6.3 Nursing Responsibilities for Clients With Chest Tube Drainage Systems

There are several nursing responsibilities related to caring for clients with chest tube drainage systems. Some assessments and interventions should occur at the start of the shift to ensure the client is stable and the chest tube drainage system is functioning appropriately, whereas other interventions and monitoring occur throughout the shift.

Assessments and Interventions at the Start of Shift

• Verify the provider’s current orders regarding chest tube setting and care. Note the level of suction prescribed, if ordered, and verify the current wall suction setting.
• Obtain and document baseline vital signs (including oxygen saturation) and perform a focused respiratory assessment, including auscultation of lung sounds, current level of dyspnea, and trachea alignment. Gathering baseline data is important because changes that occur during the shift can indicate a malfunction in the chest tube drainage system and/or a change in patient condition.
• Continually monitor vital signs closely, watching for trends and changes in respiratory rate, oxygen saturation, and blood pressure that could indicate complications are occurring, such as a pneumothorax.
• Obtain a baseline pain assessment, especially regarding the chest tube insertion site. Based on findings, reposition the client, use other nonpharmacological interventions, and/or administer pain medications as prescribed.
• Assess the dressing over the chest tube insertion site to ensure it is dry and intact. Based on agency policy and provider orders, change soiled dressings or reinforce loose dressings.
• Assess the condition of the skin surrounding the insertion site for signs of infection (redness or purulent drainage) or bleeding. Palpate the area surrounding the dressing for crepitus (i.e., puffiness or crackling that indicates subcutaneous emphysema, the leakage of air into the subcutaneous tissues surrounding the insertion site).
• Assess the chest tube drainage system:
  • Ensure the system is upright and maintained below the client’s chest to prevent fluid from flowing back into the client’s chest. Some drainage systems have floor stands to prevent the unit from tipping over; if floor stands are present, ensure they are pulled out and perpendicular to the unit. If a stopcock is attached, ensure it is positioned to allow for drainage into the drainage system.
  • Ensure the tubing is not kinked so clots do not form. Any drainage present should be flowing freely into the collection chamber. However, do not “strip” the tubing (i.e., occlude the chest tube with one hand while quickly squeezing and moving the other hand down the tube to move fluid into the drainage chamber). Doing so can cause high intraluminal pressures that can cause a life-threatening pneumothorax.
  • Ensure the system remains closed (i.e., without air leaks) by verifying all tubing connections are taped and the chest tube is securely fastened to the client’s chest wall.
  • Assess and document the amount, color, and characteristics of fluid in the collection chamber. Mark the drainage level with the time and date on the outside of the collection chamber for quick future reference during your shift.
  • Ensure the water seal chamber is filled with sterile water to the 2 cm mark (or as specified by the manufacturer). Tidaling should be seen in the water seal chamber. If tidaling is not occurring, the system may not be working properly, the tubing may not be patent, or the client’s lung may have re-expanded.
    • There should not be continuous bubbling in the water seal chamber because this may indicate a leak. Immediately try to identify and correct causes of external leaks, such as loose tubing connections. Check the insertion site to ensure the tube has not become dislodged. Immediately notify the health care provider if the tube has become dislodged or you cannot identify or correct an external leak because an air leak can indicate a complication is occurring, such as a worsening pneumothorax.
  • If the chest tube drainage system is a wet suction device, ensure the suction control chamber is filled with sterile water to the -20 cm level or as prescribed. There should be constant, gentle bubbling in the suction control chamber if it is connected to suction.
  • If the chest tube drainage system is a dry suction device, ensure the rotary dry suction control dial is turned to the ordered suction mark (typically -20 cm water). Refer to the manufacturer’s instructions regarding suction indicators. (In some systems, a ball or float appears in an indicator window to indicate the correct amount of suction, whereas other systems have a bellows that reaches a calibrated triangular mark.)
• Verify equipment and supplies are present in the room (in the event a malfunction occurs) according to agency policy and manufacturer recommendations, such as the following:
  • Two sets of rubber-tipped clamps. Chest tubes may be momentarily clamped (according to agency policy) when replacing the chest tube drainage unit, assessing for the location of an air leak, assessing the client’s tolerance of chest tube removal, and during chest tube removal. However, routine clamping of the chest tube is not recommended because of the risk of a tension pneumothorax.
  • Sterile 4” x 4” gauze pads and/or petroleum gauze and tape. For example, if air can be heard leaking from the tube insertion site on the client’s chest or the chest tube inadvertently becomes dislodged from the client’s chest, follow agency policy. Typically, this includes immediately taping a dressing over the insertion site on three sides to allow air to escape and prevent a tension pneumothorax while the provider is notified.
  • Small container of sterile water or saline to use to create a temporary water seal if the tubing becomes disconnected from the drainage system.
• Instruct the client to do the following:
  • Immediately report any breathing difficulty. (Note: Notify the provider immediately if the client develops rapid or shallow breathing, decreased oxygenation saturation level, cyanosis, subcutaneous emphysema, chest pain, or excessive bleeding.)
  • Sit upright to facilitate drainage of fluid and optimal lung expansion.
  • Splint the insertion site with a pillow while coughing to minimize pain.
  • Perform coughing and deep breathing exercises and/or incentive spirometry, change position, and ambulate as ordered, to facilitate lung expansion and drain fluid from the pleural space.

Monitoring and Interventions Throughout the Shift

• Assess the client’s respiratory and pain status every 2 to 4 hours (or according to agency policy). Assess lung sounds, noting decreased or absent lung sounds, which can indicate a worsening pneumothorax or hemothorax and requires immediate notification of the provider. Monitor for new or worsening subcutaneous emphysema and notify the provider if present. Provide pain management according to the client’s pain management goals. Obtain emergency assistance for sudden or increased intensity of dyspnea, oxygen saturation less than 90%, or tracheal deviation.
• Monitor for changes in vital signs. If the client develops tachycardia and/or hypotension, a tension pneumothorax could be occurring if there is increased pressure within the thoracic cavity.
• Assess the integrity of the drainage system and tubing every 1 to 4 hours per agency policy. Ensure the system remains intact, the tubing is patent, and there are no air leaks.
• If the chest tube was placed to remove drainage, monitor the amount, color, and consistency of drainage in the drainage tubing and in the collection chamber. Notify the provider if any of the following occur:
  • Drainage appears cloudy because this can be a sign of infection.
  • Drainage stops within the first 24 hours after the chest tube was inserted. This may indicate the tube has become displaced internally or is clotted. (However, be aware of the indication for chest tube placement because in cases addressing a pneumothorax, there may not be any drainage because only air is being removed.)
  • Drainage averages more than 200 mL/hour for 4 hours. This may indicate vascular injury that requires surgical repair.^[1]
• Periodically check that the air vent in the drainage system is working properly (if applicable). Occlusion of the air vent results in a buildup of pressure in the system that could cause the patient to develop a tension pneumothorax.
• If the client requires transport out of the room, do not clamp the tubing. Instead, disconnect the suction connector tubing from the suction source. The system will continue to collect fluid (by gravity) and/or air (by water seal). Portable suction is also available if clients have an air leak and thus cannot tolerate water seal suction or if it is ordered by the provider.
• If a specimen collection is ordered, remove fluid using a sterile needle and syringe from the self-sealing portion of the chest tube drainage tubing (or a needless syringe from the needleless site of the drainage tubing after disinfecting the collection site).
• Change the chest tube drainage system if the collection chamber becomes filled with fluid, preventing drainage from overflowing back up the drainage tube.