Orientation to Tubes, Lines, and Drains in the Critical Care Patient (Nursing)

00:01 Welcome to our overview module on managing tubes, drains and lines that you're likely to encounter in the critical care environment.

00:08 Now, I wanted to do this video for you because I don't want you to have the experience that I did after my junior year on my first day of internship when I went to the critical Care unit. They showed me this patient and I was horrified.

00:22 He had tubes coming out of everywhere.

00:25 I didn't understand what they were.

00:27 He had pelvic traction and that Betadine ointment that was around it.

00:31 I thought it was his guts coming out.

00:33 So I don't want you to be that ill informed when you go to critical care for the first time. So I'm not going to make you an expert on how to take care of each of these tubes.

00:43 We have other videos that will detail that.

00:45 Our only purpose today is for you to understand what the tube is, what some major red flags would be, some danger signs and what your role or position is.

00:56 Okay. So as we're reviewing this equipment, I want you to try to picture a patient with the tubes as I show them to you.

01:03 I didn't think I could start with anything else more important than supporting a patient's airway and breathing.

01:09 Now, that could be either an endotracheal tube or a tracheostomy tube.

01:13 Now, in critical care, if a patient has a trach and it's been recently placed, they will likely be connected to a mechanical ventilator.

01:21 Again, we have a whole video on that that you can seek out if you want to learn more about managing a ventilator.

01:27 But I want you to keep in mind a trach has to be surgically inserted right here for a patient. And the physician does that procedure slides that tube in and then it is secured with holders on each side.

01:41 Now, your role as a nurse would be to take care of that.

01:44 We're just focusing on the major purpose.

01:46 So when you put a tube in, that's going to keep that airway open because the tube is a hard plastic now an endotracheal tube is placed in the mouth or the nose.

01:57 It's the health care provider that decides what's the most important placement or safest placement for each individual patient.

02:05 So you've got either an ET tube that goes in your mouth or nose or a tracheostomy tube that's down here in your neck.

02:14 So what can go wrong? What do you need to know as a day one nursing student in critical care know that if you hear any ventilator alarms, you see any signs of respiratory distress.

02:26 That requires immediate follow-up.

02:28 That trach tube or that endotracheal tube is a lifeline to the patient.

02:33 That's the only way they're going to get oxygen to their tissues.

02:36 So be aware of what it is.

02:38 See what it looks like, your huge red flags for these tubes? You want to make sure you see any signs of respiratory distress.

02:46 Those are the types of cues that you're looking for.

02:48 Now, you're going to do some assessments.

02:49 You're going to listen to their breath sounds. And if you're in critical care and this happens, you're going to watch what your nurse does because this patient is in trouble.

02:58 Now, there's also special things you do for great care and for suctioning.

03:01 And like I said, you can get that in our other videos.

03:04 But I just wanted you to be aware that if you see a tube here, here or right here that is supporting their airway, if it's connected to oxygenation, the next line I want you to be aware of, you might have even seen in medsurg kind of unit but in critical care.

03:20 Here's what they're used for.

03:21 A central venous catheter is probably something you hear nurses talk about as a central line.

03:28 Now, what this does is it's inserted into a large vein.

03:31 This is what makes it different than a peripheral IV.

03:34 Now, you probably learned how to insert peripheral IVs early on in your nursing school career, right? RNs can do that.

03:41 Central lines cannot be placed by an RN.

03:45 This has to be placed by an advanced practitioner.

03:48 So you put in a central line, you're going to see it up in their neck or in the top of their trunk. That's where they're going to place the line because they have larger veins there, as these are the ones that are emptying directly into the heart.

04:02 So we use these because you might want to administer medications that are really tough on peripheral veins.

04:08 There are certain medications that will just wipe out a peripheral vein so we can use it to give medications.

04:15 We can use it to draw blood.

04:17 If you do that appropriately, we can also use it to give us an indication of what the patient's fluid volume status is.

