THORACOSTOMY

Close Tube Thoracostomy/ Chest Tube Insertion- insertion of tube through an intercostal space into the pleural cavity to remove air, drain fluid , drain both air and fluid and to drain blood

- following traumatic injury to the chest, blood or air can accumulate resulting in collapse of the lung. To re-expand the lung, a tube thoracostomy (chest tube) is placed, draining the blood through a one way valve.

Equipment:
- str. kelly
- dressing tray
- kelly curve
- micropore and leukoplast
- thoracostomy tube ( fr 36, 34, 32, 28, 26, 200
- mayo scissor
- glass tubing with rubber
- blade # 10
- sterile bottle #2
- sterile gloves
- connecting tube
- silk 2/0 cn
- lidocaine 2%
- silk strands 3/0
- syringe 10cc
- eye sheet or drape
- needle g 21
- sterile os 4x4

Nursing Procedure:
1. Secure consent
2. Explain the procedure thoroughly
3. Inform OR staff/ ER staff
4. Inform anesthesiologist
5. Preparation of the site
6. Remove dentures/ jewelries
7. Prepare the OR checklist

CHEST DRAINAGE
- the pleural cavity normally has negative pressure. Any drainage system connected to it must be sealed so that air or liquid cannot enter
- such a drainage system, water- sealed drainage or disposable drainage system

Three Mechanisms Used:
1. Positive expiratory pressure - when pleural cavity contains some air or fluid, a (+) pressure develops during expiration this is abnormal, but it does help expel the air and to some extent fluid from the space
2. Gravity - acts as an evacuation force when the tubing is placed so that it descends from the insertion site to the drainage receptacle
3. Suction - used in conjunction with the other two forces in some drainage systems

Kinds of Water-Sealed Drainage System:
1. One-bottle system - a single receptacle receives both the fluid and/or air from the client and seals the system. A combination of fluid from the client and sterile H2O forms the water- seal.
2. Two-bottle system- the air/fluid from the pleural cavity is received into bottle A. The air from bottle A is passed into bottle B. The air then passes through the sterile water and exits from bottle B through the air vent. The fluid from the pleural cavity remain in bottle A.
3. Three- bottle system- fluid from the pleural cavity collects in bottle A which is connected to a tube in bottle B that terminates below the fluid level. Bottle B is then connected to bottle C by a short tube. Bottle C has a manometer tube submerged in sterile water.

Monitoring a Client with Chest Drainage:

Equipments:
- 2 kelly clamp
- sterile gauze with lubricant
- sterile gauze
- sterile drainage system
- an occlusive tape

Nursing Procedure:
Procedure/ Rationale
1. Check all connections are secured with tape / To ensure that the system is alright
2. Milk or strip the chest tubing as ordered / Milking the tubing dislodges obstruction
3. Inspect the drainage in the collection container/ For proper and accurate monitoring of the changes
4. Check the fluctuation of fluid level / Absence of fluctuation may indicate tubing obstruction from a kink
5. Check for intermittent bubbling / It normally occurs when the system removes air from space
6. Inspect the air vent in the system periodically / Obstruction from the air vent causes a pressure in the system that could result in pneumothorax
7. Report drainage on dressing immediately / It is not a normal occurrence
8. Palpate the area around the chest tube insertion site / Indicates that air is leaking into the subcutaneous tissue (s.c. emphysema)
9. Situate the drainage system / To avoid breakage
10. Place the 2 clamps at the bedside / Clamps are used judiciously and only in emergency situations because they can cause tension to pneumothorax
11. Encourage deep breathing and coughing exercise / Facilitate drainage and help the lungs to re-expand
12. Reposition the client every 2 hours / Promote drainage, prevent complications and provide comfort

UPDATE :
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