WATER-SEAL CHEST DRAINAGE a. General.

Underwater-seal chest drainage is a closed (airtight) system for drainage of air and fluid from the chest cavity. (1) The underwater-seal system is established by connecting a catheter (chest tube) that has been placed in the patient's pleural cavity to drainage tubing that leads to a sealed drainage bottle. (2) Air and fluid drain into the bottle, but water acts as a seal to keep the air from being drawn back into the pleural space. (3) By keeping the drainage bottle at floor level, fluid will be prevented from being siphoned back. (4) As air and fluid are drained, pressure on the lungs is relieved and re-expansion of the lung is facilitated. b. Selection of the System. The physician will specify the drainage setup he prefers to use. It is a nursing responsibility to be familiar with the various systems and their operation. (1) When the physician specifies his preference, the nursing personnel will obtain, assemble, and check the system, maintaining asepsis within the system. (2) Chest drainage can be organized into three types of systems. Each can be used with or without suction. Refer to Figure 2-2 as you read the descriptions that follow.

Figure 2-2. Water-seal drainage system

c. The Single-Bottle Water-Seal System. (1) Connecting or drainage tubing joins the patient's chest tube with a drainage tube (glass rod) that enters the drainage bottle. (2) The end of the glass rod is submerged in water, extending about 2.5 cm (1 inch) below the water level. (3) The water seal permits drainage of air and fluid from the pleural space but does not allow air to reenter the chest. (4) Drainage depends upon gravity, the mechanics of respiration, and, if ordered, the addition of controlled suction. (5) The second tube in the drainage bottle is a vent for the escape of any air drained from the lung. If suction is ordered, it is attached here. (6) Bubbling at the end of the drainage tube may or may not be visible. Bubbling may mean persistent air leaking from the lung or a leak in the system. (7) The water level in the bottle fluctuates as the patient breathes. It rises when the patient inhales and lowers when the patient exhales. (8) Since fluid drains into this bottle, be certain to mark the water level prior to opening the system to the patient. This will allow correct measurement of patient drainage.

d. The Two-Bottle Water-Seal System.

(1) The two-bottle system consists of the same water-seal bottle plus a fluid collection bottle. (2) Pleural fluid accumulates in the collection bottle, and not in the water-seal bottle (as in the single-bottle system). (3) Drainage depends upon gravity or the amount of suction added to the system. (4) When suction is added, it is connected at the vent tube in the water-seal bottle

e. The Three-Bottle Water-Seal System. (1) This system consists of the water-seal bottle, the fluid collection bottle, and a third bottle which controls the amount of suction applied. (2) The third bottle, called the manometer bottle, has three tubes. One short tube above the water level comes from the water-seal bottle. A second short tube leads to the suction. The third tube extends below the water level and opens to the atmosphere outside the bottle. It is this tube that regulates the suction, depending upon the depth the tube is submerged. It is normally submerged 20 cm (7.6 inches). (3) The suction pressure causes outside air to be sucked into the system through the tube, creating a constant pressure. Bubbling in the manometer bottle indicates the system is functioning properly. f. Commercial Systems. There are several disposable commercial drainage systems available. They are plastic devices, divided into chambers for fluid collection, water-seal, and suction control. Follow the manufacturer's instructions for commercial drainage systems used at your facility.

ADVENTITIOUS BREATH SOUNDS 1. Rales/Crackles -result of air passing through fluid in small airways and alveoli -sounds may be stimulated by rubbing a few strands of hair between fingers near the ears -associated with conditions like COPD and pulmonary edema 2. Wheezes/Sibilant Rhonchi -result of air passing through narrowed small airways -sounds are high pitched and musical -maybe heard on either inspiratory or expiratory -associated with asthma, partial obstruction of airway, tumor 3. Sonorous rhonchi -result of air passing through narrowed large airways -sounds are low-pitched snores -associated with conditions like sibilant rhonchi 4. Pleural friction rub -result of roughened pleural surfaces rubbing across each other -sounds are crackling and grating -associated with conditions causing inflammation of the pleura

