Chest Tube With Under-water Seal Drainage

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CHEST TUBE WITH



UNDER-WATER SEAL




DRAINAGE





1 hour Practical Lecture






Julie James Abdullah

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LEARNING OUTCOMES










1. Demonstrate care of the patient with chest tube and underwater seal

drainage






2. Describe nursing responsibilities pre, during and post underwater seal

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LEARNING OUTLINES






1. Chest tube with underwater seal 2. Prepared and assist underwater

drainage seal procedure

➢Definition ➢Prepared equipment


➢Purpose ➢Prepared patient position

➢Indication ➢Procedure according to

➢Location checklist (SOP)


➢Complication ➢Documentation




3. Nursing responsibilities pre, during

and post underwater seal

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CHEST TUBE WITH UNDERWATER SEAL



DRAINAGE

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DEFINITION






A sterile procedure performed by a
doctor in which a tube is inserted

into the patient’s pleural space to

remove accumulated air, blood or
fluid in one way to allow for lung re-

expansion.

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PURPOSE










• To drain air, blood, bile, pus, or other fluids.






• Whether the accumulation of air or fluid is the result of rapid traumatic filling with air
or blood or an insidious malignant exudative fluid, placement of a chest tube allows

for continuous, large volume drainage until the underlying pathology can be more

formally addressed.

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INDICATION










• Empyema

➢drain pus from the pleural space


• Haemothorax - bleeding from the pleural space


• Pneumothorax - drains air from the pleural space


• Malignant pleural effusion


• Postoperative - thoracotomy, esophagectomy, cardiac surgery (CABG)

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CHEST TUBE LOCATION





A small tourniquet is made in the
muscular layer in the pleural parietal

space after the administration of

anaesthesia injection.






Chest tube will be inserted into the
pleural space (through the

intercostal space)

➢between ribs 2 - 4 to expel air.


➢between ribs 8 - 10 to remove
fluid / blood.

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COMPLICATION










• Atelectasis


• Pneumothorax


• Liver injury (right sided pneumothorax)


• Heart injury (left sided pneumothorax)

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CHEST TUBE INSERTION

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PREPARED AND ASSIST UNDERWATER SEAL



PROCEDURE

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PREPARATION ASSISTS CHEST TUBE



INSERTION







Upper trolley


• 3 galipot – povidone iodine


- spirit


- gauze & swab


• sponge holding forceps



• non tooth dissecting forceps


• bard paker handle with scalpel


• suture needle & silk


• needle holder

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PREPARATION ASSISTS CHEST TUBE



INSERTION







Bottom Trolley


• 2 scissor - stitch


- dressing


• disposable chest tube


• syringe 5 ml



• Sterile towel


• Sterile glove


• under-water seal with tube


• 2 artery spenser wells forceps – for clamping

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PREPARATION ASSISTS CHEST TUBE



INSERTION









Bottom Trolley


• local anesthesia (LA) • Kidney dish - dirty equipment


• antiseptic lotion - povidone iodine, • 2 pin pins

spirit, flavine • bed block to stabilize the bottle


• normal saline



• scissors


• plaster Elastoplast's


• mask


• waterproof liner

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ONE BOTTLE SYSTEM








The tube from the patient is

connected directly to the under-

water seal bottle.







The short tube serves as a water

vent - a channel for removal

deep air pressure bottle.

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ONE BOTTLE SYSTEM








Water acts as a seal to prevent

atmospheric air from re -entering the

pleural cavity.






The water level will fluctuate as the
patient breathes; up while the

patient inhales and down while

exhaling = FLUCTUATING

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ONE BOTTLE SYSTEM

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ONE




BOTTLE





SYSTEM

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MOBILE CHEST TUBE DRAINAGE



SYSTEM







• Smaller chest tube that uses a mechanical one-way
valve and has no suction control chamber.







Heimlich valve • Suitable for patients who need a chest tube but do
not need to suction / flow a lot of fluid from the

pleural cavity.






• Used for patients who need long -term treatment.






• Example:- Heimlich valve / Pneumostat chest drain
valve




Pneumostat

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PROCEDURE

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No. Procedure


1. Greet client and introduce self.

2. Explain procedure to the patient.

3. Perform hand hygiene.


4. Assess patient for:

4.1 general condition

4.2 vital signs

4.3 dressing site

Position patient in semi fowler's and reposition patient every 2
5.
hours.

6. Implement all necessary safety precautions:

2 chest tube clamp / 2 artery forceps at the bedside or

6.1 at the top of the client’s bed to clamp the chest tube in an


emergency
keep drainage system below chest level and
6.2
upright at all time

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No. Procedure


7. Maintain tube patency of the drainage system:


7.1 check and ensure all connection are secured

inspect drainage tube for kinks or loops or dangling below
7.2
the entry level of the drainage system

coil the drainage tubing next to the client, ensuring
7.3
enough slack for the client to turn or move

inspect the air vent in the system periodically to make
7.4
sure it not occluded


avoid any forceful manipulated of the tube eg: milking
7.5
or stripping the chest tubing

observe for the dislodgment of the tube and remedy
7.6
the problem promptly

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No. Procedure


Assess fluid level fluctuation and bubbling in the drainage
8.
system.

