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Care of Patients with

Pleural Disorders and Chest


Tube Drainage
Team-Based
Learning
Instructional Activity Sequence for TBL
Application of Course
Concepts
Readiness Assurance
Preparation Diagnosis-Feedback
(Pre-class) 2 hours of clinical skills practice
1hr 50 mins of class time

1. 2. 5. 6. Application
Individual Individual Instructor Orientated
Study Test Input (1hr Activities
(10mins) 20 mins)

3. Team Test 4. Appeals (5mins)


(15mins)
Team Test
Case Scenario
Peter, 20-year-old man, with no past
medical history or involve in any accident,
was admitted to the hospital. He
developed SOB and pleuritic chest pain
when having dinner with his family. He has
stopped smoking 3 years ago.
His vital signs is BP 112/70mmHg, 89 b/min,
RR 28/min, SpO2 95%, T: 36.7. An initial
assessment revealed hyperresonance to
percussion
1. The most probable diagnosis
for Peter is:

A: Empyema
B: Hematoma
C: Spontaneous pneumothorax
D: Open pneumothorax
E: Pleural effusion
Spontaneous pneumothorax

Blebs are weakened out-pouchings in the upper lung,


which can rupture, causing pneumothorax.
Pneumothorax
Pneumothorax

Traumatic Spontaneous

Open Close

Tension Pnenumothorax
Air leak into pleural space
during inspiration

Air prevents from leaking out


during expiration

Increased thoracic pressure

Mediastinum Shift

SHOCK

DEATH
2. To determine whether Peter develops
tension pneumothorax, the nurse assesses
the patient specifically for:

A: Pleuritic chest pain


B: Diminished breath sounds on the
affected side
C: Dull percussions on the injured side
D: Decreased chest movement on the
affected side
E: Severe respiratory distress and tracheal
deviation
Traumatic / Tension Hemothorax
Spontaneous Pneumothorax
Pneumothorax

SIMILARITIES

DIFFERENCES
Traumatic / Tension Hemothorax
Spontaneous Pneumothorax
Pneumothorax

SIMILARITIES
•Pleuritic Chest pain
•Absence/Diminished breath sound
•Unequal chest expansion
•SOB

DIFFERENCES
•Hyperresonance to •Severe Respiratory •Dullness to
percussion Distress percussion
•Hypotension •Hypotension
•Distended neck vein
•Tracheal deviation
Pleural Effusion
• Excess fluid in the pleural cavity
• Causes
– Increased capillary hydrostatic pressure
– Increased capillary permeability
– Decreased plasma oncotic pressure
– Obstruction of lymphatic drainage
Treatments

Chest-tube insertion
Thoracentesis
3. The chest tube drainage
system relieves Peter’s
pneumothorax by
A: Enhancing chest wall movement
B: Injecting air into the pleural space
C: Preventing air from entering the cavity
D: Restoring negative pressure in the pleural
space
E: Increasing the amount of pleural fluid
4. Which 3 chambers are found
in a closed chest drainage
system?
• Water seal, pressure, and drainage
collection chambers
• Water seal, suction control, and drainage
collection chambers
• Gravity, suction control, and drainage
collection chambers
• Pressure, water seal, and gravity
chambers
5. The main purpose of the water seal
chamber is to:

A: Prevent air from going into his chest


B: Detects air leaks
C: determines the amount of suction applied
D: Provide high negative pressure
E: Reflect the amount of drainage in the
pleural space
Chest Drainage
System

Collection Water Suction


Chamber Seal Chamber Control Chamber
Chest Drainage System

Collection Chamber Water Seal Suction Control

•Drain air & fluid from the


pleural space

•Observe & record drainage


Chest Drainage System

Collection Chamber Water Seal Suction Control

•2 cmH2O

•Act as one-way valve by bubbling out air

•Observe fluctuations in the water level


Chest Drainage System

Collection Chamber Water Seal Suction Control

•Connected to suction wall

• Remove air & fluid more


quickly
Nurses’ Roles

Chest Tube Care of Patient


Insertion with Chest Tube

Chest Tube
Removal
6. Which of the following is the most
appropriate position for Peter when
preparing him for chest-tube insertion

