Providing Care of a Chest Tube

Definition

Pneumothorax collection of air in the pleura space

Hemothorax an accumulation of blood and fluid in the pleural cavity between the
parietal and visceral pleurae, usually as the result of trauma
Chest tubes a catheter inserted through the thorax to remove air and fluids from
the pleural space and to reestablish normal intrapleural and intrapulmonic pressures

The Mechanics of Breathing

In normal situations, the pressure between the pleura of the lungs is below
atmospheric pressure.
When air or fluid enters the intrapleural space, the pressure is altered, and this can
cause collapse of a portion of the lung.
Even with adequate oxygenation and an open airway, a patient with a collapsed
portion of the lung will not have adequate oxygen - carbon dioxide exchange.
The only treatment for this altered condition is to restore the negative pressure to the
intrapleural space. This is accomplished through the use of a chest tube and
collection chamber.
Normal Chest Anatomy

Alterations in Normal Status

Indicators for Chest Tube Placement

Nursing Assessment Findings

Diminished or absent breath sounds on affected side.

 Decreased chest wall movement on affected side.

Difficulty breathing.
Tachycardia
Anxiety
Restlessness
Decreased oxygen saturation
Cyanosis
Complaints of pleuritic-type chest pain
Increased respiratory rate
Pain may worsen when attempting to breathe deeply
Equipment needed for Chest Tube Setup
Chest tube insertion tray
Tube (size per M.D.)
Local Anesthetic (Xylocaine)
Betadine (or other antiseptic)
Suturing supplies
Sterile gloves
2 1000cc bottles of sterile water
4 x 4s
Suction setup
Suction tubing
Chest tube collection system
Vaseline Gauze
Silk Tape

Components of the Chest Tube Drainage System

Suction control chamber

o The use of suction helps overcome an air leak by improving the rate
of air and fluid flow out of the patient. The simplest and most cost
effective means of controlling suction is by a calibrated water
chamber. This is axxomplished with a suction control chamber. By
addiing or removing water from the suction control chamber, the

chest drain controls the amount of suction imposed on the patient.

Lower the water content, lower the suction. Raise the water level,
raise the amount of suction.
Water Seal Chamber
The water seal chamber which is connected to the collection chamber, allows air to
pass down through a narrow channel and bubble out through the bottom of the water
seal. Since air must not return to the patient, a water seal is considered one of the
safest and most cost effective ways for protecting the patient. Also a patient air leak
can be rapidly assessed when bubbles go from right to levt in this chamber.
Continuous bubbling confirms a persistent air leak.

Collection chamber
o Fluids drain diirectly from patient into the collection chamber via a 6 patient
tube. As drainage fluids collect, the nurse must record the amount of fluid
that collects on each shift. This amount must be marked on the unit itself,
and documented in ProTouch, along with the characteristics of the fluid being
collected.
Preparing for Insertion
Gather supplies.
Prepare patient.
Open chest drainage system. As seen at right.
Swing out floor stand to stabilize the unit.
Close suction control stopcock.
Adding Sterile Water to the Unit
First, position the funnel as shown on the right, and fill to the top of the funnel. Raise
funnel to empty water into water seal to 2cm line marking.
NOTE: IF THE TUBING IS NOT CRIMPED AS IT SHOWS IN THE PICTURE, YOU WILL
OVERFILL THE CHAMBER.
Remove the vent-plug, pour sterile water in to ordered level, and replace vent-plug.
As seen at the bottom right.
Insertion
The patient will need to be positioned according to where the chest tube will be
placed. Typically having the patients arms over their head assists the physician.
Pre-medicate the patient with sedation & pain medicine as per Physicians order.
This is a scary & painful procedure for the patient.
The Physician will prep and numb the area, then make a small incision with a
scalpel, then using a trocar (a sharp, pointed rod that fits inside a tube) will insert
the chest tube. The patient will feel pressure. Once the chest tube is inserted it
may be either clamped or connected to the prepared drainage system, while the
M.D. is suturing the chest tube in place.
Connect tube to drainage system if not done previously, and apply an occlusive
vaseline gauze dressing topped with sterile 4x4s to the insertion site. Securely
tape all connections.
Post-Insertion Documentation
Reason for chest tube placement.
Patient vital signs.
Any medications given.
Location & size of chest tube.
Patients tolerance of procedure.
Drainage received (if any): color, characteristics, volume, etc.
Dressing type applied. Connections securely taped.
Vital signs during/post procedure.

 Water level ordered & set for suction control chamber.