9. Assess the drainage:

9.1 every 15 minutes for first 2 hours and 4 hourly


9.2 check sudden change of amount or colour

if drainage exceeds 100ml/h or colour change indicate
9.3
haemorrhage, notify the doctor


10. Ensure essential patient care:


- deep breathing and coughing exercise


- ROM exercise


- assist ADL

11. Provide emotional support.

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No. Procedure



12. Comfort patient.

Record the amount of drainage and its characteristics in drainage
13.
chart.

14. Document and report.

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NURSING RESPONSIBILITIES PRE, DURING



AND POST UNDERWATER SEAL

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NURSING RESPONSIBILITIES










BEFORE






• Check patient notes.


• A clear description of the procedure


• Consent


• radiological & laboratory examination results

• Prepare the trolley in compliance with surgical asepsis


• Under-water seal bottle supply-300ml


• Sit and support the patient during the OR procedure

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NURSING RESPONSIBILITIES










BEFORE






• Sit on the bed with his arms resting on a cardiac table lined with a pillow OR


• In a reclining position, lie on the side of the uninvolved chest with his arms raised on
a pillow.


• Expose the part to be punched.

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NURSING RESPONSIBILITIES










DURING






• Give emotional support


• Assist the doctor throughout the procedure


• Maintain the patient's position. Make sure the patient does not move / cough to
avoid lung injury.


• Observe the vital signs and general condition of the patient


• Make sure the under-water seal drainage system is installed properly. The end of the

tube is at the bottom of the water (2 - 2.5cm).


• Make sure the connection is tight.


• Make sure there is fluctuating in the liquid level in the long tube.

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NURSING RESPONSIBILITIES










AFTER






A. Patient care


B. Under water seal drainage system

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NURSING RESPONSIBILITIES










A. Patient care






1. Assist the patient in changing position


2. Personal hygiene such as bath wipes


3. Monitor general condition & vital signs


4. Every 15 minutes for the first 2 hours

5. Every hour for the first 24 hours


6. Every 4 hours on the next time


7. Provide emotional support & encourage expression of feelings


8. Encourage deep breathing exercises & coughing to re-expand the lungs

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NURSING RESPONSIBILITIES










A. Patient care






6. Encourage a change of position every 2 hours.


7. Give O2 if necessary, according to the doctor's instructions.


8. Observe the dressing area ≥ every 4 hours


-bleeding / foul-smelling discharge.

9. Palpate around the dressing area. There is a crackling sound if there is

subcutaneous emphysema.

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NURSING RESPONSIBILITIES










B. Under water seal drainage system






1. Monitor & maintain the patency & integrity of the drainage system.


2. Prepare 2 pairs of forceps arteries with gauze in a kidney container by the side of
the bed.


3. Take care of the drainage bottle in the right way


* place below the patient's chest level


* place in container / basin


* change bottles and connecting tubes daily


according to hospital protocol

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NURSING RESPONSIBILITIES










B. Under water seal drainage system






4. Proper care of the drainage tube


* long enough - easy to move & avoid being pulled out


* not looped / twisted


* pinned and pinned on the sheets

5. Make sure the drainage system is closed & not leaking.


* tighten all tube connections


* note the fluctuation of the fluid in the tube

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NURSING RESPONSIBILITIES










B. Under water seal drainage system






6. Documentation


Observe the air bubbles and take notes


+++ ....... very much


++ ....... a lot

+ ....... a little


Drainage color


Total fluid excreted (total fluid - normal amount of saline fluid)

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BOTTLE CHANGE




UNDER WATER SEAL

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NURSING RESPONSIBILITIES










BEFORE






• Check patient notes.


• Explain the procedure to the patient.


• Wash your hands socially.



• Prepare equipment.

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NURSING RESPONSIBILITIES










DURING






• Clamp chest tube & chest tube connecting tube with artery forcep after lining with
a piece of gauze.


• Prepare an under-water seal bottle by filling 300 ml of Normal Saline with the tip of

the glass rod below the water level by 2-2.5cm (depending on the type of bottle)


• Practice aseptic techniques throughout the procedure.

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NURSING RESPONSIBILITIES









AFTER






• Make sure the under-water seal bottle is below the patient's

chest level.


• Secure the position of the tube with plaster / pin pins.


• Make observations on:-


• Flow - works


• Vital signs

• Patient complaints


• Documentation in patient progress notes.

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NURSING DIAGNOSIS










1. Comfort disturbances: Pain associated with chest tube insertion


2. The potential for infection is associated with chest tube insertion


3. Potential respiratory pattern disorders