04:23 So you can look at measuring central venous pressure, which is an indication of if the patient is fluid, volume overloaded or not enough fluid in the vascular space.

04:34 So they're bigger, they're in a different location, and they usually have multiple ports. If you're going to put in a central line, you want to make sure that you have enough ports to do all the things that you need to do.

04:46 Now, I want to talk about what's most important that you know about this.

04:50 Well, this the biggest problems with this two things.

04:54 I'm going to be worried about infection because, wow, that's a direct route into the body. And I'm also going to be worried about.

05:01 Occlusion. So those are the things that you'll be on the lookout for.

05:05 Is part or all of that catheter blocked or is the patient showing signs and symptoms of infection? And that means you'd be looking at that entry site, the dressing right around that. This is an arterial line.

05:18 It can do some really cool things, but it's not so fun if you're a patient, if you have to have this inserted, it can be kind of painful.

05:25 Now you see it there in the patient's arm.

05:28 Now some cool things we can do about this is to draw arterial blood gases.

05:33 All you have to do is turn a little stopcock and you can withdraw the blood sample and you don't have to re-stick the patient.

05:39 But this is invasive as most things are that we're talking about in this video.

05:44 But this is invasive in the artery.

05:46 You often have to have the patient on an arm board so they're not moving their arm as much because we don't want to lose that arterial line.

05:53 Now, this is another line or tube that is connected, right? The arterial line is connected to special tubing.

06:00 And this tubing goes to a transducer and the transducer translate this electrical signal up to the monitor and you'll see an arterial waveform.

06:10 Now, experienced nurses will look at that waveform, make sure they know it's a good, solid, accurate waveform, and also make sure that the tube is in alignment to give us an accurate measurement.

06:22 So priority responsibilities here? Let's see, you've got something in an artery.

06:29 So I know that arteries supply blood to my tissue.

06:32 So I always want to watch the extremity that is distal to where the arterial line is inserted, make sure it's not cool or showing signs of poor perfusion or inadequate perfusion. The other thing is pretty common.

06:46 Whenever you break the skin, you're worried about infection.

06:49 Now special things like making sure the waveform is appropriate and zeroing the lines, those are all things we're not going to cover here, but those are the things you want to watch for, because if that waveform is altered or dampened, that might be an early sign of a complication like decreased perfusion or some other potential problems.

07:08 But a nasal gastric tube is a tube that's inserted in the nose and it is fed through down to the stomach.

07:18 Right. That's another thing when you're inserting those, you want to make sure that it doesn't go into the lung.

07:23 You want it to go into the stomach.

07:25 Now, there are kind of a flexible tube, right, Because they're going in the nose and as they warm up, they become a little more flexible.

07:32 The purpose of these tubes is to decompress the stomach.

07:35 So when you put this tube in, you put it on intermittent suction so you'll see that this NG tube is most likely connected to suction tubing, which is going to a suction canister.

07:47 NG tubes are always supposed to be on intermittent suction.

07:51 And you're going to see some nasty colored stuff coming out into that suction container, depending on what's going on in the patient's gut.

07:58 But we use these if we decompress the stomach, we can try to avoid or minimize the risk of the patient throwing up and aspirating what they threw up.

08:08 So an NG tube first is meant to decompress the stomach.

08:12 As we're progressing in the patients getting better.

08:15 You may see it hooked up to tube feeding and if they stay on it too long, they'll replace it with a much smaller feeding tube or an enteral feeding tube.

08:22 So an NG tube in the nose down to the stomach, they'll have tape secured on their nose. They have nice tube holders now, so they won't likely see just a piece of tape on their nose. You'll see a secure holder.

08:36 This is a swan-ganz.

08:38 Now you'll learn more about this in our critical care course.

08:41 But I want you to know that this is called a pulmonary artery catheter for a reason.

08:46 Now, Swan-ganz, they're the people who figured it out, right? They're the ones who discovered it and mastered it.

