CREATIVE TEACHING STRATEGIES FOR CHEST DRAINAGE … · CREATIVE TEACHING STRATEGIES FOR CHEST...

TEACHER’S COLLEGE

Patricia Carroll, RN,BC, CEN, RRT, MS

Owner, Educational Medical Consultants

CREATIVE TEACHING

STRATEGIES FOR CHEST DRAINAGE

MMoorree∧∧

CREATIVE TEACHING

STRATEGIES FOR CHEST DRAINAGE

Patricia Carroll, RN,BC, CEN, RRT, MS

Participant ObjectivesAt the end of this session, you should be able to...

...describe three interactive activities used to teach chest drainage content

...develop a plan for using any of these activities in your practice setting

Interactive Activities

Four Facts pages 3-5

Do You Remember? pages 6-9

Chest Drainage Tic Tac Toe pages 10-15

Pop! Goes The Case Study pages 16-24

Question Box pages 25-34

What’s My Problem? pages 35-40

New Product Introduction Worksheets pages 41-46

Resources pages 47-55

1

MMoorree∧∧

Interactive Teaching and Learning

Today’s Instructional Environment• Limited resources

• Need to save time

• Tradition - Lectures are traditional

• Results-based education

• Helping learners remember

• Repetition is essential for learning

Keys to Success• Don’t call these activities games! They are interactive activities for

content reinforcement

• Make sure learners know the purpose of the activity

• Help learners see the connection to content

• Use teams to foster healthy competition

• Don’t force people to stand alone

• Help everyone participate

• Be concise, to the point, upbeat

• Use activities to energize

• Don’t forget to have fun!

2

Four Facts

PurposeThis exercise provides an opportunity to discuss stereotypes in a non-threatening

way. Encourages learners to think about how they make judgements about others

— patients, classmates, co-workers. Also a good icebreaker at the beginning of a

course, new employment situation.

How to do itMake a list of four facts about yourself — three should be true and one should be

false. Choose items that are not always obvious, especially those that are

different from typical stereotypes (i.e. a woman being a big sports fan, an unusual

hobby, a special talent.) Share the four “facts” with the group. (Usually best to

show the facts on an overhead projector.) Then, invite the group to share their

own “facts”. You can pair group members, and have them share one-to-one, or, if

you have more time, you can form teams and have each member of the team

share facts with other team members.

Instructions to GroupWrite four facts of your own. Remember, one is false, three are true. After you

write the facts, you’ll share them with a partner [other members of your team].

You will then need to determine which of your partner’s facts is false.

Follow UpSee sample discussion sheet.

Apply the exercise to your practice setting. For example, can be used to

emphasize that you can’t tell who is HIV positive just by looking at them. Can be

used to discuss stereotypes about people who receive Medicare and Medicaid

assistance. Can be used to launch discussion about racial and other cultural

stereotypes.

3

Part I On this sheet please list four facts about yourself. Three of them

should be true. One of them should be false.

1.

2.

3.

4.

Part II Now as a group, do the following steps, in order, one at a time.

1. List below the name of each person in your group.

2. Each person reads their four statements aloud.

3. As each person reads the four statements, list next to his or her name the

number of the statement you think is false about them and why.

4. Once each person has completed sharing the statements, take one person

at a time and have each of the remaining people tell which statement is

false and why. Then the person who shared the four statements originally

can reveal which one was really false.

5. Do this for each of the people in your group.

1. Name Statement # is false

because


because


because


because


because


because

4

Group Leader read:

1. Were you surprised at some of the “facts” that people shared? Which?

Why?

2. How good were you as a group and individually at picking the false

statement? What does this tell you about making assumptions and

judgements about people?

3. Were some of the statements made by different people similar? What

reasons could you give for this?

4. Were some of the “facts” quite different? What reasons could you give for

this?

5

Do You Remember?

PurposeThis exercise makes it easier for learners to remember lists of information by

linking content on the list to common, everyday items.

How to do itLink a list of content to common, everyday items. Collect the items, and lay them

out on a table top. Ask learners to come up and pick up one item each. In

content order, stand beside each learner, describe what the learner is holding, and

then explain how that item represents the content. After each item is described,

review content in order. Next, ask the original participants to go back to the

group, and give their item to another group member. Ask the new team to arrange

themselves in the proper order. Ask the seated group to determine if the standing

team is in the correct order. Then, review each step by linking the content to the

common item one more time. Ask learners holding the items to put them back on

the table and take a seat.

Instructions to GroupI need X people to come up to the front and pick up an item

Follow UpFor additional reinforcement, list the items on paper, and cut the paper so each

item is on a separate strip of paper. Add in three or four items that are not a part

of the content list as distractors. Put the sheets of paper in an envelope, mixed up.

Break the group into teams, and tell them this is a timed exercise. One member is

the timer. They are to take the pieces of paper out of the envelope and arrange

them in order. DO NOT tell learners there are distractors mixed in. Once they

have placed the items in the correct order, ask them to stand and cheer. Once all

teams are done, ask them to check their work against their notes. During this

activity, play loud music as a distraction.

After the exercise, learners will usually complain that there were extra items in

the envelope and the music was distracting. The teaching point is that we learn

information in the classroom where conditions are controlled. Then, when we

apply that information in the clinical setting, there are often a number of

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interfering factors. This helps learners experience distractions in a safe, otherwise

controlled setting, to help prepare them for “real life” in the clinical setting.

When you do the entire exercise, the content list will be reviewed 6 times —

which significantly enhances retention.

