Jhaella Marie Pague

BSN 4A
Water Sealed Drainage System

Chest Tube Drainage System

Purposes
* To remove air or fluids from the pleural space.
* To re-establish negative pressure and reexpand
the lungs
- MEDIASTINAL SHIFTING- increased pressure
Affect mediastinal structures such as the trachea,
heart and causes movement of these to the
unaffected area; causes deviated trachea
- Negative pressure allows O2 to be inhaled and
CO2 exhaled

To drain within pleural space the air- catheter is

inserted at the second intercostal space
To drain a pleural cavity with blood and fluids-
safest insertion at the fourth and fifth intercostal * Three Way Bottle System
- First bottle for drainage
Ex. Pleur Evac - Second water seal bottle; 2-3 cm water
- Third is suction control; suction is lesser
Bottle system- most common in ward pressure to prevent trauma
* One way bottle system- acts as the drainage - The same process with Pleur- evac
system and air is evacuated
- 2 cm water is immersed to prevent air from
going back to the pleural space
- Air removed out thru a vent
- Water acts as the seal
- Principle of gravity; bottle should be below chest

* Two way bottle system

- first bottle acts as the water seal and drainage
bottle ; 2-3 cm water immersed
- Mark the height of drainage bottle upon receiving
the client to monitor output of drainage system;
baseline data
- second bottle acts as suction control
- Attached to suction machine; 20 mmhg pressure - with fluid collection chambers
(high suction pressure affects the integrity of - Water sealed chamber with regulated 2 cm water
lungs) for immersion
- With air leak monitor with is calibrated from 1-5
; air that is evacuated from the pleural space
*air from pleural should be evacuated in 5 days; if
goes beyond 5 days it means that the infection or
problem still exists; if there is air leak secondary
to pneumothorax it means client is evacuating air
• Water-seal Chamber with Air Leak Monitor.
observe for tidaling or fluctuation sleady rise and
fall with breathing)
• Reduced or stopped as the lung re-expands OR
there is blockage (presence of clots) within the
tube or a kink
• Continuous bubbling - AIR LEAK there should be
NO continuous bubbling)
Jhaella Marie Pague
BSN 4A
- suction control chamber takes control of the internally such as pneumothorax or externally if at
amount of pressure needed for air or fluids to be the tubings)
suctioned; water at suction chamber should be at
20 cm for appropriate removal of air and fluids - To identify location, clamp tubing close to the
(called WET SUCTION CONTROL) client's chest, if bubbling continues it must be the
• Suction Control Chamber. leak is at the tubing and move forward to identify
gentle, sleady or continuous bubbling (NOT exact location; or when bubbling is stopped
vigorous bubbling which means directly when clamped expect for leak at insertion
pressure is too high) site or inside; dont clamp unnecessarily; clamping
- DRY SUCTION CONTROL utilizes manual control can place the client in tension pneumothorax
of pressure; 20 mmhg default pressure
- put on petroleum gauze to seal insertion site; if
leak still persist, it must be from the air of the
pleural because of unresolved pneumothorax or
pleural injury or inappropriate communication
between bronchial and pleural space; palpate for
SUBCUTANEOUS EMPHYSEMA - feel crackling
and inform physician

- At water seal chamber observe for OSCILLATION

or tidalling or fluctuations which is the steady rise
and fall within the water seal chamber which is
often influenced by breathing; during inhalation
the water rises up and in exhalation falls down
(implies proper communication between plueral
space and system; patent tubings)
- When oscillation stops, it may imply that the
lungs have expanded already or there is a
BLOCKAGE within the tube or KINK or presence of
dependent LOOPS that makes fluid will collect at
the loop and cause cessation of tidalling or
oscillation

- Continuous bubbling often caused by EXTERNAL

air leak or leak within the drainage tube

* Suction Control Chamber: gentle, steady or - Intermittent air leak it may be from pleural space
continuous bubbling (not vigorous bubbling which and caused by coughing of client
means the pressure is too high)
* Water Seal Chamber with Air Leak Monitor: • Maintain a closed chest drainage system
observe for tidaling or fluctuation (steady rise and - be sure to tape all connections, and secure
fall with breathing)- reduced or stopped as the the tube carefully at the insertion site
lung re-expands OR if there is blockage within the with adhesive bandages.
tube OR a kink; continuous bubbling means an air - Regulate suction according to the chest
leak (thus no continuous bubbling in the air leak tube system directions; generally, suction
chamber) does not exceed 20 to 25 cm H20 negative
pressure.

