6.7: Assisting With Chest Tube Placement
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Nurses may assist a provider with inserting a chest tube. Table 6.7 describes how to apply the nursing process before and after the chest tube is placed.
Table 6.7 Using the Nursing Process When Assisting With Chest Tube Placement
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Nursing Process Phase
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Nursing Actions
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Assessment
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Obtain and analyze the client’s vital signs and pulse oximetry.
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Complete and document a focused respiratory assessment.
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Verify client allergies, particularly allergies to latex or any substance applied to the skin.
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Review client medications, noting the use of NSAIDs or prescribed anticoagulants, such as aspirin, ibuprofen, or warfarin, that increase the risk for bleeding.
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Review any client lab results such as hemoglobin, hematocrit, and INR (if the client is taking warfarin).
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Assess the client’s knowledge and understanding of the procedure.
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Assess the client’s need for analgesia and antianxiety medication.
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Diagnosis
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Determine nursing diagnoses based on the client’s condition/needs at this time, such as impaired gas exchange, ineffective breathing pattern, acute pain, or anxiety.
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Outcomes Identification/
Planning
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There are several expected outcomes after the insertion of a chest tube, such as the following:
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Stable vital signs
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Optimal oxygenation status indicated by oxygen saturation level
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No chest pain
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Baseline levels of alertness and orientation
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Reduced level of anxiety, if present
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Breath sounds present in all lung lobes with symmetric lung expansion
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Unlabored respirations
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Chest tube correctly placed
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Chest tube drainage system functioning appropriately
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Interventions Post-Procedure
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The tube will be connected to the chest drainage system and may be connected to suction based on provider orders.
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In the trauma setting, notify the provider if initial output is over 1500 mL or there is 200 mL/hour because this may indicate vascular injury that may require surgical repair.
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Assess the client’s respiratory status post-procedure, including lung sounds, chest expansion, and reported dyspnea.
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Monitor vital signs, including oxygen saturation level.
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Assess the client’s comfort level and compare to baseline. Administer pain medications as indicated.
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Confirm accurate placement of the chest tube has been verified by a chest X-ray.
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Inspect the dressing over the chest tube insertion site to ensure it is intact. (The tube is secured to the chest wall according to institutional preference with sutures, tape, or manufactured appliance.
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Evaluation
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Evaluate client response with anticipated decreased dyspnea and decreased pain.
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Evaluate the client’s ability to cough and deep breathe to promote lung expansion.
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Evaluate for proper functioning and maintenance of the chest tube drainage system.
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Evaluate for evidence of lung re-expansion.
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