If fluid or air accumulates in the pleural space, the negative subatmospheric pressure becomes positive, and the lungs will collapse. Chest tube insertion can help drain the pleural space, enable optimal lung expansion, and reestablish negative pressure.
A thoracostomy involves inserting a flexible tube through the chest wall and into the pleural space. Chest tubes vary in size and are about 20 inches long. The size of the chest tube inserted will depend on the patient’s condition. Small tubes are used to drain air, medium tubes drain fluids, and large tubes drain blood.
After chest tube placement, the tube is attached to a pleur-evac system which has three chambers: the suction chamber, the water seal chamber (one-way valve allowing air to escape and not enter the thoracic cavity), and the collection chamber.
Indications for chest tube insertion include the following:
- A collapsed lung (pneumothorax)
- Hemothorax
- Lung infection
- Fluid buildup due to pneumonia or cancer
- Breathing difficulties
- Post-heart, lung, or esophageal surgery
Chest tube insertion can take place in the emergency department, operating room, or at the patient’s bedside. The patient is placed in a position with the arm raised above the head on the affected side to expose the midaxillary area and spread the intercostal space. The head of the bed is elevated about 45 degrees to lower the diaphragm and reduce the risk of injury.
The chest tube is advanced up or over the top of the rib to avoid intercostal nerves and blood vessels. Once the chest tube is in place, it is secured with sutures and connected to the pleural drainage system.
The wound is covered with an occlusive dressing sealing it with petroleum gauze. Proper tube placement is then confirmed through a chest x-ray.
Possible complications of chest tube insertion include the following:
- Pain during the procedure
- Infection
- Bleeding
- Collapsed lung during tube removal
- Injury to the diaphragm, lung, or other organs
Nursing Process
Nursing care for patients with a chest tube includes assessment of the chest tube site to prevent dislodgement and infection, management of effective suction and drainage, pain relief, monitoring the respiratory status, and providing overall supportive care.
Nursing Care Plans Related to Chest Tube Insertion
Acute Pain
Chest tube insertion has been reported to be a very painful procedure, though it can be managed through anesthetics and medications.
Nursing Diagnosis: Acute Pain
Related to:
- Procedural effects
- Inflammatory process
- Surgical intervention
- Impaired pleural integrity
As evidenced by:
- Distraction behavior
- Expressive behavior
- Facial expression of pain
- Guarding behavior
- Positioning to ease pain
- Tachycardia and hypertension
- Rapid, shallow breathing
Expected outcomes:
- Patient will report pain relief and demonstrate effective pain relief interventions.
- Patient will demonstrate controlled pain as evidenced by vital signs within expected limits.
Assessment:
1. Assess the level of pain and pain characteristics.
Chest tube insertion is painful due to the rich innervation of the pleural space. Pain assessments can help determine the trend and effectiveness of the treatment regimen.
2. Assess for the psychological causes of pain.
Several factors, other than the procedure or medical condition, can precipitate pain. Fear, anxiety, and distress can impair the patient’s ability to cope and make the patient’s pain experience worse.
Interventions:
1. Administer medications as indicated.
After sterilizing the area, a local anesthetic is often injected. An IV opioid may also be given in instances of trauma or severe pain. A nerve block can also be administered and can help reduce the need for postoperative opioids.
2. Teach the patient about splinting.
Coughing and breathing use accessory respiratory and abdominal muscles, which can cause excessive pain after chest tube placement. Splinting the area where the chest tube is inserted can help reduce discomfort.
3. Allow adequate rest periods in between interventions.
Adequate rest periods promote recovery, decrease oxygen demand, reduce discomfort, and conserve energy.
4. Reposition the patient while ensuring the chest tube is secure.
Proper repositioning of the patient may reduce discomfort and facilitate drainage.
Impaired Gas Exchange
Chest tube insertion is often indicated for patients with pneumothorax. When air, blood, or fluid enters the pleural space, this causes positive intrapleural pressure, lung compression, and gas exchange impairment.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Underlying cause or medical condition
- Alveolar-capillary membrane changes
- Ineffective airway clearance
- Ineffective breathing pattern
- Ventilation-perfusion mismatch
- Pain or discomfort when breathing
- Inflammatory process
As evidenced by:
- Altered respiratory depth
- Altered respiratory rhythm
- Hypoxemia
- Hypoxia
- Bradypnea
- Nasal flaring
- Dyspnea
- Tachycardia
- Confusion
Expected outcomes:
- Patient will demonstrate improved ventilation and adequate oxygenation as evidenced by ABGs within expected limits.