08:51 But it's called a pulmonary artery catheter because it goes in through the vessels.

08:58 It's threaded through the right atrium, through the tricuspid valve into the right ventricle and then up into the pulmonary artery.

09:08 And it stays there.

09:10 That, to me is incredible that it does that.

09:14 But this has some risks, right? It's it's just like a central line.

09:18 But like on steroids, we can do a lot more with this one.

09:22 We can give vasoactive drips through it.

09:25 We can monitor all kinds of pressures, not just a CVP, but all kinds of wedge pressures and all.

09:32 I don't even want to go into those here because we've got a great course on it, but know that this gives us incredible and valuable hemodynamic data, Right? And this can help us know, hey, where's the volume in the patient? Is it in the intravascular space, Is it in their tissues, Are they dry, are they overloaded? It gives you incredible information.

09:50 But remember, it's significantly invasive.

09:53 Possible complications could be infection, it could be dysrhythmias.

09:57 All types of things could happen.

09:59 Even some weird things like there's a little balloon tip on the end.

10:02 Now, the balloon tip on the end is meant to kind of float that catheter to where it wedges into that pulmonary artery.

10:10 So if you want to learn more, make sure that you check out our series on hemodynamic monitoring. Remember, it's an invasive procedure.

10:17 You're going to watch for signs of infection and any signs that this is irritating the heart possibly causing dysrhythmias.

10:25 Now, how do we take the ratings on a swan-ganz? Same thing.

10:29 We have that magic tubing that connects to a transducer that takes the electrical signals and translates them into waveforms and pressure readings on a critical care monitor.

10:40 Chest tubes or chest drains are used for patients who've experienced something like a pneumothorax or they've got a hemothorax or pleural effusion.

10:48 If a patient's lungs has been compromised, we'll put a chest tube in to try to restore homeostasis. So again, we have a really cool video on chest tubes and what to expect and how to assist, but know that it's critically important that you don't allow that chest tube to become dislodged.

11:05 As a nursing student, that's your main role when it comes to chest tubes.

11:09 Make sure that chest tube is protected and doesn't become dislodged.

11:13 You never want to tape it down to a sheet in case the patient turns we're going to be very careful to keep that tube where it's supposed to be.

11:22 If that tube comes out, the patient is at risk for their lung to collapse.

11:27 One chamber I want you to pay attention to is the water seal chamber.

11:31 If you see a sudden it should bubble.

11:34 If you see that suddenly stop, that is an emergency.

11:37 So check out our video to learn more of that.

11:41 Now, these aren't very glamorous, but they do some good things.

11:44 We have a urinary or a fecal catheter.

11:46 This is for a patient.

11:48 Either we want extra precise urinary output for intake and output, or we might use some type of fecal catheter and insert it into the rectum.

11:57 If the patient is having a lot of watery diarrhea and it's breaking down their skin.

12:02 Now, there's less risk of infection with a fecal catheter, but with a urinary catheter, there is a high risk of infection.

12:11 Even now we have special catheters that are coded to try to minimize the risk.

12:15 But any urinary catheter puts a patient at an increased risk for a UTI, which can spread into bigger problems rapidly.

12:23 There's no really great way for draining liquid stool, and hopefully that will be short term if your patient has to use it now, what are the risks? Any sign of infection, particularly with a urinary catheter, with the fecal catheter, it could be draining or leaking.

12:38 And so keep an eye on those tubes, make sure they're patent and that they're draining.

12:43 So those are some very common and kind of scary tubes that you could see in critical care. This is not an exhaustive list.

12:51 There's other tubes and drains and bags.

12:53 Just know that as you enter into care and you're in specific types of critical care units, you'll experience some different opportunities.

13:02 But your clinical experience and on-the-job training is what's going to help orient you to the huge diversity of this aspect of nursing care.

13:10 So when in doubt, it's always recommended to look at the research on what equipment is the best and safest practice for your patients.