- external air leak may indicate holes of the tube of Nursing Management
the drainage system Collection chamber:
- when bubbling goes to 5 at the air leak monitor; * Assess every hour for the first 8 hours after
we should check for air leaks of the system as insertion and every 8 hours thereafter
needed; determine location of leak (can be * Bright red blood over 100 ml/hr (after first hour
of placement - active hemorrhage -report
Jhaella Marie Pague
BSN 4A
* Stopped drainage or decreased: Assess * Range of Motion exercises
respiratory status frequently; * The following should be documented and
* Auscultate lung sound; check for diminished assessed according to agency policy:
breath sounds Breath sounds
* Turn, cough, deep breath Patient comfort level or pain level
* Reposition Appearance of insertion site andlor dressing
~in the presence of clots, NEVER MILK OR STRIP Presence of air leaks
TUBE; may cause increased tension within Fluctuation in water seal chamber
pneumothorax Amount of drainage and type
Presence of subcutaneous emphysema
* Keep the system below the chest level eure-Vac
* Make sure all connections are secured. Tension Pneumothorax-
* Ensure that the suction control chamber is set to Through this valvular mechanism, air will
the 20 cm or 20 mmhg or as prescribed accumulate in the pleural cavity with increased
* Ensure that the water is filled with sterile water positive pressure.
to the level specified (usually 2 cm) and tidaling is - lung collapse on the affected side with shift of
observed. mediastinum to the other side
* Assess for constant or intermittent bubbling in - leads to the kinking of the caval veins resulting in
the water-seal chamber. impairment of venous return and low cardiac
* Assess the amount, color, consistency of output.
drainage. - Compression to the other lung leads to
* Mark the drainage level every 8 hours or more significant hypoxia.
frequently if indicated. - Severe mediastinal shifting
* Assess for any kinks or dependent loops.
* Encourage deep breathing, coughing exercises, * Stabilize the chest tube so that it does not drag
incentive spirometer use. or pull against the patient or against the drainage
* Assist with repositioning and ambulation. system.
* Assess vital signs. * Disconnection from patient:
* Assess breath sounds. * Cough and exhale as (to prevent air from being
* Ensure the chest drainage unit is below the level sucked into the lungs); valsalva maneuver to
of the insertion site, upright, and secured to prevent air from being ducked to lungs to avoid
prevent it from being accidentally knocked over. tension pneumothorax
* Assess chest tube insertion site to ensure sterile - Apply occlusive (petroleum gauze) dressing
dressing is dry and intact and that the chest tube secured on 3 sides; to allow air to go out during
is secured to reduce risk of it being pulled out. exhalation
* Check the insertion site for subcutaneous
emphysema.
* Assess insertion site for drainage and
subcutaneous emphysema
* Range-of-motion exercises of arms; prevent
ankylosis or frozen shoulder; analgesics is
commonly prescribed
* Monitor a chest tube unit for any kinks or
bubbling, which could indicate an air leak, but do
not clamp a chest tube without a physician's order
because clamping may lead to tension
pneumothorax.
* Reflect date and time, and the oxygenation by
amount of drainage, and mark on the outside of
the chamber at the end of each shift and prn Disconnection from the collection chamber:
● Promote oxygenation by encouraging - Drainage tube:
frequent position changes, - if without contamination, use an antiseptic swab
deep-breathing, and coughing exercises. and reconnect
*Record amount and characteristics of the - If damage to the water-seal: place the distal end
drainage on the fluid into 250 sterile saline
Jhaella Marie Pague
BSN 4A
DO NOT CLAMP CHEST TUBE - CAN LEAD TO - Tremors usually resolve with continued
TENSION PNEUMOTHORAX medication use.
- Exemptions: when replacing the system, an air
leak, assessing tolerance of chest tube removal, * When a client is prescribed an inhaled
and during chest tube removal beta2-agonist and an inhaled glucocorticoid,
advise the client to inhale the BETA AGONIST
Patient Transport before inhaling the GLUCOCORTICOID. (dilate first