Application to Chest Drainage Content

Steps to Assessing the Chest Drainage System Represented by(in order from patient to wall)

Check the dressing A large doll dress

Check tubing for dependent loops A large, loopy straw

Do not strip or milk tubing Playboy magazine with

on cover, or can of

paint stripper

Check drainage Sink drain

Check for bubbling in water seal Bottle of bubbles; have

participants blow bubbles

Check for tidalling in water seal Play tape of waves from

the ocean (tide)

Check the level of water Carpenter’s level

(water seal and suction chambers)

Adjust for gentle bubbling in suction chamber Bubble bath

Make sure tubing is open Open sign (such as you

would see in a business

window)

7

�

The key to this activity is to make it fun and interactive. Ask the participant to

blow the bubbles; have another participant play the audio tape. By using different

types of items, you’ll also involve more of the learner’s senses — tactile,

auditory, visual. The more people are involved with the content, the more they

will remember. Learners will also better remember a fun lesson.

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Check the dressing

Avoid dependent loops

Do not strip or milk the tubing

Check the drainage

Look for bubbling in water seal

Look for tidalling in water seal

Check the water level in the suction chamber

Turn suction on until gentle bubbling appears

Make sure suction tubing remains open

Chest Drainage Tic Tac Toe

PurposeThis activity provides the opportunity to review content on any topic. Useful at

the end of a unit to wrap up and summarize important content.

How to do itPhotocopy the tic tac toe board on page 10 to make an overhead transparency.

Place the board on the overhead projector, with a plain, clear acetate on top of it.

Choose two teams. One will be X, the other O. Determine which team will go

first. The team chooses a box, and must answer a question about the topic

represented in the box in order to win the box. If the team answers the question

correctly, write their letter on the clear acetate on the game board over the

appropriate box. This will save your game board for future use. If the team

answers incorrectly, the other team has a chance at the question. If the other team

answers correctly, they win the box. (If you’re using true/false questions, choose

another question for the opposing team.)

The first team to get three in a row is the winner. Award prizes to the winning

team.

To make this more interactive, if all participants are not on the teams, have the

“audience” be the judge to determine if the questions were answered correctly and

if the team earned the square.

Instructions to GroupThis activity will review the content about chest drainage. You will form teams.

Each team will, in turn, choose a box and answer a question about the topic

represented by the phrase in the box. If you answer correctly, you win the box. If

you are incorrect, the other team has a chance to answer the question and win the

box. If the question is true/false, another question will be chosen. The first team

to win three boxes in a row will win the game.

Follow UpPlay as many games as needed to adequately review the content. At the end of

the game, you may reveal what topics the phrases represent.

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Chest DrainageTic Tac Toe

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Bubble, bubble,

toil & troubleIt’s a Hoover

... a window to

the soul

The beat goes

onAAA

That thing

that you do

Pressure... it’s

all about

pressure

I’m all shook

up

Vegetable

salad

Questions and Answers

Bubble, bubble, toil & trouble Bubbling in chest drain

Q. What does bubbling in the water seal chamber represent?

A. An air leak; air entering the system

Q. Describe the desired pattern of bubbling in a wet suction control chamber.

A. Gentle, not vigorous bubbling

Q. If a patient receiving mechanical ventilation has an air leak from the lung,

during which part of the respiratory cycle would bubbling be evident?

A. Inspiration; when a patient is on a ventilator, inspiration creates positive

pressure in the chest; this will push air out of the chest tube.

It’s a Hoover Chest drainage suction

Q. How do you set the level of suction in a wet suction chest drain?

A. The water level determines the level of suction.

Q. How do you set the level of suction in a dry-suction chest drain?

A. Dial in the desired level with the regulator on the chest drain.

Q. What is the most common level of suction used for the average patient?

A. 20 cm H2O

... a window to the soul Water seal manometer

Q. What do the numbers on the water seal chamber mean?

A. They reflect pleural pressure; this is a true manometer

Q. What does it mean when the water level rises half way up the water seal

chamber?

A. There is a condition of increased negative pressure in the chest

Q. Describe tidalling and what it reflects physiologically.

A. Tidalling is the rhythmic movement of the water level in the water seal that

follows pressure changes in the chest seen with respirations.

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The beat goes on Mediastinal chest tubes

Q. Define cardiac tamponade.

A. In cardiac tamponade, fluid or air collects between the pericardium and the

heart. As the air or fluid becomes greater, pressure builds, and the heart is

compressed. If the pressure is high enough, the heart cannot expand to accept

venous return and cardiac output will fall.

Q. Name four signs of cardiac tamponade.

A. Muffled / distant heart tones, increased CVP, tachycardia, decreased BP,

decreased cardiac output, jugular venous distension.

Q. Explain why it would be more unusual to see bubbling in the water seal

chamber of the chest drain of a patient with a mediastinal chest tube

compared with a pleural tube.

A. Bubbling in the water seal indicates air entering the system. There shouldn’t

be an air leak from the heart; there can be from the lung.

AAA Autologous transfusion

Q. Why can blood drained from the chest through a chest tube be used for

autologous transfusion?

A. Blood that comes into contact with the pericardium or pleurae is

defibrinogenated and will not clot.

Q. According to American Association of Blood Banks guidelines, what is the

maximum number of hours that can elapse from the beginning of blood

collection to the end of the transfusion?

A. Six hours.

Q. Describe the difference between intermittent and continuous autotransfusion

from a chest tube.

A. Intermittent ATS uses bags to collect blood. The bag is removed from the

system and hung on the IV pole for reinfusion. In continuous ATS, IV tubing

is connected to the collection chamber, and an infusion pump is used to pump

blood from the collection chamber to an IV site. The system is not opened

for reinfusion.