PROCEDURES RELATED TO RESPIRATORY SYSTEM 1. Abdominal thrust (Heimlich maneuver) -short abrupt pressure against the abdomen to raise intrarespiratory pressure, which will lodge an obstruction such as bolus of food or a foreign body 2. O2 administration -serve as supplemental oxygen when clients respiratory system is compromised and tissue hypoxia is threatened 3. Arterial blood gases -measurement of arterial pH, partial pressure of oxygen and carbon dioxide, bicarbonate ion, and oxygen saturation 4. Bronchoscopy -visualization of tracheobronchial tree via a scope advanced through the mouth or nose into the bronchi -perform to remove foreign body, secretions or obtain specimen 5. Chest tubes -Use of tubes and suctions to return negative pressure to the intrapleural space -to drain air (chest tubes is placed at the 2nd and 3rd intercostals space) -to drain blood or fluid (catheter is placed at the lower site, usually the eighth or ninth intercostals space)

MAJOR DISORDERS
PULMONARY EMBOLISM AND INFRACTION -Post-op clients, as well as those confined to bed, are prone to venous stasis and causes peripheral thrombus formation -Pulmonary infarction result when an embolus lodges in the pulmonary artery causing hemorrhage and necrosis of lung tissue Clinical findings: severe dyspnea that occur suddenly Anxiety Restlessness Sharp upper abdominal and thoracic pain Violent coughing with hemoptysis On auscultation, dullness over area of infarct Increased temperature

Therapeutic Mgt: 1. Anticoagulant therapy 2. Maintenance of blood pressure 3. Angiography; if severe an embolectomy is done Nursing Mgt: 1. Place pt in a high fowlers position to aid respirations 2. Monitor Vital signs 3. Administer meds and O2 4. Maintain safe environment to decrease fear.

PULMONARY EDEMA -an acute emergency condition characterized by a rapid accumulation of fluid in the alveolar spaces resulting from increased pressure within the pulmonary system Causes: valvular disease, left ventricular failure, circulatory overload or congestive heart disease

Clinical findings: 1. History of premonitory symptoms such as shortness of breath, paroxysmal nocturnal dyspnea, wheezing and orthopnea 2. Acute anxiety, apprehension, restlessness 3. Rapid thready pulse 4. Pink frothy sputum 5. Elevated central venous pressure (CVP) 6. Decreased circulation time 7. Cyanosis 8. Wheezing; crackles 9. Stertorous respirations Therapeutic Interventions: 1. Aimed at decreasing cardiac workload and improving cardiac output (Morphine sulfate, digitalis, diuretics, bronchodilators) 2. O2 in high concentration 3. Phlebotomy-to remove approximately 500ml of blood or the application of rotating tourniquets to reduce the volume of circulating blood 4. Cardiac monitoring Nursing Care: 1. Support client to high fowlers or semi-fowlers position 2. Observe and record vital signs and monitor cardiac activity, intake, and output 3. Provide reassuring environment to allay anxiety 4. Suction as needed to maintain a patent airway 5. Apply rotating tourniquets when ordered

PLEURAL EFFUSION -collection of fluid in the plural space -generally occurs secondary to diseases (cancer of the lung, tuberculosis, CHF) Clinical findings: 1. Pleuritic pain that is sharp and increases on inspiration 2. Dyspnea 3. Malaise 4. Tachycardia 5. Elevated temperature 6. Cough (maybe productive or nonproductive depending on the cause) 7. Decrease breath sounds 8. Chest X-ray- shows obliteration of the angle between the ribs and diaphragm; may reveal mediastinal shift away from the fluid Therapeutic interventions: 1. Thoracentesis 2. Treatment of underlying cause Nursing Care: 1. Encourage deep breathing and coughing exercises 2. Increase fluid intake 3. Place the client in a higher fowlers position for maximum air exchange

