Cheat injuries nursing students and.pptx

a detailed lecture on chest injuries

1. Disorders Of the Respiratory System Chest injuries 1

2. INTRODUCTION Injuries to the chest and abdomen can be difficult to recognize and treat, and many injuries can go unnoticed until they become very serious. The muscle and bones that serve to protect vital organs can also mask their injuries - or at worst contribute to them. It is important for the rescuer to consider injuries that lie beneath the skin 2

3. Intro cont ………. Different organs react in different ways when subjected to trauma. Hollow organs (such as the bladder) tend to rupture, releasing their contents into the surrounding space. Solid organs (such as the liver) tend to tear instead, often bleeding at a slow enough rate to be overlooked. 3

4. CLOSED CHEST INJURIES Chest injuries can be inherently serious, as this area of the body houses many critical organs, such as the heart, lungs, and many blood vessels. Most chest trauma injuries should receive professional medical attention. 4

5. OPEN CHEST WOUNDS An open Pneumothorax or sucking chest wound - the chest wall has been penetrated (by knife, bullet, falling onto a sharp object) Recognition An open chest wound – escaping air Entrance and possible exit wound (exit wounds are more severe) 5

6. SIGNS AND SYMPTOMS Trouble breathing Sucking sound as air passes through opening in chest wall Blood or blood-stained bubbles may be expelled with each exhalation Coughing up blood 6

7. TREATMENT Assess ABCs and intervene as necessary Do not remove any embedded objects Call for an ambulance Flutter valve over wound. Lateral positioning: victim's injured side down Treat for shock Conduct a secondary survey Monitor vitals carefully 7

8. MAKING A FLUTTER VALVE Get some sort of plastic that is bigger than the wound. Tape the plastic patch over the wound on only 3 sides. The 4th side is left open, allowing blood to drain and air to escape. This opening should be at the bottom (as determined by the victim’s position). When the casualty inhales, the bag will be sucked in, but when the casualty exhales, the air will exit through the untaped side. 8

9. RIB INJURIES A common result of trauma to the chest is damage to the victim's rib cage. The curved shape of the rib cage helps to deflect the force of some injuries, but damage to cartilage or the ribs themselves can still result. While a single broken rib can be very painful for the patient, a number of broken ribs can lead to other complications. A victim with broken ribs may take very shallow breaths without even noticing it, as their body tries to prevent the pain with taking a full breath. 9

10. When many adjoining ribs are broken in different places, a portion of the rib cage can move in the opposite direction the chest should. This is known as a "flail" segment, and can make breathing very painful and less effective. 10

11. SIGNS AND SYMPTOMS Trouble breathing Shallow breathing Tenderness at site of injury Deformity & bruising of chest Pain upon movement/deep breathing/coughing Dusky or blue lips or nail beds May cough up blood Crackling feeling upon touching victim's skin. 11

12. TREATMENT Assess ABCs and intervene as necessary Call for an ambulance Assist the victim into a position of comfort (typically seated upright, to avoid fighting gravity) Conduct a secondary survey Monitor patient's condition carefully Be vigilant, keep alert for any changes. If a flail segment is suspected, tightly secure a bulky dressing (such as a tightly folded hand towel) to help stabilize the injury. 12

13. FLAIL CHEST Major physiological insult is contusion of underlying lung and decreased vital capacity Occurs when 3 or more consecutive ribs or costal cartilages are fractured bifocally. These circumscribed segments, having lost continuity with the rigid thorax, move inwards with inspiration and push outward with exhalation, thus moving paradoxically . 13

14. PRESENTING SYMPTOMS Chest pains Tachypnoea Dyspnoea Thoracic splinting, along with chest wall contusions, Tenderness, Crepitance, Palpable rib fractures N.B : these symptoms are are suggestive, but paradoxical chest wall motion is the diagnostic sine qua non. 14

15. INVESTIGATIONS may be difficult to diagnose if patient is already mechanically ventilated, in pain, obese, or has large breasts or subcutaneous emphysema. CXR is helpful in identifying multiple fractured ribs, but will not reveal cartilaginous disruptions. Major value of the CXR is in detecting associated injures 15