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That thing you do Functions of the parts of the chest drain

Q. Describe the function of the collection chamber.

A. The collection chamber collects fluid drainage from the chest.

Q. Describe the function of the water seal chamber.

A. The water seal chamber creates a one-way valve. Air is allowed to leave the

system, but not re-enter.

Q. Describe the function of the suction control chamber.

A. The suction control chamber limits the amount of negative pressure that can

be transmitted to the pleural or mediastinal space.

Pressure... it’s all about pressure Tension pneumothorax

Q. Define tension pneumothorax

A. A tension pneumothorax describes air collected in the pleural space under

pressure. As the tension increases, the lung collapses and the mediastinum

can shift.

Q. List 3 signs of tension pneumothorax.

A. Decreased breath sounds on the affected side, hyperresonance to percussion

on the affected side, tracheal shift away from the affected side, affected side

does not move with respirations, sustained increase in pressure on the

pressure manometer on a ventilator, difficulty compressing the manual

resuscitation bag.

Q. What is the emergency treatment for tension pneumothorax when the patient’s

condition is rapidly deteriorating?

A. Needle thoracotomy

I’m all shook up Chest trauma

Q. Describe the difference between an open and closed pneumothorax.

A. An open pneumothorax is a penetrating wound; the pneumothorax occurs

because of a hole in the chest wall. A closed pneumothorax occurs when

the chest wall is intact.

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Q. For the three following conditions, identify whether it would cause a closed

or open pneumothorax: A. rib fractures B. knife stab wound C. deceleration

injury

A. rib fractures: closed; stab wound: open; deceleration: closed

Q. Explain why children are less likely to have rib fractures with chest trauma

compared with adults.

A. Children’s ribs are more cartilaginous than adults’. They will bend, but not

break as easily.

Vegetable salad CABG

Q. When two chest tubes are used post-operatively in the mediastinum, where are

they positioned in the chest?

A. Anterior and inferior to the heart.

Q. In which type of CABG surgery is the surgeon more likely to enter the pleural

space?

A. Internal mammary artery grafts.

Q. Name two indications mediastinal chest tubes can be removed following

CABG.

A. Drainage < 100 ml in previous 8 hours; no air leak; patient is weaned from the

ventilator; chest x-ray is normal; coagulation studies are normal.

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POP! Goes the Case Study

PurposeThis activity provides an interactive opportunity for participants to answer

questions about case studies. This activity tests / reviews a higher level of

knowledge than the Tic Tac Toe game in this kit because these questions require

the participant to apply content knowledge to patient situations.

How to do itPhotocopy the questions that appear on pages 21, 22 & 23. Cut them into

individual squares. Each question is assigned a point value; the lower the point

value, the easier the question.

Collect 12 balloons — four each in three different colors. Stuff one question into

each balloon. Choose all of the same color balloons for the same point value (100

point questions pink, 200 point questions blue, 300 point questions yellow, for

example.) Blow up the balloons with the questions inside.

Divide participants into teams. A team will choose the point value they desire,

then pop the proper color balloon and read the question. If they answer the

question correctly, they earn the points. If they answer incorrectly, the other team

can try — if they get it right, they earn the points. Alternate questions back and

forth between teams until all the balloons have been popped. Whichever team has

the most points wins. Award prizes to the winning team.

Instructions to GroupThis activity will help you apply the content you’ve learned about chest drainage.

[break group into teams]

Each balloon has a question in it. The balloon colors represent the point value of

the question [explain which point value is assigned to each color.] Your team will

choose a balloon, pop it, and ask the question contained inside. If you get it right,

you earn the points. If you get it wrong, the other team can try the question.

Whichever team has the most points when the balloons are gone is the winner.

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Follow UpAt the end of the activity, answer any questions from the participants about

applying their knowledge of chest drainage to patient situations. Provide

remediation if there are content areas that need reinforcement.

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100 Point Questions

Q. The patient has had coronary artery bypass surgery. Drainage collection for

autotransfusion was begun at 2 pm, when the patient was admitted to the

ICU from the OR. An intermittent ATS system is being used. According

to AABB guidelines, the transfusion should be completed by what time?

A. 8 pm

Q. At the beginning of your shift, you’re caring for a patient with a

spontaneous pneumothorax. You walk into the patient’s room, and you can

hear the suction control chamber’s bubbling sound from the doorway.

When you look at the chamber, you see vigorous bubbling. What would

you do next?

A. Assess the patient; turn vacuum regulator (wall) down until there is only

gentle bubbling in the chamber.

Q. You’re caring for a patient breathing spontaneously following lung volume

reduction surgery. While you’re assessing the water seal chamber, the

patient coughs. You see bubbling in the chamber only during the cough.

What does this mean, and what nursing actions are required?

A. It is common to see bubbling with a cough. A cough generates high

intrapleural pressures, and can push air out through the chest tube and into

the water seal chamber. No nursing actions are required except for regular

assessment of the patient and chest drainage system.

Q. Your patient had a thoracotomy 36 hours ago; a lobectomy was performed.

You turn the patient from supine into a side-lying position, and

approximately 200 cc of dark blood spills into the collection chamber of the

chest drain. What does this mean, and what nursing actions are required?

A. Since blood coming in contact with the pleurae is defibrinogenated, it does

not clot within the chest. It’s not uncommon for drainage to be

inaccessible to the chest tube until the patient is turned. As long as it is

dark in color, there is no indication of fresh bleeding, and no nursing

actions are required other than regular assessment of the patient and chest

drainage system.

