NURS4322 Nursing in Complex Situations Fall 2019 Chest Tubes & Chest Physiotherapy

Chest tubes and performing chest physiotherapy are patient interventions that can be seen on every
hospital unit and in community health provider agencies. While chest tube insertion is a medical function,
it is the nurses’ responsibility to understand respiratory function, perform chest tube maintenance and
assessments, and provide chest physiotherapy as a nursing intervention.

Objectives:
After completion of this lab, students will be able to:
· Describe the anatomy associated with chest tubes.
· Describe the clinical indications for chest tube insertion.
· Identify different types of chest tube drainage systems.
· Identify materials required for the insertion and maintenance of chest tubes.
· Demonstrate nursing interventions in caring for a chest tube.
· Describe nursing responsibilities related to care of a client with a chest tube.
· Describe indications for chest physiotherapy.
· Demonstrate effective chest physiotherapy technique.

Complete appropriate documentation related to chest tube maintenance/assessment and performing chest
physiotherapy.

Lab Preparation

Required Readings (Chest Tubes):

Kozier, B., Erb, G., Berman, A., Snyder, S.J., Buck, M., Yiu, L., Stamler, L.L. (2014). Fundamentals of
Canadian Nursing: Concepts, process, and practice (3rd Canadian ed., pp. 634-648 (Omit Skill 28.10),
1398-1400). Upper Saddle River, NJ: Pearson Education Inc.
Paul, P., Day, R.A., Williams, B. (2016). Textbook of medical-surgical nursing (3rd Canadian ed. pp. 621-
627, 700-705). Philadelphia, PA: Lippincott, Williams, & Wilkins.
Required Readings (Chest Physiotherapy):
Paul, P., Day, R.A., Williams, B. (2016). Textbook of medical-surgical nursing (3rd Canadian ed. pp. 675-
678). Philadelphia, PA: Lippincott, Williams, & Wilkins.

Videos:
Chest Tubes Explained https://www.youtube.com/watch?v=JB-CqwMyrTM (16 mins)
Chest Physio-Percussion https://www.youtube.com/watch?v=1ZRk55sHJ1I (5 mins)
Chest Physio-Manual Vibration https://www.youtube.com/watch?v=mHfgP7z5qQk (2 mins)
Chest Physio- Vibration https://www.youtube.com/watch?v=WwovCnSkO34 (1 min)

Case Study Questions (Chest Tubes)

Janet, age 52 has not been feeling well for the past two days and is now at the emergency room
accompanied by her daughter. Diagnostic tests have detected a large lung mass and a hemothorax in the
left lower lobe. The physician has ordered the insertion of a chest tube at - 20cm of suction, IV infusion of
0.9% NaCl at 75ml/hr, and oxygen therapy (nasal cannula) at 2 litres.
1. What are some signs and symptoms of a hemothorax that the nurse may expect Janet to be
exhibiting and why?
· Chest pain
· Cold, pale, or clammy skin
· Rapid heart rate
· Low blood pressure
· Tense, paid, or shallow breathing
· Difficulty breathing
· Feelings of restlessness
· Anxiety

2. What is the nurses’ role in chest tube insertion? What is the nurses’ role in chest tube
removal?
Insertion:
 Administer analgesic
 Assemble chest drainage unit
 Position the client
 After insertion connect the chest tube to drainage unit
 Secure all connections
 Apply a sterile occlusive dressing over insertion site
 Assess as per policy standards
Chest tube removal
 Administer analgesic
 Perform hand hygiene and don PPE
 Position the client
 Once the chest tube has been removed, apply an air occlusive dressing and leave
in place for a minimum of 24 hrs.
 Auscultate lungs and heart and assess vital signs
 Document

3. What are the priority assessments and nursing responsibilities related to chest tube care for
Janet post chest tube insertion?
-assess patient (vital signs, lungs, heart)
-assess the chest tube drainage system for patency
-promote lung expansion ((deep breathing and coughing exercises, position changes, and
ambulation as required)

4. What qualities of drainage is the nurse assessing in the chamber of the chest tube canister?
How is this recorded?
 -color, consistency, volume, rate

5. What are the two things that the nurse is assessing in the water seal area of the chest tube
canister?
-That the water seal moves up and down with respirations

6. How does the nurse know that there is enough suction applied to the canister? How would
the nurse trouble-shoot if there is no suction found?
-Gentle bubbling in the suction control chamber

7. What is subcutaneous emphysema? Is it harmful for a patient?

-Subcutaneous emphysema is air trapped beneath the skin. Yes because it increases the risk for a
tension pneumothorax or surgical emphysema.

Janet is awaiting room confirmation on the internal medicine unit and has been in the ER for 7 hours post
chest tube insertion. The chest tube canister has 800mls of serosanguinous drainage in it, has continuous
bubbling noted in the water seal chamber, and no tidaling noted.

8. Should the nurse be concerned with 800mls of serosanguinous drainage over 4 hours? Why
or why not?
-the nurse should not be concerned as the chest tube was just inserted and its draining fluid that
was collected in the area
-serosanguinous drainage is a normal finding

9. Should the nurse be concerned with the continuous bubbling? Why or why not? What
possible steps could be taken to assess the continuous bubbling?
· Yes, because this could indicate an air leak – negative pressure could be lost, and the
lungs could not expand effectively
· Clamp off suction for one minute – if there is constant bubbling in the water seal
chamber then a leak is present
· Assess all tubing and connections

10. Should the nurse be concerned that no tidaling is noted in the chest tube canister? Why or
why not? What steps could the nurse take to assess the absence of tidaling?
· Yes/no, the water level should fluctuate in the water seal chamber – rising during
inhalation and decreases during exhalation

Janet now has her room number on the internal medicine unit and will be transferred there shortly. The
nurse has decided to change the chest tube canister prior to transfer.
 11. Identify the steps needed to safely change the chest tube canister.
Case Study Questions (Chest Physiotherapy)
Case Study #1

Andrew, age 12 has cystic fibrosis and is being discharged from the pediatric unit following treatment for
a lung infection. The nurse is preparing to teach his parents how to do daily chest physio to help keep
Andrew healthy.

1. Why would daily chest physio be prescribed for Andrew?

-Due to his diagnosis of cystic fibrosis and to aid in the removal of thick secretions

Case Study#2
Manny, age 84, has had a complicated and lengthy hospital stay following a lung resection. He is unable
to ambulate due to deconditioning and is having trouble repositioning himself in bed. His O2 saturations
continue to decrease despite continuous oxygen therapy, spirometer use, and deep breathing and
coughing. A chest x-ray has confirmed the presence of a mucus plug. There are orders for TID chest
physio.

1. The nurse is unable to locate the chest physio machine and must do manual chest physio.
Will this still be effective?
-Yes as long as properly executed

2. What would be the optimal positioning for this patient to receive chest physio? What would
be an appropriate length of time for performing chest physio?

3. What are the nursing responsibilities when performing Chest physiotherapy?

-assessment
-percussion
-vibration
-postural drainage
-deep breathing and coughing
-position changes
-documentation
4. What are some patient signs and symptoms that would indicate to the nurse that the chest
physio treatment session should be stopped?
-Client is having trouble breathing
-Client is having pain