16. MANAGEMENT Half the cases can be managed without ventilation others require ventilation for 1-3 weeks chest wall usually stabilises in 1-2 weeks operative fixation is suggested by some authors. Main benefit is to prevent deformity. weaning should not wait till paradoxical movement improves, rather should be initiated when gas exchange is adequate. In absence of systemic hypotension control administration of IV fluids to prevent over hydration 16

17. LUNG CONTUSION Essentially a bruise of the lung. Direct injury causes pulmonary vascular damage with secondary alveolar haemorrhage Initially not much shunt as these alveoli are poorly perfused Subsequently tissue inflammation develops. 17

18. INVESTIGATIONS CT more sensitive and better method of assessing severity . May be irregular nodular densities that are discrete or confluent . Homogeneous consolidation . Diffuse patchy pattern 18

19. INVESTIGATIONS A chest X-ray, which will show opacity in the peripheral lung near the injured chest wall Early pulmonary contusion infiltrates are due to alveolar haemorrhage 19

20. MANAGEMENT supplemental oxygen good analgesia Physiotherapy In severe pulmonary contusion, the patient may need intubation and mechanical ventilation to allow the lung time to recover 20

21. PNEUMOTHORAX Collection of air in the pleural space that separates the lung from the chest wall thereby interfering with normal breathing Can occur as a result of direct transfer of energy to the chest wall or rapid deceleration, in which the lung hits something inside the body, like the ribs. 21

22. TENSION PNEUMOTHORAX One way valve effect allowing air to enter the pleural space, but not to leave. Air builds up forcing a mediastinal shift. This leads to decreased venous return to the heart and lung collapse/compression causing acute life-threatening respiratory and cardiovascular compromise. Ventilated patients are particularly high risk due to the positive pressure forcing more air into the pleural space. Tension pneumothorax can result in rapid clinical deterioration and is an emergency situation 22

23. HAEMOTHORAX accumulation of blood in the pleural space Accumulation of more than 1500 ml of blood in chest cavity is called Massive haemothorax Clinical signs : unilateral dullness to percussion Tachycardia Shock unilateral absence of breath sounds on affected side deviation of trachea to unaffected side Cyanosis Unequal chest rise 23

24. MANAGEMENT Manage initially by simultaneous restoration of volume deficits and decompression of chest cavity. If auto-transfusion device is available it should be used Emergency thoracotomy for massive haemothorax 24

25. PULMONARY EMPYEMA Collection of pus in the pleural space Causes : Pulmonary infection lung abscess or infected pleural effusion. Lymph node obstruction can cause retrograde flood of infected lymph into the pleural space Liver abscess or abdominal abscess can spread through the lymphatic system into the lung area 25

26. SIGNS AND SYMPTOMS Chest pain Dyspnoea Cough Fever Night sweats investigations Chest X-ray Thoracentesis –pleural fluid tapping Fluids sent to the laboratory for analysis 26

27. TREATMENT Closed chest drainage- underwater seal drainage Antibiotics coverage preferably intravenously Analgesics 27

28. EMPHYSEMA The collection of air in lung tissue. In people with emphysema, the tissues necessary to support the shape and function of the lungs are destroyed. As it worsens, it turns the spherical air sacs into large, irregular pockets with gaping holes in their inner walls. 28

29. EMPHYSEMA Also destroys the elastic fibers that hold open the small airways leading to the air sacs. This allows them to collapse when breathing out, so the air in the lungs can't escape. This reduces the surface area of the lungs and, in turn, the amount of oxygen that reaches the bloodstream. 29

30. CAUSES Smoking tobacco exposure to air pollution Marijuana smoke Manufacturing fumes Coal and silica dust 30

31. SYMPTOMS Dyspnea on exertion Expanded chest. Trouble coughing Decreased amounts of sputum. Weight loss. 31

32. INVESTIGATIONS Computerized tomography (CT). CT scans combine X-ray images taken from many different directions to create cross-sectional views of internal organs. Pulmonary function tests or spirometry , can measure the air flow into and out of the lungs and be used to predict the severity of emphysema They can also measure how well the lungs deliver oxygen to the bloodstream. 32

33. INVESTIGATIONS Oximetry -to measure the percentage of red blood cells that have oxygen. A plain chest X-ray may show lungs that have become too inflated and have lost normal lung markings, consistent with destruction of alveoli and lung tissue. 33

