NCLEX Memory Hints: Chest Tubes
Tuesday, March 25, 2025
Pulmonary System: Chest Tubes
NCLEX Memory Hints © BrainyNurses.com
Chest tubes are used after chest surgery or injury which resulted in a pneumothorax or hemothorax. They are also needed when a large pleural effusion is present and needs to be drained. The chest tubes may be positioned high in the chest to remove air and low in the chest to remove fluid. In general, if a hemothorax is present, a pneumothorax will also be present, and more than one chest tube will be needed. The Memory Hint for placement of chest tubes is “Air rises and fluid falls.”
Subcutaneous emphysema will be felt with a pneumothorax. It may also be present at the chest tube site and may be a normal variant or indicate a leak.
Chest tubes can be wet suction or dry suction. The advantage of the dry suction is that they are easier to set up and there will not be the constant bubbling associated with the wet suction which can be disturbing to the patient.
Important facts for the NCLEX exam include the chest tube device, trouble shooting a leak, positioning, and types of thoracic surgeries and if a chest tube is needed.
Chest Tube Device
The suction control is set at 20 cm. When a wet suction device is used, the chamber always bubbles, water may evaporate as a result, and additional sterile water will need to be added.
The water seal is set at 2 cm. This chamber will bubble when the chest tube is inserted as the air is removed from the pleural space. If there is a large pneumothorax, extensive bubbling may be seen on insertion. As long as the lung is not yet re-expanded, slight bubbling will persist.
The water in the water seal chamber will fluctuate up and down as long as the air in the pleural space persists. The term often used for this fluctuation is “tidaling”. When caring for a patient with a pneumothorax, the water seal chamber is assessed. When bubbling is seen and tidaling persists, the pneumothorax is not yet resolved. Once the lung fully expands, the bubbling and tidaling will stop, a chest X-ray will be performed for confirmation, and plans made to remove the chest tube.
The drainage collection chamber never bubbles. The amount of fluid collected on insertion will be noted. Hourly outputs should be completed after a surgical procedure. Expected amount is 100 mL per hour for the first two hours and a total of 500 mL in 24 hours. If drainage suddenly increases after surgery, bleeding is suspected, and return to the operating room may be considered.
With removal of a chest tube, the Valsalva maneuver should be performed by the patient to prevent air from entering the pleural space.
Trouble Shooting a Leak
If a sudden increase in bubbling is noted in the water seal chamber, the priority is to check for a leak in the system. If a leak exists, or the system is compromised, the priority is to disconnect the chest tube attached to the patient from the system and place the end of the tube in a bottle of sterile saline or sterile water which should be at the bedside. Then notify the provider. The chest tube should never be clamped without a specific order. Clamping the tube may cause the development of a tension pneumothorax.
Positioning
Positioning must always be on the side opposite the chest tube. Placing the patient on the side of the tube may lead to kinking of the tube and the development of a tension pneumothorax.
Types of Thoracic Surgeries
A segmental or wedge resection is removal of part of a lobe of the lung. A lobectomy is removal of an entire lobe. Post-operatively, chest tubes will be needed for both. Immediately after surgery, turning slightly to either side is permitted for assessment. Then, the patient will be turned to the non-operative side to prevent bleeding and maintain chest tube patency.
A pneumonectomy is removal of the entire lung. Post-operatively, chest tubes are not needed. Immediately after surgery, turning slightly to either side is permitted for assessment. After 48 hours, the patient is turned more toward the operative side to promote consolidation in the space left by the removed lung. With a pneumonectomy, the phrenic nerve is severed on the side of the surgery which decreases the amount of elevation of the diaphragm on the operative side. Postoperatively, there is a risk of cardiac overload, pulmonary hypertension, and atrial fibrillation.
Summary
In preparing for the NCLEX exam, knowledge of chest tubes is needed. To remember position of the chest tube(s), use the hint “Air rises and fluid falls.” When a pneumothorax is present, the tube is placed high in the pleural space. When there is fluid, the tube is placed low in the space. With the chest tube device, the suction control at 20 cm and the water seal at 2 cm. If the lung is not yet expanded, the water seal will bubble and tidal. If a leak is suspected, place the end of the tube in a bottle of sterile solution. After trouble shooting through the emergency, notify the provider. Never clamp a chest tube without a specific order.
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