Review of the Use of Common Tubes

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Table 11-5

Tube or Apparatus	Purpose	Examples of Use	Key Nursing Points
Chest tubes	Anterior tube drains mostly air from pleural space Posterior tube drains mostly fluid from pleural space Removal of fluid and air from pleural space is necessary to reestablish negative intrapleural pressure	Thoracotomy Open heart surgery Spontaneous pneumothorax Traumatic pneumothorax	See Key Points for each of the three entries under Drainage system, Review of the Use of Common Tubes Sterile technique is used when changing dressings around the tube insertions Fowler’s position to facilitate air and fluid removal Cough, deep breathe q1h; splint chest; medicate for pain Manage pain carefully in order not to depress respirations Prepare for removal when there is little or no drainage, air leak disappears, or fluctuations stop in water seal; have suture set, air-occlusive dressing, and sturdy elastic tape ready; medicate for pain before removal; monitor breathing after removal (breath sounds, rate, chest pain)
Drainage system (see Figure. 11.2. Chest Drainage System, Reduction of Risk Potential)
#1: drainage compartment	Collect drainage		Mark level in bottle each shift to keep accurate record—not routinely emptied; replaced when full *Never* raise container above the level of the chest; otherwise backflow will occur
#2: water-seal chamber	Water seal prevents flow of atmospheric air into pleural space; essential to prevent recollapse of the lung		Air bubbles from postoperative residual air will continue for 24–48 hr Persistent large amounts of air bubbles in this compartment indicate an air leak between the alveoli and the pleural space Clamp tube(s) only to verify a leak; replace a broken, cracked, or full drainage unit; or verify readiness of client for tube removal; not necessary to clamp when ambulating if water seal intact If tube becomes disconnected, place tubing end in sterile water or saline; if dislodged from chest, seal insertion site *immediately* on expiration if possible; use sterile air-occlusive dressing If air leak is present, clamping the tube for very long (more than 10 sec) may cause a tension pneumothorax Fluctuation of the fluid level in this bottle is expected (when the suction is turned off) because respiration changes the pleural pressure: if there is no fluctuation of the fluid in the tube of this bottle (when the suction is turned off), either the lung is fully expanded or the tube is blocked by kinking or by a clot Although not routinely used, milking (gently squeezing) the tubes, if ordered, will prevent blockage from clots or debris; otherwise gravity drainage is sufficient to maintain patency Drainage of more than 100 mL in 1 hr should be *reported* to physician
#3: suction control—connected to wall suction	Level of the column of water (i.e., 15–20 cm) is used to control the amount of suction applied to the chest tube—if the water evaporates to only 10 cm depth, this will be the maximum suction generated by the wall suction		Air should continuously bubble through this compartment when the suction is on; the bubbles are from the atmosphere—not the client; when the wall suction is turned higher, the bubbling will increase, but the increased pulling of air is from the atmosphere and not from the pleural space Because the level of H₂O determines the maximum negative pressure that can be obtained, make sure the water does not evaporate—keep filling the bottle to keep the ordered level; if there is no bubbling of air through this container, the wall suction is too low
Heimlich flutter valve	Has a one-way valve so fluids and air can drain out of the pleural space but cannot flow back Eliminates the need for water seal—no danger when tube is unclamped below the valve	Same as for other chest tubes	Can be connected to suction if ordered Sometimes can just drain into portable bag so client is more mobile
Tracheostomy tube	Maintains patent airway and promotes better O₂-CO₂ exchange Makes removal of secretions by suctioning easier Cuff on trach is necessary if need air-tight fit for assisted ventilation	Acute respiratory distress due to poor ventilation Severe burns of head and neck Laryngectomy (trach is permanent)	Use oxygen before and after each suctioning Humidify oxygen Sterile technique in suctioning; clean technique at home Cleanse inner cannula as needed–only leave out 5–10 min Hemostat handy if outer cannula is expelled—have obturator taped to bed and another trach set handy Cuff must be deflated periodically to prevent necrosis of mucosa, unless low-pressure cuff used
