Nursing theory: postoperative care of closed chest drainage

Closed thoracic drainage is a widely used technique in thoracic surgery, and is an effective method of treating pyothorax, traumatic hemothorax, pneumothorax, and spontaneous pneumothorax. Based on the principle of gravity drainage, it is an important measure to rebuild and maintain negative pressure in the thoracic cavity, drain accumulated air and fluid in the thoracic cavity, and promote lung expansion after open heart surgery. Its purpose is to better improve the negative pressure of the thoracic cavity, so that gas, blood and fluid can be discharged from the pleural cavity and prevent its reflux, promote lung reopening and pleural cavity closure; balance the pressure and prevent mediastinal displacement and lung compression. For patients with pyothorax, drainage should be carried out as soon as possible to remove pus and eliminate the pus cavity, so that the lungs can be reopened as soon as possible and lung function can be restored.

1, postoperative nursing routine

1.1 Change the drainage bottle 1 to 2 times a day (depending on the drainage fluid), and observe the size and fluctuation of the negative pressure to understand the lung expansion. If a large amount of foam exists in the drainage bottle to affect the drainage of gases, several drops of 95% alcohol can be added to the drainage bottle to reduce the surface tension of the foam, eliminate the foam and ensure smooth drainage. In order to keep the drainage tube smooth, the drainage tube should be squeezed frequently after surgery, in general, every 30min squeeze 1 time, so as not to block the mouth of the tube by blood clots.

Extrusion method: (1) the nurse stood on the patient's side of the operation, holding the drain tube with both hands from the intubation of 10 to 15cm, too close to the drain tube easily pulled causing pain, too long to affect the effect of extrusion. When squeezing the two hands before and after each other, the back hand pinched the drainage tube, so that the drainage tube is occluded, with the forefinger of the front hand, middle finger, ring finger, pinky finger abdomen force, rapid extrusion of the drainage tube, so that the extrusion pressure and the palm of the hand reaction force exactly overlap with the diameter of the drainage tube, the frequency of fast, which can make the airflow repeatedly impact on the mouth of the drainage tube, to prevent the formation of blood clots to block the mouth of the tube, and then the two hands release, due to gravity effect Then both hands are released, and due to gravity, the fluid in the pleural cavity can be discharged from the drainage tube, and the operation is repeated.

Method (2) Use hemostatic forceps to clamp the lower end of the drainage tube, squeeze the drainage tube with both hands at the same time and then open the hemostatic forceps, so that the drainage fluid flows out. When encountering special circumstances, such as patients with active internal bleeding, the drainage tube should be squeezed without stopping.

1.2 Every time the drainage bottle is changed, the cap should be tightly capped, the connection between the various parts should be tight, do not leak, and the head of the connecting drainage tube should be 2~4 cm below the liquid surface, so as to prevent air from entering the pleural cavity. The length of the drainage tube should be moderate, generally 60~70 cm. Too long is not easy to drain, too short is easy to slip off, and the texture is flexible. The water-seal bottle should be filled with 500ml of sterile saline, and the liquid level should be lower than 60~70cm at the thoracic outlet of the drainage tube, so as to prevent the liquid from flowing backward into the pleural cavity. The water-seal bottle and the outer receiver should be sterilized aseptically and have a scale.

1.3 Frequent ward rounds to observe the drainage situation, such as whether there is gas escaping from the liquid level in the bottle or whether the liquid level in the glass tube is fluctuating up and down, and whether the drainage tube is twisted and pressed, etc., and pay attention to keep the drainage tube unobstructed. When draining out the fluid, pay attention to observe the nature, amount and color of the fluid, and make a record. Due to the open-heart surgery, there will be gas left in the chest cavity, coupled with the lung segmental resection or incomplete lobectomy caused by lung segmental air leakage, postoperative patients will have gas escaping from the drainage tube after coughing and deep breathing, which is a normal phenomenon and can be healed by itself. For patients with serious air leakage, do not encourage the patient to cough, so as not to prolong the healing time of the lung segmental surface, which is not conducive to early postoperative extubation. Closely observe the amount, color and nature of the drainage fluid, under normal circumstances, the drainage flow should be less than 100ml/h, the beginning of the blood, and then the color of light red, should not be coagulated. If the amount of drainage is high, the color is bright red or dark red, the nature is thicker, easy to coagulate, then it is suspected to be active bleeding in the thoracic cavity. The main reason is that the local hemostasis is poor during the operation, and the patient can also cause acute postoperative hemorrhage due to the stimulation of sputum choking before removing the endotracheal tube, and the patient's strong struggle before waking up from anesthesia. If the drainage flow exceeds 100 ml/h, and no reduction is seen in 4-6h of continuous observation, and the bedside chest X-ray shows the shadow of coagulative hemothorax, with respiratory and circulatory disorders, with pulse rate over 120 times/min, and respiration over 30 times/min, then the diagnosis of active intrathoracic hemorrhage will require reopening of the chest to stop the hemorrhage. Therefore, if the chest drainage is more than 100 ml per hour, report to the physician. Postoperative complications in addition to intrathoracic hemorrhage, celiac disease may also occur due to rupture of the thoracic duct or one of its major branches. Injury to the thoracic duct occurs after almost all thoracic surgical procedures, and there is a latent period of about 2 to 10 days from the time of injury to the appearance of clinically significant celiac disease. Observation of negative intrathoracic pressure and fluctuation of the fluid level in the water-sealed tube at any time is one of the non-negligible elements of drainage tube care. With the discharge of gas and liquid in the pleural cavity, the residual cavity shrinks, and the fluctuation range of negative pressure is mostly 1-3cm water column after 48h and 72h after surgery, combined with the chest X-ray, and the removal of the tube is considered according to the specific situation of the patient. ［

1.4 When the drainage tube is found to be unobstructed, active measures should be taken to squeeze the drainage tube or empty needle pumping or gently rotate the drainage tube to make it unobstructed, and if it is still unobstructed, report to the doctor and assist in the re-treatment.

