Nursing Considerations and Troubleshooting

Nursing assessment and trouble-shooting skills are essential to providing care for the patient with a chest tube. The following chart outlines a systematic approach for patient and chest drainage system assessment and lists the actions required for each assessment finding.

RESPIRATORY STATUS Are there signs of respiratory distress or a change from the baseline respiratory assessment? In pleural chest drainage, the major hazard is tension pneumothorax. The most likely cause is obstructed tubing. Quickly assess the tubing’s patency and notify the doctor immediately.

Watch for signs and symptoms of recurring pneumothorax and pleural effusion.
Are there signs of cardiac
If yes, notify surgeon immediately and follow emergency protocol for milking or stripping chest tubes to dislodge clots.
Is dressing clean, dry, and intact?

Is there crepitus upon palpationaround the site?

Has the thoracic catheter been pulled out of the chest?
Mark any drainage on dressing; notify doctor if significant.

Change dressing according to hospital policy.
If new, notify doctor. Mark the borders of the crepitus and reassess periodically for any increase.

If there is a pleural air leak, apply a dressing with your hand, but release it periodically or at any sign of respiratory distress, so pleural air can escape. Notify the doctor immediately and prepare for replacement of the tube.
PATIENT DRAINAGE TUBES Are all connections securely taped or banded?

Is the tube patent and free of

Are there any dependent loops in the tube?

Is the clamp open?
Reconnect any loose connections and tape securely; assess for a new or increased air leak. Notify doctor if new or increased air leak present.

If drainage tube is disconnected and contaminated, you may submerge the chest tube 1 to 2 inches (2-4 cm) below the surface of a 250 ml bottle of sterile water or saline until a new chest drainage unit is set-up. This establishes a water seal, allows the escape of air, and prevents the re-entry of air.

If no water is available and there has been bubbling in the water seal/air leak meter of a pleural tube, or there has been copious drainage from mediastinal tubes, leave the chest tube open. The entry of a small amount of air is not as dangerous as the potential for tension pneumothorax or cardiac tamponade.

Make sure tube is unclamped. Reposition as needed to avoid kinking of thoracic catheter or patient tube.

Reposition tubing to eliminate dependent loops; fluid in the hanging loops causes resistance to flow out of the chest.

You may coil the long tubing and secure it to a draw sheet with a safety pin (allowing enough tubing so that the patient can move in bed comfortably) to prevent dependent loops.

The tube should be open unless:
a. You are changing the unit. Clamp only briefly.
b. Specifically ordered by the doctor.

Do not clamp the chest tube during transport or ambulation unless specifically ordered by the doctor. Clamping the chest tube in patients with an air leak increases the chance for pneumothorax.

Position the open clamp away from the patient to avoid accidental closure.
COLLECTION CHAMBER What is the character of the
drainage; is it bloody, strawcolored, or purulent?

What is the rate of drainage?

Has the drainage stopped

Are the columns only partially

Is the collection chamber full?
Document findings. Notify doctor if character of drainage is a significant change, (i.e. straw-colored drainage at last check is now bloody).

Position the tubing and drainage system below the patient’s chest at all times to allow for gravity drainage and prevent fluid backflow.

Mark the level of drainage with date and time of measurement.

Sudden hemorrhage in a postoperative cardiac patient is likely caused by a ruptured suture line or blown graft. The patient can lose 1,000 to 1,500 ml of blood in a matter of minutes.
Immediately alert the surgeon and prepare for return to the operating room.

A sudden (not gradual) cessation of drainage in the patient with mediastinal tubes can be caused by accumulated clotted blood occluding the tube. This can lead to life-threatening cardiac tamponade. To keep the tubes patent, or to dislodge clots, gently milk the tube.

If the patient’s condition is deteriorating rapidly, follow the emergency procedures of milking/stripping to dislodge clots.

If the patient appears stable, make sure the unit is low enough so gravity can assist drainage; raise the bed, lower the Pleur-evac or turn the patient on his affected side.

Check tubing for kinks or bends. Make sure tube is not clamped.

If the drainage has been tapering off over the past few shifts, lack of drainage may be normal.

Surface tension of the fluid may pull drainage into the next column if the drainage nears the top OR the unit has tipped over.

In a water seal unit:
• Check the fluid level in the water seal and   adjust to 2 cm.
• Assess for new or increased air leak; notify   doctor if present.
• Mark the level of drainage in each column and   add to calculate the total drainage.
• If water from a wet suction control unit entered   the collection chamber, note the amount of   water that entered the chamber and subtract   from the total drainage. Refill the suction control   chamber to the desired level.

Change the chest drainage unit according to the set-up instructions printed on the front of each Pleur-evac.


Is the water level correct at 2 cm?