Post-insertion chest x-ray taken.
Maintenance of Chest Tubes
Cardiovascular assessments must be performed every 4 hours at least for all patients
with chest tubes.
Encourage patient to cough & deep breathe.
Check insertion site every morning at 0800 and replace dressing at that time.
Assess water levels in drainage unit each shift and correct fluid levels if not as
ordered.
Report to Physician immediately any change or complication with the chest tube.
Maintenance of Chest Tubes
Check all tubing connections and re-tape as needed EVERY FOUR HOURS.
I & O to be completed
Monitor for air leaks, chest x-ray results, oxygen saturations, and peak airway
pressures. Report any alterations immediately to M.D.
Keep tubing coiled on bed, NEVER allow tubing to dangle.
Ensure that bedside collection unit NEVER goes above chest level.
Potential Complications with Chest Tubes
Subcutaneous emphysema - a collection of free air or gas in the tissue under the
skin. Can be mild or severe. Needs to be measured, reported to M.D., and
documented.
Air leak - noted by constant bubbling in the bottom of the water-seal chamber.
Potential causes listed on next page.
Potential Sources of Air Leaks
Poor tubing connections.
Tube dislodgement from pleural space.
Cracked bedside collection unit.
To locate air leak, clamp the tubing momentarily at various points along tubing
length. When bubbling stops, the clamp is between the air leak and the water seal.
If youve clamped the whole length of tubing, it may be a cracked collection chamber.
Safety Concerns
Sealed, taped tubing connections
Chest tube maintained in pleural space
Infection at site
Tubing not disconnected or pulled
Constant water levels in unit & constant suction (if ordered)
Sterile 1000cc bottle of saline and tubing clamps at bedside continuously.
What to do if...
Chest tube becomes dislodged: cover open insertion site with vaseline gauze at peak
of patient inspiration. Cover with 4x4s, tape on three sides only, notify M.D. STAT,
chart event.
Drainage system breaks: insert the uncontaminated end of tubing into a bottle of
sterile water 2cm deep until new unit can be setup. Notify M.D. & document.
*Make sure to review the Chest Tube Policies that are attached, and return your completed
answer sheet to your nursing manager.
FUNCTIONS
A rigid external immobilizer to secure body part
To maintain support
To protect realignment of bone
To promote healing and early weight bearing
To prevent or correct deformity

When to cast
Indications:
Circumferential casts may be used for:
Fractures
Severe sprains
Dislocations
Protection of post-operative repairs
Gradual correction of a deformity with serial casting
Contraindications:
Circumferential casts should not generally be used with:
Open fractures
Severe swelling
Compartment syndrome
Insensate limbs
Ulcers or draining wounds
assessment
History Taking
Mechanism of injury
Medical history
Social background
allergies
Physical assessment
Neurovascular status
Skin integrity
Presence of wound and drainage
Alignment and position
Respiratory, abdominal, urologic status
Materials needed
Stockinette
Stockinette is usually the first layer applied over the area to be cast. Its ends can
be folded over the cast edges to soften them. It may be omitted in acute fracture
treatment as it may restrict swelling.
Webril
Webril comes in a range of widths from 5-15 cm; the smallest ones are easiest to
work with. 5-10 cm webril should be used for the upper extremity and 10-15 cm
for the lower extremity.
Plaster of Paris
Plaster is the most commonly used casting material because of its ease of use.
Immersion in water initiates an exothermic reaction in the plaster causing it to
harden. Once applied, it will feel hard within 4 minutes, however, it takes 2-3 days
to dry completely.
bucket
The bucket should be filled with water at or below room temperature. Cooler
water decreases the risk of burning the patients skin as the plaster sets and also
allows for more working time with the casting material.
Patient instructions
1. Keep the cast dry! If your cast gets wet, see your doctor. The only exception to this rule is
fiberglass casts with gortex linings.
2. Plaster casts take 2-3 days to dry completely, thus, they should be left uncovered for at
least 2 days to allow for total water evaporation. For walking casts, weight bearing should be

