Chest Tubes Nursing Diagnosis and Nursing Care Plan

A chest tube is also known as a chest drain tube or a chest drainage tube. A chest tube thoracostomy is the insertion of a chest tube that aims to drain blood, air, or fluid from the heart and lungs.

Thoracostomy is typically an emergency procedure, but it may also be beneficial if the patient had previous surgery on the organs or tissues in the chest cavity.

Purpose of Chest Tubes

The lung has two tissues called pleura, which contain fluid that help the patient breathe effectively. Pleural effusion, emphysema, tumors, heart failure, hemothorax, infection, and pneumothorax are all conditions and diseases that can cause blood, air, or additional fluid to accumulate in the pleural space.

Hence, the chest tube improves the patient’s breathing by expanding the lungs. Patients with certain conditions and diseases may have their lungs collapse if the pressure in their chest becomes too high without using a chest tube.

Indications of Chest Tubes

The following are the indications for chest tube insertion:

• Pneumothorax. The chest tube procedure during pneumothorax cases is achieved by inserting a flexible plastic tube along with a one-way valve that consistently removes air from the chest cavity until the lung heals and re-expands.
• Hemothorax. A chest tube is positioned between the ribs through the chest wall to drain the blood. It is left in place and suctioned for several days to re-expand the lung.
• Hemopneumothorax. Chest tube thoracostomy is the primary treatment for hemopneumothorax. The tube may be attached to a machine to assist with air and blood drainage in the lungs.
• Hydrothorax. A noninflammatory collection of serous fluid within the pleural cavities is known as hydrothorax.
• Chylothorax. Chylothorax is an uncommon but severe condition wherein the lymph (chyle) of the digestive tract lymph (chyle) accumulates in the chest cavity.
• Empyema. Empyema is a clinical term for pus pockets that have formed inside a chest cavity. Thus, empyema management includes inserting a chest tube to drain the pus completely.
• Pleural effusion. Chest tube placement is a minimally invasive procedure that prevents and treats pleural effusions (comparatively tiny incisions 2-3 inches in length with local anesthesia). Pleural effusion is a condition in which there is an excess of fluid within the lungs, particularly the pleura.
• Beneficial for intubated or about to be intubated patients with penetrating chest wall injury
• Beneficial for individuals who are about to travel by air and are at risk of pneumothorax.

Risks of Chest Tubes

The insertion of a chest tube puts the patients at risk of several complications. These are some examples:

• Pain during the procedure. Insertion of a chest tube is excruciatingly painful. Someone doctor will help the patient manage the pain by injecting an anesthetic directly into the chest tube site or through IV line. The patient will either receive general anesthesia, which will put them to sleep, or local anesthesia, which will numb the area.
• Infection. Infection is a possibility with any invasive procedure. Using sterile tools during the process minimizes this risk.
• Bleeding. A small amount of bleeding may occur if a blood vessel is ruptured during the chest tube insertion.
• Poor chest tube positioning. Sometimes, the chest tube may be placed too far or too close to the pleural cavity. In this instance, the tube may fall out, and the patient needs to stay in the hospital for further observation.

Severe risks of chest tubes are uncommon, but they can include the following:

• hemorrhage into the pleural cavity
• lung, diaphragm, or stomach injury
• The lung may collapse during tube removal.

Pre-Procedure Nursing Care: Preparing the Patient for Chest Tube Insertion

• The nurse should monitor the patient’s vital signs, especially respiratory effort.
• Before coming into contact with the patient, the nurse should thoroughly wash her hands with soap and lukewarm water and put on sterile gloves.
• The nurse should educate and counsel the patient to lessen the patient’s anxiety about the procedure.
• The nurse should elevate the patient’s bed head by 30-60 degrees and raise the affected side’s arm above the head.
• The nurse should assist the doctor in locating the tube insertion site. This location is usually between the fourth and fifth or fifth and sixth ribs, just beneath the pectoralis (chest) muscle.
• The nurse should clean the patient’s skin around the insertion site using a solution such as povidone-iodine or chlorhexidine.
• Before placing a sterile drape over the patient, the nurse should allow the skin to dry.
• The nurse should assist the doctor in desensitizing the insertion site with a local anesthetic.

