Closed-Tube Thoracostomy

Nelia B. Perez RN MSN

Indications for CTT

• If fluid, such as blood, or air, gets into the pleural space, the lung can collapse, preventing adequate air exchange. Chest tubes are used to treat conditions that can cause the lung to collapse, such as:

• air leaks from the lung into the chest (pneumothorax)

• bleeding into the chest (hemothorax) • after surgery or trauma in the chest

(pneumothorax or hemothorax) • lung abscesses or pus in the chest

(empyema).

PREPARATION

• CXR

• UTZ

• CT SCAN

Types of Chest Tube Drainage

1. Three-chamber system: includes one chamber that serves to collect drainage, one that acts as water-seal, and one that has levels of water to control the amount of suction regardless of the amount of negative pressure applied.

2. Commercially prepared plastic unit designed for closed chest suction: combines the features of the other systems and may or may not be attached to suction (e.g., PleurEvac)

Chest Tube Insertion• Chest tubes are inserted to drain blood, fluid, or air and

allow full expansion of the lungs. The tube is placed in the pleural space.

• The area where the tube will be inserted is numbed (local anesthesia). The patient may also be sedated.

• The chest tube is inserted between the ribs into the chest and is connected to a bottle or canister that contains sterile water. Suction is attached to the system to encourage drainage. A stitch (suture) and adhesive tape is used to keep the tube in place.

• The chest tube usually remains in place until the X-rays show that all the blood, fluid, or air has drained from the chest and the lung has fully re-expanded. When the chest tube is no longer needed, it can be easily removed, usually without the need for medications to sedate or numb the patient. Medications may be used to prevent or treat infection (antibiotics).

PROCEDURAL OVERVIEW (537)• The chest wall is incised.• A long pean ( or any tube-pulling clamp)is inserted

into the intercostal space. The tapered end of the tube is placed into the jaws of the clamp, and the tube is pulled through the tissue layer.

• The tube is positioned, X-rays are taken are taken to confirm proper positioning and the tube is sutured to the skin; the incision is closed.

• The tube is connected to a sealed drainage unit.

NORMAL RESULTS

• Drainage of pus, blood or gas.

• Lungs reinflate

• Lungs begin to function more efficiently.

• Site at which the tube was inserted heals normally.

Nursing Care for pt with CTT:• Ensure that the tubing is not kinked; tape all

connections to prevent separation• Do not milk the tube• Maintain the drainage system below the level

of the chest; mark and monitor drainage• Turn the client frequently, making sure the

chest tubes are not compressed.• Observe for fluctuation of fluid in tube; the

level will rise on inhalation and fall on exhalation; if there are no fluctuations, either the lung has expanded fully or the chest tube is clogged

Nursing Care for pt with CTT:

• Place two clamps at your bedside for use if the underwater-seal bottle is broken; clamps are used judiciously and only in emergency situations

• Encourage coughing and deep breathing every 2 hours, splinting the area as needed

• After lung re-expansion is verified by chest x-ray, instruct the client to exhale or strain (Valsalva’s Maneuver) as the tube is withdrawn by the physician; apply a gauze dressing immediately and firmly secure the tape to make an airtight dressing

CHANGING CTT BOTTLES

• Identify the patient.• Prepare all materials needed on

patient’s bedside.• Wash hands and put on gloves• Provide privacy.• Explain to the patient the

procedures.• Instruct the patient to perform

controlled breathing.

• Secure two clamps on rubber tubing.• Change the CTT drain bottle. NSS

level should be 200 – 300 mL. • Secure the cover by using plaster.

Make sure that air is unable to penetrate the closed-system drain.

• Remove the clamps.• Instruct the patient to perform deep

breathing exercises. • Observe fluctuation of the NSS inside

the drain bottle.• Remove gloves.• Perform Handwashing.

Complications of CTT

• Complications of tube thoracostomy include death, injury to lung or mediastinum, hemorrhage (usually from intercostal artery injury), neurovascular bundle injury, infection, bronchopleural fistula, and subcutaneous or intraperitoneal tube placement

PROVIDING WOUND CARE

Nelia B. Perez

Northeastern College

Santiago City, Philippines

WOUND

• The skin is the body’s largest organ and is the primary defense of the body.

• A disruption in the integrity of the body tissue is a wound

• A wound occurs if the integrity of any tissue is compromised.

Types of Wound healing

• Tissue may heal through one or two methods which are characterized by degree of tissue loss.

1. Primary Intention Healing

2. Secondary Intention Healing

Primary Intention

• Primary intention healing occurs in wounds that have minimal tissue loss and edges that are well approximated (closed).

• If there are no complications, such as infection, necrosis, or abnormal scar formation, wound healing occurs with minimal granulation tissue and scarring.

Secondary Intention

• Secondary Intention Healing is seen on wounds with extensive tissue loss and wounds to which edges can not be approximated.

• The wound is left open and granulation tissue gradually fills in the deficit.

• Repair time is longer, tissue replacement and scarring are greater, and the susceptibility to infection is increased because of the lack of an epidermal barrier to microorganisms.

Factors that Affect Wound Healing• Age

• Nutrition

• Oxygenation

• Smoking

• Drug therapy

• Diabetes Mellitus

Closed Dressings

• Dressings that closed over the wound.

Open dressings

• No dressings that cover the wound

Three Layers of Dressings

• First Layer – covers the wound and collects blood, fibrin and debris.

• Second Layer – collects excess drainage.

• Third Layer – protects the wound from external contamination.

Purposes of Wound Dressings• To promote wound healing.

• To absorb blood and drainage from the wound.

• To prevent pathogens from entering the wound.

• To remove drainage, blood, debris and harmful microorganisms from the wound.

How to perform Wound dressing• Identify the patient and explain the

procedure before beginning. Gather the supplies.

• Provide privacy

• Cleanse hands

• Apply clean gloves

• Remove dressing and place in appropriate receptacles.

• Assess the undressed wound.• Cleanse the suture line with prescribed

solution.• Used Applicators should not be

reintroduced into the solution.• Remove gloves and cleanse hands.• Apply clean gloves• Grasping just the edges, apply a new

gauze dressing. Tape lightly.• Remove gloves and cleanse hands.

ANY QUESTIONS???