Clinical Findings

Neuro: Restlessness, anxiety, decreased LOC.

Resp: Respiratory distress, rapid, shallow, or increased work of breathing, cyanosis, and decreased SpO₂.

CV: Tachycardia.

Skin: Diaphoresis, cyanosis, pallor.

Equipment: Whistling sound as air enters or exits wound site or chest tube, partially or completely dislodged chest tube, visible chest tube drain pores.

Possible Causes: Excessive torque or tension on chest tube due to multiple possible causes (chest tubes not hanging freely during movement, improper transfer technique, Pt confused).

Collaborative Management

Dislodgement from Pt

• Immediately cover chest tube insertion site with sterile petroleum gauze (occlusive dressing). Tape three sides of dressing, leaving one side open for air to escape.
• Notify HCP, STAT; continue to monitor Pt for distress.
• Administer supplemental O₂ to maintain SpO₂ >92%.
• Assess LOC, SpO₂, skin color, and work of breathing.
• Auscultate lung fields and compare chest movements left to right.
• Assess LOC, VS, and pain level.
• Assist HCP with reinsertion of chest tube.
• Ensure CXR is obtained after reinsertion.
• Continue to evaluate lung sounds and quality of oxygenation (see additional information about chest tubes starting on page 36).
• Assess drainage system for proper functioning—Make sure all connections are secure and that tubing is not tangled or encumbered.
• Maintain drainage system in upright position below heart.
• Place emergency chest tube equipment in Pt’s room (sterile normal saline, 4 × 4 pads, petroleum gauze, tape, and nontoothed padded clamps).
• Ensure that extra drainage collection system is readily available on the unit.
• Assist Pt with movement and repositioning.