Penrose drain	Soft collapsible latex rubber drain inserted to drain serosanguineous fluid from a surgical site; usually brought out to the skin via a stab wound	Bowel resection	Expect drainage to progress from serosanguineous to more serous Sterile technique when changing dressing—do often Physician will advance tube a little each day
Nasogastric (NG) tubes
Levin tube and small-bore feeding tubes	Inserted into stomach to decompress by removing gastric contents and air—prevents any buildup of gastric secretions, which are continuous Used when stomach must be washed out (lavage) Used for feedings when client is unable to swallow (gavage)	Any abdominal or other surgery after which peristalsis is absent for a few days Overdoses Gastrointestinal hemorrhage Cancer of the esophagus Early postoperative care for client who had a laryngectomy or radical neck dissection	Connect to low intermittent suction Irrigate prn with normal saline or puffs of air Clean, but not sterile, procedure Mouth care needed Report “*coffee ground” material (digested blood) For overdose, stomach is pumped out as rapidly* as possible For hemorrhage, tepid normal saline may be used to lavage Critical to make sure tube still in stomach before beginning feeding; listen for air passing into stomach, and if possible aspirate gastric contents; small-bore tubes require placement check by x-ray Follow feeding with some water to rinse out the tube Clamp tube when ambulating With larger-bore tubes, determine residuals and withhold feeding if large residuals obtained
Salem sump	Double-lumen tube with vent to protect gastric mucosa from trauma of suctioning	Same as Levin tube	Irrigate vent (blue tubing) with air only See Levin tube
Gastrostomy tube	Inserted into stomach via abdominal wall May be used for decompression Used long term for feedings	Conditions affecting esophagus in which it is impossible to insert a nasogastric tube	Principles of tube feedings same as with Levin nasogastric tube, except no danger that tube is in trachea If permanent, tube may be replaceable
Miller-Abbott tube Cantor tube	Longer than Levin tube—has mercury or air in bags so tube can be used to decompress the lower intestinal tract	Small-bowel obstructions Intussusception Volvulus	Care similar to that for Levin NG tube—irrigated Connected to suction, not sterile technique Orders will be written on how to advance the tube, gently pushing tube a few inches each hour; client position may affect advancement of tube X-rays determine the desired location of tube
T-tube	To drain bile from the common bile duct until edema has subsided	Cholecystectomy when a common duct exploration (CDE) or choledochostomy was also done	Bile drainage is influenced by position of the drainage bag Clamp tube as ordered to see if bile will flow into duodenum normally
Hemovac	A type of closed-wound drainage connected to suction—used to drain a large amount of serosanguineous drainage from under an incision	Mastectomy Total hip procedures Total knee procedures	May compress unit, and have portable vacuum or connect to wall suction Small drainage tubes may get clogged—physician may irrigate these at times
Jackson Pratt	A method of closed-wound suction drainage—indicated when tissue displacement and tissue trauma may occur with rigid drain tubes (e.g., Hemovac) See Hemovac	Neurosurgery Neck surgery Mastectomy Total knee and hip replacement Abdominal surgery Urological procedures	Empty reservoir when full, to prevent loss of wound drainage and back-contamination See Hemovac.
Three-way Foley	To provide avenues for constant irrigation and constant drainage of the urinary bladder	Transurethral resection (TUR) Bladder infections	Watch for blocking by clots—causes bladder spasms Irrigant solution often has antibiotic added to normal saline or sterile water Sterile water rather than normal saline may be used for lysis of clots
Suprapubic catheter	To drain bladder via an opening through the abdominal wall above the pubic bone	Suprapubic prostatectomy	May have orders to irrigate prn or continuously
Ureteral catheter	To drain urine from the pelvis of one kidney, or for splinting ureter	Cystoscopy for diagnostic workups Ureteral surgery Pyelotomy	*Never* clamp the tube—pelvis of kidney only holds 4–8 mL Use *only* 5 mL sterile normal saline if ordered to irrigate

Note: This review focuses on care of tubes, not on total client care.

Source: Jane Vincent Corbett, RN, MS, EdD, Professor Emerita, School of Nursing, University of San Francisco.

Used with permission.