avoided for at least the first two days (whether weight bearing is permitted at all is fracture
dependent).
3. To reduce and minimize swelling, the limb should be elevated above the heart for at least
2 days.
4. Fingers and toes should be wiggled often
5. DO NOT: put anything down the cast, trim or cut the cast, remove any padding from the
cast, drive while in a cast.
6. To relieve itch, a blow dryer on a cool air setting may help.
7. Seek immediate medical attention if:
Pain or swelling increases
There is any numbness or tingling
There is drainage or an unusual smell
The digits distal to the cast are purple
There is swelling not relieved by elevation
The cast breaks
Cast removal
It is important to remember that removing a cast can be a frightening experience for
patients - children and adults alike. A clear explanation of how the cast saw works - that they
may feel heat but that it is unlikely to cut their skin, will help improve the patients comfort.
It should also be explained that there is a greater risk of skin injury if the cast being cut is
wet, if too much pressure is applied, if the patients skin is relatively fragile (babies and the
elderly), or if the cast has a gortex lining.
Both the person removing the cast and the patient should wear ear protection, as the cast
saw is loud. Someone who removes casts frequently may also wish to wear a mask to
decrease the risk of respiratory complications from the dust of the casts.
Removing the cast (equipment)
Cast saw
The blade of the cast saw oscillates from side to side cutting through the hard cast material
without damaging the padding or soft tissue beneath.
Cast spreaders
Cast spreaders are used to split apart the edges of the cast after it is cut with the saw.
Bandage scissors
Bandage scissors are used to cut through the padding of webril and stockinette. The blunt
tip protects the patients skin.
Short arm cast
The short arm cast may be used for:
Distal forearm fractures
Wrist sprains and carpal injuries
Some metacarpal fractures
The cast should allow for full elbow movement, and should not extend beyond the distal
palmar crease to preserve motion at the MCP joints. The thumb should also maintain full
range of motion. The wrist should be in neutral alignment.
Thumb spica cast
The thumb spica cast may be used for:
Scaphoid fractures
Some thumb fractures
For scaphoid fractures, newer materials like polypropylene may be used which will not be
visualized on radiographs, so a scaphoid fracture can be monitored with less cast changes.
Long arm cast
The long arm cast may be used for:
Mid to proximal forearm fractures
Elbow fractures and dislocations
Distal humeral fractures

The guidelines for casting around the hand are the same as in short arm casts.
Below the knee cast
The below the knee cast may be used for:
Distal tibial fractures
Ankle fractures and dislocations
Foot fractures
Serial/deformity casting
The ankle should be immobilized at a 90 angle; patients may inadvertently plantar flex
their foot during casting. Because it will rest on the ground, a good foot plate, flat, with extra
layers of cast material, is also essential. The cast should not impede range of motion at the
knee.
Long leg cast
The long leg cast may be used for:
Tibial fractures
Like the below the knee cast, the long leg cast requires a 90o angle at the ankle and a thick,
flat foot plate.
Cylinder/stovepipe cast
The cylinder/stovepipe cast may be used for:
Patellar fractures or dislocations
Distal femoral fractures (some)
As the inactive leg muscles atrophy and the cast becomes loose, it may slip. Good moulding
may help to avoid this, but should loosening occur, the patient should have a new cast
applied.
ABDUCTION BOOT CAST
Applied from upper thighs to the feet. A bar is placed between both legs to keep the
legs and hips immobilized
Used to hold the hip muscles and tendons in place after surgery to allow time for
healing
CLUBFOOT CAST
Used to treat clubfoot
Applied from upper thighs to toes
Usually changed every 5-7 days
UNILATERAL HIP SPICA CAST (ALSO KNOWN AS SINGLE HIP SPICA)
Applied from the chest to the foot on one leg
Used for thigh fractures
Also used to hold the hip or thigh muscles and tendons in place after surgery to
allow healing
ONE AND ONE-HALF SPICA CAST
Applied from the chest to the foot on one leg, and to the knee on the other leg. A
bar is placed between both legs to keep the hips and legs immobilized
Used for thigh fractures
Also used to hold the hip or thigh muscles and tendons in place after surgery to
allow healing
BILATERAL LONG LEG HIP SPICA CAST (ALSO KNOWN AS DOUBLE HIP SPICA)
Applied from the chest to the feet. A bar is placed between both legs to keep the hips
and legs immobilized
Used for pelvis, hip, or thigh fractures
Also used to hold the hip or thigh muscles and tendons in place after surgery to allow
for healing
SHOULDER SPICA CAST
Applied around the trunk of the body to the shoulder, arm, and hand