34. TREATMENT Medications Bronchodilators Corticosteroids Antibiotics Oxygen 34

35. CARDIAC TAMPONADE The mechanical compression of the heart resulting from large amounts of fluid collecting in the pericardial space and limiting the heart’s normal range of motion Most commonly results from penetrating injuries but may follow blunt trauma Relatively small amounts of blood (approx. 100 ml) required to restrict cardiac activity and interfere with cardiac filling. Removal of small amounts of blood or fluid (often as little as 15-20 ml) by pericardiocentesis may have enormous beneficial effects 35

36. MANAGEMENT OF CHEST DISORDERS THORACOSTOMY is the creation of a surgical opening in the chest wall through which a chest tube (also called thoracic catheter) is placed, which allows air and fluid to flow out of the chest 36

37. INDICATIONS Pneumothorax : accumulation of air or gas in the pleural space Pleural effusion : accumulation of fluid in the pleural space Chylothorax : a collection of lymphatic fluid in the pleural space Empyema : a pyogenic infection of the pleural space 37

38. Haemothorax : accumulation of blood in the pleural space Hydrothorax : accumulation of serous fluid in the pleural space Postoperative: for example,thoracotomy, cardiac surgery 38

39. THORACOTOMY Thoracotomy is an operation that is used to enter the chest to gain access to the thoracic organs, most commonly the heart , the lungs , or the esophagus , or for access to the thoracic aorta. It is used for lung operations such as lobectomy, pneumonectomy, removal of deep lung tumors, or extensive decortication. It may be required for the removal of mediastinal tumors, or small tumors that are adherent to large blood vessels. 39

40. THORACOTOMY The intercostal muscle, which is the small, sheet-like muscle that connects the ribs to each other, is then separated from the rib, and the chest is entered. Metal devices called retractors are then placed into the opening that has been made between the ribs, and the opening is slowly enlarged. The ribs are somewhat flexible, like a bow, and can be "sprung open" with the use of the retractor. 40

41. THORACOTOMY At this point, more of the intercostal muscle is separated from the rib forward and backward (beneath the skin) to release the rib so that the opening can be enlarged without breaking the rib. After the main operation has been performed, one or two chest tubes (drains) are placed, and secured to the skin. 41

42. The retractors are removed, the ribs are put back together, and the skin is closed with absorbable suture. The chest tubes remain in place for three to four days, on average. 42

43. DECORTICATION It is a surgical procedure that removes a restrictive layer of fibrous tissue overlying the lung, chest wall, and diaphragm. The aim of decortication is to remove this layer and allow the lung to re-expand. When the peel is removed, compliance in the chest wall returns, the lung is able to expand and deflate, and patient symptoms improve rapidly. 43

44. When pressures are disrupted If air or fluid enters the pleural space between the parietal and visceral pleura, the -4cmH 2 0 pressure gradient that normally keeps the lung against the chest wall disappears and the lung collapses 44

45. Conditions requiring chest drainage 45 Air between the pleurae is a pneumothorax Pleural space Visceral pleura Parietal pleura

46. Conditions requiring chest drainage 46 Blood in the pleural space is a hemothorax

47. Conditions requiring chest drainage 47 Transudate or exudate in the pleural space is a pleural effusion

48. Pneumothorax PNEUMOTHORAX Occurs when there is an opening on the surface of the lung or in the airways, in the chest wall — or both The opening allows air to enter the pleural space between the pleurae, creating an actual space 48

49. Open pneumothorax OPEN PNEUMOTHORAX Opening in the chest wall (with or without lung puncture) Allows atmospheric air to enter the pleural space Penetrating trauma: stab, gunshot, impalement Surgery 49

50. Open pneumothorax CLOSED PNEUMOTHORAX Chest wall is intact Rupture of the lung and visceral pleura (or airway) allows air into the pleural space 50

51. Open pneumothorax An open pneumothorax is also called a “sucking chest wound” With the pressure changes in the chest that normally occur with breathing, air moves in and out of the chest through the opening in the chest wall Looks bad and sounds worse, but the opening acts as a vent so pressure from trapped air cannot build up in the chest 51

52. Closed pneumothorax In a closed pneumothorax , a patient who is breathing spontaneously can have an equilibration of pressures across the collapsed lung The patient will have symptoms, but this is not life-threatening 52

