Following chest tube insertion, certain emergency and maintenance items should always be kept at the bedside to ensure patient safety and proper function of the drainage system. These include oxygen for respiratory support, sterile water to maintain the water seal, enclosed hemostat clamps for emergency use, and an occlusive dressing to seal the site if the tube becomes dislodged.

Rationale for Correct Answers

1. Oxygen: Chest tube insertion is often performed for conditions such as pneumothorax or hemothorax, where oxygenation can be compromised. Supplemental oxygen should be readily available to support ventilation and oxygen delivery, especially if respiratory distress occurs.

2. Sterile water: Sterile water (or sterile saline) is essential to maintain or reestablish the water seal in the drainage system if it becomes disrupted. It may also be used to immerse the tube’s end temporarily if the drainage system disconnects, preventing air from entering the pleural space.

3. Enclosed hemostat clamps: Two sterile, rubber-tipped or enclosed hemostat clamps are kept at the bedside for brief, emergency clamping—such as changing the drainage system or identifying air leaks. Clamps should never be used continuously, as this can cause a tension pneumothorax.

5. Occlusive dressing: If the chest tube accidentally comes out, an occlusive (petroleum gauze) dressing should be immediately applied over the site to prevent air entry into the pleural space, which could cause a pneumothorax.

Rationale for Incorrect Answer

4. Indwelling urinary catheter: This is not routinely required for chest tube management. A urinary catheter is indicated only if close urine output monitoring is necessary due to other medical reasons, not specifically for chest tube care.

Take-Home Points

• Always keep oxygen, sterile water, enclosed hemostats, and an occlusive dressing at the bedside of a patient with a chest tube.
• Never clamp the chest tube unless momentarily needed for a procedure or troubleshooting under guidance.
• Occlusive dressings are critical for preventing air re-entry if the tube is accidentally removed.
• The goal is to maintain an intact, sterile, and functional drainage system that prevents air or fluid reaccumulation in the pleural space.

Following chest tube insertion, nursing care focuses on maintaining tube patency, promoting lung re-expansion, and preventing complications. The nurse should encourage coughing and deep breathing, monitor for continuous bubbling in the suction chamber, and ensure a follow-up chest x-ray is performed to verify proper placement and lung re-expansion.

Rationale for Correct Answers

1. Encourage the client to cough every 2 hr: Coughing and deep breathing exercises promote lung expansion, facilitate drainage of air and fluid, and prevent atelectasis. Regular pulmonary hygiene supports recovery and prevents respiratory complications.

2. Check for continuous bubbling in the suction chamber: Continuous bubbling in the suction control chamber indicates that the suction source is functioning properly. However, intermittent bubbling should occur only in the water-seal chamber during exhalation or coughing—continuous bubbling there suggests an air leak.

5. Obtain a chest x-ray: A chest x-ray is obtained after insertion to confirm the tube’s correct placement and lung re-expansion. It also serves as a baseline for monitoring future progress and identifying potential complications such as malposition or pneumothorax recurrence.

Rationale for Incorrect Answers

3. Strip the drainage tubing every 4 hr: Stripping or milking the tubing can create high negative pressure in the pleural space, causing tissue damage and promoting air leaks. The tubing should instead be kept free of kinks and dependent loops without stripping.

4. Clamp the tube once a day: Routine clamping is contraindicated because it can lead to tension pneumothorax from trapped air. Clamping is done only briefly and under specific conditions, such as changing the drainage system or checking for leaks.

Take-Home Points

• Encourage coughing and deep breathing every 2 hours to promote lung expansion and prevent atelectasis.
• Continuous bubbling should be present in the suction chamber, not in the water-seal chamber.
• Always verify chest tube placement and lung re-expansion with a chest x-ray after insertion.
• Never strip or clamp the chest tube routinely—these actions can cause injury or tension pneumothorax.

After a lobectomy, sudden dyspnea, tachypnea, hypotension, asymmetric chest expansion, tracheal deviation, and low oxygen saturation suggest a tension pneumothorax, a life-threatening emergency. The nurse’s first priority is to check the chest tube for obstruction or disconnection to relieve trapped air and restore negative pressure in the pleural space.

Rationale for Correct Answer

3. Check the chest tube to make sure it is not obstructed: These symptoms indicate that air is accumulating in the pleural space, collapsing the lung and shifting the mediastinum. An obstructed or clamped chest tube prevents air escape, causing rising intrathoracic pressure. The nurse must first assess and ensure the tube is patent and properly functioning. If obstructed, immediate intervention is needed to restore drainage and prevent cardiopulmonary collapse.

