Chest Tube Care

Equipment:

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• Stethoscope
• Tape
• Sharpie marking pen
• Paper and pen for recording drainage amount

Steps:

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1. WIIAPA:

1. 1. Wash hands
   2. Introduce self
   3. Identify patient (use 2 identifiers)
   4. Allergies – don’t forget food allergies
   5. Plan of care
   6. Assess patient

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2. With new chest tube monitor patients’ vital signs, oxygen saturation, breath sounds, and insertion site every 15 minutes for first 2 hours, and then every shift.
3. Ensure an occlusive dressing is at bedside such as (sterile 4X4 gauze or petroleum gauze)
4. Monitor chest tube drainage
5. Observe type and amount of fluid drainage
6. Note color and amount of drainage, patient’s vital signs, and skin color
7. Evaluate patient for increased respiratory distress and chest pain, breath sounds over affected lung area, and change in oxygen saturation
8. patients pain level on a scale of 0 to 10.
9. Observe the drainage system
10. chest tube dressing and drainage, if dressing is wet, change with dry dressing
11. tubing for kinks and dependent loops
12. sure chest drainage system remains upright and below level of tube insertion- Note presence of clots or debris in tubing
13. water seal for fluctuations with patient’s inspiration and expirations
14. suction water-seal system: Diagnostic indicator for fluctuations with patient’s inspirations and expirations
15. Dry suction water-seal system: Intermittent bubbling in the water-seal chamber, gentle
16. After first 2 hours, assess patient’s physical and psychological status at least every 4 hours or according to agency policy
17. Document