1、胸腔闭式引流,内容提要,复习胸膜腔有关知识胸腔闭式引流的目的胸腔闭式引流的原理胸腔闭式引流的装置胸腔闭式引流管的位置安放胸腔闭式引流的护理,胸膜腔有关知识,胸膜腔是由脏胸膜与壁胸膜之间形成的封闭腔隙腔内呈负压,助于肺组织膨胀、维持肺的通气和换气功能;增加上下腔静脉的回心血量,气体进入胸膜腔，造成积气状态，称为气胸（pneumothorax）。 正常胸腔内没有气体，胸腔内出现气体仅在三种情况下发生： 肺泡和胸腔之间形成破口 胸壁创伤产生与胸腔的交通 胸腔内有产气的微生物,胸腔闭式引流的目的,排除胸膜腔内积液排除胸膜腔内积气恢复和保持胸膜腔负压，维持纵隔的正常位置，促使术侧肺迅速膨胀发现胸膜腔内活
2、动性出血，支气管残端瘘等,适应症和禁忌症,适应征外伤性血气胸，影响呼吸、循环功能者。 气胸压迫呼吸者（一般单侧气胸肺压缩在20以上时）。 切开胸膜腔者。禁忌证 结核性脓胸则禁忌。 CoagulopathyPulmonary bullaePulmonary, pleural, or thoracic adhesionsLoculated pleural effusion or empyemaSkin infection over the chest tube insertion site,Chest tube drainage device with water seal (autotransf
3、user unit is an option)Suction source and tubingSterile glovesPreparatory solutionSterile drapesSurgical markerLidocaine 1% with epinephrineSyringes, 10-20 mL (2)Needle, 25 gauge (ga), 5/8 inNeedle, 23 ga, 1.5 in; or 27 ga, 1.5 in; for instilling local anesthesiaBlade, No. 10, on a handleLarge and m
4、edium Kelly clampsLarge curved Mayo scissorsLarge straight suture scissorsSilk or nylon suture, 0 or 1-0Needle driverVaseline gauzeGauze squares, 4 x 4 in (10)Sterile adhesive tape, 4 in wideChest tube of appropriate size: Man - 28-32F; woman - 28F; child - 12-28F; infant - 12-16F; neonate - 10-12F,
5、PositioningThe patient should be positioned supine or at a 45 angle. Elevating the patient lessens the risk of diaphragm elevation and consequent misplacement of the chest tube into the abdominal space.The arm on the affected side should be abducted and externally rotated, simulating a position in w
6、hich the palm of the hand is behind the patients head.A soft restraint or silk tape can be used to secure the arm in this location. If a restraint is used, make sure that good blood flow to the hand is present.,引流的原理,当胸膜腔内因积液或积气形成高压时，胸膜腔内的液体或气体可排至引流瓶内.当胸膜腔内恢复负压时，水封瓶内的液体被吸至引流管下端形成负压水柱，阻止空气进入胸膜腔.,引流的装
7、置,胸腔闭式引流管,水封瓶,一个无菌引流瓶，内装无菌蒸馏水或无菌生理盐水；瓶口用带两个圆孔的橡皮塞封柱；长、短两根玻璃管分别插入圆孔；长管应在水面下3-4cm，且保持直立，另一端与病人的胸腔引流管相连，短管作为空气通路,引流管的位置安放,引流气体一般选在锁骨中线第2肋间或腋中线第3肋间插管 引流液体选在腋中线和腋后线之间的第68肋间插管,胸腔闭式引流管的植入,局部浸润麻醉壁层胸膜后，进针少许，再行胸膜腔穿刺抽吸确诊。沿肋间做23CM的切口，依次切开皮肤及皮下组织,胸腔闭式引流管的植入,用2把弯止血钳交替钝性分离胸壁肌层达肋骨上缘，于肋间穿破壁层胸膜进入胸膜腔，此时可有突破感，同时切口有液体或气
8、体溢出。,胸腔闭式引流管的植入,立即将引流管顺止血钳进入胸膜腔; 侧孔位于胸腔23CM.,切口间断缝合12针，并结扎固定引流管;引流管结于水封瓶，各接口处必须严密，以防漏气;,套管针穿刺置管,严格灭菌妥善固定,管道密封保持引流通畅注意观察发生意外，及时处理拔管,胸腔闭式引流的护理,严格无菌操作，防止逆行感染,引流装置保持无菌；保持伤口处敷料清洁干燥，一旦浸湿及时更换；引流瓶位置低于胸腔60cm100cm，防止引流液逆流；定时更换引流瓶；严格无菌操作。,妥善固定,管道密封,胸腔闭式引流主要是靠重力引流，水封瓶应置于病人胸部水平下60100cm，并应放在特殊的架子上，防止被踢倒或抬高。各衔接处均要
9、求密封引流管固定搬运病人前，先用两把止血钳双重夹住引流管，将引流瓶放在病床上以利搬运。搬运后，先把引流瓶放于低于胸腔的位置，再松止血钳。,保持引流通畅,术后病人血压平稳,应取半卧位. 鼓励病人咳嗽及深呼吸运动。避免引流管受压、折曲、阻塞。尤其病人躺向插管侧，注意不要压迫胸腔引流管。,注意观察,观察玻璃管水柱随呼吸波动的幅度观察并记录引流液量，颜色，性状,发生意外，及时处理,水封瓶破裂或连接部位脱节应立即用血管钳夹闭软质的引流管。用手将其折叠后捏紧，勿使漏气，立即更换新的无菌引流装置。鼓励病人咳嗽和深呼吸，排出胸膜腔内的空气和液体。引流管脱落应及时用手指捏压伤口，消毒后以无菌敷料封闭，报告医生及