Problems
anxiety

Used for shoulder dislocations, or after surgery on the shoulder area

encountered by a patient with cast

Explain the purpose of immobilization and area involved

Describe the procedure and sensation patient may experience when applying the
cast
Complication of casting
Compartment syndrome
Ischemia and neurologic injury
Heat injury
Pressure sore and skin breakdown
Allergy
Dermatitis and infection
Joint stiffness and muscle atrophy
Compartment syndrome
Increased of pressure because of edema within a closed space that compromises
blood flow and tissue perfusion; this causes ischemia and reduce capillary flow which
leads to more edema.
A vicious cycle develops, resulting in potentially irreversible damage to the soft
tissues within the space.
Signs and symptoms: 5 Ps
Pain
- greater than expected
Paresthesia
- early sign
Paralysis
- late sign
Pallor
- not reliable
Pulselessness - not reliable
Passive stretching elicit excessive pain, a reliable early sign!
Risk of peripheral neurovascular dysfunction
Causes
Unexpected excessive swelling
Cast being applied too tightly
Insufficient padding to allow more expected swelling
Local pressure on areas where the blood vessels or nerves closed to the skin
Elevation (above the heart level)
Check tightness of the cast
Encouragement movement of the extremities
Check neurovascular status
Ulnar nerve
Sensation distal fat pad of the small finger
Motion abduct all fingers
Radial nerve
Sensation web space between the thumb and index finger.
Motion hyperextend finger or wrist
Peroneal nerve
Sensation web space between the big toe and 2nd toe
Motion dorsiflex ankle and extend toes
Tibial nerve
Sensation medial and lateral surfaces of the sole
Motion plantar flex ankle and flex the toes

Risk of peripheral neurovascular dysfunction

Instruct patient to report any abnormality. E.g. Numbness, tingling or increased in
pain.
Have cast cutter, spreader ready for use.
Altered comfort; pain
Elevation
Check tightness of the cast
Well padded the involved bony prominence
Careful handling of the affected part
Adequate analgesics
Impaired skin integrity
Clean and dry skin prior to cast
Dress wound properly
Ensure smooth surfaces
Adequate padding
Ensure the edges of the cast are well padded
Clean and remove excessive plaster from the skin with warm water.
Handle the cast with the palms of the hands instead of the fingers to prevent
indentations in the soft plaster
Aware of plaster sore
Plaster sore
Causes
- Uneven bandaging technique
- Insufficient padding over bony areas
- Cast is too tight or too loose
- Foreign body inside the cast
s/s
- Itching
- Burning sensation
- Fever
- Sleep disturbance
- Foul smell
- discharge
Impaired mobility
Exercise joints above and elbow the affected limb to prevent stiffness of the joints
Perform muscle strengthening exercises
Encourage self-help. Provide appropriate mobilization aids.
Assist in reposition of patient.
Adopt fall prevention measures.
Weight bearing is not allowed until cast is dry/instructed by surgeon.
Cast boot
Walking heel
Risk of loss alignment
Maintain the reduction and keep the affected part in a desired position during cast
application.
Promote drying of the unconsolidated cast.
Use pillow to support the cast
Support the cast with palms
Check for cracks/softening/loosening
Allergic reaction
Check for allergy history before apply cast

Excessive irritation
remove the cast, cleanse the skin thoroughly and reapply
other materials
Body image disturbance
Allow to choose the preferable color esp. in adolescence
Discuss expectation of activity and appearance of cast
Knowledge deficit
Assess concern and knowledge of POP care
Provide education and pamphlet in care of POP cast and discuss in adaptation of daily
activities
Patient education
Stay in a well-ventilated environment to promote drying up of the cast.
Keep the cast away from heat.
Never put the cast on hard surface.
Elevate your limb at heart level to help reduce pain and swelling. Support the arm
with arm sling and use pillows to elevate the lower limb.
Move your fingers and toes frequently to prevent swelling and joint stiffness.
Avoid pumping and knocking your cast against hard surfaces
Do not walk on a walking cast until it is completely dry and hard, and instructed
by doctor.
Do not push anything down the plaster.
Do not use device (e.g. Stick) to scratch underneath the cast. If itching persists,
contact your doctor.
Keep the cast dry and prevent it from getting wet.
To avoid getting your cast wet when taking a shower, cover it with plastic bag and
secure the bag to your skin with waterproof tape, making sure that it does not
allow water to leak in.
Report immediately if:
There is any pain, offensive smell or discharge from the plaster.
The fingers or toes become blue, swollen or tingling sensation.
Any hard objects drop into the plaster.
The plaster becomes too tight, loose, soft, or cracked.
The child become irritable and is crying with no obvious reason.
Advice on diet
Calcium and vitamin C aid in bone healing
A balance diet: milk product, fish, fruit, vegetables
Care after cast removal
The skin may become dry and scaly.
Wash skin with mild soap and water daily and use moisturizing lotion helps the
dead skin to slough off and soften the new skin.
Inform patient that it is expected the affected limb will be smaller than the other
limb. Once patient start to use the muscle again, the muscles will build back up.
It is normal to have some joint stiffness following cast removal. The joint stiffness
is caused by lack of motion of the joint while in the cast. It will improve with time.