• Bed rest for about 2 hours to minimize activity d/t
complication such as dyspnea.
• Blood pressure and breathing will be checked hourly until
base line established and prevent further complications. • May
change dressings if becomes soiled or saturated to prevent
infection.
• Resume regular diet to promote wound healing.

Complications
1. Pulmonary edema
2. Respiratory distress
3. Air embolism
4. Bleeding
5. Infection Pleural Space Functions
6. Dyspnea and cough − Prevent friction between the outer lining of the lung and
7. Atelectasis (lung collapse) inner lining of the thoracic cavity during respiration.
− Hold the two pleural surfaces together, creating negative
Nursing Diagnosis pressure (a vacuum) that keeps the lungs expanded
1. Ineffective Breathing Pattern RT Decreased Lung Volume (Coughlin & Parchinsky, 2006).
Capacity
2. Impaired Gas Exchange RT Alveolar Capillary Membrane Size of Chest Tube
Changes − Pneumothorax – Small 24 French
3. Impaired Skin Integrity RT Mechanical Factors Secondary to − Hemothorax – Large 38 French
Thoracentesis and CTT Insertion
4. Acute Pain RT Surgical Incision, Chest Tube Sites, and
Immobility
CHEST TUBES THORACOSTOMY

Tube Thoracostomy
− The insertion of a tube (chest tube) into the pleural cavity to
drain air, blood, bile, pus, or other fluids.
− The skin incision is made in between the midaxillary line and anterior
axillary lines over a rib that is below the intercoastal
 2. Reduce patient’s anxiety.
3. Prepare the underwater seal bottle.
4. Connect the closed system.

CHEST TUBE INSERTION

THREE BOTTLE CHEST DRAINAGE SYSTEM

Post Procedure
− Monitor vital signs
• 15 mins. – 1st hour
• 30 minutes
• 1 hour until stable
− Take note of the respirations
• Rate
• Rhythm
• Pattern
− Check saturation
• Administer oxygen when necessary
1. Care of Patient
− Auscultates lungs to assess air exchange in the affected
lung.
− Place patient in fowler’s position.
Purpose 2. Care of the Wound
− It is used to remove air, fluid or pus. − Change the gauze when necessary.
− To establish normal negative pressure in the pleural cavity − Strict aseptic technique when performing dressing. −
for lung expansion. Check skin integrity or redness or swelling or loose
− To equalize pressure on both sides of the thoracic cavity suture.
− To provide continuous suction to prevent tension 3. Care of Tubing
pneumothorax. − Intact and taped
• Maintain patency
Indication
− Check for obstruction
• Pneumothorax: accumulation of air.
− Teach patient on how to take care of the tubing
• Pleural effusion: accumulation of fluid.
• Place a pillow between patient and tubing
• Chylothorax: a collection of lymphatic fluid.
• Coil the tube
• Emphysema: a pyogenic infection of the pleural space. •
• Instruct patient to cough if tube is blocked
Hemothorax: accumulation of blood.
• Milking and stripping of the tube when blocked
• Hydrothorax: accumulation of serous fluid.
4. Clamps
Open vs. Closed Pneumothorax − Use rubber tips
− Open: opening in the chest wall (with or without lung − Clamped at the bedside
puncture). − Clamping
− Closed: chest wall is intact. Rupture of the lung and visceral • During transfer not more than 1 minute.
pleura (or airway) allows air into the pleural space. • Upon doctor’s order.
• Assess air leak.
Treatment for Pleural Conditions
• Quickly empty or change disposable systems.
1. Remove fluid & air as promptly as possible.
• Assess if patient is ready to have chest tube
2. Prevent drained air & fluid from returning to the pleural
removal.
space.
− Note: clamping chest tube will accumulate in the pleural
3. Restore negative pressure in the pleural space to re-expand
cavity since the air has no means of escape. This can
the lung.
rapidly lead to tension pneumothorax.
Pre-Procedure
Three
1. Confirm the procedure.
Principles of
2. Inform patient. Under
3. Check for the consent. Water Seal
4. Prepare the equipment. −
5. X-ray.
6. Position client.

During Procedure
1. Observe and monitor patient’s Respiration and O2
saturation.
 Gravity drainage.
− Water seal − No need to clamp the tube.
− Suction − Maintain chest tube below chest wall.
9. Exercise
− Encourage deep breathing and arm exercise.
− On the first post op day.
− When patient is not in severe pain.
− Assist patient.
− To enhance the lung expansion.
− Prevent stiffness of the arm.
10. Comfort
− Administer analgesic in the first 24-hours.
− Allow position that is comfortable to the patient. −
Assist patient in daily living activity.
− Hygiene.

Emergency Care
− Bleeding
− Observe wound dressing
5. Water Seal − Observe drainage
− Enhances flow from high to low. − Dislodgement
− Place below patient’s chest wall (gravity) • From insertion site: place a gauze immediately
− Fill with sterile water. • From connection: clamp chest tube immediately
− Rod must be immersed 2 cm in water.
Complication
− Observe for the fluctuation of water level.
− Bleeding
a. Fluctuation
− Pulmonary embolus
− To ensure the patency of the system
− Cardiac tamponade
− It will stop when:
• Lung is fully expanded − Atelectasis
• There is an obstruction
− Check for obstruction
• Tubing kinked
• Patient’s position
b. Bubbling
− Intermittent bubbling: NORMAL
− Continuous bubbling: ABNORMAL
− Check:
• Wound
• Tube
• Connection
− If rapid bubbling without air leak: inform
doctor immediately
c. Drainage output
− 70-100 mL per hour
− Observe for any change in drainage color
− Mark the amount
− Document in I/O chart
− Change bottle every 24 hours or when full
6. Suction apparatus
❖ Low suction pump
− Must be controlled
− Suction valve/meter is inserted for wall
suction
− Check for bubbling
❖ If no bubbling:
− Clamp chest tube to check for air leaks
− Check tubing and connection
− Observe patient’s condition while chest tube
is clamped.
7. Safety
i. Tube
− Prevent kinking
− Place a pillow as barrier
− Never clamp unnecessarily
ii. Bottle
− Must be below chest
− Keep bottle in basin
− Inform relatives and housekeeping
8. Ambulation
− Encourage patient to change position to promote