- If the patient needs to be transferred to another to enhance absorption) The beta2-agonist
department or is ambulant, the suction should be promotes bronchodilation and enhances
disconnected and left open to air. absorption of the glucocorticoid
- DO NOT CLAMP THE TUBE
- Clamps must not be used on the patient for METHYLXANTHINES
transport because of the risk of tension - theophylline (Theolair, Theo-24)
pneumothorax - Theophylline causes relaxation of bronchial
- Ensure the chamber is below the patients chest smooth muscle, resulting in bronchodilation
level during transport
Nursing Considerations
- Advise clients to avoid consuming caffeinated
beverages (coffee, caffeinated colas); Cause
CHEST TUBE REMOVAL tachycardia
* TAKE A DEEP BREATH, HOLD IT AND BEAR - Phenobarbital and phenytoin (antiseizures)
DOWN (VALSALVA MANEUVER) - to prevent air to decrease theophylline levels.
get into pleural space - Cimetidine (Tagamet), ciprofloxacin (Cipro), and
* TAKE CHEST X-RAY other fluoroquinolone antibiotics increase
theophylline levels; cause theophylline toxicity
Management for COPD - Advise clients to take the medication
BRONCHODILATORS asprescribed. If a dose is missed, the following
* Beta2 Adrenergic Agonists dose should not be doubled.
ALBUTEROL (Proventil, Ventolin) - short acting
Formoterol (Foradil Aerolizer) - long acting INHALED ANTICHOLINERGICS
Salmeterol (Serevent) - long acting Ipratropium (Atrovent)
TERBUTALINE (Brethine) - long acting tiotropium (Spiriva)
- stimulate beta receptors in the lung causing - These medications block muscarinic receptors of
relaxation of bronchial smooth muscle, increased the bronchi, resulting in bronchodilation.
vital capacity and decreased airway resistance.
Nursing Considerations
Side Effects and Contraindications - Advise clients to rinse the mouth after inhalation
* Tachycardia, angina, tremors to decrease unpleasant taste; meter dose inhaler
* Pregnancy Risk - Usual adult dosage is 2 puffs. Instruct clients to
* Contraindicated in clients with wait the length of time directed between puffs;
tachydysrhythmia normally client waits one min before the next puff
* Use cautiously in clients who have diabetes, - If clients are prescribed two inhaled medications,
hyperthyroidism, heart disease, hypertension, and instruct clients to wait at least 5 min between
angina. medications.
* Beta-adrenergic blockers should not be used
concurrently. GLUCOCORTICOIDS
- steroid hormones widely used for the treatment
Nursing Considerations of inflammation, autoimmune diseases, and
* Instruct clients on how to check pulse and to cancer; immunosuppressant
report an increase of greater than 20 to 30 Prednisolone (Prelone)
beats/min. beclomethasone dipropionate (QVAR)
* Instruct clients to report changes in heart rate prednisone (Deltasone)
and chest pain. Budesonide (Pulmicort Flexhaler)
* Advise clients to avoid caffeine. Fluticasone propionate (Advair,Flovent)
Triamcinolone acetonide (Azmacort)
Jhaella Marie Pague
BSN 4A
Hydrocortisone sodium succinate (Solu-Cortef)
Methylprednisolone sodium succinate Nursing Considerations
(Solu-Medrol) * Obtain baseline diver function tests and monitor
periodically.
Side Effects and Contraindications * Advise clients to monitor for signs of liver
- Difficulty speaking hoarseness, and oral damage (nausea, anorexia, abdominal pain).
candidiasis or thrush (immunosuppression); * Instruct clients to notify the provider if
effects on larynx symptoms occur.
Prednisone when used for 10 days or more can * Advise clients to observe for signs of bleeding
result in: and to notify the provider.
- Suppression of adrenal gland function, Bone loss, * Monitor prothrombin time (PT) and INR levels.
Hyperglycemia and glycosuria, Peptic ulcer * Monitor theophylline levels.
disease, infections,Disturbances of fluid and * Advise clients to observe for signs of
electrolytes theophylline toxicity (nausea, vomiting, seizures),
and to notify the provider
* Contraindicated in clients who have received a * Advise clients to take montelukast once daily at
live virus vaccine bedtime.
* Contraindicated in clients with systemic fungal
infections
* Use cautiously in children, and in clients who
have diabetes, hypertension, peptic ulcer disease,
and/or renal dysfunction.
* Use cautiously in clients taking NSAIDs.