53. Tension pneumothorax A tension pneumothorax can kill Chest wall is intact Air enters the pleural space from the lung or airway, and it has no way to leave There is no vent to the atmosphere as there is in an open pneumothorax Most dangerous when patient is receiving positive pressure ventilation in which air is forced into the chest under pressure 53

54. Tension pneumothorax Tension pneumothorax occurs when a closed pneumothorax creates positive pressure in the pleural space that continues to build That pressure is then transmitted to the mediastinum (heart and great vessels) 54

55. Mediastinal shift Mediastinal shift occurs when the pressure gets so high that it pushes the heart and great vessels into the unaffected side of the chest These structures are compressed from external pressure and cannot expand to accept blood flow 55

56. Mediastinal shift Mediastinal shift can quickly lead to cardiovascular collapse The vena cava and the right side of the heart cannot accept venous return With no venous return, there is no cardiac output No cardiac output = not able to sustain life 56

57. tension pneumothorax When the pressure is external, CPR will not help – the heart will still not accept venous return Immediate, life-saving treatment is placing a needle to relieve pressure followed by chest tube 57

58. Hemothorax Hemothorax occurs after thoracic surgery and many traumatic injuries As with pneumothorax, the negative pressure between the pleurae is disrupted, and the lung will collapse to some degree, depending on the amount of blood The risk of mediastinal shift is insignificant, as the amount of blood needed to cause the shift would result in a life-threatening intravascular loss 58

59. Hemothorax is best seen in an upright chest radiograph Any accumulation of fluid that hides the costophrenic angle on an upright CXR is enough to require drainage 59 Note air/fluid meniscus

60. Pleural effusion Fluid in the pleural space is pleural effusion Transudate is a clear fluid that collects in the pleural space when there are fluid shifts in the body from conditions such as CHF, malnutrition, renal and liver failure Exudate is a cloudy fluid with cells and proteins that collects when the pleurae are affected by malignancy or diseases such as tuberculosis and pneumonia 60

61. Treatment for pleural conditions Remove fluid & air as promptly as possible Prevent drained air & fluid from returning to the pleural space Restore negative pressure in the pleural space to re-expand the lung 61

62. Remove fluid & air Thoracostomy creates an opening in the chest wall through which a chest tube (also called thoracic catheter) is placed, which allows air and fluid to flow out of the chest 62

63. Remove fluid and air 63 A clamp dissects over the rib to avoid the nerves and vessels below the rib Small incision The clamp opens to spread the muscles Finger is used to explore the space to avoid sharp instrument Clamp holds chest tube and guides into place

64. Remove fluid & air 64

65. Remove fluid & air through chest tube Also called “thoracic catheters” Different sizes From infants to adults Small for air, larger for fluid Different configurations Curved or straight Types of plastic PVC Silicone Coated/Non-Coated Heparin Decrease friction 65

66. Remove fluid and air after thoracic surgery At the end of the procedure, the surgeon makes a stab wound in the chest wall through which the chest tube is placed into the pleural space 66

67. Prevent air & fluid from returning to the pleural space Chest tube is attached to a drainage device Allows air and fluid to leave the chest Contains a one-way valve to prevent air & fluid returning to the chest Designed so that the device is below the level of the chest tube for gravity drainage 67

68. Prevent air & fluid from returning to the pleural space 68 It’s all about bottles and straws How does a chest drainage system work?

69. Prevent air & fluid from returning to the pleural space Most basic concept Straw attached to chest tube from patient is placed under 2cm of fluid (water seal) Just like a straw in a drink, air can push through the straw, but air can’t be drawn back up the straw 69 Tube open to atmosphere vents air Tube from patient

70. Prevent air & fluid from returning to the pleural space This system works if only air is leaving the chest If fluid is draining, it will add to the fluid in the water seal, and increase the depth As the depth increases, it becomes harder for the air to push through a higher level of water, and could result in air staying in the chest 70

71. Prevent air & fluid from returning to the pleural space For drainage, a second bottle was added The first bottle collects the drainage The second bottle is the water seal With an extra bottle for drainage, the water seal will then remain at 2cm 71 Fluid drainage 2cm fluid Tube open to atmosphere vents air Tube from patient

