Providing Care of a Chest Drainage System

Skill 14-14

Providing Care of a Chest Drainage System

Skill Variation: Providing Care of a Chest Drainage System Using Dry Seal or Dry Suction

A chest tube is indicated when negative pressure in the pleural space is disrupted, as from thoracic surgery (post-thoracotomy) or unanticipated trauma (Muzzy & Butler, 2015). Chest tubes may be inserted to drain fluid (pleural effusion), blood (hemothorax ), or air (pneumothorax) from the pleural space to restore the negative intrathoracic pressure and allow the compressed lung to reexpand (Hinkle et al., 2022). A chest tube may also be indicated for pleurodesis (pleural sclerosing; installation of anesthetic or sclerosing agent to achieve inflammatory adherence of the visceral and parietal pleural to each other) (Burns & Delgado, 2019; Hinkle et al., 2022). A mediastinal chest tube may be placed after cardiac surgery to drain blood from around the heart (Morton & Fontaine, 2018). A tunneled pleural catheter (tunneled under the skin before entering the pleural space) may be used to improve quality of life in patients with recurrent pleural effusions related to some end-stage diseases, such as malignancy (Miller et al., 2018).

A chest tube is a firm plastic tube with drainage holes in the proximal end that is inserted in the pleural space. Once inserted, the tube is secured with a suture at the insertion site, covered with a dressing, secured with tape a few inches below the insertion site, and attached to a drainage system that may or may not be attached to suction. Other components of the system may include a closed water seal drainage system that prevents air from reentering the chest once it has escaped, and a suction control chamber that prevents excess suction pressure from being applied to the pleural cavity. The suction chamber may be a water-filled or a dry chamber. A water-filled suction chamber is regulated by the amount of water in the chamber, whereas dry suction is controlled by a knob and internal valves to control suction and is automatically regulated to changes in the patient's pleural pressure (Sasa, 2019; Zisis et al., 2015). There are also portable drainage systems that use gravity for drainage. Table 14-2 compares different types of chest drainage systems.

Nursing responsibilities include assisting with insertion, monitoring the patient's status and response to the treatment, monitoring the patency of the chest drainage system, providing patient education, and assisting with removal of the chest tube. Once the tube is in place, monitor the patient's response, including respiratory status and vital signs, check the site and site dressing, and maintain the patency and integrity of the drainage system.

The following procedure is based on the use of a traditional water seal, three-compartment chest drainage system. Figure 1 is an example of this system. The Skill Variation following the procedure describes a technique for caring for a chest drainage system using dry seal or suction.

Delegation Considerations

Care of a chest tube is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, care of a chest tube may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Bottle of sterile normal saline or water
Two pairs of padded or rubber-tipped Kelly clamps (if a clamp is not in place on the drainage system tubing)
Pair of clean scissors
Disposable gloves
Additional PPE, as indicated
Foam tape
Prescribed drainage system, if changing is required

Assessment

Assess the patient's vital signs and mental status. Significant changes from baseline may indicate complications. Assess for restlessness and shortness of breath. Assess the patient's respiratory status, including respiratory rate, rhythm and depth, and oxygen saturation level. If the chest tube is not functioning appropriately, the patient may become tachypneic and hypoxic. Assess the patient's lung sounds. The lung sounds over the chest tube site may be diminished due to the presence of fluid, blood, or air. Also assess the patient for pain. Sudden pressure or increased pain indicates potential complications. In addition, many patients report pain at the chest tube insertion site and request medication for the pain. Assess the patient's knowledge of the chest tube to ensure that they understand the rationale for the chest tube.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Impaired gas exchange
Knowledge deficiency
Acute pain

Outcome Identification and Planning

The expected outcome to achieve is that the patient will not experience complications related to the chest drainage system or experience respiratory distress. Other outcomes that may be appropriate include that the patient will verbalize an understanding of the need for the chest tube, the patient will have adequate pain control at the chest tube insertion site, lung sounds will be clear and equal bilaterally, and the patient will be able to increase activity tolerance gradually.