10、时处理。绝不可擅自将脱出的引流管再插入胸膜腔内，以免造成污染或损伤。,引流管的长度与固定,引流管的长度以能将引流管固定在床缘，且能使它垂直降到引流瓶为宜。过长时易扭曲，还会增大死腔，影响通气。过短时病人翻身或坐起时易牵拉到引流管。固定引流管时，可将引流管两端的床单拉紧形成一凹槽，再用别针固定。,拔管,24小时引流液小于50ml，脓液小于10ml，无气体溢出病人无呼吸困难，听诊呼吸音恢复，X线检查肺膨胀良好,拔管方法,拔管时病人应取半卧位或坐在床边，鼓励病人咳嗽，挤压引流管后夹闭，嘱病人深吸一口气后屏住。病人屏气时拔管，拔管后立即用凡士林纱布覆盖伤口。,拔管后，要观察病人有无呼吸困难、气胸和皮下
11、气肿。检查流口覆盖情况，是否继续渗液，拔管后第二天应更换敷料。,问题 Which of the following statements is true about intrapleural (the space between the parietal and visceral or pulmonary pleurae) pressure under normal conditions?A.It is always positive B.It is negative during inhalation; positive during exhalationC.It is positive d
12、uring inhalation; negative during exhalationD.It is always negative,If the chest tube is pulled out of the patients chest, and the patient had an air leak from the lung, after asking a colleague to call a physician STAT, emergency nursing management is to:a.Cover the opening with a sterile dressing,
13、 taped on three sidesb.Cover the opening with a sterile Vaseline gauze, taped securely on all sidesc.Leave the opening alone and monitor the patient until a physician can assess the situationd.Try to put the tube back in place as quickly as possible,Which of the following statements is true regardin
14、g patient movement while requiring chest drainage? (assume a physician order or protocol exists)A.Patients may go only from bed to a chair while the chest tube is connected to a chest drainB.If patient must leave nursing unit, suction tubing should be clamped shut while chest drain is disconnected f
15、rom suctionC.If a patient is ambulatory, the chest tube should be clamped shut while the chest drain is disconnected from suctionD.Patients may walk around once the nurse disconnects the drain from suction as long as the drain remains below the chest,Chest tube clamping is only recommended for:a. Ch
16、anging the drainage container and this should be done quickly and then promptly unclampedb. Whenever a patient leaves the nursing unit and cannot be monitoredc. When ambulating a postoperative patient with a chest tubed. It is never beneficial to clamp a patients chest tube,New bubbling is observed
17、in the water seal chamber after a patient with a pleural chest tube returns from a test. The nurse clamps the chest tube momentarily with a tubing clamp at the dressing site. When this is done, bubbling in the water seal stops. The next appropriate nursing action is to:A.Continue to monitor the wate
18、r seal chamber for bubbling every hour for the next four hoursB.Do nothing. This bubbling is normal in patients with pleural chest tubesC.Call the physician immediately and do not leave the patients bedside because of the risk of respiratory failureD.Remove the chest tube dressing to see if one or more eyelets of the chest tube have been pulled out of the chest,谢谢！,