Nursing Considerations
- Administer using an MDI device or nebulizer;
with spacer to enhance delivery; client must PULMONARY TUBERCULOSIS
exhale first before inhaling medication * Infectious Agent: Mycobacterium tuberculosis
- If a client is on long-term oral therapy, additional * Acid-fast (stains RED); remains red even after
doses of oral glucocorticoids are required in times series of staining
of stress (infection, trauma). * Aerobic (loves 02) - reside in upper parts of the
- Clients who discontinue oral glucocorticoid lobe (higher amounts of oxygen)
medications or switch from oral to inhaled agents * Airborne by droplet infection - very small -
require additional doses of glucocorticoids during suspends in air - identification of persons in close
periods of stress. contact with the infected individual
* Insidious onset
LEUKOTRIENE MODIFIERS
montelukast (Singulair) RISK FACTORS: "TB RISK"
zileuton (Zyflo) * T - Tight Living quarters
zafirlukast (Accolate) * B - Below or at poverty line
- Long term asthma treatment (Leukotriene * R - Refugee
modifiers prevent the effects of leukotrienes, * I - Immune system issue
thereby suppressing inflammation, (immunocompromised)
bronchoconstriction airway edema, and mucus * S - Substance abusers
production) * K- Kids < 5 years old

Side Effects and Contraindications

- c/i for liver injury
- Zileuton and zafirlukast inhibit metabolism of
warfarin (Coumadin), leading to increased
warfarin levels; Predispose to bleeding
- Zileuton and Zafirlukast inhibit metabolism of
theophylline, leading to increased theophylline
levels.
Jhaella Marie Pague
BSN 4A
- Pott's disease
* Genito-urinary
- Urogenital tuberculosis