Rationale for Incorrect Answers

1. Notify the physician: While the physician must be notified promptly, assessment and correction of a potentially obstructed chest tube take priority because the client is in acute respiratory distress. Delaying to make a call without addressing the cause could worsen hypoxia and hemodynamic instability.

2. Give the client the prescribed medication to decrease anxiety: The client’s anxiety is secondary to severe hypoxia. Sedation could further depress respiratory function and delay life-saving intervention. The focus must be on resolving the underlying cause of respiratory distress.

4. Turn up the oxygen liter flow: Increasing oxygen flow will not correct the problem because the issue is not oxygen delivery but air trapping from impaired chest tube function. Without reestablishing lung expansion, oxygenation cannot improve.

Take-Home Points

• Tracheal deviation, hypotension, and absent chest movement on one side indicate a tension pneumothorax.
• The nurse’s first action is to check for chest tube obstruction or disconnection to restore air drainage.
• Increasing oxygen or giving medication does not address the cause of hypoxia in this emergency.

Continuous bubbling in the water-seal chamber indicates a possible air leak in the chest tube system. The nurse should immediately assess the system from the patient to the drainage unit to locate and correct the leak, as persistent bubbling prevents proper re-expansion of the lung and may lead to complications.

Rationale for Correct Answer

1. There is continuous bubbling in the water-seal chamber: Intermittent bubbling during exhalation or coughing is normal as air exits the pleural space. However, continuous bubbling suggests that air is entering the system from an external source—such as a loose connection, cracked tubing, or dislodged drain. The nurse should systematically check the tubing, connections, and drainage unit to identify the leak’s origin.

Rationale for Incorrect Answers

2. There is constant bubbling of water in the suction control chamber: Continuous bubbling in the suction control chamber is expected and indicates that suction is functioning properly. The intensity of bubbling can be adjusted by regulating the suction source but does not signify a leak.

3. Fluid in the water-seal chamber fluctuates with the patient’s breathing: This is called tidaling and is a normal finding, reflecting changes in intrathoracic pressure during respiration. The absence of tidaling may indicate lung re-expansion or an obstruction in the tubing—not an air leak.

4. The water levels in the water-seal and suction control chambers are decreased: A drop in water levels indicates evaporation or loss of sterile fluid, not a leak. The nurse should simply add sterile water to the prescribed levels to maintain proper function.

Take-Home Points

• Continuous bubbling in the water-seal chamber is the hallmark sign of an air leak in the chest tube system.
• Intermittent bubbling during exhalation is normal and expected.
• Constant bubbling in the suction chamber indicates normal suction function, not a leak.
• Always inspect tubing, connections, and the drainage unit from the patient outward to identify the leak’s source.

The nurse should intervene if the unlicensed assistive personnel (UAP) strips or milks the chest tube, as this practice is unsafe. Stripping or milking creates dangerously high negative pressure in the pleural space, which can damage lung tissue and cause air leaks or re-expansion pulmonary edema.

Rationale for Correct Answer

3. Stripping or milking the chest tube to promote drainage: This action is contraindicated because it can generate excessive negative intrathoracic pressure, leading to lung injury or tissue trauma. Proper drainage depends on gravity and a functioning water-seal system, not manual manipulation. The UAP should never perform this action, and the nurse must provide education on safe chest tube handling.

Rationale for Incorrect Answers

1. Looping the drainage tubing on the bed: While the tubing should not be allowed to hang loosely or kink, looping it on the bed temporarily without dependent loops is acceptable as long as drainage flows freely and the tubing is below chest level. The nurse should ensure there are no obstructions, but this action alone does not require intervention.

2. Securing the drainage container in an upright position: This is correct and safe practice. The drainage system should always remain upright and below the patient’s chest to facilitate drainage and prevent backflow of fluid into the pleural space.

4. Reminding the patient to cough and deep breathe every 2 hours: This is an appropriate intervention that promotes lung expansion, prevents atelectasis, and helps re-expand the affected lung following chest surgery or pneumothorax.