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200 Point Questions

Q. A patient was in an auto accident. His car struck a telephone pole. He is

admitted to the ICU because of neurological injuries. On physical exam,

the patient has a reddened area the size of a fist over his sternum, and

marks from the seat belt on his chest. Four hours post injury, you make the

following assessment:

BP 90/60; HR 128 ST; JVD; CVP changed from 7 to 15.

What is your next action? What do you think is going on?

A. Listen to heart tones, notify physician; possible cardiac tamponade from

deceleration injury.

Q. A patient has had a thoracotomy after being stabbed in the chest. He is on

a ventilator and has two pleural chest tubes in place. During the night, the

patient becomes disoriented and pulls out the chest tubes. What key pieces

of information do you need to guide your emergency actions? Besides

calling for help and notifying the physician, what would you do next?

A. The nurse must know whether there was an air leak. If an air leak was

present, a DSD should be applied to the chest, but only secured on three

sides so air can leave the chest through the dressing. If there was no air

leak, an occlusive dressing can be applied.

Q. A patient has had a CABG with the internal mammary artery. During your

assessment of the chest drain, you note new bubbling in the water seal

chamber. Describe what you would do to determine where this air leak is

from.

A. Clamp the chest tube momentarily, beginning at the patient, where the chest

tube leaves the chest. Clamp and look at the chamber to see whether the

bubbling has stopped. If you clamp at the chest and the bubbling goes

away, the leak is coming from the chest. If you clamp at the chest and the

bubbling persists, the leak is between the clamp and the water seal chamber.

Move the clamp down the tubing toward the chest drain — clamp and

reassess. When the bubbling goes away, the clamp is below the site of the

leak.

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Q. A multiple trauma patient is on a ventilator post op without PEEP. She is

unconscious, and has a left chest tube. You are alerted to the bedside by the

high pressure alarm on the ventilator. When you look at the ventilator’s

manometer, the needle does not go to zero. You disconnect the patient from

the ventilator to bag her, and have a very difficult time squeezing the bag

between your hands. You call for help. What do you think the problem is,

and what should be done next?

A. Tension pneumothorax. Assess to see if the problem is on the side with the

chest tube or the other side. Listen to breath sounds, look at water seal

chamber of chest tube, follow tubing to make sure the tubing is not occluded.

Prepare for needle thoracotomy and possible chest tube placement.

300 Point Questions

Q. A patient has severe ARDS. She is on a ventilator with maximal support,

including 20 cm H2O of PEEP. She has a chest tube to treat a pneumo-

thorax that occurred as a result of barotrauma. When you assess the water

seal chamber, you see continuous bubbling. Explain this assessment finding;

how do you explain it, and do you need to do anything about it?

A. This is to be expected. The PEEP creates positive pressure within the chest,

and pushes air out through the hole in the lung and the chest tube. When

PEEP is that high, the leak can be continuous. No nursing intervention is

required except to carefully monitor the patient.

Q. A trauma patient comes into the Emergency Department. He has been shot

and is bleeding from the chest. The bullet entrance wound is in the right

lower quadrant of the abdomen; the exit wound is from the chest under the

left arm. Is this patient an ideal candidate for autotransfusion from the chest

tube? Why or why not?

A. With that bullet path, bacteria from the bowel could have been carried into

the chest. Bacterial contamination is a contraindication to autotransfusion.

But, it is a relative contraindication. If the patient will bleed to death

without the transfusion, the risk of bacterial contamination may be worth

taking. There’s always antibiotics...

20

Q. A patient has had a lung volume reduction surgery. The surgeon wants the

suction level in the suction chamber of the chest drain set at 10 cm H2O.

There is minimal bubbling in the water seal chamber. On chest x-ray, the

lung is not completely expanded. What can be done with the chest drainage

system to enhance evacuation of the chest?

A. The setting on the vacuum regulator can be increased to increase flow rate

through the system without increasing imposed negative pressure. This may

help evacuate the chest and re-expand the lung.

Q. At the beginning of your shift, you assess your patient’s chest drain. The

water level in the water seal chamber is all the way at the top of the chamber.

What does this mean, and what should you do about it?

A. It means a condition of high negativity has occurred in the chest. This can

mean the chest tube was stripped. This can be due to respiratory distress, in

the case of a pleural tube, or it can mean the chest tube was stripped. Vent

the pressure by pressing the manual negative pressure release valve. The

water level should then return to baseline. Continue to monitor the patient,

assessing for conditions that could have caused the high negativity.

21

22

100 Points

The patient has had coronary

artery bypass surgery. Drainage

collection for autotransfusion was

begun at 2 pm, when the patient

was admitted to the ICU from the

OR. An intermittent ATS system

is being used. According to

AABB guidelines, the transfusion

should be completed by what

time?

100 Points

At the beginning of your shift,

you’re caring for a patient with a

spontaneous pneumothorax. You

walk into the patient’s room, and

you can hear the suction control

chamber’s bubbling sound from

the doorway. When you look at

the chamber, you see vigorous

bubbling. What would you do

next?

100 Points

Your patient had a thoracotomy

36 hours ago; a lobectomy was

performed. You turn the patient

from supine into a side-lying

position, and approximately

200 cc of dark blood spills into

the collection chamber of the

chest drain. What does this mean,

and what nursing actions are

required?

100 Points

You’re caring for a patient

breathing spontaneously

following lung volume reduction

surgery. While you’re assessing

the water seal chamber, the

patient coughs. You see bubbling

in the chamber only during the

cough. What does this mean, and

what nursing actions are

required?

23

200 Points

A patient was in an auto accident.

His car struck a telephone pole.

He is admitted to the ICU

because of neurological injuries.