SPUTUM CULTURE DIAGNOSIS

* ACTIVE TB + POSITIVE Tuberculin Skin TEST
90% of infected individuals- Latent TB Infection - Early morning sterile sputum specimen for 3
10% of infected individuals- Active TB Infection consecutive days; sputum smear, acid fast bacilli
smearing and sputum culture
* NOTE: Most people who become infected with
the TB organism, DO NOT PROGRESS TO ACTIVE * AFB smear and SPUTUM CULTURE
DISEASE - Sputum specimen even for those without
- during primary and latent, client does not respiratory symptoms.
manifest symptoms - 3 consecutive specimen are needed, each
collected in 8 - 24 hour intervals, with at least one
Main Symptoms: being an early morning specimen
- May be asymptomatic in primary infection
- Fatigue for more than 3 weeks Two main types of AFB tests
- Persistent cough and the production of mucoid AFB Smear:
and mucopurulent sputum-blood tinged * sample is "smeared" on a glass slide; determine
- Low-grade fever for more than 2 weeks presence of acid fast bacillus
- Drenching night sweats * provide results in 1-2 days; faster than sputum
- Anorexia culture which is 2-3 wks
- Unexplained weight loss (more than 1.5 kg in a * Smear positive result occurs when at least two
month) sputum smear results are positive.
* Detection of acid-fast bacilli in stained and
Main sites of Extrapulmonary tuberculosis acid-washed smears
* Central nervous system * Provides an INITIAL bacteriologic evidence of
- Meningitis the presence of TB
* Lymphatics * Does NOT confirm a diagnosis of TB
- Scrofula (of the neck)
* Pleura SPUTUM CULTURE
- Tuberculosis pleurisy - Positively confirms a diagnosis of Mycobacterium
* Disseminated TB - positive culture
- Miliary tuberculosis - Sputum cultures are taken until 3 negative
* Bones and joints of spine cultures on 3 different days after TREATMENT =
Jhaella Marie Pague
BSN 4A
NO LONGER INFECTIOUS; cannot contaminate * A POSITIVE TUBERCULIN TEST A CLIENT HAS
another person TB INFECTION OR PREVIOUS EXPOSURE TO
- After medications are started (2-3 wks TUBERCULOSIS BUT CHECK IF THE CLIENT HAS
treatment), sputum samples are obtained again to ACTIVE OR LATENT TB (those who has had TB
determine the effectiveness of therapy; most with vaccine or BCG) therefore CHEST XRAY AND
active tb are no longer infectious after 2-3 weeks SPUTUM TEST is done
of treatment
- Family members should be tested for TB; contact BLOOD TEST
traced for testing - INTERFERON GAMMA RELEASE ASSAY (IGRA)
- Most clients have negative cultures after 3 Benefits:
months of treatment * Client does not have to return for result reading
* Great for clients who received BCG vaccine (no
TUBERCULIN SKIN TEST: Mantoux test, PPD false positive)
(purified protein derivative; an attenuated or - Does not tell if latent or active - chest x-ray and
weakened mycobacterium) sputum culture are needed
* Positive reaction does not mean that active
disease is present but indicates - previous SPUTUM CULTURE
exposure to tuberculosis or the presence of - AFB SMEAR: COUGH,
inactive (dormant) disease. - SPUTUM: 3 DIFFERENT COLLECTION ON 3
* ONCE POSITIVE -POSITIVE IN ALL FUTURE DIFFERENT DAYS
TESTS - BEST IN THE MORNING BEFORE BREAKFAST

* Those who have had BCG vaccine- FALSE INTERFERON GAMMA RELEASE ASSAY (IGRA)
POSITIVE PPD - HAS EXPOSURE TO Benefits:
MYCOBACTERIUM TUBERCULOSIS - Client does not have to return for result reading
- once positive- CHEST X-RAY (to rule out active - Great for clients who receivedBCG vaccine (no
TB or to detect old healed lesions) false positive)
* Does not tell if latent or active - chest ×-ray and
TUBERCULIN TEST: Mantoux test sputum culture are needed
- Read 48-72 hours after injection
INTERPRETATION OF RESULTS: LATENT
* In a healthy person whose immune system is * NOT CONTAGIOUS
normal, induration greater than or equal to 15 mm * NO SIGNS AND SYMPTOMS
is considered a positive skin test. * NORMAL CHEST X-RAY
* NEGATIVE SPUTUM CULTURE
Considered positive if induration less than 15 mm * (+) PPD or TST
is present (for example, an area of induration of 10 * STILL NEEDS TREATMENT TO PREVENT ACTIVE
mm) in the following groups: INFECTION
* Recent immigrants from high-prevalence areas
* Residents and employees of high-risk areas ACTIVE
* IV drug abusers * CONTAGIOUS'
* Children under 5 years old * POSITIVE SIGNS AND SYMPTOMS
* People who work with mycobacteria in * ABNORMAL CHEST X-RAY
laboratories * POSITIVE SPUTUM CULTURE
* (+) PPD or TST
An induration of 5 mm is considered positive for * CAN SPREAD TO OTHER PARTS OF THE BODY-
the following groups: extra pulmonary PTB
* People with suppressed immune systems
* HIV-infected people, cancer, autoimmune Treatment GOALS:
* People with changes seen on chest X-ray that are * To prevent transmission
consistent with previous TB * Control symptoms
* Recent contacts of people with TB * Prevent progression of the disease
* People who have received organ transplants
Standard treatment regimen for New and
Previously treated patients
Jhaella Marie Pague
BSN 4A
* Intensive phase lasting 2 months - isoniazid, - N - Neuropathy = report new numbness, tingling
rifampicin, pyrazinamide, and ethambutol (RIPE) extremities and ataxia
* Continuation phase lasting 4 months- - H - Hepatotoxicity - Monitor ALT (SGPT), AST
isoniazid, rifampicin (RI) (SGOT)
- given 7 days a week * Report immediately: dark urine, fatigue,
- Therapy must be extended if the patient has jaundice, elevated liver enzymes (AST/ALT),
cavitary disease (active ptb) and remains unusual bleeding = HOLD THE MED
culture-positive after 2 months of treatment; may * Administer 1 hr or 2 hours after meals;
go until the 12th month depending on labs administer 1 hour before antacids.
- Noninfectious after 2-3 weeks of continuous * No alcohol
medication therapy
* PYRAZINAMIDE (PZA)
PROPHYLACTIC MEASURES: - Hepatotoxicity, increased uric acid - GOUT-
* Taking daily doses of ISONIAZID/ INH for 6-12 MONITOR URIC ACID LEVEL
months
Risks: * ETHAMBUTOL (EYE)
- Household family members of patients with * Optic neuritis, skin rash
active disease * Symptoms and signs- Reduced red-green color
- HIV-infected patients with a PPD test reaction of discrimination- Blurred vision- Difficulty in
5 mm of induration or more reading
- Chest x-ray suggestive of old TB * Ophthalmologic examination at regular
- IV or injectable drug users with PPD test results basis-should undergo baseline and periodic visual
of 10 mm of induration or more acuity and red-green color perception testing.