72. Prevent air & fluid from returning to the pleural space The two-bottle system is the key for chest drainage A place for drainage to collect A one-way valve that prevents air or fluid from returning to the chest 72

73. How a chest drainage system works Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva ) Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest Suction can improve the speed at which air and fluid are pulled from the chest 73

74. At the bedside Keep drain below the chest for gravity drainage This will cause a pressure gradient with relatively higher pressure in the chest Fluid, like air, moves from an area of higher pressure to an area of lower pressure Same principle as raising an IV bottle to increase flow rate 74

75. Monitoring intrathoracic pressure The water seal chamber and suction control chamber provide intrathoracic pressure monitoring Gravity drainage without suction : Level of water in the water seal chamber = intrathoracic pressure (chamber is calibrated manometer) 75

76. Monitoring intrathoracic pressure Slow, gradual rise in water level over time means more negative pressure in pleural space and signals healing Goal is to return to -8cmH 2 With suction : Level of water in suction control + level of water in water seal chamber = intrathoracic pressure 76

77. Monitoring air leak Water seal is a window into the pleural space Not only for pressure If air is leaving the chest, bubbling will be seen here Air leak meter (1-5) provides a way to “measure” the leak and monitor over time – getting better or worse? 77

78. Disposable chest drains Collection chamber Fluids drain directly into chamber, calibrated in mL fluid, write-on surface to note level and time Water seal One way valve, U-tube design, can monitor air leaks & changes in intrathoracic pressure Suction control chamber U-tube, narrow arm is the atmospheric vent, large arm is the fluid reservoir, system is regulated, easy to control negative pressure 78

79. UNDERWATER SEAL DRAINAGE Chest drains are inserted to allow draining of the pleural spaces of air, blood or fluid, allowing expansion of the lungs and restoration of negative pressure in the thoracic cavity. The underwater seal also prevents backflow of air or fluid into the pleural cavity. 79

80. UNDERWATER SEAL DRAINAGE Appropriate chest drain management is required to maintain respiratory function and haemodynamic stability. Chest drains may be placed routinely in theatre, PICU & NNU; or in the emergency department and ward areas in emergency situations. Underwater-seal chest drainage is a closed (airtight) system for drainage of air and fluid from the chest cavity. 80

81. 81

82. MEDICAL MANAGEMENT FIRST AID Upright position or lying on the affected side. Penetrating foreign bodies are not removed until intensive care facilities are available,in case their removal causes massive haemorrhage. Open wound can be covered by a clean occlusive dressing which must be released at intervals to avoid a tension Pneumothorax developing.   82

83. MEDICAL MANAGEMENT Physical examination will reveal the following; Reduced breath sounds on auscultation Hyperresonance on percussion Prominence of the involved side of the chest, which moves poorly with respirations 83

84. MEDICAL MANAGEMENT Deviation of the trachea away from (closed) or toward (open) the affected side Chest x-ray for diagnosis. Chest tubes may be needed to allow the air to escape and the lung to re-inflate. 84

85. MEDICAL MANAGEMENT An apical intercostal chest drain will be inserted and connected to under water seal drainage system Narcotic analgesia are given to manage the patient’s pain and anxiety   85

86. NURSING CARE OF A CLIENT ON UWSD Assisting with insertion of a chest drain The nurse assisting should offer simple explanations and reassurance. If possible the patient should be sat up so that he can lean his arms forward on an over bed table. This will help to expand the thoracic cavity and provide good support for the patient. The pressure needed to pierce the chest wall is unpleasant but should not be painful. 86

87. The nurse assembles all the equipment. Often a complete sterile chest drain set is kept prepackaged in the emergence unit. Before the chest drain is inserted, the drainage system should be opened, and the drainage jar filled with sterile water to the requisite level. The whole system should be carefully checked to ensure that it is airtight 87

88. A local anaesthetic is then given at the chosen site ,a small incision made ,and the chest drain inserted into the pleural cavity, connected to the underwater seal drainage system and sutured in place. A chest X-ray must be performed after a chest drain has been inserted to verify its correct placement, the degree of re-expansion of the lung and the residual pleural fluid and/or Pneumothorax . 88

89. Once a chest drain is inserted, it is important for the nursing staff to ensure that the patient and the drain are closely monitored. 89