On physical exam, the patient has

a reddened area the size of a fist

over his sternum, and marks from

the seat belt on his chest. Four

hours post injury, you make the

following assessment:

BP 90/60; HR 128 ST; JVD; CVP

changed from 7 to 15

What is your next action? What

do you think is going on?

200 Points

A patient has had a thoracotomy

after being stabbed in the chest.

He is on a ventilator and has two

pleural chest tubes in place.

During the night, the patient

becomes disoriented and pulls out

the chest tubes. What key piece

of information do you need to

guide your emergency actions?

Besides calling for help and

notifying the physician, what

would you do next?

200 Points

A patient has had a CABG with

the internal mammary artery.

During your assessment of the

chest drain, you note new

bubbling in the water seal

chamber. Describe what you

would do to determine where this

air leak is from.

200 Points

A multiple trauma patient is on a

ventilator post op without PEEP.

She is unconscious, and has a left

chest tube. You are alerted to the

bedside by the high pressure

alarm on the ventilator. When

you look at the ventilator’s

manometer, the needle does not

go to zero. You disconnect the

patient from the ventilator to bag

her, and have a very difficult time

squeezing the bag between your

hands. You call for help. What

do you think the problem is, and

what should be done next?

24

300 Points

A patient has had lung volume

reduction surgery. The surgeon

wants the suction level in the

suction chamber of the chest

drain set at 10 cm H20. There is

minimal bubbling in the water

seal chamber. On chest x-ray, the

lung is not completely expanded.

What can be done with the chest

drainage system to enhance

evacuation of the chest?

300 Points

At the beginning of your shift,

you assess your patient’s chest

drain. The water level in the

water seal chamber is all the way

at the top of the chamber. What

does this mean, and what should

you do about it?

300 Points

A patient has severe ARDS. She

is on a ventilator with maximal

support, including 20 cm H20 of

PEEP. She has a chest tube to

treat a pneumothorax that

occurred as a result of

barotrauma. When you assess the

water seal chamber, you see

continuous bubbling. Explain this

assessment finding; how do you

explain it, and do you need to do

anything about it?

300 Points

A trauma patient comes into the

Emergency Department. He has

been shot and is bleeding from

the chest. The bullet entrance

wound is in the right lower

quadrant of the abdomen; the exit

wound is from the chest under the

left arm. Is this patient an ideal

candidate for autotransfusion

from the chest tube? Why or why

not?

Question Box

PurposeThis activity provides learners with an interactive opportunity to answer questions

and earn points while reviewing their knowledge of chest drainage and related

conditions. This activity is designed as an end-of-course, comprehensive review.

How to do itPhotocopy the game board on page 33 on an acetate so it can be used as an

overhead transparency. Place the transparency on the overhead projector.

Divide learners into teams. The number of teams and the number of learners per

team will depend on the total number of learners. Have a member of each team

draw a numbered piece of paper (from a box or paper bag) to determine the order

in which the teams will ask and answer questions.

The team that chose the number one will go first; number two will go second and

so on. The first team will choose a category and point value. The facilitator asks

the question (questions and answers listed by category and point value begin on

page 26.) If the team answers correctly, they are awarded the points assigned to

the question. If the team answers incorrectly, the next team in order has the

chance to answer the question. This continues until the correct answer is given. If

none of the teams answers correctly, the facilitator provides the correct answer,

discusses the rationale, and no points are awarded. The first team then starts over,

selecting another question. Once a correct answer is given, the next team chooses

a category and point value and another question is asked.

Teaching TipOnce a question has been asked and correctly answered, the facilitator covers the

game board box corresponding to that question with a 2" x 1.5" self-stick note.

This will black out the box on the overhead, indicating the question is "gone."

The game board is specially designed to accommodate the notes of this size.

The game continues until all questions are asked and answered. The team with the

most points at the end of the game wins. Award small prizes to the winning team.

25

Instructions to GroupThis activity will allow you to review your knowledge of chest drainage and

related conditions.

[break group into teams]

You will draw lots to determine the order in which your teams will be able to

choose questions and answer them. If your team answers correctly, your team will

win the corresponding number of points. If you answer incorrectly, the next team

will get the chance to answer the question. The lower the point value, the easier

the question. At the end of the game, the team with the most points will win a

prize.

Follow UpProvide rationales for answers when learners have trouble mastering a subject.

Provide any remediation for content as indicated by learners' responses to

questions. Relate questions and answers to hospital policy / procedure /

competencies whenever possible.

26


Mediastinal Drainage

100 Points

Q. Chest tubes placed after coronary artery bypass surgery are positioned in

this sac.

A. Pericardial

200 Points

Q. This complication is characterized by muffled heart tones, decreased

cardiac output and increased right atrial pressure.

A. Pericardial / cardiac tamponade

300 Points

Q. This action can create negative pressures as high as -400 cm H2O in the

chest and is no longer recommended for routine postoperative nursing care

of patients with mediastinal chest tubes.

A. Stripping the tubing

400 Points

Q. This type of coronary artery bypass surgery grafting may require a pleural

chest tube postoperatively if the pleural space is entered.

A. Left internal mammary artery graft (LIMA)

500 Points

Q. This substance, covalently bonded to some chest tubes, decreases the

incidence of catheter thrombosis.

A. Heparin.

27

Pleural Drainage

100 Points

Q. This condition is characterized by an accumulation of air between the

visceral and parietal pleurae.

A. Pneumothorax

200 Points

Q. This condition is characterized by diminished or absent breath sounds on

the affected side, a shift of the trachea away from the affected side, and

hyperresonance to percussion.