Implementation

Action	Rationale
1. Gather equipment.	Assembling equipment provides for an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Close the curtains around the bed and close the door to the room, if possible.	This ensures the patient's privacy.
6. Explain to the patient what you are going to do and why.	Explanation relieves anxiety and facilitates engagement.
7. Assess the patient's level of pain. Administer prescribed medication, as needed, and/or implement the use of nonpharmacologic interventions.	Regular pain assessments are required to maintain adequate analgesic relief from the discomfort and pain caused by chest drains (Kane et al., 2013; Muzzy & Butler, 2015).
8. Put on gloves.	Gloves prevent contact with contaminants and body fluids.
Assessing the Drainage System
9. Move the patient's gown to expose the chest tube insertion site. Keep the patient covered as much as possible, using a bath blanket to drape the patient, if necessary. Observe the dressing at the chest tube insertion site and confirm that it is dry and intact (Figure 2).	Keeping the patient as covered as possible maintains the patient's privacy and limits unnecessary exposure of the patient. Use of a dressing at the site is supported in the evidence, including petroleum gauze, dry gauze, silicone foam, and transparent film (Gross et al., 2016; Jeffries et al., 2017; Sasa, 2019; Upvall et al., 2019; Wood et al., 2019). Some patients experience significant drainage or bleeding at the insertion site. If this occurs, the dressing needs to be replaced to maintain occlusion of the site.
10. Check that all connections are securely taped. Check that the tube is secured with tape to the patient's skin a few inches below the insertion site. Gently palpate around the insertion site, feeling for crepitus, a result of air or gas collecting under the skin (subcutaneous emphysema). This may feel crunchy or spongy, or like “popping” under your fingers.	The chest tube drainage system integrity must be intact to function as intended (Sasa, 2019). Taping secures the tube to help prevent accidental dislodgment and kinking and tension at the insertion site (Sasa, 2019). The body will absorb small amounts of subcutaneous emphysema after the chest tube is removed. Larger or increasing amounts could indicate improper placement of the tube or an air leak and can cause discomfort to the patient.
11. Check the drainage tubing to ensure that there are no dependent loops or kinks. Position the drainage collection device below the tube insertion site.	Dependent loops or kinks in the tubing can prevent the tube from draining properly and result in increased intrathoracic pressure (Sasa, 2019). The drainage collection device must be positioned below the tube insertion site so that drainage can move out of the tubing and into the collection device.
12. If the chest tube is prescribed to be connected to suction, note the fluid level in the suction chamber and check it with the amount of prescribed suction. Look for bubbling in the suction chamber. Temporarily disconnect the suction to check the level of water in the chamber. Add sterile water or saline, if necessary, to maintain the correct amount of suction.	Some fluid is lost due to evaporation. If suction is set too low, the amount needs to be increased to ensure that enough negative pressure is placed in the pleural space to drain the pleural space sufficiently. If suction is set too high, the amount needs to be decreased to prevent any damage to the fragile lung tissue. Gentle bubbling in the suction chamber indicates that suction is being applied to assist drainage.
13. Observe the water seal chamber for fluctuations of the water level with the patient's inspiration and expiration (tidaling). If suction is used, temporarily disconnect the suction to observe for fluctuation. Assess for the presence of bubbling in the water seal chamber. Add water, if necessary, to maintain the level at the 2-cm mark or the mark recommended by the manufacturer.	Fluctuation of the water level in the water seal chamber with inspiration and expiration is an expected and normal finding. Bubbles in the water seal chamber, after the initial insertion of the tube or when air is being removed, are a normal finding. Constant bubbles in the water seal chamber after the initial insertion period indicate an air leak in the system. Leaks can occur within the drainage unit or at the insertion site.
14. Assess the amount and type of fluid drainage. Measure drainage output at the end of each shift by marking the level on the container or placing a small piece of tape at the drainage level to indicate date and time (Figure 3). The amount should be a running total because the drainage system is never emptied. If the drainage system fills, remove and replace it (see Guidelines below).	Measurement allows for accurate intake and output measurement and assessment of the effectiveness of therapy, and it contributes to the decision to remove the tube. The drainage system would lose its negative pressure if it were opened.
15. Remove gloves. Perform hand hygiene. Assist the patient to a comfortable position. Raise the bed rail and place the bed in the lowest position, as necessary.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. Placing the patient in a comfortable position ensures patient comfort. Proper positioning with raised side rails and the proper bed height provides for patient comfort and safety.
16. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
Changing the Drainage System
17. Some drainage systems have a clamp on the drainage tubing. If one is present, there is no need to use other clamps. Otherwise, obtain two-padded Kelly clamps, a new drainage system, and a bottle of sterile water. Add water to the water seal chamber in the new system until it reaches the 2-cm mark or the mark recommended by the manufacturer. Follow the manufacturer's directions to add water to the suction system, if suction is prescribed.	Gathering equipment provides for an organized approach. An appropriate level of water in the water seal chamber is necessary to prevent air from entering the chest. An appropriate level of water in the suction chamber provides the prescribed amount of suction.
18. Put on clean gloves and additional PPE, as indicated.	Gloves prevent contact with contaminants and body fluids.
19. Engage the clamp on the drainage tubing. Alternatively, apply Kelly clamps 1.5 to 2.5 inches from insertion site and 1 inch apart, going in opposite directions (Figure 4).	Clamps provide a more complete seal and prevent air from entering the pleural space through the chest tube.
20. Remove the suction from the current drainage system by unrolling (Figure 5) or use scissors to carefully cut away (Figure 6) any foam tape on the connection of the chest tube and drainage system. Using a slight twisting motion, remove the drainage system. Do not pull on the chest tube.	Removing suction permits application of the new system. In many facilities, bands or foam tape are placed where the chest tube meets the drainage system to ensure that the chest tube and the drainage system remain connected. Due to the negative pressure, a slight twisting motion may be needed to separate the tubes. The chest tube is sutured in place; do not tug on the chest tube and dislodge it.
21. Keeping the end of the chest tube sterile, insert the end of the new drainage system into the chest tube (Figure 7). Unclamp the tubing clamp or remove the Kelly clamps. Reconnect the suction, if prescribed. Apply foam tape to the chest tube/drainage system connection site.	The chest tube is sterile. The tube must be reconnected to the suction to form a negative pressure and allow for reexpansion of the lung or drainage of fluid. Prolonged clamping can result in a pneumothorax. Bands or foam tape help prevent the separation of the chest tube from the drainage system.
22. Assess the patient and the drainage system as outlined (see Steps 9 to 15).	Assess for changes related to the manipulation of the system and placement of a new drainage system.
23. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the chest drainage system has remained patent and functioning. In addition, the patient has remained free of signs and symptoms of respiratory distress and complications related to the chest drainage system, has verbalized adequate pain relief, has gradually increased activity tolerance, and has verbalized an understanding of the need for the chest tube.