Take-Home Points

• Never strip or milk chest tubes—this can cause dangerously high negative pressures and lung injury.
• The drainage system should always remain upright and below chest level for proper function.
• Encourage the patient to cough and deep breathe every 2 hours to promote lung re-expansion.
• UAPs may assist with positioning and patient reminders but must avoid manipulating the drainage system.
• The nurse is responsible for monitoring safety and providing education on appropriate chest tube care practices.

Tidaling, or the rising and falling of fluid in the water-seal chamber with the patient’s respirations, is a normal finding in a closed chest tube drainage system. It reflects pressure changes in the pleural space as the patient breathes and indicates that the system is patent and functioning properly.

Rationale for Correct Answer

1. Continue to monitor the patient: Tidaling confirms that the chest tube is maintaining negative pressure and allowing air or fluid to drain appropriately from the pleural space. As the lung re-expands, tidaling will gradually decrease and eventually stop—this is expected and not a sign of malfunction. The nurse should continue monitoring respiratory status and drainage characteristics.

Rationale for Incorrect Answers

2. Check all connections for a leak in the system: Air leaks cause continuous bubbling in the water-seal chamber, not tidaling. Since tidaling is a normal movement with respiration, there is no indication of a leak or need to inspect connections.

3. Lower the drainage collector further from the chest: The drainage system should already be positioned below the level of the chest to facilitate gravity drainage. Tidaling is unrelated to the height of the system; lowering it further does not improve function and could risk disconnection or kinking.

4. Clamp the tubing at progressively distal points away from the patient until the tidaling stops: Clamping the chest tube is contraindicated unless specifically ordered for a short diagnostic purpose. Clamping during normal tidaling interrupts drainage, increases intrathoracic pressure, and can lead to a tension pneumothorax.

Take-Home Points

• Tidaling in the water-seal chamber is a normal and expected finding that reflects changes in pleural pressure with breathing.
• Decreased or absent tidaling may indicate lung re-expansion or tube obstruction.
• Continuous bubbling, not tidaling, signals an air leak that requires investigation.
• The drainage system should remain below chest level, upright, and secure at all times.

When a chest tube is accidentally removed, the nurse’s first priority is to assess the client’s respiratory status. This determines whether the patient is experiencing respiratory distress, decreased oxygenation, or signs of a pneumothorax. Immediate assessment ensures that life-threatening complications are identified and addressed without delay.

Rationale for Correct Answer

4. Assess the client’s respiratory status: The nurse must first quickly evaluate the client’s airway, breathing, and circulation (ABCs). Assessing respiratory effort, oxygen saturation, breath sounds, and chest expansion helps determine the severity of the situation. Findings guide the urgency and type of intervention required, such as sealing the site or notifying the provider for reinsertion.

Rationale for Incorrect Answers

1. Place the tubing in sterile water to restore the water seal: This action is appropriate only if the chest tube becomes disconnected from the drainage system, not if it is removed from the client’s chest. Re-immersing the tubing in water after removal would not help because the open insertion site, not the tubing, is the concern.

2. Apply sterile gauze to the insertion site: After assessing the client, the nurse should cover the site with a sterile occlusive or petroleum gauze to prevent air entry into the pleural space, which can cause a pneumothorax. However, this comes after assessing the client’s respiratory condition.

3. Place tape around the insertion site: Taping all four sides of the dressing can trap air inside the pleural space, leading to a tension pneumothorax. The dressing should be taped on only three sides if air leakage is suspected, allowing trapped air to escape while preventing more air from entering.

Take-Home Points

• First action: Assess the client’s respiratory status to determine the impact of tube removal.
• If the tube is completely removed, apply a sterile occlusive or petroleum gauze dressing to the site.
• Do not tape all four sides—leave one side open if air is suspected to escape.
• Placing the tubing in water is only appropriate for system disconnections, not accidental removals.

When assessing a client with a chest tube, the nurse should recognize gentle bubbling in the suction control chamber and tidaling in the water-seal chamber as normal, expected findings. These indicate that the drainage system is functioning properly and that the pleural space pressure is being effectively managed.

Rationale for Correct Answers

2. Gentle constant bubbling in the suction control chamber: This is an expected finding that shows the suction source is functioning correctly. Bubbling here reflects the amount of suction being applied, not air movement from the pleural space. The bubbling should be gentle and continuous—vigorous bubbling indicates excessive suction and evaporation of water.

3. Rise and fall in the level of water in the water seal chamber with inspiration and expiration: This fluctuation, known as tidaling, indicates that pressure changes occur in the pleural space during breathing and that the chest tube is patent. As the lung re-expands, tidaling will gradually lessen and eventually stop.