What Happens During a Chest Tube Insertion

• The patient will be connected directly to apparatuses that measure heart rate, blood pressure, oxygen level, and pulse.
• An intravenous (IV) line will be inserted into a vein in the patient’s hand or arm by a nurse to administer a sedative.
• During this procedure, sedating the patient is essential. It does not require using a breathing tube, but some patients may have to undergo general anesthesia.
• The doctor will use a local anesthetic to numb the area. This procedure may cause a burning or stinging sensation before the area becomes numb.
• The nurse will sterilize the area of the patient’s body where the catheter will be inserted. The nurse will also fix the area and cover it with a surgical drape.
• The doctor will make a minimal skin incision at the insertion site.
• The doctor will incorporate a chest tube into the surgical site through the skin.
• The doctor will take images to ensure the tube is in the right site.
• A suture or adhesive tape holds the chest tube securely in place. The nurse may also add a drainage system.
• The tube is left in place until imaging indicates that the excess fluid or air in the chest has been drained and the lung has fully expanded. This procedure will only take around 30 minutes.
• The doctor will ask the patient to take deep breaths to help expand the lungs as fluid or to check if air is removed. In assessing the patient’s lung capacity, a spirometer is necessary.
• The patient can either remain at the hospital until the chest tube is removed or go home with a portable drainage system.
• When the chest tube is no longer required, the physician will remove it by loosening the suture or tape, having the patient take a deep breath, and removing the tube. A suture in the insertion site may be required or not but putting a bandage or dressing is critical. The doctor may recommend another x-ray to ensure that no extra fluid or air has accumulated in the pleural cavity.

Immediate Post-Procedure Care

• The patient will not be released from the hospital until the incision site heals. Before the patient leaves, the nurse should educate the patient on what the incision looks like so the patient can recognize if there are any signs that it is not healing correctly.
• Reassure the patient and his guardian that some light yellow or pink-colored drainage from the incision site is normal. If it continues, advise them to note the amount, color, and smell. If it produces an unpleasant smell, notify the doctor immediately.
• Instruct the patient to call a doctor if the drainage quickly changes or becomes substantial.
• Educate the patient on the following during their recovery:
  • Take a short walk outside to get some light exercise.
  • To assess lung capacity, use the incentive spirometer.
  • Perform deep breathing and frequent coughing to help the lungs re-expand.
  • Regular consumption of well-balanced meals
  • Consume plenty of water
  • Avoid drinking and smoking, as both can impede recovery.
  • Avoid anyone sick in the household because of microorganisms since the patient is more susceptible to infection.
  • Get plenty of rest at night, but avoid naps during the day if possible.
  • Take any prescribed medication regularly.
  • Take a shower before going to bed.

Chest Tube Nursing Care and Troubleshooting

• Bleeding at the insertion location of the chest tube
  • The nurse should wear gloves and put pressure on the insertion site.
  • The nurse should cover the wound with an occlusive dressing and examine the coagulation results.
  • The nurse should check the drain chamber for extreme blood loss, then consult the doctor immediately.

• Infection at the site of insertion
  • The nurse should cleanse the wound site and consider performing blood cultures.

• Chest tube system disconnection by accident
  • At the patient end, the nurse should clamp the drain tubing.
  • Examine the patient’s vital signs and consider getting a CXR.
  • Notify the doctor if the problem is not resolved.

• Difficulty in the removal of chest drain
  • The nurse must notify the doctor immediately if they cannot remove the chest drain even after good traction.

• Chest drain that remained after removal
  • If the tube fractures during drain removal and tubing remnants are found within the patient, the nurse should immediately contact the treating team.
  • Because an urgent chest x-ray is required, the nurse should assist the patient.

Removal of Chest Tube

• The doctor usually orders the chest tube to stay in its insertion site for several days. The chest tube will only be removed once the doctor determines that no additional fluid or air needs to be drained.
• The removal of the chest tube does not typically require the use of general anesthesia. After the chest tube removal, the doctor will give the patient specific instructions on appropriate breathing. Most of the time, the chest tube will be removed while holding the breath. This technique prevents extra air from entering the lungs.
• After removing the chest tube, the doctor will place a bandage over the insertion site. The patient might have a minor scar. The doctor will likely order an X-ray later to ensure no further accumulation of air or fluid inside the chest.
• The doctor may prescribe antibiotics to prevent or treat an infection.

See my article on Chest Tubes with DOPE Mneumonic

Nursing Diagnosis for Chest Tubes

Nursing Care Plan for Chest Tubes 1

Risk for Infection

Nursing Diagnosis: Risk for Infection related to insufficient primary defenses, inadequate knowledge to prevent pathogen exposure, site of pathogen invasion, contact with an infectious agent, and enhanced patient vulnerability secondary to chest tube insertion.