Documentation

Guidelines

Document the site of the chest tube; the amount and type of drainage; the amount of suction applied; and the presence of any bubbling, tidaling, or subcutaneous emphysema. Document the type of dressing in place and the patient's pain level as well as any measures performed to relieve the patient's pain. Document the changing of the drainage system, if complete.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Chest tube becomes separated from the drainage device: Put on gloves. Open the normal saline solution or sterile water and submerge the chest tube into the bottle 1 to 2 inches below the surface of the solution, taking care to avoid contaminating the chest tube. This creates a water seal until a new drainage unit can be attached. Assess the patient for any signs of respiratory distress. Notify the health care team. Do not leave the patient. Summon a coworker to obtain a new chest drainage unit and reconnect the drainage system (Sasa, 2019). Alternatively, clamp the chest tube using a rubber-tipped clamp, but only for a few minutes to obtain and reconnect a new chest drainage unit; clamping poses the risk of tension pneumothorax (Sasa, 2019). Anticipate the need for a chest x-ray.
Chest tube becomes dislodged: Put on gloves. Immediately apply an occlusive dressing to the site. There is controversy in the evidence for practice over whether the occlusive dressing should be a sterile petroleum gauze covered with an occlusive tape or a sterile 4 × 4 gauze folded and covered with an occlusive tape. (An example of an occlusive tape would be foam tape or the clear dressing used to cover IV insertion sites.) Assess the patient for any signs of respiratory distress. Notify the health care team of the incident and to determine whether the chest tube should be replaced. Anticipate the need for a chest x-ray.
While assessing the chest tube, you notice a lack of drainage when there had been drainage previously: Check for kinked tubing or a clot in the tubing. Note the amount of suction on which the chest tube is set.Do not“milk” the tubing (i.e., squeezing and releasing small segments of tubing between the fingers) or “strip” the tubing (i.e., squeezing the length of the tube without releasing it) (Makic et al., 2015; Kane et al., 2013; Muzzy & Butler, 2015; Sasa, 2019). Bruising and trauma of lung tissue can occur as a result as well as dangerously increased intrathoracic pressure (Sasa, 2019). If the suction is not set appropriately, adjust it until the prescribed amount is achieved. Keeping the tubing horizontal across the bed or chair before dropping it vertically into the drain device and avoiding dependent loops optimize drainage. Notify the health care team if the lack of drainage persists.
Drainage dramatically increases or becomes bright red: Notify the health care team immediately. This can indicate fresh bleeding.
Chest tube drainage suddenly decreases, and the water seal chamber is not tidaling: Notify the health care team immediately. This could signal that the tube is blocked. Assess the patient's respiratory status.
The chest drainage unit is knocked over: Promptly return it to its upright position and check all connections. Most chest drainage units have mechanisms to contain fluids in their respective chambers, but assess all chambers for any changes (Sasa, 2019). Inspect the water seal chamber to ensure the sterile water is at the 2-cm mark. Check the suction control chamber and add sterile water as needed. Re-mark the drainage chambers if fluid has redistributed between the chambers.