Rationale for Incorrect Answers

1. Continuous bubbling in the water seal chamber: Continuous bubbling in the water seal chamber is not normal and indicates an air leak in the system or from the patient’s pleural space. The nurse should inspect all connections and notify the provider if the leak source cannot be found.

4. Exposed sutures without dressing: The insertion site should always be covered with a sterile occlusive dressing to prevent infection and air entry. Exposed sutures without a dressing indicate improper care and increase infection risk.

5. Drainage system upright at chest level: The drainage system should always be below the level of the chest to allow gravity drainage of air and fluid. Keeping it at chest level or higher can cause backflow into the pleural space, leading to lung collapse or infection.

Take-Home Points

• Gentle bubbling in the suction control chamber confirms proper suction function.
• Tidaling in the water-seal chamber shows normal pressure changes and tube patency.
• Continuous bubbling in the water-seal chamber signals an air leak that must be investigated.
• The insertion site should be covered with a sterile dressing at all times.
• The drainage system must remain below chest level to promote safe and effective drainage.

When assisting with chest tube removal, the nurse should instruct the client to perform the Valsalva maneuver. This involves taking a deep breath, holding it, and bearing down as if exhaling forcefully with a closed airway. The maneuver increases intrathoracic pressure, preventing air from entering the pleural space during tube removal and reducing the risk of pneumothorax.

Rationale for Correct Answer

4. Perform the Valsalva maneuver: The Valsalva maneuver temporarily increases intrathoracic pressure, which helps seal the pleural space as the tube is withdrawn. This technique prevents air from being sucked into the chest cavity and supports lung re-expansion. The nurse should also ensure that a sterile occlusive dressing is immediately applied to the site after removal to maintain a closed system.

Rationale for Incorrect Answers

1. Lie on his left side: Positioning on a particular side is not necessary during chest tube removal. The client is typically positioned in a semi-Fowler’s or supine position to allow comfort and easy access to the insertion site.

2. Use the incentive spirometer: Incentive spirometry is useful for promoting lung expansion after the procedure, not during removal. It should be resumed once the site is sealed and stable to prevent atelectasis.

3. Cough at regular intervals: Coughing during removal could force air into the pleural space through the open site, increasing the risk of pneumothorax. Controlled breath-holding or the Valsalva maneuver is safer and more effective.

Take-Home Points

• Instruct the client to perform the Valsalva maneuver during chest tube removal to prevent air entry into the pleural space.
• Immediately apply a sterile occlusive dressing after tube removal to maintain a closed seal.
• The semi-Fowler’s position is ideal for comfort and accessibility during removal.
• Incentive spirometry should be used after the procedure to promote lung expansion.

Following placement of a chest tube connected to a wet-suction drainage system, certain observations indicate normal function (such as gentle suction-chamber bubbling and a secure occlusive dressing), while others require immediate correction to prevent impaired drainage and respiratory compromise. A dependent loop hanging off the edge of the bed allows fluid to collect and obstruct flow, so it requires immediate intervention to restore proper, gravity-assisted drainage.

Rationale for Correct Answer

2. Dependent loop hanging off the edge of the bed: Dependent loops permit fluid to pool, creating a site of obstruction and increasing the risk of impaired drainage, backflow, and possible tension physiology. The tubing should run straight, without kinks or dependent loops, and remain below chest level to ensure continuous gravity drainage.

Rationale for Incorrect Answers

1. Bubbling in the suction chamber: Gentle, continuous bubbling in the suction control chamber is an expected finding in a wet-suction system and indicates the suction source is functioning. Only excessive or violent bubbling would prompt further assessment for excessive suction or evaporation.
3. Banded connections between tubing sections: Secured (taped or banded) connections are appropriate and help maintain an airtight system, preventing air leaks.
4. Occlusive dressing over chest tube insertion site: An occlusive dressing at the insertion site is correct practice to prevent air entry and infection; it does not require intervention.

Take-Home Points

• Dependent loops in drainage tubing must be eliminated immediately to prevent obstruction and backflow.
• Keep the drainage tubing straight, below chest level, and free of kinks or dependent areas.
• Gentle bubbling in the suction chamber and a secure occlusive dressing are expected, appropriate findings.
• Secure connections (taped/banded) help prevent air leaks and maintain system integrity.