Desired Outcomes:

• The patient will remain infection-free, as demonstrated by typical vital signs and the absence of infection-related signs and symptoms.
• The patient will maintain or restore defenses against infection.
• The patient will be able to alleviate or minimize the infection’s symptoms.

Nursing Intervention for Chest Tubes	Rationale
Maintain strict asepsis when changing dressings, caring for wounds, administering intravenous therapy, and handling chest tubes.	The aseptic technique reduces the possibility of transmitting pathogens or spreading to or between patients. Controlling the chain of infection is an effective method for avoiding infection dissemination.
Educate patients and significant others on properly cleaning, sanitizing, and sterilizing items used in chest tube insertion or drainage.	Knowing how to reduce or eliminate pathogens minimizes the possibility of infection transmission.
Encourage the patient to consume protein- and calorie-rich foods and a balanced diet.	Proper nutrition and a well-balanced diet improve the responsiveness of the immune system and the overall health of the body’s tissues. Adequate nutrition allows the body to preserve and restore tissues while assisting the immune system in functioning correctly.
Encourage the patient to have sufficient rest and sleep.	Sleep is a critical modulator of immune responses. Sleep deprivation can reduce immunity and make the patient more susceptible to infection.
Before making contact with the patient, wash hands or practice hand hygiene. Also, teach these responsibilities to the patient and their caregivers, and be aware of when to perform hand hygiene or “5 moments for hand hygiene”:   Before touching a patientBefore any clean or aseptic procedure (wound dressing, starting an IV).After the risk of exposure to bodily fluidsAfter contact with a patientAfter interacting with the patient’s surroundings	Microorganisms are effectively removed from hands by friction and running water. Washing hands between procedures lowers the risk of pathogen transmission from one body region to another. Hands should be washed with antibacterial soap and water for a minimum of fifteen seconds before using an alcohol-based hand rub.

Nursing Care Plan for Chest Tubes 2

Risk for Bleeding

Nursing Diagnosis: Risk for Bleeding related to narrow pleural effusion, complex pleural space, inexperienced doctor, and large-volume drainage secondary to chest tube insertion.

Desired Outcomes:

• The patient will take preventative measures and recognize signs of bleeding that must be reported immediately to a health care provider.
• The patient will demonstrate typical blood pressure, steady hematocrit and hemoglobin levels, and desired ranges for coagulation profiles since no bleeding occurs.

Nursing Intervention for Chest Tubes	Rationale
Examine the patient’s medical history for signs that may indicate a risk of bleeding. Comorbidity in the patient may cause bleeding during or after chest tube insertion.	Early detection of potential bleeding risks establishes the foundation for implementing appropriate preventative measures.
Keep track of the patient’s hematocrit (Hct) and hemoglobin levels (Hgb).	When there is no observable bleeding, lower Hgb and Hct levels may be an early symptom of bleeding.
Before inserting the chest tube, evaluate the patient’s laboratory results for coagulation status, such as prothrombin time/international normalized ratio (PT/INR), platelet count, fibrinogen, activated partial thromboplastin time (aPTT), bleeding time, fibrin degradation products, activated coagulation time (ACT).	The blood clotting cascade is a complex system requiring intrinsic and extrinsic factors. Clot formation ability can be affected by changes in any of several factors. These laboratory tests provide crucial data about a patient’s coagulation status and bleeding risk.
Before inserting a chest tube, assess the patient’s intake of medications that may interfere with hemostasis (such as anticoagulants, salicylates, NSAIDs, or cancer chemotherapy).	Drugs that disrupt clotting mechanisms or platelet activity raise the risk of bleeding during chest tube insertion. Salicylates and other nonsteroidal anti-inflammatory drugs (NSAIDs) impede cyclooxygenase 1 (COX)-1, an enzyme that promotes platelet aggregation.
Before inserting a chest tube, observe the patient’s vital signs, especially blood pressure and heart rate. Keep an eye out for signs of orthostatic hypotension.	Initial compensatory mechanisms such as hypotension and tachycardia are commonly observed with bleeding during or after chest tube insertion.

Nursing Care Plan for Chest Tubes 3

Knowledge Deficit

Nursing Diagnosis: Knowledge Deficit related to a lack of exposure, a misinterpretation of information, lack of familiarity with the procedure, information complexity, and an absence of interest or unwillingness to learn secondary to chest tube insertion as evidenced by the occurrence of supposedly avoidable complications, repeated questioning, and exhibiting exaggerated behavior patterns to compensate for their lack of comprehension.