Special Considerations

General Considerations

Ensure that a bottle of sterile water or normal saline is at the bedside at all times. Never clamp chest tubes except to change the drainage system, or when there is a prescribed intervention, such as for a trial before chest tube removal. If the chest tube becomes accidentally disconnected from the drainage system, place the end of the chest tube into the sterile solution (see Unexpected Situations above). This prevents more air from entering the pleural space through the chest tube but allows for any air that does enter the pleural space, through respirations, to escape once pressure builds up.
Evidence supports the use of a dressing at the chest tube insertion site; historically, petroleum gauze dressings have been the standard of care. Current evidence suggests that the use of petroleum gauze macerates the skin at the site over time and may increase the risk of infection and presents several alternative ways of dressing the chest tube site, including dry gauze, silicone foam, and transparent film (Gross et al., 2016; Jeffries et al., 2017; Morton & Fontaine, 2018; Sasa, 2019; Upvall et al., 2019; Wood et al., 2019).
Keep two rubber-tipped clamps and additional dressing material at the bedside for quick access, if needed.
Do not“milk” the tubing (i.e., squeezing and releasing small segments of tubing between the fingers) or “strip” the tubing (i.e., squeezing the length of the tube without releasing it) to promote drainage. This creates excessive negative pressure that can damage delicate lung tissue. Stripping and milking are not necessary to maintain chest tube patency and probably do more harm than good (Makic et al., 2015, p. 44; Sasa, 2019).
If the patient has a small pneumothorax with little or no drainage and suction is not used, the tube may be connected to a Heimlich valve. A Heimlich valve is a small one-way valve chamber that allows air or drainage to exit from, but not enter, the chest tube (Burns & Delgado, 2019) (Figure 8). The valve drains into a plastic bag that can be held at any level, allowing the patient to be ambulatory simply by carrying the bag (Gogakos et al., 2015). Check to assure that the valve is pointing in the correct direction. The arrow on the casing points away from the patient.

Maintain the chest drainage system in an upright position and lower than the level of the tube insertion site. This is necessary for proper functioning of the system and to aid drainage.
Encourage the use of an incentive spirometer, if prescribed, and/or frequent deep breathing and coughing by the patient. This helps drain the lungs, promotes lung expansion, and prevents atelectasis.

Providing Care of a Chest Drainage System Using Dry Seal or Dry Suction

Perform hand hygiene and put on PPE, if indicated.
Identify the patient.
Assemble equipment on the bedside stand or overbed table or other surface within reach.
Close the curtains around the bed and close the door to the room, if possible.
Explain to the patient what you are going to do and why.
Assess the patient's level of pain. Administer prescribed medication, as needed.
Put on gloves. Move the patient's gown to expose the chest tube insertion site. Keep the patient covered as much as possible, using a bath blanket to drape the patient, if necessary. Observe the dressing around the chest tube insertion site and confirm that it is dry and intact.
Check that all connections are taped securely. Check that the tube is secured with tape to the patient's skin a few inches below the insertion site. Gently palpate around the insertion site, feeling for subcutaneous emphysema, a collection of air or gas under the skin. This may feel crunchy or spongy, or like “popping” under your fingers.
Check the drainage tubing to ensure that there are no dependent loops or kinks. The drainage collection device must be positioned below the tube insertion site.
If the chest tube is to be connected to suction, assess the amount of suction set on the chest tube against the amount of suction prescribed. Assess for the presence of the suction control indicator, which is a bellows or float device, when adjusting the regulator to the desired level of suction, if prescribed.
Assess for fluctuations in the diagnostic indicator with the patient's inspiration and expiration.
Check the air-leak indicator for leaks in dry systems with a one-way valve.
Assess the amount and type of fluid drainage. Measure the drainage output at the end of each shift by marking the level on the container or placing a small piece of tape at the drainage level to indicate date and time. The amount should be a running total because the drainage system is never emptied. If the drainage system fills, it is removed and replaced.
Some portable chest drainage systems require manual emptying of the collection chamber. Follow the manufacturer's recommendations for timing of emptying. Typically, the unit should not be allowed to fill completely because drainage could spill out. Wear gloves, clean the syringe port with an alcohol wipe, use a 60-mL Luer-Lok syringe, screw the syringe into the port, and aspirate to withdraw fluid. Repeat, as necessary, to empty the chamber. Dispose of the fluid according to facility policy.
Remove gloves and additional PPE, if used. Perform hand hygiene.

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Skill 14-14