PLEURISY -Inflammation of the visceral and parietal membranes, which rub together during respiration and cause pain -caused: chest trauma, tuberculosis, pneumonia, chest surgery Clinical symptoms: 1. Knifelike pain on inspiration 2. Apprehension 3. Dyspnea 4. Decreased excursion of involved chest wall 5. Pleural friction rub (found during auscultation of chest wall) Therapeutic interventions: 1. Treat the underlying condition 2. Analgesic for pain 3. Applications of heat or cold to thoracic area Nursing Care: 1. Instruct the client to lie on the affected side to splint the chest wall and lessen pain on inspiration 2. Administer medications as ordered 3. Allay anxiety by checking at frequent intervals 4. Observe for signs of shock or pulmonary emboli

EMPYEMA -Collection of pus within the thoracic cavity -may occur following staphylococcal pneumonia, tuberculosis, chest trauma, or surgery Clinical findings: 1. Unilateral chest pain 2. Malaise 3. Anorexia 4. Dyspnea 5. Chest x-ray examination-shows pleural exudates 6. Elevated temperature 7. Cough 8. Unequal chest expansion Therapeutic interventions: 1. Thoracentesis-to obtain a specimen of exudates to culture 2. Chest tubes inserted to drain thoracic cavity 3. Antibiotics-maybe instilled through the chest tube or given systematically

4. If condition is long-standing, the area of inflammation is surgically removed (Decortication) Nursing care: 1. Monitor chest tubes 2. Provide emotional support 3. Administer antibiotics as ordered 4. Monitor vital signs, particularly temperature and character of respirations

PNEUMONIA - Inflammatory disease usually caused by an infection agent (bacterial, viral, protozoan, or fungal) but may also be caused by inhalation of chemicals and aspiration of gastric contents -commonly spread by respiratory droplets -bacterial pneumonias include : Klebsiella pneumoniae, Haemophilus Pseudomonas, Proteus, Straptococcus species and staphylococcus aureus -ASPIRATION PNEUMONIA-occurs when gastric contents and the normal flora of the upper respiratory tract are aspirated into the lungs -PNEUMOCYSTIS CARINII pneumonia-a rare protozoan infection, seen in clients with impaired immune infection (AIDS) Clinical findings: 1. Lassitude 2. Chest pain that increases on inspiration 3. Dyspnea 4. Elevated temperature 5. Cough 6. Chest x-ray-reveals pulmonary infiltration 7. Sputum production: -Pneumococcal: purulent, rusty sputum -Staphylococcal: yellow, blood-streaked sputum -klebsiella: red gelatinous sputum -Mycoplasmal: nonproductive that advances to mucoid Therapeutic interventions: 1. for bacterial pneumonia: culture and sensitivity test is done 2. Adm. O2 via nasal cannula 3. Inhalation therapy and use of incentive spirometer

Nursing intervention: 1. Encourage coughing and deep breathing, splinting chest if necessary 2. Collect sputum specimen for culture and sensitivity test 3. Increase fluid intake 4. Monitor vital signs 5. Observe for signs of respiratory distress, such as labored breathing, cool clammy skin and cyanosis 6. Plan rest periods 7. Instruct client to cover nose and mouth when coughing 8. Adm. Antibiotics as ordered

ATELECTASIS -occurs since bronchioles are obstructed by secretions and alveoli distal to the bronchioles collapse -caused: compression-resulting from large pleural effusion Empyema or pneumothorax Obstruction of a bronchus by a tumor Deficiency of surfactant in an infant -clinical findings: 1. Restlessness 2. Anxiety 3. Rapid shallow respirations 4. Diminished breath sounds in lower lobes 5. Reproductive cough 6. Temperature elevation Therapeutic interventions: 1. O2 therapy 2. Prophylactic antibiotics Nursing interventions: 1. Encourage deep breathing and coughing 2. Monitor respirations closely 3. Place in a high fowlers position; turn every 2 hours