A. Tension pneumothorax.

300 Points

Q. Using anatomical directional terms, describe the position a chest tube is

ideally located in when placed in the chest to drain fluid alone.

A. Inferior and posterior

400 Points

Q. Using anatomical directional terms, describe the position a chest tube is

ideally located in when placed in the chest to evacuate air alone.

A. Anterior and superior

500 Points

Q. This amount of fluid (in cc or mL) is required for a pleural effusion to be

seen on an upright chest radiograph.

A. 300 to 500

28

Water Seal Chamber

100 Points

Q. Seeing these in the water seal chamber indicates an air leak in the chest

drainage system.

A. Bubbles

200 Points

Q. This is the name for the up and down motion of the water in the water seal

chamber that corresponds to the intrathoracic pressure changes associated

with a patient's respirations.

A. Tidalling

300 Points

Q. When a patient takes in a very deep breath before a cough, and creates high

negative intrathoracic pressure, what will happen to the water level in the

water seal chamber?

A. It will rise.

400 Points

Q. Describe what the numbers on the long arm of the water seal chamber

mean.

A. The water seal chamber is a U-tube manometer. The numbers are

measurements of negative pressure in cm H2O

500 Points

Q. If the level of water in the water seal chamber is halfway up the long arm

of the chamber, the nurse should perform this action to return the water

back down to the baseline level in the chamber after the patient's condition

has been assessed.

A. Depress the manual high negativity vent on the top of the chest drain.

29

Managing Chest Tubes

100 Points

Q. What is the time interval for routinely changing a chest tube dressing?

A. A chest tube dressing should not be changed routinely; only when it is

soiled, loose or otherwise compromised.

200 Points

Q. A patient with a chest tube is scheduled to go to the radiology department

for a chest radiograph. What would you do with the drain and the tubing

when the patient is on the stretcher, ready for transport?

A. Disconnect from suction; if stopcock is present on suction tubing, check to

see that the stopcock is in the completely open position; assure that the

drain remains below the patient's chest level to allow for gravity drainage;

check to see that there are no dependent loops in the tubing [Teaching

point: key aspect is that the chest tube should NOT be clamped for

transport]

300 Points

Q. Describe how the wall vacuum regulator should be adjusted for a patient

with routine chest drainage with a water-filled suction control chamber.

A. Turn suction regulator down until bubbling just stops. Then, increase the

wall vacuum source until gentle bubbling just begins in the suction control

chamber.

400 Points

Q. There has been no evidence of an air leak in the water seal chamber, the

lung is fully re-expanded on a chest radiograph, and fluid drainage has been

less than 50 cc in the past 24 hours. What procedure can you expect to

prepare the patient for?

A. Chest tube removal.

30

500 Points

Q. A mechanically ventilated patient's chest tube has become disconnected

from the tubing leading to the drain, and the drain is cracked. Prior to this

event, there was bubbling in the water seal chamber. While a colleague is

getting another drain, what immediate nursing action would be best for this

patient?

A. Stick the end of the chest tube into a bottle of sterile saline or sterile water

to a depth of approximately 2 cm. [the bubbling in the water seal indicates

an air leak. DO NOT clamp the tube, because a tension pneumothorax

could result. Placing the chest tube under water creates a water seal,

allowing air to leave and not re-enter the chest. This action will best protect

the patient until a new chest drain is set up and available to be connected to

the chest tube.]

31

Potpourri

100 Points

Q. Describe, specifically, the emergency treatment for a patient with a tension

pneumothorax whose condition is rapidly deteriorating while equipment is

being set up for chest tube insertion.

A. Needle decompression in the second intercostal space, in the mid-clavicular

line.

200 Points

Q. What is the difference between an open pneumothorax and a closed

pneumothorax?

A. In an open pneumothorax, the chest wall is penetrated (such as a stab

wound or gunshot); this is often called a sucking chest wound. In a closed

pneumothorax, the chest wall is intact (such as injury to the lung from a

broken rib, or barotrauma during mechanical ventilation.)

[Teaching point: a closed pneumothorax is potentially more dangerous

because it can lead to tension pneumothorax. An open pneumothorax

naturally vents pressure through the opening in the chest, so tension

pneumothorax will not occur unless a pressure / occlusive dressing is

applied. A dressing should only be taped on three sides to allow pressure to

be relieved through the open side of the dressing for safety until a chest

tube can be inserted.]

300 Points

Q. Describe how you would check for the source of an air leak in a chest

drainage system when bubbles are present in the water seal chamber.

A. Momentarily clamp the chest tube, with a padded clamp or special flat

tubing clamp (without teeth that could damage the tubing) starting at the

place where the tube leaves the chest. When the tube is clamped, look at

the water seal chamber. When the clamp is placed distal to the leak, the

bubbling will stop. Work your way down the tubing with the clamp to

determine the location of the leak. [Teaching point: if the chest tube is

clamped as it leaves the chest and the bubbling stops immediately, the leak

is from the lung. If the tubing is clamped as it enters the drain, and the

bubbling continues, the leak is in the drain itself.]

32

400 Points

Q. What would you do if you inadvertently overfilled the water seal chamber

above the 2 cm AFill to here@ line?

A. Use a needle and syringe and withdraw the extra fluid through the rubber

grommet on the front of the drain.

500 Points

Q. How does PEEP on a ventilator affect bubbling in the water seal chamber

when a patient has an air leak from a pneumothorax?

A. Bubbling will be continuous when PEEP is used. [The positive pressure

from the PEEP during exhalation will continue to push the air through the

hole in the lung.]

33

110000

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00

4400

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What's My Problem?