DOTS (Directly Observed Treatment, * STREPTOMYCIN

Short-Course) - given before
* DOTS works by assigning a responsible person * Ototoxicity (8TH CN damage, acoustic),
(fam member before but has lack of compliance; nephrotoxicity
now a nurse or doctor is assigned) to observe or * Monitor hearing - watch for reports of ringing in
watch the patient take the correct medications the ears
daily during the whole course of treatment.
* The strategy developed to ensure treatment
compliance. NURSING CARE: HOSPITALIZED CLIENT
* NEGATIVE-PRESSURE ROOM (TIGHTLY
Multidrug-Resistant Strain of Tuberculosis CLOSED)- AIRBORNE PRECAUTIONS - contain the
(MDR-TB) microorganism within the room without
* Due to improper or noncompliant use of transmission outside; doors tightly closed; ideally
treatment programs causing the mutations of the has atmospheric air that is contained within
tubercle bacilli * WEAR N95 MASK AND A GOWN
* THOROUGH HANDWASHING
Common side effects of TB drugs * WHEN PATIENT LEAVES THE ROOM, LET HIM
* RIFAMPICIN (RED-FAMPIN) WEAR A SURGICAL MASK
- Red-orange color of body secretions, nausea and
vomiting, hepatotoxicity, thrombocytopenia with * ACTIVE TB: Isolation - no visitors, no school. No
bleeding precautions (sweat, tears etc) public outings, closed rooms and windows
- Will stain contact-lenses * RESPIRATORY ISOLATION - discontinued -
- Birth control less effective when the client is considered to be less infectious
- Photosensitivity - sunburn (apply sun block) * OUT OF ISOLATION: On Medication for at least
- No alcohol; aggravate effect on liver 2-3 weeks, 3 negative cultures, decreased signs
and symptoms
* ISONIAZID (INH)
- I - Interferes with absorption of B6 (pyridoxine) HEALTH EDUCATION
= low Vit B6 = peripheral neuropathy = take Vit B6 * MEDICATION REGIMEN
25- 50mg/day * SIDE-EFFECTS AND ADVERSE EFFECTS OF THE
MEDICATIONS
Jhaella Marie Pague
BSN 4A
* GRADUAL RESUMPTION OF ACTIVITIES
* ADEQUATE NUTRITION AND WELL BALANCED
DIET (HIGH IN IRON, PROTEIN, AND VITAMIN C)
* Cough, sneeze in paper towel - flush or put inside
air tight bag
* Negative 3 sputum cultures, not anymore
infectious - can return to former employment
* Avoid excessive exposure to dust
* Compliance with treatment, follow-up care and,
sputum culture