Policy Manual sample

MDT Home Health Care Agency, Inc. suction is confirmed by noting a gentle bubbling in the suction control chamber The suction control stopcock can be adjusted to increase or decrease suction control bubbling. Monitoring Intrathoracic Pressure If a chest drainage unit is not connected to suction, it is utilizing gravity to drain fluid from the chest cavity. To accurately read intrathoracic pressure when using gravity only (no suction), the nurse should read directly from the water seal. A rise in the water seal indicates that negative pressure is present in the pleural space (this confirms that the patient is healing). On the other hand, bubbling indicates positive pressure (air leak). When recording intrathoracic pressure in a unit on suction: Add the readings of suction control chamber plus the level of the water seal chamber. For Example: -20cmH20 + -5cmH20 = -25cmH20 intrathoracic pressure. Tidaling With a chest tube in the pleural space, the water level should fluctuate in the water seal chamber. This is known as tidaling, and should correspond with respiration. When there is no air leak, the water level in the water seal chamber should rise and fall with the patient's respiration. During spontaneous respiration, the water level will rise during inhalation and fall during exhalation. If the patient is receiving positive pressure ventilation, the oscillation will be just the opposite. If the lung is re-expanded, tidaling may not be present Sampling the Pleural Fluid While the chest tube is in place, the physician may order tests on the pleural fluid for various reasons. As needed, sample fluids from the tubing with a 20 to 24 gauge needle after cleaning the tubing with an alcohol swab or betadine swab. With newer chest drainage units, there are needleless ports to remove fluid immediately before the fluid enters the chest drainage unit Drainage Depending on Physician order, and the patient’s condition, it is necessary to monitor and document chest drainage or as condition warrants: • Closely monitoring the output will enable the nurse to notify the physician if there is excessive output. • To assess drainage level, mark the drainage level on the outside of the drainage collection chamber in hourly or shift increments with the date and time. Record the output information on the progress note to provide a reference point for future measurements. • In the nurse’s note, a description of the drainage color will also help the physician to guide the care. For example, with a hemothorax, the color should change from bloody to straw color (sanguinous to sero-sanguinous to serous). Accurate documentation will facilitate early identification of any changes in the patient’s condition related to the chest tube. • Significant changes should be reported to the physician. Examples of this are: the drainage color changed from serous to bloody or drainage output was greater than 100 ml in one hour when the output was normally 10 ml in 12 hours or there is increasing bloody drainage greater than 100 ml in one hour. If there is no drainage inform the physician, he may order a chest x-ray to see if the lung has re- expanded. If it has not re-expanded, the chest tube may be displaced or it may be clogged. The physician should be notified so that the patient can be reassessed. Air Leaks Assess the patient for an air leak. It is important to rectify any air leaks because an airtight system Home Health Agency Nursing Care & Procedures K-215