Policy Manual sample

MDT Home Health Care Agency, Inc. reestablishes negative pressure and permits the lungs to expand effectively. Assessing for an air leak: Clamp off suction for one minute. An air leak is present if there is constant bubbling in the water-seal chamber. An air leak alerts the nurse that he or she must assess for the location of the leak by checking the connections from the chest drainage unit to the insertion site. If there is excessive, continuous bubbling in the water-seal chamber, there is most likely a large air leak. Starting from away from the patient and going towards the patient, check all connections. Lastly, change the dressing and make sure there is good seal with the dressing around the insertion site. If it is the pleural space that is leaking, intermittent bubbling with respiration is normal. This will resolve as the lung re-expands. Therefore, when a pneumothorax is the indication for the chest tube, an air leak is to be expected; yet, should decrease with patient improvement. Chest Tube Maintenance Keep all tubing patent and free of kinks or obstructions. Dependent loops with the chest tube tubing should be avoided since they obstruct chest drainage into the collection system and increase pressure within the lung. The tubing should also never dangle; coil it on the bed and anchor tubing when securing the chest tube. It is acceptable for the nurse to gently milk the tubing when a visible clot or obstructing drainage is in the tubing by squeezing hand over hand along the tubing and releasing the tubing between squeezes. However, excessive chest-tube manipulation should be avoiding, as this can create negative pressures in the tube and does little to maintain chest-tube patency. If you see visible clots, squeeze hand-over-hand along the tubing and release the tubing between squeezes to help move the clots into the CDU. Clamping the Chest Tube Never clamp the chest tube unless the physician orders it or when a nurse is changing the chest drainage unit. If the patient on water suction is going off the unit for a procedure/diagnostic test or being transferred, put the chest drainage unit to under water seal (UWS), which is a one-way valve which allows air to exit the chest and prevents air returning to the patient under normal conditions. Ensure that the tube is functioning & the connections are secure. Also ensure that the UWS is at least 20cmH2O below the patient's fluid level. When it is medically necessary to clamp the chest tube, clamp for no longer than one minute, to prevent increased pressure within the lung. Dislodgement or Disconnection If the chest tube accidentally falls out, instruct the patient to perform the Valsalva maneuver. (A Valsalva maneuver occurs when a person tries to exhale forcibly with a closed glottis (the windpipe) so that no air exits through the mouth or nose. This may occur during strenuous coughing, straining during a bowel movement, or lifting of a heavy weight. The Valsalva maneuver impedes the return of venous blood to the heart. Initially during a Valsalva, intrathoracic pressure becomes very positive due to the compression of the thoracic organs by the contracting rib cage.) At end-expiration immediately cover the insertion site with vaseline gauze (if indicated by the Physician), a dry sterile dressing, and occlusive tape. In the event of chest-tube disconnection with contamination, you can submerge the tube 1" to 2" (2 to 4 cm) below the surface of a 250-mL bottle of sterile water or saline solution until a new CDU is set up. This establishes a water seal, allows air to escape, and prevents air reentry. The nurse should immediately call the physician and prepare for re-inserting of the chest tube. While informing the physician, place oxygen on the patient and sit patient in high-Fowlers. Home Health Agency Nursing Care & Procedures K-216