Angelite Nurses

Nursing diagnoses for the client with a respiratory dysfunction may include

1. Impaired gas exchange
2. Ineffective airway clearance
3. Ineffective breathing pattern
4. Impaired verbal communication
5. Activity intolerance
6. Anxiety
7. Altered nutrition: less than body requirements
8. Risk for infection

Goals

1. Adequate ventilation will be maintained.
2. Maintenance of patent airway.
3. Effective breathing patterns will be maintained.
4. Client will communicate in an effective manner.
5. Client will demonstrate increased tolerance for activity.
6. Anxiety will be reduced.
7. Adequate nutritional status will be maintained.
8. Client remains free from infection.

Interventions


Chest Tubes/Water-seal Drainage

1. Insertion of a catheter into the intrapleural space to maintain constant negative pressure when air/fluid have accumulated.
2. Chest tube is attached to underwater drainage to allow for the escape of air/fluid and to prevent reflux of air into the chest.
3. For evacuation of air, chest tube is placed in the second or third intercostal space, anterior or midaxillary line (air rises to the upper chest).
4. For drainage of fluid, chest tube is placed in the eighth or ninth intercostal space, midaxillary line.
5. Chest tube is connected to tubing for the collection system; the distal end of the collection tubing must be placed below the water level in order to prevent atmospheric air from entering the pleural space.
6. Drainage systems: a water-seal drainage system can be set up using one, two, or three bottles; or a commercial, disposable device (e.g., Pleur-evac®) may be used.
1. One-bottle system (Figure 4.12A)
1. Operates by gravity, not suction; the bottle serves as both collection chamber and water seal.
2. Two hollow tubes (glass rods) are inserted into the stopper of the bottle; the drainage tube is connected to the glass rod that is submerged approximately 2 cm below the water level; the second glass tube allows for the escape of air.
3. If considerable drainage accumulates it is difficult for the client to expel air and fluid from the pleural space. If this occurs, the glass rod may be pulled up or a new drainage bottle may be set up (according to physician's orders).
2. Two-bottle system (Figure 4.12B,C)
1. One bottle serves as a drainage collection chamber, the other as a water seal.
2. The first bottle is the drainage collection chamber and has two short tubes in the rubber stopper. One of these tubes is attached to the drainage tubing coming from the client; the other is attached to the underwater tube of the second bottle (the water-seal bottle). The air vent of the water-seal bottle must be left open to atmospheric air. If suction is used, the first bottle serves as drainage collection and water-seal chamber, and the second bottle serves as the suction chamber.
3. Three-bottle system (Figure 4.12D)
1. This system has a drainage collection, a water-seal, and a suction-control bottle.
2. The third bottle controls the amount of pressure in the system. The suction-control bottle has three tubes inserted in the stopper, two short and one long. One short tube is joined with the tubing to the former air vent of the water-seal bottle; the second short tube is connected to suction. The third (long) tube (or suction-control tube) is located between the short tubes and has one end open to the atmosphere and the other below the water level.
3. The depth to which the suction-control tube is immersed controls the amount of pressure within the system. The pressure is determined by the physician.
4. Commercial water-seal units: most popular is Pleur-evac® (Figure 4.12E); lightweight, disposable; functions like a three-bottle system, may be used with or without suction.
7. Nursing care: without suction
1. Prepare the unit for use and connect the chest catheter to the drainage tubing.
2. Examine the entire system to ensure airtightness and absence of obstruction from kinks or dependent loops of tubing.
3. Note oscillation of the fluid level within the water-seal tube. It will rise on inspiration and fall on expiration due to changes in the intrapleural pressure. If oscillation stops and system is intact, notify physician.
4. Check the amount, color, and characteristics of the drainage. If drainage ceases and system is not blocked, assess for signs of respiratory distress from fluid/air accumulation.
5. Always keep drainage system lower than the level of the client's chest.
6. Keep Vaseline gauze at bedside at all times in case chest tube falls out.
7. Encourage coughing and deep breathing to facilitate removal of air and drainage from pleural cavity.
8. Provide ROM exercises.
8. Nursing care: with suction
1. Attach suction tubing to suction apparatus, and chest catheter to drainage tubing.
2. Open suction slowly until a stream of bubbles is seen in the suction chamber. There should be continuous bubbling in this chamber and intermittent bubbling in the water seal. Check for an air leak in the system if bubbling in water seal is constant; notify physician if air leak.
3. Check drainage, keep drainage system below level of client's chest, keep Vaseline gauze at bedside, encourage coughing and deep breathing, and provide ROM exercises as noted above.
9. Never clamp chest tubes unless a specific order is written by the physician. Clamping the chest tubes of a client with air in the pleural space will cause increased pressure buildup and possible tension pneumothorax.
10. Removal of the chest tube: instruct the client to perform Valsalva maneuver; apply a Vaseline pressure dressing to the site.
11. If the water-seal bottle should break, immediately obtain some type of fluid-filled container to create an emergency water seal until a new unit can be obtained.

FIGURE 4.12 Water-seal drainage systems: (a) one-bottle system; (B) two-bottle system without suction; (C) two-bottle system with suction; (D) three-bottle system; (E) Pleur-evac®. Adapted from "You can manage chest tubes confidently," by B. Mims, RN, 48(1), 39-44.

Heimlich Flutter Valve

1. This disposable valve allows a unidirectional flow of air and fluid from the pleural space into a drainage bag and prevents any reflux of air or fluid. A water-seal drainage system is not necessary.
2. Controlled suction can be attached if ordered.
3. The valve is encased in clear plastic, which eliminates the possibility of kinks. Its small size, approximately 7 inches, permits greater mobility.