90. Mechanism of functioning The intra pleural drain is attached to the drainage tube. This should lead to the long tube whose end is under seal. The water seal drainage provides for escape of air, fluids and debris into a drainage bottle . The water acts as a seal and keeps the air from being drawn back into the pleural space The drainage tubing should be 2.5cm below the water level. This level prevents it from emerging above water line when the bottle is moved. 90

91. Mechanism of functioning If the tube is too deep, a higher intrapleural pressure is required to expel the air. The other shorter tube is left open to the atmosphere and attached to the controlled suction apparatus. This is to allow gas to escape. Although drainage of liquids and /or debris relies on gravity and the mechanics of respiration, additional controlled suction may be necessary to accelerate the process. 91

92. POSITIONING The patient should be placed in a semi-recumbent position with regular position changes in order to encourage drainage and prevent stiffening of the shoulder joints. These might enhance breathing and expectoration, as well as allowing full lung expansion and possibly preventing complications of prolonged immobilization. 92

93. PAIN MANAGEMENT The pain could be substantial and might affect coughing, ventilation, sleep as well as re-expansion of the lung. Nurses should be aware of the potential need for prescribed on-demand pain killers or inform the surgeon about the possible requirements. Proper patient positioning can contribute greatly to pain relief. 93

94. PAIN MANAGEMENT Chest tubes are painful as the parietal pleura is very sensitive. Patients require regular pain relief for comfort, and to allow them to complete physiotherapy or mobilise Pain assessment should be conducted frequently and documented 94

95. MARKING FLUID LEVELS Use a piece of tape for marking or calibrated bottle. This provides baseline for measurement fluid drainage. When recording fluid drainage; note the date and time. Mark hourly or daily increments by taping the level on the drainage bottles. When using the tape, specify whether the upper,mid or lower border of the tape is the level to be measured at. 95

96. The marking will show the amount of fluid loss and how fast fluids collecting in the drainage bottle. If the fluid is blood, it serves as a basis for retransfusion or reopening if following surgery. Inaccuracies of 100-200ml can occur if the incorrect border is used. 96

97. CARE OF THE DRAINAGE TUBING Secure tubing to the bed clothes by the use of tape and safety pins. This helps to prevent kinking, looping or pressure on the tubing which may cause reflux of the fluid into the pleural space or impede drainage causing blocking of the intrapleural drain by debris. Ensure that artery clamps are in close proximity to patient . i.e taped to the wall, clamped to the bed clothes or on the bed side locker . 97

98. CARE OF THE DRAINAGE TUBING In an event of accidental disconnection of the drainage tubing from the intrapleural drain, the artery clamps should be applied immediately to the intrapleural drain. This is to prevent entry of air (on inspiration) into the pleural space leading to Pneumothorax. 98

99. CARE OF THE DRAINAGE TUBING When moving the patient, the drainage tubing is more likely to become disconnected, therefore ,the artery clamps should be readily available. There may be medical order to clamp the tubing such as during instillation of drugs or radioactive substances to delay the drainage. 99

100. CARE OF THE DRAINAGE TUBING Volume Document hourly the amount of fluid in the drainage chamber on the Fluid Balance Chart Calculate and document total hourly output if multiple drains Calculate and document cumulative total output 100

101. Notify medical staff if there is a sudden increase in amount of drainage greater than 5mls/kg in 1 hour greater than 3mls/kg consistently for 3 hours Blocked drains are a major concern for cardiac surgical patients due to the risk of cardiac tamponade 101

102. Notify medical staff if a drain with ongoing loss suddenly stops draining If the chamber tips over and blood has spilt into next chamber, simply tip the chamber up to allow blood to flow to original chamber 102

103. OSCILLATION The water in the water seal chamber will rise and fall (swing) with respirations. This will diminish as the Pneumothorax resolves. Watch for unexpected cessation of swing as this may indicate the tube is blocked or kinked. Cardiac surgical patients may have some of their drains in the mediastinum in which case there will be no swing in the water seal chamber. Document on Fluid Balance Chart  103

104. CHEST DRAIN DRESSINGS Dressings should be changed if: No longer dry and intact, or signs of infection e.g. redness, swelling, exudate Infected drain sites require daily changing, or when wet or soiled No evidence for routine dressing change after 3 or 7 days This procedure is a risk for accidental drain removal so avoid unnecessary dressing changes 104