1.5 When moving the patient, attention should be paid to keep the drainage bottle lower than the pleural cavity, so as to avoid the backflow of liquid in the bottle, resulting in infection; for patients with gas escape, always keep the drainage tube open, and never clip the tube at will.

1.6 During operation, strict aseptic operation and sterilization isolation, routine application of antibiotics to prevent secondary infection.

1.7 Strengthen basic nursing care, such as oral care, skin care, decubitus ulcer care, to prevent nursing complications.

1.8 If the patient's condition improves, respiration improves, and no gas escapes from the drainage tube, report to the doctor, clamp the tube for 24-hour photo review, and consider removing the tube.

Indications for extubation

① Vital signs are stable.

① Vital signs are stable, and there is no gas overflow from the drainage bottle.

③ Drainage of liquid is very small, drainage flow <100ml in 24 hours.

④ Auscultation of the remaining lungs breath sounds clear, chest radiographs show that the injured side of the lungs reopened good enough to pull out the tube.

Winter extubation should pay attention to keep the patient warm, before extubation, the patient was asked to inhale y, and then exclude to avoid damage to the lung or pain at the end of the tube during extubation, and immediately after extubation, the wound at the intubation site was pressed with aseptic gauze to prevent gas from entering the thoracic cavity. In order to prevent recurrence of pneumothorax, 50% dextrose 40 ml plus tetracycline 0.5g was injected into the chest cavity before extubation, which induced aseptic inflammation in the chest cavity to make the pleura exudate and the dirty and wall layers adhered to each other, and at this time, the patient had different degrees of chest pain and fever, and was given symptomatic treatment, and at the same time, the patient was encouraged to change the body position constantly.

1.9 Within 24 hours after extubation, patients should be closely observed for chest tightness, breath-holding, dyspnea, pneumothorax, subcutaneous emphysema, etc.; observe whether there is any localized blood oozing and seepage, and if there is any change, report to the doctor for timely treatment.

2, special care

2.1 Choose the appropriate position, the patient's position to the slope (head of the bed elevated 45-60 degrees, the end of the bed elevated 10 degrees) position is appropriate, the patient's blood pressure can be taken after the stability of the slope position, in order to facilitate the outflow of fluid in the pleural cavity, and at the same time also conducive to the respiratory and circulatory function, but also play a role in reducing the tension of the incision. Avoid pressure on the drainage tube, often squeeze the drainage tube, so as not to cause blockage of fibrous material deposited in the mouth of the drainage tube. If the body position is not appropriate, part of the fluid remains in the thoracic cavity for a long time, easy to cause adhesive pleurisy, or even cause encapsulated effusion and affect the respiratory function. Clinical poor drainage, mostly related to improper position, especially in patients with pyothorax to take effective position is essential. When the cough is strong, cough suppressant is given, and when the sputum is thick, oral sputum chemotherapeutic drugs or nebulized inhalation and intravenous drugs are given. And the patient or the companion must be instructed to press the chest wall intubation site, otherwise the drainage tube is easy to fall off into the skin, resulting in subcutaneous emphysema. General anesthesia after surgery, fully awake patients, the morning of the first postoperative day to assist the patient to sit up, rocking the head of the bed, behind a thin pillow, so that the patient is comfortable. Due to the sitting up activities, the patient sometimes pain and reluctance to cooperate. Early postoperative activities can not only prevent postoperative complications, favorable body recovery, but also conducive to drainage, early extubation, reduce pain.

2.2 Coughing is good for drainage, encourage the patient to cough, in order to discharge sputum and old blood clots in the lungs as soon as possible, so that the lungs can be reopened, lung reopening is conducive to the discharge of air and fluid in the thoracic cavity. For patients who are incapable of coughing, the nurse presses the incision with one hand, and presses the middle finger of the other hand on the upper fossa of the sternum to stimulate the common airway, in order to cause cough reflex favorable for coughing up sputum. Surgery and thoracic tube can make the intercostal muscles and diaphragm movement is limited, respiratory function is affected, so that the elasticity of the lung tissue retraction is weakened, alveolar and bronchial secretions are easy to accumulate, and gradually become viscous, and it is not easy to be coughed up. In the morning of the first postoperative day to the patient to do ultrasonic nebulizer inhalation, and require each nurse to be skilled in lung auscultation, such as sputum sound obvious, immediately give nebulizer, patting the back, to assist in the expectoration of sputum until the lungs breath sound clear.

2.3 This method of operation damage, easy to infection. Preoperative psychological care, postoperative use of appropriate analgesics, prevention of wound infection, you can drop gentamicin around the wound 2 times a day, you can change the medicine 2 times a week, if the wound is infected, change the medicine 1 time a day. After tube change, fill the wound with petroleum jelly gauze, cover the gauze, keep clean around the wound and dry the dressing.

2.4 If the pain is worse, apply painkillers, such as painkillers, Valium, and Prednisolone, respectively, without tube blockage. If the wound is infected with pus, use metronidazole to change the dressing for 1 week after extubation, and most of the wounds can be healed.

2.5 Psychological care, such as pneumothorax patients most of the emergency hospital, especially the first patient due to the torture of the disease and the lack of knowledge, often panic, easy to aggravate the condition. Therefore, the patient should be warmly received, kindly attitude, language, appropriate time to give the necessary explanation and knowledge of the disease of the mission, encourage the patient to overcome the disease, and cite similar cases of successful resuscitation, so that the patient from the state of nervousness quiet down, in order to facilitate the restoration of health.