PurposeThis activity provides an interactive opportunity for learners to review the

assessment findings of patients with a variety of conditions related to chest

drainage.

How to do itPhotocopy the list of thoracic disorders on page 37. Cut the copy into sections, so

that each section contains a single disorder.

Tape a different disorder on each learner's back. Each learner's task is to

determine what disorder is taped on his or her back by asking other learners

questions related to how he or she would assess a patient with a disorder related

to chest drainage.

This activity can be carried out in a number of ways to vary the level of difficulty

and evaluate learning at different cognitive levels. For example:

• You may copy the list of disorders on acetate to make an overhead

learners can refer to as they are trying to determine which disorder is "theirs"

to make the exercise a bit easier

• You can provide a list of assessment questions to direct learners, such as:

breath sounds, percussion findings, degree of dyspnea, assessment of chest

drain, heart sounds, and so on.

This is a particularly effective learning activity because not only do the people

with the disorders on their backs have to determine what "their" disorder is, based

on the assessment data they collect, but they must know about other disorders in

order to answer other learners' questions.

Instructions to GroupThis activity will allow you to review your knowledge of the assessment of

patients with a variety of conditions relating to chest drainage and pleural

disorders.

35

Each of you will have a disorder taped to your back. You will ask other members

of the group to look at your back to see "what your problem is," and then you will

ask one assessment question of each of your colleagues. You might ask about

breath sounds, heart tones, vital signs, the chest drainage system and so forth. You

should be collecting assessment data to answer the question "What's my

Problem?"

[Note: if the group is small, people may ask multiple questions of other learners,

or the facilitator may choose to pair up learners to ask each other questions.]

When you wish to name your problem, tell another learner of your diagnosis, and

the other learner will tell you whether you are correct. If you are incorrect,

continue to collect assessment data until you reach the correct answer.

[The facilitator may provide the list of disorders or sample assessment questions

as noted above; the use of these tools should also be explained to the learners.]

An abbreviated listing of assessment findings related to the eight conditions listed

on page 37 is on pages 38-39.

Teaching TipThis technique can be applied to many different aspects of content in a critical

care nursing course.

Blood Gas InterpretationNames of blood gas interpretations are taped to learners' backs; for example:

• Compensated metabolic acidosis

• Partially compensated respiratory alkalosis

Instruct learners to ask questions that can only be answered yes or no, such as "Is

my pH high?" Instead of using numerical values, yes and no questions that refer

to high, normal or low values reinforce the concept of how the different values

change in different conditions; specific numbers are not as important as knowing,

for example, that the PaCO2 level would be high, low or normal for a given

condition.

ECG InterpretationLearners' understanding of concepts relating to rhythm strip interpretation can be

tested on two cognitive levels. At the lower level, the name of the rhythm in

words is used, such as atrial fibrillation, sinus bradycardia and so forth.

36

To evaluate at a higher level, simply tape rhythm strips on the learners' backs.

Then, the other learners must be able to interpret the rhythm in order to provide

accurate information as they are asked questions.

In this case, questions would relate to ECG configuration such as: Is my PR

interval prolonged? Does a P wave come before every QRS complex? Is my rate

above 60? and so forth.

37

My Chest Drainage Problems

Tension pneumothorax without a chest tube

15% pneumothoraxpatient came to the ER with pleuritic chest painno intervention yet

1000cc right sided pleural effusionno intervention yet

Routine postoperative thoracotomy patientmechanical ventilation without PEEPair leak from the lung through the chest tube

Postoperative trauma patient with flail chest and pneumothoraxARDSmechanical ventilation with 12 cm H2O PEEP

Postoperative coronary artery bypass graftmedian sternotomyleft internal mammary artery graftpleural space entered during surgery; pleural tube in place

Postoperative coronary artery bypass graftmedian sternotomy, saphenous vein graftcardiac tamponade

Postoperative coronary artery bypass graftmedian sternotomy, saphenous vein graftroutine

38

Condition

Tension pneumothorax without a chesttube

15% pneumothoraxpatient came to the ER with pleuriticchest painno intervention yet

1000 cc right sided pleural effusionno intervention yet

Routine postop thoracotomy patientmechanical ventilation without PEEPair leak from lung through chest tube

39

Assessment

Decreased or absent breath sounds on

affected side

Trachea deviated away from affected

side

Hyperresonance to percussion

Decreased blood pressure

Increased heart rate

Increased right sided heart pressures

Jugular venous distension

May or may not have decreased breath

sounds

No tracheal shift

Pleuritic chest pain on affected side

Vital signs normal; may have slightly

increased respiratory rate

Typically adolescent male, may have

had this before

Typically treated with watchful waiting

& repeat chest radiograph; perhaps 23

hour admission for observation

Diminished breath sounds on affected

side

May have pleuritic chest pain on

affected side

Dyspnea due to lung compression

Increased respiratory rate

Dullness to percussion

History of CHF, cancer or other

condition that could lead to pleural

effusion

Should have normal vital signs

One or two chest tubes in place

Bubbling in water seal chamber with

ventilator breath

Chest drain on suction

Postoperative trauma patient with flailchest and pneumothoraxARDSMechanical ventilation with 12 cmH2OPEEP

Postoperative coronary artery bypassgraft via median sternotomyLeft internal mammary artery graftPleural space entered during surgeryPleural chest tubes in place

Postoperative coronary artery bypassgraftMedian sternotomy, saphenous vein graftRoutine postoperative course

Postoperative coronary artery bypassgraftMedian sternotomy, saphenous vein graftCardiac tamponade