105. SUCTION AND CHEST DRAINS Suction may be attached to the underwater seal drain to manage a non-resolving Pneumothorax following thoracic surgery or to facilitate drainage of a pleural effusion. Ideally, a high volume /low-pressure system should be used. 105

106. DRAIN PATENCY Drainage can be impeded by excessive coiling, dependent loops, kinked or blocked tubes, and which potentially might lead to tension Pneumothorax or surgical emphysema. The tubing should be lifted regularly to drain the fluid into the collection bottle if the coilings cannot be avoided. The effects of clamping, milking and striping of chest tubes are controversial and are usually not advised. 106

107. OBSERVATIONS Start of shift checks: Patient assessment Chest drain assessment Equipment Other considerations e.g physiotherapy referral 107

108. OBSERVATIONS Drain insertion site Observe for signs of infection and inflammation and document findings Check dressing is clean and intact Observe sutures remain intact & secure (particularly long term drains where sutures may erode over time) 108

109. OBSERVATIONS Patient’s vital signs, oxygen saturation as well as the presence of tidaling and bubbling in chest drainage system should be closely monitored. Any deterioration or distress of the patient should be reported to the doctors immediately. ensure that there is fluctuation(swinging) of the fluid level in the drainage tube underwater seal. This shows that there is effective communication btn the pleural cavity and the drainage bottle. 109

110. OBSERVATIONS It provides the valuable indication of the patency of the drainage system, and is a gauge of intrapleural pressure. Ensure that the drainage bottle remains at floor level, except when the patient is being helped to move. The drainage bottle should never be raised above the level of intrapleural drain to prevent backflow of fluid into the pleural space . 110

111. OBSERVATIONS Caution visitors and ancillary staff against handling any part of the system or displacing the drainage bottle. This is to prevent backflow and also to guard against accidental disconnection of the tubing which would allow air entry. 111

112. OBSERVATIONS Observations should include breath sounds and equality of chest movements, respiration rate, pattern, depth and effort associated with breathing. If any deterioration or distress is detected, the medical team must be notified at once and another chest X-ray should be ordered. The patient and the chest drain site should be assessed at least daily for signs of systemic or local infection. 112

113. OBSERVATIONS The drainage bottle must be kept below chest level to prevent fluid re-entering the pleural space. The activity of the chest drain, including fluctuation of the water level in the underwater seal chamber (swinging) and the bubbling of air through the underwater seal, should be monitored. 113

114. OBSERVATIONS The fluid level in the underwater seal drain should be checked regularly and the level of drainage marked on the bottle each time, as therapeutic decisions are based on the quantity of drainage and its colour and consistency. Immediately after chest surgery the extent of the drainage must be monitored every 30 minutes. 114

115. Colour and Consistency Monitor the colour/type of the drainage. If there is a change eg . Haemoserous to bright red or serous to creamy, notify medical staff. 115

116. OBSERVATIONS Following thoracic surgery, the patient may drain up to 100ml/h of blood and haemoserous fluid for three to four hours. If drainage suddenly ceases, this may indicate that the drain is blocked. If there is an increase in blood and haemoserous fluid this may be an indication of haemorrhage, and the nurse should inform the surgeon. 116

117. RECORDING AND OBSERVING DRAINAGE Volume, color, tidaling , bubbling of drainage fluid and level of suction pressure should be regularly evaluated and recorded on patient’s chest drain chart. The frequency of recording will vary depending on the condition of the patients and their underlying disease(s). 117

118. DRAIN SECURITY AND WOUND MANAGEMENT The use of transparent, water-proof and secure tapings might be necessary in a busy and congested ward environment. The insertion site should be checked everyday to ensure that the wound is dry and clean, with no loosen sutures or visible side hole(s) of chest tube (i.e. slipping out). Presence of or increasing surgical emphysema, pus, or excessive bleeding around insertion sites should also be noted . 118

119. Potentially dangerous conditions that require urgent attention Large amount of bubbling in the water seal chamber, which might signify a large patient air leak or a leak in a system Sudden or unexpected cessation of bubbling, which may indicate a blockage in the tubing. Large amount of bloody discharge might indicate haemothorax or trauma to underlying organ (s) 119