- Patient will maintain clear lung fields and remain free from any signs and symptoms of respiratory distress.
Assessment:
1. Assess respiratory rate, rhythm, depth, and ease of respiration.
Alterations in these parameters can indicate respiratory distress and reduced gas exchange.
2. Assess for any signs of hypoxia.
Indicators of hypoxia include anxiety, restlessness, tachycardia, and a decreased level of consciousness. Hypoxia can signal the possibility of respiratory complications and must be corrected immediately.
3. Assess chest tube drainage and positioning.
Frequent monitoring of patients with chest tubes enables prompt detection of issues such as dislodgement, air leaks, or abnormalities in drainage.
Interventions:
1. Position the patient with the head of the bed elevated.
Semi-Fowlers position can help facilitate drainage and promote comfort in patients with a chest tube. It can enable full expansion of the unaffected lung, promote adequate chest wall expansion, and descent of the diaphragm.
2. Encourage deep breathing and other exercises.
Deep breathing exercises decrease the risk of atelectasis, enhance gas exchange, and promote lung expansion. Encourage the patient to use an incentive spirometer hourly while awake.
3. Administer oxygen supplementation as needed.
Providing supplemental oxygen ensures adequate oxygenation as the lung heals.
4. Monitor blood gas values and x-rays.
Monitoring is an essential part of the recovery process for patients with a chest tube. Blood gas values can indicate the effectiveness of the treatment regimen and signal the need for interventions such as a chest x-ray if complications arise.
5. Encourage ambulation.
Patients who are able to should be assisted in ambulating. The chest tube drainage system can be attached to a walker or IV pole below the level of insertion to allow for movement. Ambulation allows for lung expansion and prevents atelectasis.
Risk for Infection
Chest tube insertion is a minimally invasive procedure that requires making an incision and inserting a thin plastic tube into the pleural space. Infection increases with the duration of the chest tube placement.
Nursing Diagnosis: Risk for Infection
Related to:
- Invasive procedure
- Compromised tissue
- Increased duration of chest tube placement
- Insufficient primary defenses
- Underlying infectious process
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at the prevention of signs and symptoms.
Expected outcomes:
- Patient will remain free from infection.
- Patient will not display signs of infection, such as bloody drainage; an increase in drainage; redness, warmth, or pus at the insertion site.
Assessment:
1. Assess the chest tube insertion site.
Signs of infection like redness, warmth, bleeding, inflammation, drainage, and abscess can occur in the chest tube insertion site.
2. Assess and monitor laboratory values.
An elevated white blood cell count can indicate a systemic infection.
3. Monitor vital signs.
Tachycardia, dropping oxygen saturation, tachypnea, fever, and changes in blood pressure signal an infectious process.
Interventions:
1. Maintain sterile technique.
Sterile technique is required when inserting and removing a chest tube, as well as performing dressing changes to reduce the transmission of pathogens.
2. Consider a swab or blood cultures.
If the insertion site shows redness, swelling, or drainage, consider obtaining a swab of the area for culturing. Blood cultures can also be obtained to assess for a systemic infection.
3. Practice handwashing before and after patient interventions.
Handwashing is an effective infection control intervention that reduces the risk of pathogen transmission.
4. Administer antibiotics.
IV antibiotics can be administered to prevent or treat an infection.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Chest Tube Placement (Thoracostomy) and Pleurodesis. RadiologyInfo.org. Reviewed: November 1, 2022. From: https://www.radiologyinfo.org/en/info/thoracostomy
- Chest Tube Procedure. American Lung Association. Updated: November 17, 2022. From: https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/chest-tube-procedure.
- Chest Tube. Ravi C, McKnight CL. [Updated 2022 Oct 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459199/
- Chest Tube Thoracostomy. American Thoracic Society. Online version updated: February 2020. From: https://www.thoracic.org/patients/patient-resources/resources/chest-tube-thoracostomy.pdf
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
