Page 134 - Critical Care Notes

4223_Tab03_107-130 29/08/14 8:28 AM Page 128

RESP
■ Heimlich valves (one-way flutter valves) are used in the outpatient and ED
setting or by emergency medical providers in the field.
Management
■ Perform CXR immediately after insertion and every day thereafter.
■ Apply sterile occlusive gauze dressing to the chest tube site. Change
dressing as per institutional policy.
■ Attach chest tube to water seal drainage; use wall suction or gravity as
indicated.
■ Suction control chamber should be set to 20 cm H 2 O level. Fluid level
regulates amount of suction → low → add sterile water to chamber.
Bubbling should be constant but gentle → “slow boil.”
■ Wall suction is contraindicated after pneumonectomy.
■ Monitor vital signs every 15 min until stable, then every 4 hr.
■ Monitor color, amount, and consistency of drainage every 2 hr. Notify
physician if drainage >100–200 mL/hr or if sudden change in drainage
characteristics. Progress to every 8 hr.
■ Administer O 2 via nasal cannula or mask; monitor oxygenation levels.
■ Medicate for pain as needed.
■ Reposition patient every 2 hr.
■ Make sure all connections are tight.
■ Avoid dependent loops, kinks, or pressure in tubing.
■ Keep drainage system below the level of the chest.
■ Palpate for subcutaneous emphysema or crepitus around insertion site and
chest wall. Assess for air leak around insertion site and within chest
drainage system.
■ Signs of air leak may include bubbles in water seal chamber during inspiration,
coughing, and large area of subcutaneous emphysema. Locate source of air
leak by gently clamping chest tube near insertion site. If bubbling stops → leak
is at the insertion site or inside the patient. If bubbling persists → leak in the
system → replace chest tube, retape connections or replace drainage system.
■ Auscultate breath sounds; assess respirations.
■ Observe color and consistency of drainage; mark fluid level of drainage.
■ Check water seal level; add sterile water if needed.
■ Avoid clamping the chest tube; can lead to tension pneumothorax.
■ Never clamp the chest tube to transport the patient.
■ Change drainage system if significant air leak in the system or if drainage
chambers full. Double clamp chest tube close to the insertion site with two
clamps facing in opposite directions. Never leave chest tube clamped for
more than 1 min.
Complications:
■ Rapid and shallow breathing
■ Cyanosis
■ Hemorrhage
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