thoracostomy

Ateneo de Zamboanga University College of Nursing Nursing Skills Output (NSO) Report No: 4 “THORACOSTOMY” Definition: A thoracostomy is the creation of an opening in the chest wall for the purpose of drainage. It is done with a puncture, using a sharpened, hollow probe (trocar). A thoracostomy is commonly performed for the insertion of a chest tube. This procedure is most often used to evacuate air (pneumothorax), blood (hemothorax), or fluids (pleural effusions, empyema) from the chest cavity. Purpose: Is the insertion of a tube (chest tube) into the pleural cavity to drain air, pus and fluid to help regain negative pressure. Under normal circumstances, intrapleural pressure is below atmospheric pressure. When this pressure changes because of excess air and/or fluid, the lung may collapse. If this occurs, a chest tube is inserted into the intrapleural space. This lets excess fluids drain, restores normal pressure, reinflates the lung, and allows adequate gas exchange. Persons experiencing a pleural effusion (accumulation of fluid in the spaces of the pleura), hemothorax (accumulation of blood in the pleural cavity), pneumothorax (collapsed lung), and empyema (accumulation of pus in the pleural cavity) may all require the insertion of a chest tube. Materials/ Equipment:

-Tube thoracostomy tray - Silk or nylon suture, 0 or 1-0 -Sterile gloves - Vaseline gauze -Sterile drapes - Gauze squares, 4 x 4 in (10) -Surgical marker -Sterile adhesive tape, 4 in wide -Lidocaine 1% with epinephrine -Large straight suture scissors \ -Syringes, 10-20 mL (2) -Large curved Mayo scissors -Needle, 25 gauge (ga), 5/8 in -Needle, 23 ga, 1.5 in; or 27 ga, 1.5 in; for instilling local anesthesia -Blade, No. 10/11 Blade, on a handle -Large and medium Kelly clamps -Chest tube of appropriate size : Man - 28-32F, Woman - 28F, Child - 12-28F, Infant - 12-16F, Neonate - 10-12F Procedues: Preparatory Phase 1. Informed consent 2. Chest x-ray result 3. Wash hands. 4. Assemble the drainage system/ other equipment needed. 5. Reassure the patient and reinforce the steps of the procedure. Inform the patient to expect a needle prick and a sensation of a slight pressure during infiltration of anesthesia 6. Position the patient as described above (intercostal nerve block) 7. Clearly mark the site of chest tube insertion (right or left). 8. Shave excessive hair and apply a preparatory solution to a wide area of the chest wall as shown below. Skin preparation and marking. 9. Wear sterile gloves, gown, hair cover, and goggles or face shield, and apply sterile drapes to the area. 10. Identify the fifth intercostal and the midaxillary line. 11. The skin incision is made in between the midaxillary and anterior axillary lines over a rib that is below the intercostal level selected for chest tube insertion. 12. A surgical marker can be used to better delineate the anatomy. Performance Phase (by the surgeon) 13. Administer a systemic analgesic (unless contraindicated). 14. Use the 25-ga needle to inject 5 mL of the local anesthetic solution into the skin overlying the initial skin incision, 15. Use the longer needle (23 or, preferably, 27 ga) to infiltrate about 5 mL of the anesthetic solution to a wide area of subcutaneous tissue superior to the expected initial incision 16. Use the No. 11 or 10 blade to make a skin incision approximately 4 cms long overlying the rib that is below the desired intercostal level of entry. 17. A curve hemostat is inserted into the pleural cavity and the tissue is spread with a clamp. 18. A tract is explored with an examining finger. 19. The tube is held by the hemostat and directed through the opening up over the ribs and into the pleural cavity. 20. The clamp is withdrawn and the chest tube is connected to a chest drainage system.

21. A 0 or 1-0 silk or nylon suture is used to secure the chest tube to the skin. 22. Apply petrolatum (eg, Vaseline) gauze over the skin incision. 23. Create an occlusive dressing to place over the chest tube by turning regular gauze squares (4 x 4 in) into Y-shaped fenestrated gauze squares and using 4-in adhesive tape to secure them to the chest wall 24. Strap the emerging chest tube on to the lower trunk with a adhesive tape, as this avoids kinking of the tube as it passes through the chest wall. Follow- up Phase 25. Observe the drainage system for blood or air. Observe for fluctuation in the tube on respiration. 26. Secure a follow-up x-ray 27. Assess for bleeding, infection, leakage of air and fluid around the tube Diagram: Figure 1 Figure

Nursing Responsibilities: PRE-PROCEDURE CARE  Ensure a signed informed consent for chest tube insertion.  Provide additional information as indicated. Explain that local anesthesia will be used but that pressure may be felt as the trochar is inserted. Reassure that breathing will be easier once the chest tube is in place and the lung reexpands.  Gather all needed supplies, including thoracostomy tray, injectable lidocaine, sterile gloves, chest tube drainage system, sterile water, and a large sterile catheter-tipped syringe to use as a funnel for filling water-seal and suction chambers.  Position as indicated for the procedure. Either an upright position (as for thoracentesis) or sidelying position may be used, depending on the site of the pneumothorax.  Assist with chest tube insertion as needed. The procedure may be performed in a procedure room, in the surgical suite, or at the bedside. Although chest tube insertion is a relatively simple procedure, nursing assistance is necessary to support the client and rapidly establish a closed drainage system. POSTPROCEDURE CARE  Assess respiratory status at least every 4 hours.  Maintain a closed system.Tape all connections, and secure the chest tube to the chest wall.  Keep the collection apparatus below the level of the chest. Pleural fluid drains into the collection apparatus by gravity flow.  Check tubes frequently for kinks or loops. These could interfere with drainage.  Check the water seal frequently.The water level should fluctuate with respiratory effort. If it does not, the system may not be patent or intact.Periodic air bubbles in the water-seal chamber are normal and indicate that trapped air is being removed from the chest.  Measure drainage every 8 hours, marking the level on the drainage chamber. Report drainage that is cloudy, in excess of 70 mL per hour,or red,warm,and free flowing.Red, free-flowing drainage indicates hemorrhage; cloudiness may indicate an infection. Emptying the drainage would disrupt integrity of the closed system.  Periodically assess water level in the suction control chamber, adding water as necessary.Adequate water in the suction control chamber prevents excess suction from being placed on delicate pleural tissue.  Assist with frequent position changes and sitting and ambulation as allowed. Chest tubes should not prevent performance of allowed activities. Care is needed to prevent inadvertent disconnection or removal of the tubes.  When the chest tube is removed, immediately apply a sterile occlusive petroleum jelly dressing. An occlusive dressing prevents air from reentering the pleural space through the chest wound. Reference:  http://www.mdguidelines.com/thoracostomy  Lippincott Manual of Nursing Practice by LWW, pp 265-267  http://www.enotes.com/chest-tube-maintenance-reference/chest-tube-maintenance