120. Increasing dyspnoea, increased heart rate, lowered blood pressure and low oxygen saturation. These may signify recurrent Pneumothorax (after drain removal) or insufficient drainage or tube blockage Absence of gentle bubbling in suction control bottle/ chamber may indicate disconnection of the suction pressure or inadequate suction force to counteract the large air leakage. 120

121. CLAMPING DRAINS   Clamping a chest drain tube can increase the risk of a tension pneumothorax . This occurs when air from the alveoli enters, but cannot leave, the pleural space. The air can build up, causing a mediastinal shift towards the unaffected lung, leading to compression of the vena cava, which is associated with shock and collapse. The condition can be fatal. If bubbling is observed in the underwater seal drain, the chest tube should never be clamped. 121

122. MILKING AND STRIPPING DRAINAGE TUBING Routine milking or stripping of tubing to maintain the patency of the drainage system should be avoided as this increases the negative pressure in the intrathoracic cavity. 122

123. Changing the Chamber Indications The chest drain chamber needs to be replaced when it is ¾ full or when the UWSD system sterility has been compromised eg . Accidental disconnection . Equipment Required New UWSD Dressing pack Gloves Eye Protection 123

124. Procedure Perform hand hygiene Use personal protective equipment to protect from possible body fluid exposure Using an aseptic technique, remove the unit from packaging and place adjacent to old chamber Prepare the new UWSD as per manufacturers directions supplied with drain 124

125. Ensure patients drain is clamped to prevent air being sucked back into chest Disconnect old chamber by holding down the clip on the in line connector to pull the tubing away from the chamber. Insert the tubing into the new chamber until you hear it click Unclamp the chest drain Check drain is back on suction Place old chamber into yellow infectious waste bag & tie Perform hand hygiene 125

126. MOBILITY WITH A CHEST DRAIN Patients should be encouraged to walk around the ward or exercise around the bed if their drain is attached to wall suction. This facilitates drainage and prevents stiffness of the shoulder joints. Deep breathing exercises and coughing should be encouraged so as to open the airways and increase intrathoracic pressure and promote re-expansion of the lungs 126

127. REMOVAL OF THE CHEST DRAIN Chest drains are usually removed when the drainage is less than 100-150ml over 24 hours, breath sounds have returned to normal, bubbling in the underwater seal drain has ceased and the chest X-ray shows that the underlying problem has been resolved. Two nurses must perform the procedure: one removes the drain, the other ties the suture to close the wound. If the patient has had a Pneumothorax, the chest drain should not be clamped when it is removed .   127

128. Analgesia and a full explanation of the procedure must be given to patients. Before any attempt is made to remove the drain, the position and viability of the suture used to close the wound should be inspected to ensure that it will close the site. If in doubt, the medical staff should be notified, as a further suture may be required before removing the drain. 128

129. In order to reduce the complication of recurrent pneumothorax , Valsalva’s manoeuvre can be used. This requires patients to hold their breath and to bear down or try to breathe out against a closed glottis. This increases the intra-thoracic pressure, which reduces the possibility of air re-entering the pleural space through the drain site . 129

130. The drain can be removed while the patient is holding her breath or on expiration. As soon as one nurse has briskly removed the drain, the other nurse immediately ties the suture in order to form an airtight seal. The patient can then breathe normally. A chest X-ray should be performed to check that a Pneumothorax has not recurred, and both the patient and the drain site should be monitored closely. 130

131. COMPLICATIONS Pneumothorax Request urgent CXR Ensure drain system is intact with no leaks, or blockages such as kinks or clamps Prepare for insertion/ repositioning of chest  drain 131

132. Bleeding at the drain site Apply pressure to insertion site Place occlusive dressing over site Notify medical staff Check Coagulation results Check drain chamber to ensure no excessive blood loss 132

133. Infection of insertion site Notify medical staff Swab wound site Consider blood cultures 133

134. Accidental disconnection of system Clamp the drain tubing. Clean ends of drain and reconnect. Ensure all connections are cable tied. If a new drainage system is needed cover the exposed patent end of the drain with sterile dressing while new drain is setup. Ensure clamp removed when problem resolved Check vital signs Alert medical staff 134

135. Accidental drain removal Apply pressure to the exit site and seal with steri -strips. Place an occlusive dressing over the top Check vital signs Alert medical staff. 135

136. THE END!!!! 136