Med-Surg - Respiratory System, part 11: Pleural Disorders, Chest Tubes, Tension Pneumothorax

by Cathy Parkes August 27, 2021 Updated: August 29, 2021

Full Transcript

Hi, I'm Cathy, with Level Up RN. In this video, we are going to talk about pleural disorders, as well as chest tubes and a tension pneumothorax. And at the end of the video, I will give you guys a little quiz to test your understanding of some of the information I'll be covering in this video. So definitely stay tuned for that. So if you recall, and if you watched the beginning of this video playlist, we did a little anatomy and physiology review for the respiratory system. So there are pleura that surround and protect each of the lungs. In this pleura, it has two layers. In the space between those two layers is the pleural cavity. And we would not expect the accumulation of air, blood, or fluid in that pleural cavity. Because if we do get one of those things in between those two layers, that puts pressure on the lungs and can lead to a lung collapse. So if we have the accumulation of air in that pleural cavity, that is called a pneumothorax. If we have the accumulation of blood in that space, that is a hemothorax. And then if we have the accumulation of fluid in that pleural cavity, that is a pleural effusion.

So in terms of the signs and symptoms of a pleural disorder, the patient may exhibit respiratory distress. They may have reduced or absent breath sounds on the affected side. And then when you perform percussion, if you hear hyperresonance, then that is indicative of a pneumothorax. And if you hear dull percussion, then that would be more indicative of a hemothorax or a pleural effusion. So in terms of diagnosis, we would diagnose a pleural disorder using a chest X-ray. And then treatment involves the placement of a chest tube to get rid of that accumulation of air, blood, or fluid. And we're going to talk a lot more about chest tubes here in a minute. And then medications that can be provided to the patient include benzodiazepines for anxiety, as well as opioid analgesics for pain.

All right. Let's now talk more about chest tubes. So as I mentioned, the chest tube is going to help drain the blood, the air, or the fluid out of that pleural space. Let's first talk about the three chambers of the chest tube. And I'm going to describe them from right to left. So the first chamber is the drainage collection chamber. And as the nurse, you are going to need to chart the amount of drainage and the color of drainage on a regular basis. And you're going to want to report excess drainage to the provider. So if the patient is having over 100 milliliters an hour of drainage, that would be considered excessive, and you would definitely want to notify the provider. And as a side note, you want to notify the provider any time you see excess drainage in any type of device. So with a wound VAC, if you see excess drainage, that would be cause for concern, and you would need to notify the provider. It goes for drains, too, their JP drain or Hemovac drain. If you see it fill up with a lot of fluid very quickly, you would want to notify the provider.

Okay. So after the drainage collection chamber, we have the water seal chamber. And in this chamber, you want to add sterile fluid to keep it at the two-centimeter line. You want to make sure the chamber is kept upright and below the chest insertion site. There will be tidaling present in this chamber. So that's the up and down movement of water that occurs with inspiration and expiration. Lack of tidaling can indicate that the lungs have reexpanded, which is great. However, it could also mean that there's an obstruction in the system, which is not so great. So you're definitely going to need to do some troubleshooting if you notice that there is lack of tidaling in this chamber. Continuous bubbling is not expected in this chamber and is indicative of an air leak. So our little cool chicken here on this card for remembering that tidaling is expected in the water sealed chamber is that seals swim in the tides. So tidaling is expected in the water seal chamber. And then the last chamber we have is the suction control chamber. Continuous bubbling is expected in this chamber.

All right. Let's now talk about nursing care of a patient who has a chest tube and some best practices. So after the patient gets their chest tube inserted, they need to have a chest X-ray to confirm the tube position. You want to have an occlusive dressing over the insertion site, and you want to check the insertion site on a regular basis to check for subcutaneous emphysema, which is where air becomes trapped under the skin. And then we also want to monitor the site for signs of infection. And that subcutaneous emphysema, it kind of feels like Rice Krispies, for lack of a better description. It's kind of crunchy. If you push on there and you feel that kind of crunchiness, then that would be indicative of subcutaneous emphysema. You only want to clamp the chest tube if it is ordered by the provider. You never want to strip the tubing. And then you want to encourage the patient to deep breathe, to cough and use their incentive spirometer to help with that lung expansion, reinflating the lungs. And then you want to keep padded clamps, sterile water, and sterile gauze at the bedside. If the chest tube becomes disconnected from the drainage system, you want to place the end of the tube in sterile water in order to maintain that water seal. And then if the chest tube becomes accidentally removed from the patient's chest, you want to place dry, sterile gauze over the insertion site and notify the provider. And these instructions may vary depending on facility policy. So definitely check on your particular facility. And then lastly, you want to monitor for complications such as a tension pneumothorax, which we're going to talk about next.

With a tension pneumothorax, air becomes trapped in that pleural cavity under positive pressure, meaning that air enters that pleural space upon inspiration but can't escape upon expiration. And this can lead to lung collapse. So occlusion of the chest tube is definitely a key risk factor with a tension pneumothorax. Other risk factors can include mechanical ventilation, as well as fractured ribs. Signs and symptoms of a tension pneumothorax include tracheal deviation towards the unaffected side, as well as absent breath sounds on the affected side. You may see asymmetry of the thorax. The patient will likely be exhibiting respiratory distress, tachycardia, tachypnea, neck vein distention, pallor, and anxiety. So diagnosis of this can be done with a chest X-ray and with ABGs. And then treatment includes immediate insertion of a large bore needle into that pleural space to remove that air to allow for lung expansion. And then we would place a chest tube as well.

All right. It's time for a quiz. There's actually a lot of questions I could ask you. There's just a lot of important information to know about the conditions we just went over and chest tubes. So if you have our flashcards, definitely review the bold red items to make sure you have those facts and concepts down. All right. Question number one, if a patient has a pneumothorax, what type of sound will you hear upon percussion of the chest? If you answered hyperresonance, you are correct. Question number two, in which chest tube chamber is continuous bubbling expected? If you said the suction control chamber, you are correct. Question number three, tracheal deviation is indicative of what disorder? The answer is a tension pneumothorax. I hope you did well with that quiz. And if you didn't, just go back and watch the video again and review the flashcards. You got this. I know you can do it. Take care. Good luck studying.

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