PULMONARY Tuberculosis -Infection of lings caused by Mycobacterium tuberculosis, an acid-fast bacterium -causes tubercles, fibrosis and calcification within the lungs -Tubercle bacilli maybe communicated by others by means of droplet formation, ingestion or inoculation Predisposing factors: Alcoholism, cardiovascular diseases, HIV infection, diabetes mellitus and cirrhosis as well as poor nutrition and crowded living condition Clinical Findings: Malaise, pleuritic pain, easily fatigued, fever, night sweats, cough that progressively become worse, hemoptysis weight loss, chest x-ray-(done to determine presence of active or calcified lesions),Analysis of sputum and gastric contents for the presence of acid-fast bacilli TUBERCULIN TESTING -Tine test, Heaf test, Mantoux test- (frequently involves the use of purified protein derivative (PPD) -determines antibody response to tubercle bacillus -indicates prior exposure to bacillus, which may or may not indicate active disease state (a sudden change from negative to positive requires follow up testing) -Injected intradermally, redness and edema is present 48-72 hours later indicate a positive finding Therapeutic interventions: 1. Program of combined antituberculin drugs such as ISONIAZID, STREPTOMYCIN, PYRAZINAMIDE, RIFAMPICIN AND ETHAMBUTOL HYDROCHLORIDE FOR 9-24 MONTHS 2. Bed rest until symptoms abate or therapeutic regimen is established

3. Determine whether surgical resection of the lobe is necessary if symptoms such as hemorrhage developed or chemotherapy to immediate contacts (all cases and follow-up of contacts must be reported to public health agency) 4. Have the client begin a high-carbohydrate, high-protein, high vitamin diet with supplemental vitamin B6 Nursing care: 1. Teach client to provide for scheduled rest periods are nutritious betweenmeal supplements. 2. Teach the importance of adhering to the drug program regimen/compliance to treatments 3. Teach proper techniques to prevent spread of infections 4. Instruct client to avoid any medications such as cough syrups without physicians approval. 5. Help plan client realistic schedule for taking the large number of necessary medications.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) -group of diseases that result in obstruction of airflow Causes: air pollution, smoking, chronic respiratory infections, exposure to molds and fungi, and reactions Types: 1. ASTHMA-obstruction of the bronchioles characterized by attacks that occurs suddenly and last from 30-60 minutes STATUS ASTHMATICUS- asthmatic attack that is difficult to control 2. BRONCHITIS- inflammation of the bronchial walls with hypertrophy of the mucous goblets cells cha. by a chronic cough 3. EMPHYSEMA- characterized by distended, inelastic, or destroyed alveolar with bronchiolar obstruction and collapse; these alterations greatly impair the diffusion of gases through the alveolocapillary membrane -Clients with COPD become accustomed to an elevated carbon dioxide level and do not respond to high CO2 concentrations, they respond instead to a drop in oxygen concentration in the blood Clinical findings: Fatigue and weakness, headache, impaired sensorium, dyspnea, orthopnea, expiratory wheezing, stertorous breathing sounds, cough, Barrel chest,cyanosis,clubbing of the fingers,distention of neck veins, edema of extremities,increased PCO2 and decreased PO2 of arterial blood gases,polycythemia

Therapeutic interventions: 1. Adm. Antibiotics and cortisone to prevent and reduce inflammation 2. Bronchodilators to reduce muscular spasm 3. Mucolytics and expectorants to liquefy secretions and to facilitate their removal 4. O2 at 2-3L even if hypoxia is severe 5. Respiratory therapy program to include nebulizer therapy, postural drainage and exercise 6. High protein, soft diet Nursing interventions: 1. Advise the elimination of smoking and other external irritants (dust) 2. Supervise the clients respiratory exercises such as pursed lip or diaphragmatic breathing 3. Carefully observe the symptoms of carbon dioxide intoxication (CO2 narcosis) if oxygen is being administered 4. Teach client to adjust activities to avoid overexertion 5. Teach client to avoid people with respiratory infections 7. Teach client to maintain the highest resistance possible by getting proper rest, eating proper food, dressing properly for weather conditions 8. Encourage to take meds as prescribe 9. Monitor clients compliance with therapeutic regimen