Anna Dianelli Masicap IV BSN 3

September 9, 2011

CHEST TUBE THORACOSTOMY

MATERIALS 1. Chest tube with or without trocar; OR Fuhrman catheter 2. Chest tube suction unit (Pleurevac or Sahara), tubing, wall suction hookup 3. Chest tube tray to include scalpel blade and handle, large Kelly clamps, needle driver, scissors 4. Packet of 0 or 1.0 silk suture on a curved needle 5. Tape, gauze 6. 2% lidocaine with epinephrine, 20 cc syringe, 23-gauge needle for infiltration 7. Sterile prep solution; mask, gown and gloves Size of Chest Tube Adult or Teen Male Adult or Teen Female Child Newborn 28 Fr 18 Fr 12-14 Fr 28-32 Fr

PRE-PROCEDURE PATIENT EDUCATION 1. Obtain informed consent. 2. Inform the patient of the possibility of major complications and their treatment. 3. Explain the major steps of the procedure, and necessity for repeated chest radiographs.

PROCEDURE NOTE: Conscious sedation during this procedure is an option for those patients who are clinically stable. 1. Examine the patient and assess need for placement of a thoracostomy tube. Obtain preprocedure chest X-ray. 2. Select site for insertion: mid-axillary line, between 4th and 5th rib (this is usually on a line lateral to the nipple). 3. Don mask, gown and gloves; prep and drape area of insertion. Have patient place ipsilateral arm over head to open up ribs.

4. Widely anesthetize area of insertion with the 2% lidocaine. Infiltrate skin, muscle tissues, and right down to pleura. CHEST TUBE INSERTION -After infiltrating insertion site with local anesthetic, make a 3-4 cm incision through skin and subcutaneous tissues between the 4th and 5th ribs, parallel to the rib margins (Figure 1) -Continue incision through the intercostal muscles, and right down to the pleura -Insert Kelly clamp through the pleura and open the jaws widely, again parallel to the direction of the ribs (this creates a pneumothorax, and allows the lung to fall away from the chest wall somewhat, See Figure 2)
Figure 1: Incising the chest wall

Insert finger through your incision and into the thoracic cavity. Make sure you are feeling lung (or empty space) and not liver or spleen Grasp end of chest tube with the Kelly forcep (convex angle towards ribs), and insert chest tube through the hole you have made in the pleura. After tube has entered thoracic cavity, remove Kelly, and manually advance the tube in (Figure 3).

Figure 2: Opening the incision with a Kelly clamp

If the tube is of the trocar variety, grasp tube with one hand close to the sharp trocar end and guide the tube slowly and gently through the hole in the pleura into the chest cavity (Figure 4). Remove trocar once tube has just entered the cavity, and feed tube in approximately 1/2 to 2/3 of its length, until all the fenestrations of the tube are within the chest.

Figure 3: Using a Kelly clamp to guide insertion of the chest tube

-Clamp outer tube end with Kelly -Suture and tape tube in place -Attach tube to suction unit -Obtain post procedure chest X-ray for placement; tube may need to be advanced or withdrawn slightly.

Figure 4: Inserting a trocar chest tube

Reaction: Most of the nurses do not consider the ideal procedure to be done in measuring the chest tube secretions it is because the hospital or the institution does not have enough budgets for these procedures. But the nurses are very resourceful; they do make it a point that the procedure can also be accurate in other ways or materials that can be used. Because of these many nurses in the Philippines are really good at serving our country. Even though the Filipino nurses lack of many things their rendered care to the patient are still good. It is not difficult to measure the secretions in a bottle but it far easy to know that you are accurate in measuring the secretions with the use of a ruler. But still it is the way of the Filipino nurses in measuring it. This could be less accurate but at least there is the effort and resourcefulness of the Filipino nurses.