40

May have decreased breath sounds on

affected side

May have one or multiple chest tubes

Poor oxygenation

High levels of mechanical ventilatory

support

Continuous bubbling in water seal

chamber due to PEEP

Chest drain on suction

Vital signs should be stable

Patient’s condition overall should be

stable

Mediastinal chest tubes in place

Pleural chest tube in place

May have more than one chest drain

May or may not have bubbling in water

seal, depending if there is an air leak

from the lung where the pleural space

was entered

Bloody to serosanguinous drainage in

collection chamber

Vital signs should be stable

Patient’s condition overall should be

stable

Mediastinal chest tubes in place

Should not have bubbling in water seal

Bloody to serosanguinous drainage in

collection chamber

Muffled heart tones

Reduced drainage from mediastinal

chest tubes

Decreased BP, increased HR, decreased

cardiac output, increased right heart

pressure

Jugular venous distention

41

New Product Introduction Worksheet

1. Specifically, what is being introduced? Pneumostat chest drain valve

2. Why is this product being introduced?

Innovation, regulatory requirement, better

product, standardization?

Innovation, better product than current one-way valve

3. What does the learner already know that

can be used as a foundation for learning

about this product? (It's similar to X)

Relate to water seal of chest drain system,relate to current one-way valve used forpneumothorax

4. How can learners "play" with the new

product to validate it based on past

experience?

Product inexpensive, able to unwrap sterileunits for handling for teaching purposes ,learners can hold

5. What information is the "need to know"

that will be immediately useful to the

learners in their "real world"?

How to hook up, how to assess air leak,how to drain fluid, when to change device,not to tape to chest, use clip to attach toclothing

6. How will this product solve a problem or

fill a need the learner has? Make their job

easier?

No need to jury-rig one -way valve for fluiddrainage, self-contained, no risk of spillage& violating standard precautions, lighter forpatient

7. How can learners be actively involved in

learning about this new product?

Let them handle device, refer to CreativeTraining Strategies Handbook for ideas

8. How will the information you provide

apply to everyday practice? (Relate content

to practice)

One-way valve already in use, no theoryneeded - purely practical info on how deviceworks & how to monitor

9. What are the likely perceptions of

patients/families the nurse should be ready

for?

Patients should be pleased, device muchlighter than drainage tubing, allowsmobility

42

Notes to Users:

Items 2 - 8 focus on adult learning principles

Items 1, 9 - 13 focus on product introduction principles

References:

Impact of self-instructional module for the nurses on nursing-management of the patients

having chest tube drainage. Nursing Journal of India 2002; 94(2):33-34.

McClellan M, Henson RHS: Introducing new technology: confusion or order? NursingManagement 1994;25(7):38-41.

Padberg RM, Padberg LF: Strengthening the effectiveness of patient education: applying the

principles of adult education. Oncology Nursing Forum 1990;17(1):65-69.

10. Does the nurses need to know a lot of

information to use the product safely, or

does the nurse need to know about the

product, but the primary user will be

someone else?

Nurses will need to be experts, monitor thedevice and perform pulmonary assessmentsas with any patient with a chest tube

11. What support is available to nurses

using the product? (24 hour telephone

support, learning guides, internal support)

24/7 toll free number from manufacturer

12. How will this product affect the nursing

role? Simplify or make more complex?

Should make nursing role easier - self-contained unit eliminates need to rig updrainage collection - no risk of spillage

13. Is this product introduction an

organization priority? Can it be delayed?

Who benefits from successful introduction?

Priority for fast-track program, do not wantto delay, benefits: patient, hospital withreduced LOS, surgeons, pulmonaryphysicians, interventional radiologists, ER,nurses

43


1. Specifically, what is being introduced? Express Mini 500 Chest Drain




Innovation, key to fast-track program tofacilitate early ambulation in effort toreduce LOS




Same principles as traditional chest drain:collection chamber, mechanical one-wayvalve instead of water seal, preset suctionlevel -20cmH2O



experience?

Small compact drain, able to unwrap sterileunits - can demo negative pressure indicatorby inhaling through patient tube




How to hook up, how to assess air leak ornegative intrapleural pressure, how toapply straps so patient can ambulate easily



easier?

Lighter weight, less pain for patient, mucheasier for patient to get out of bed; patientcan walk independently



Handle device, refer to strategies inCreative Training Strategies Handbook



to practice)

Chest drains already standard practice,emphasize organizational goals of earlyambulation and shorter LOS



for?

Patients should be pleased, device is muchlighter than traditional drain, less pullingon chest tube; may be apprehensive aboutwalking soon after surgery

44

Notes to Users:



References:

Impact of self-instructional module for the nurses on nursing-management of the patients

having chest tube drainage. Nursing Journal of India 2002; 94(2):33-34.








someone else?

Nurses will be the experts, monitor thedevice and perform assessments as with anypatient with a chest tube




24/7 toll-free support from manufacturer,self-study CE program from manufacturer



Should simplify nursing care becausepatients will be able to walk moreindependently




Priority for fast-track programs in cardio-thoracic surgery and to enhance safety fortransportation on LifeFlight; want toimplement ASAP, patients, staff andorganization all benefit

45


1. Specifically, what is being introduced?









experience?






easier?





to practice)



for?

46

Notes to Users:



References:








someone else?









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Pike RW: Creative training techniques handbook ed 2. 1994 Lakewood Books.

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Pike RW: Creative training techniques workbook. 1990 Creative Training

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Zielinski D ed: The best of creative training techniques newsletter. 1990

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Chest Drainage

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47

Broscious SK: Music: an intervention for pain during chest tube removal after

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48

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50

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Patricia Carroll

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