Is the negative pressure indicator (YES) visible?
Adjust the level, if needed, using a syringe and 18 gauge (or smaller) needle through the self-sealing diaphragm on the front of the water seal.

During gravity drainage, the indicator may intermittently indicate a negative pressure in the collection chamber with patient respiration.
The negative pressure indicator (YES) should remain visible continuously when the intrapleural pressure remains negative throughout the patient’s respiratory cycle. During suction
drainage, the pressure indicator should indicate a negative pressure continuously.

CAUTION: If the negative pressure indicator does not show the YES as described, 1) check patient connections for leaks, 2) check tubing connections on the unit. If all connections are
secure and the YES does not appear, replace the unit. The negative pressure indicator does not confirm drainage tube patency. Routinely check the drainage tube patency.
AIR LEAK METER Is there bubbling?

Is the bubbling continuous or
Identify the source of the air leak:
• Check and tighten connections.
• Test the tubing for leaks.*
• If leak is in the tubing, replace the unit.
• If the leak may be at the insertion site, remove   the chest tube dressing and inspect the site.   Make sure the catheter eyelets have not pulled   out beyond the chest wall. If you cannot see or
  hear any obvious leaks at the site, the leak is   from the lung. Replace the dressing.
• Check patient history. Would you expect a   patient air leak?

Note the pattern of the bubbling. If it fluctuates with respirations (i.e. occurs on exhalation in a patient breathing spontaneously), the most likely source is the lung.

Notify doctor of any new, increased, or unexpected air leaks that are not corrected by the above actions.

Document the magnitude of a patient air leak using the air leak meter. The higher the numbered column through which the bubbling occurs, the greater the degree of air leak. If bubbling is noted in first two columns of airleak meter, document ‘Airleak 2’.
* To test the system for the site of an air leak: Using a booted (or padded) clamp, begin at the dressing   and clamp the drainage tubing momentarily. Look at the water seal/air leak meter chamber. Keep   moving the clamp down the drainage tubing toward the chest drainage system placing it at 8-12 inch   (20-30 cm) intervals. Each time you clamp, check the water seal/air leak meter chamber. When you   place the clamp between the source of the air leak and the water seal/air leak meter chamber, the   bubbling will stop. If bubbling stops the first time you clamp, the air leak must be at the chest tube   insertion site or the lung.
  If there is no bubbling, does the fluid move up and down with respirations?

Has water risen in the small arm of the water seal/air leak meter?
In a patient with a pleural chest tube, tidaling is normal. Oscillations are more apparent when suction is momentarily turned off.

If there is no tidaling, consider 1) an occlusion somewhere between the pleural cavity and the water seal, 2) a full expansion of the lung where suction has drawn the lung up against the holes in the chest tubes, or 3) PEEP, which can dampen oscillation. Check tubing for occlusion as noted previously. Oscillations may also be dampened in one-way valve units.

In a patient with a mediastinal tube, there should be no bubbling or movement in the water seal/air leak meter. Lack of bubbling is normal.

Depress the high negativity relief valve until the water level reaches the desired level. CAUTION: If suction is not operative, or if operating on gravity drainage, depressing the high negativity relief valve can reduce negative pressure within the collection chamber to zero (atmosphere) with the resulting possibility of a pneumothorax.
WET SUCTION CONTROL Is there continuous bubbling?

Is the chamber underfilled or
Gentle continuous bubbling indicates suction is operative. Vigorous bubbling speeds the evaporation of fluid which results in a lower level of suction.

If no bubbling:
• Make sure the suction tubing is connected and   not occluded.
• Turn the source suction higher.
• If the patient has a large pleural air leak, the   amount of air flowing out is more than the   suction can handle. You are likely to see this   only in patients receiving mechanical ventilation,   and you will see vigorous bubbling in the water   seal chamber.

Momentarily discontinue suction to observe the fluid level in the suction control chamber.

If underfilled, add fluid through the atmospheric vent on top of the Pleur-evac.

If overfilled, withdraw fluid from the self-sealing diaphragm on the front of the suction chamber until desired level is achieved.

Resume suction.
DRY SUCTION CONTROL Is the dial set at the prescribed suction?

Is the orange float in the
indicator window?

Does the water rise in the small arm of the air leak meter when the dry suction setting is lowered?
Turn the dial to click into the correct suction setting. -20 cm H2O suction is most common for adults.

If not, check the suction tubing to make sure it’s not disconnected or occluded.

Turn up the source suction until the orange float appears.

This is normal. It simply reflects the previous higher setting. If the patient does not have an air leak, vent the excess negativity by depressing the high negativity relief valve.
GRAVITY DRAINAGE Is the suction tube/port open? If gravity drainage is prescribed, the short suction tube or port should remain UNCAPPED, UNCLAMPED, and free of OBSTRUCTIONS to allow air to exit and minimize possibility of tension pneumothorax.