A chest tube, or thoracostomy tube, is a catheter inserted into the chest cavity to remove unwanted air, fluid, or blood from the pleural space. Its primary function is to re-establish the normal negative pressure required for the lung to fully expand. When a chest tube is accidentally dislodged, the opening immediately compromises this negative pressure, creating a medical emergency. Outside air rushes into the chest cavity, which can rapidly lead to a collapsed lung (pneumothorax) or a life-threatening tension pneumothorax. Swift, precise nursing action is paramount to secure the site and stabilize the patient before severe respiratory compromise occurs.
Immediate Site Management and Occlusion
The first response to a dislodged chest tube is to remain calm, apply immediate pressure to the insertion site, and call for assistance. This initial action prevents air from rushing into the pleural space while the nurse prepares a definitive dressing. Immediately retrieve a sterile dressing, such as a 4×4 gauze, to apply over the open wound.
The immediate action shifts to creating a temporary, life-saving seal over the opening with an occlusive dressing. This dressing must be a sterile material, such as petroleum gauze (Xeroform), placed directly over the wound to prevent air from passing through.
A non-porous material, such as plastic sheeting or a transparent adhesive dressing, is then secured over the petroleum gauze. To prevent a tension pneumothorax, the dressing must be taped down firmly on three sides only, leaving the fourth side open and untaped.
This three-sided seal acts as a flutter valve, functioning as a one-way mechanism that is critical for patient safety. When the patient inhales, negative pressure pulls the untaped edge closed, preventing air entry. When the patient exhales or coughs, positive pressure pushes air out through the untaped side, preventing a dangerous build-up of air. This mechanism ensures that any air that may have entered the chest can escape, mitigating the risk of a tension pneumothorax.
Rapid Respiratory and Hemodynamic Assessment
Once the insertion site is secured, the nurse must immediately assess the patient’s physical response to the event. This assessment begins with an evaluation of the patient’s respiratory status, looking for specific signs of distress. The nurse should observe for tachypnea (rapid breathing), the use of accessory muscles, and any signs of cyanosis (bluish discoloration).
Auscultation of the chest is a high-priority step to compare breath sounds between the affected and unaffected sides. Diminished or absent breath sounds on the affected side indicate a pneumothorax or lung collapse. Other signs of increasing pressure include asymmetric chest expansion and subcutaneous emphysema, which is a crackling sensation felt under the skin.
The assessment must also include obtaining a full set of vital signs to evaluate hemodynamic stability. Hypotension coupled with tachycardia can signal a developing tension pneumothorax, as increased pressure compresses the heart and major blood vessels. Also look for jugular vein distension, which suggests impaired venous return.
To support breathing, administer supplemental oxygen as needed, guided by pulse oximetry readings. Reposition the patient into a semi-Fowler’s position to facilitate optimal lung expansion and ease the work of breathing. This combination of assessment and supportive interventions must be performed rapidly to stabilize the patient while further medical help is summoned.
Documentation and Follow-Up Procedures
Following stabilization and assessment, quickly notify the healthcare provider and potentially the rapid response team (RRT) if the patient shows signs of distress. This time-sensitive communication should include the time of dislodgement, interventions performed, and the patient’s current status. The provider will then issue orders for further management, often including preparation for the reinsertion of a new chest tube.
Ensure all actions and observations are meticulously documented in the patient’s chart. Documentation must detail the exact time of dislodgement and the appearance of the insertion site, noting any active air leak or bleeding. It is mandatory to record the specific type of occlusive dressing applied and the three-sided taping technique used to create the flutter valve.
Critical to the record are the patient’s vital signs and breath sound assessment before and immediately after the intervention. Documentation must also include the time and name of the healthcare provider notified, along with any new orders received. Following the event, continuous and frequent monitoring of the patient’s respiratory status is required, often every 15 minutes, until the chest tube is re-established or the provider confirms stability.