A: Prone position with head to the side


B: Lateral supine position with the legs bent
C: Upright seated position, leaning over a
table
D: Semi-Fowler’s position with a pillow
under the back
E: Supine position with the legs straighten
3rd, 4th 5th or 6th intercostal
space in the mid axillary
line
Chest Tube Insertion (Before)
• Informed consent
• Administer pain medication
• Prepare equipment
• Set up drainage system
• Obtain baseline vital signs
• Position patient
Chest Tube Insertion (During)
• Assist Dr with chest tube insertion
• Monitor patient’s condition
• Provide emotional support
• Apply dressing on the insertion site
• Taped all connections
Chest Tube Insertion
(Immediately After)
• Call for chest x ray
• Monitor patient’s vital signs hrly X 6hrs
• Administer pain medications
• Observe complications
• Assess drainage system
Chest Tube Care of Patient
Insertion with Chest Tube

Chest Tube
Removal
Care of Patient with Chest-tube
drainage system

I
Monitor & Maintain Assess
Respiratory Insertion Site
Function

Check
Chest-tube
Drainage System
Monitor & Maintain
Respiratory Function

• Monitor vital signs & SpO2


• Auscultate breath sounds
• Encourage deep breathing & coughing
• Encourage use of incentive spirometery
• Prop up patient
• Reposition patient
Assess Insertion Site
7. When palpating around Peter’s chest
tube insertion site, you detect crepitation
and tissue swelling, you suspect:

A: Infection
B: Subcutaneous emphysema
C: Tension Pneumothorax
D: Unresolved pneumothorax
E: Bleeding
Assess Insertion Site
• Bleeding
• Infection
• Subcutaneous emphysema
Check Chest Drainage System
• Tubing avoid dependent loops, kinking &
clamping

• Connection taped securely

• Drainage bottle below level of patient’s


chest
Check Chest Drainage System
• Check water seal
• Level
• Bubbling
• Fluctuations
• Check suction pressure
• Assess drainage
Chest Tube Drainage
8. Peter needs to be transported to the x ray
department. The concern during transport
include assure that:

A: the chest tube is clamped


B: the chest tube bottle is below the
insertion site
C: Suction tubing is open to air
D: B & C
E: A & B
9. At the X ray department, you notice the
drainage tubing was disconnected from the
drain. Your first action is to

A: Re-established connection
B: Clamp Peter’s chest tube immediately
C: Notify doctor immediately
D: Send him back to the ward immediately
and change another drainage system
E: Check Peter’s vital signs
Common Problems
• Disconnection of drainage tubing from drain
– Clamp with artery forceps
– Re-establish connection ASAP
– Notify Dr
– KIV chest x ray
• Lack of Drainage
– check tubing for kinks or obstruction
Common problems
• Collecting bottle fall over
– Re-establish water seal level
• Intrapleural drain fall out
– Tie the purse-string suture
– Cover with gauze and pressure bandage
– Notify Dr
– Monitor Patient
Chest Tube Care of Patient
Insertion with Chest Tube

Chest Tube
Removal
10. The doctor plan to remove the Peter’s
chest tube. Which of the following signs
suggests the pneumothorax has resolved?

A: An air leak in the water seal chamber


B: Bubbling in the suction control chamber
C: Clear lung sound that extend to the
periphery
D: More than 100mil of fluid in the collection
chamber
E: C & D
Removal of Chest Tube
(Indicator)
• Little to no drainage
• Normal breathing
• Fluctuations in water seal stopped
• Chest X ray shows lung re-expansion with
no residual air or fluid
• Able to tolerate chest tube clamping
• Monitor respiratory status
Removal of Chest Tube
• Administer pain medication
• Prepare equipment
• Patient hold his breath, Dr tie the purse string &
nurse remove the chest tube in one quick
movement
• Apply dressing
• Monitor respiratory status
• Arrange for chest X ray
Pleural Conditions

Chest Tube Care of Patient


Insertion with Chest Tube

Chest Tube
Removal
Instructional Activity Sequence for TBL
Application of Course
Concepts
Readiness Assurance
Preparation Diagnosis-Feedback
(Pre-class) 2 hours of clinical skills practice
1hr 50 mins of class time

1. 2. 5. 6. Application
Individual Individual Instructor Orientated
Study Test Input (1hr Activities
(10mins) 20 mins)

3. Team Test 4. Appeals (5mins)


(15mins)
Clinical Lab Skills
• Prepare Equipment
• Set up drainage system
• Apply dressing on the insertion site
• Taped all connections
• Documentation
Video Show
Mosby’s Chest Tubes and Closed
Chest Drainage System
RD539Vhe2007