Desired Outcomes:

• The patient will exhibit an understanding of the procedure.
• The patient will be able to recognize complications of chest tube insertion.

Nursing Intervention for Chest Tubes	Rationale
Assist the patient in incorporating information about chest tube insertion into their daily lives.	This technique assists the learner in making daily adjustments that will lead to the desired behavioral change.
Encourage patients to ask more questions about the insertion of a chest tube.	Asking questions is significant in starting a practical discussion between patients and health care professionals and confirming the patient’s comprehension of the information.
Provide the patient with physical comfort.	According to Maslow’s hierarchy of needs, basic physiological needs must be met before patient education can begin. The patient can focus on what is being explained or demonstrated by ensuring maximum comfort.
Explanations and demonstrations of chest tube insertion or drainage should be straightforward, detailed, and comprehensible.	Patients are more capable of asking questions when they understand what to expect from the procedure.
Include the patient in developing the teaching plan about chest tube insertion, starting with setting objectives and learning goals at the start of the session.	Setting goals informs the learner about what will be explained and expected during the discussion. Adults tend to prioritize immediate, problem-solving education.

Nursing Care Plan for Chest Tubes 4

Anxiety

Nursing Diagnosis: Anxiety related to worry of complications, concern for family members, and post-procedure pain secondary to chest tube insertion as evidenced by sleepiness, difficulty concentrating, lethargy, hopelessness, and appetite suppression.

Desired Outcomes:

• The patient will be able to overcome their fear of chest tube insertion.
• The patient will verbalize his feelings and inform the healthcare team if they need assistance.

Nursing Intervention for Chest Tubes	Rationale
Assist the patient in identifying anxiety triggers that may require immediate interventions.	Identifying the reason behind the anxiety and fears about chest tube insertion will help determine how to manage it.
Familiarize the patient with chest tube insertion. Educate them about what to expect with the procedure.	Educating and informing the patients about the procedure can diminish their anxiety. If patients understand what will happen before, during, and after the chest tube insertion, they will be less afraid of the process.
Examine how the patient copes with anxiety using coping mechanisms and defense strategies.	Inquiring questions that require informative answers aid in assessing the effectiveness of the patient’s current coping strategies. This approach may make the patient feel like they are contributing to patient care.
Recognize the patient’s anxiety. Avoid invalidating their feelings.	Sometimes, medical procedure-related anxiety is uncontrollable. Therefore, recognizing the patient’s feelings affirms them and will help them to overcome their fear and anxiety about chest tube insertion.
Interact with the patient calmly.	The nurse or health care provider’s anxiety can be transmitted to the oversensitive patient. Relaxed and non-threatening surroundings tend to increase the patient’s sense of stability.

Nursing Care Plan for Chest Tubes 5

Risk for Injury

Nursing Diagnosis: Risk for Injury related to chest tube kinking and migration, milking, or clamping, and difficulty breathing secondary to chest tube insertion or removal.

Desired Outcome:

• The patient and significant other will recognize when is the right time to call for help in case a chest tube is dislodged or kinking.
• The patient will be able to know if there is a problem in his or her chest tube.

Nursing Intervention for Chest Tubes	Rationale
If the chest tube is dislodged, apply immense pressure to the insertion site and apply sterilized gauze or dry dressing over the insertion area to ensure a tight seal. When the patient exhales deeply, apply the bandage. If the patient develops respiratory distress, call the doctor.	Keep in mind that a chest tube falling out is an emergency. Be sure that this situation will not occur.
Ascertain that the patient’s chest tube is securely connected to the drainage system and that there is no leakage.	Since the pleural cavity is generally under negative pressure, allowing for lung expansion, any tube attached must be secured so that no air or liquid can access the space where the tube is inserted.
Continuously check the patient’s chest tube to see any presence of air bubbles in the chest tube chamber. If the nurse cannot resolve the problem, notify the doctor immediately.	This chamber’s continuous bubbling indicates a significant air leak in the drainage system. Examine the drain for disconnection, dislodgement, and loose connections, and evaluate the patient’s condition.
Continuously monitor the patient’s respiration even after removing the chest tube.	The patient may experience trouble breathing after chest tube removal. Therefore, encourage deep breathing and frequent auscultation of breath sounds, especially during the post-procedure period.
Make sure the patient’s chest tube itself is not kinked. If it happens, provide immediate intervention.	A kinked chest tube within the pleural space can result in poor drainage, distress, and trauma and may necessitate repositioning.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

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The medical information on this site is provided as an information resource only and should not be used or relied on for diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.