Nursing Care Related to the Cardiovascular and Respiratory Systems


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a. When using suction with water-seal drainage, the system should be open to the atmosphere when the suction is turned off for any reason. This will allow intrapleural air to escape from the system. To do this, simply detach the tubing from the suction port to create an air vent.


b. Observe the water-seal chest drainage system for patency to ensure that it is functioning properly.

(1) Fluid in glass rod (or water seal chamber of commercial devices) should rise and fall with respirations.


(2) Fluctuation should continue until the lung has re-expanded.

c. Observe amount, color, and consistency of chest drainage at ordered time intervals and record results in patient's clinical record.

(1) Notify charge nurse immediately if chest drainage exceeds 100 cc/hour.


(2) Notify charge nurse immediately if chest drainage color changes to indicate an active bleeding problem.


(3) Mark the level of drainage on a piece of adhesive tape affixed to the drainage system every shift, or as ordered; include date, time, and your initials.


(4) Do not empty the drainage system unless directed to do so by the physician.

d. Observe drainage tubing for any kinking.

(1) Do not allow drainage tubing to loop below drainage system entry level.


(2) Fasten the tubing to the draw sheet with rubber bands and safety pins so the flow by gravity will occur.

e. Milk the chest tube, as ordered by the physician, in the direction of chest drainage to promote chest tube patency.

(1) Lubricate the drainage tubing with lubricant (water-soluble) for approximately 12 inches.


(2) Pinch the tubing above the lubrication with one hand; with the other hand compress the tubing, allowing the fingers to slide over the lubrication toward the drainage bottle and release both hands.

f. Observe the patient carefully for any signs of respiratory difficulty, cyanosis, chest pressure, crepitus, and/or hemorrhage.

(1) Monitor vital signs every 4 hours, or as ordered, and record.


(2) Auscultate patient's lung sounds every 4 hours and record findings.

g. Check to see that the drainage bottle is secured to the floor or is in a special holder.

(1) Prevent bottle from being kicked or tipped over.


(2) Caution visitors against handling equipment.

h. Observe the dressing at the chest tube insertion site for air leakage or excessive drainage and record findings.

(1) Dressing changes are performed only according to physician's orders.


(2) Observe skin condition during dressing changes and record.

i. Encourage the patient to cough and deep breath at least every 2 hours or as ordered.

(1) Patient should be assisted to a sitting position if possible to promote effective deep breathing and coughing.


(2) A pillow or blanket should be used to splint the affected area.

j. Encourage the patient to change position every 2 hours to promote drainage and prevent complications; make sure tubing remains free from kinks and is in proper position.


k. Encourage the patient to perform range of motion exercises for the affected upper extremity to maintain joint mobility.


l. Transport or ambulate a patient with a chest tube carefully, keeping the water-seal unit below chest level and upright at all times.


(1) Assist or instruct personnel from other departments in transporting or ambulating the patient.


(2) Nursing staff should accompany the patient.


(3) Disconnect the closed chest drainage system from suction for transportation or ambulation; make sure air vent rod is open.


(4) Attach hemostats (Kelly Clamps) to the patient's hospital gown during transportation or ambulation for emergency use.

m. As indicated, provide emergency care to the patient if the water- seal unit becomes broken or emptied.

(1) Clamp the chest tube unless there has been a large air leak; chest tube with a large air leak should be left open, since clamping may cause a rapid pneumothorax.


(2) Reestablish a closed drainage system.


(3) Remove clamps, if applied.


(4) Notify the professional nurse/physician, as indicated.


(5) Observe the patient for respiratory distress.

n. As indicated, provide emergency care to the patient if the chest tube becomes disconnected from the drainage system.

(1) Clamp the chest tube.


(2) Cleanse the end of the tubing with an antiseptic solution and reconnect or cut off the contaminated tips of the chest tube and tubing and insert a sterile connecting piece.


(3) Securely tape the connection.


(4) Notify the professional nurse/physician, as indicated.


(5) Observe the patient for respiratory distress.

o. As indicated, provide emergency care to the patient if the water- seal unit is tipped over.

(1) Return unit to upright position.


(2) Instruct the patient to deep breathe and cough to force air out of the pleural space.


(3) Notify the professional nurse.


(4) Assess the patient for respiratory distress.

p. As indicated; provide emergency care to the patient whose chest tube has accidentally been pulled out of the chest wall.

(1) Cover the site with sterile 4"x4" gauze sponges and tape occlusively.


(2) Notify the professional nurse/physician immediately.


(3) Monitor the patient for respiratory distress.

q. Record significant nursing observations in the patient's clinical record and report the same to the professional nurse.

(1) Amount, color, and consistency of chest drainage.


(2) Presence or absence of air leaks or bubbling in the water-seal unit.


(3) Presence or absence of fluctuation in the glass rod of the water-seal unit.


(4) Time and results of chest tube milking. Specific observations about the patient, such as vital signs, breathe sounds, and skin color.


(5) Results of deep breathing and coughing.


(6) Position changes or activity, including range of motion.


(7) Condition of chest tube insertion site and dressing.

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