Nursing Field Notes / Cardio · Congenital Heart Defects VI · NUR 235 Peds

🫀 HEART DEFECTS SET NG-151 ASD·VSD·PDA·AVSD NG-118 Tetralogy of Fallot NG-183 Stenosis & Coarctation NG-201 Surgery & Chest Tubes

Surgery & Chest Tubes 🫧

Cardiac catheterization, post-op care, and the 3-chamber chest drainage system

NG-201 CARDIO · PEDS ADHD-friendly visual edition

Whichever defect a child has — hole, block, or blue baby — surgery or a cardiac catheter procedure is usually the definitive fix. This page is the after: what you assess before, what you watch for after, and how to manage the chest tube that comes home from the OR with almost every open-heart repair. Know your 3 chambers cold — it is one of the most-tested skills in peds cardiac nursing.

📄 Simple Nursing original — opens in Drive →

🩸 #1 priority after a cathCheck pulses distal to the site first. Weak = expected. Cool, pale, pulseless = call now.

🫧 3 chambers, 1 orderPatient → ① collection → ② water seal → ③ suction control → wall.

〰️ Tidaling = patent + normalStops when the lung has re-expanded (good) or the tube is kinked/clamped (bad) — check the tubing to tell which.

🚨 2 chest tube emergenciesTube out → gauze taped 3 sides. Tubing disconnects → submerge in sterile water or clamp per policy.

🫀

THE BASE HEART

STEP 0 · SAME PICTURE AS EVERY PAGE

Same drawing as the rest of the set. Every defect on every page — hole, block, or blue baby — can end up here: the OR or the cath lab.

🫀 The normal heart — the drawing all four pages share

right heart · O₂-poor left heart · O₂-rich L → R shunt R → L shunt obstruction (bow-tie)

🧠 “Blue in on the left of the page, red out on the right.” Right heart (blue) is drawn on your left, left heart (red) on your right — an anatomic view, facing the patient.

⭐ Every group on this page's set, and how each gets fixed

Group	Shunt / flow	Fixed by
💛 ACYANOTIC	LEFT → RIGHT, ↑ pulmonary flow	Device closure (cath) or surgical patch
🧡 OBSTRUCTIVE	narrowed road	Balloon valvuloplasty/angioplasty (cath) or surgical repair
💜 CYANOTIC	RIGHT → LEFT, ↓ pulmonary flow	Surgical repair — usually open-heart
🩵 MIXED	both ways	Staged surgical repair

🧠 “Cath first when you can, cut when you must.” Many holes and blocks close with a catheter device or balloon. Cyanotic and mixed defects — and blocks that fail catheter repair — need open-heart surgery, which is where chest tubes come in.

🔁 Two routes to the same goal — cath lab vs OR

	Cardiac catheterization	Open-heart surgery
Access	Femoral vein/artery — no chest incision	Sternotomy (chest incision)
Used for	ASD/VSD/PDA device closure, balloon valvuloplasty, balloon angioplasty ± stent for coarctation	Complex repairs — Tetralogy, transposition, large VSDs, coarctation resection
Chest tube?	Usually none	Yes — placed during surgery to drain the chest
Recovery focus	Access-site & pulse checks	Incision, pain, respiratory effort, chest tube

🧠 “No cut, no tube.” A chest tube almost always means the child went to the OR, not the cath lab.

💉

BEFORE — PREP

STEP 1 · SET THE BASELINE

Whatever you assess before the procedure is what you compare everything to afterward.

🚨 Ask about an iodine / contrast allergy

Cardiac catheterization uses iodinated contrast dye. An iodine or shellfish allergy history must be flagged before the procedure — the team may premedicate or choose an alternate approach.

🧠 “Dye day, ask about iodine.” Any procedure with contrast = ask the allergy question.

⏰ NPO status before sedation/anesthesia

Children are typically kept NPO around 4–6 hours before a cath or surgery requiring sedation; infants often get a shorter NPO window because they tolerate fasting less well and are at higher risk for hypoglycemia. Exact hours vary by facility protocol and anesthesia team — always confirm the order.

🧠 “Littler belly, shorter wait.” Infants generally get shorter NPO times than older children.

✅ Baseline assessment — your comparison point

Weight in kilograms — needed later to judge chest tube drainage rates.
Baseline vital signs and O₂ saturation.
Mark and document baseline pulses in both extremities — you will compare post-procedure pulses to this.

🧠 “Can't know what changed if you never charted normal.”

👨‍👩‍👧 Family & child preparation

Age-appropriate teaching, honest and simple explanations, comfort items from home, and — when the unit allows it — a parent present for induction can meaningfully reduce a child's fear and distress.

🧠 “Prep the parent, calm the child.” An anxious caregiver makes a harder induction.

🩺 What a cardiac catheterization actually does

A thin catheter is threaded through the femoral vessels up to the heart. It can be diagnostic (pressures, oxygen saturations, angiography to map the anatomy) or interventional — closing a hole with a device, opening a narrowed valve with a balloon, or placing a stent in a narrowed vessel.

🧠 “Same door, two jobs.” The femoral approach can look, or it can fix — sometimes both in one trip.

🔎

AFTER — PRIORITY CHECKS

STEP 2 · MOST TESTED

Answer first: after a cath, the #1 priority is the pulse below the site. After surgery, it is airway/breathing and the incision.

🚨 PRIORITY #1 after cardiac catheterization — pulses distal to the site

Check the pulse below (distal to) the femoral access site frequently in the first hours — often per protocol every 15 minutes initially, then tapering.

Expected/normal: a weak but present pulse right after the procedure, warm foot, brisk capillary refill.

REPORT NOW A cool, cold, pale, or pulseless extremity distal to the site — this can mean arterial occlusion or thrombosis and needs the provider immediately.

Keep the leg straight for roughly 4–8 hours post-cath (per facility protocol) to protect the access site from bleeding, and keep the child on bedrest during that window.

🧠 “Weak is fine, gone is not.” A weak pulse below the site is expected; an absent one is an emergency.

🔎 Access-site assessment

Assess for bleeding or an expanding hematoma at the site.
No baths / no submerging the site until it's healed — infection risk.
Watch for signs of infection at the puncture site.

🧠 “Dry, flat, warm below.” Dry site, flat (no swelling), and a warm limb below = a good site check.

🚨 Report to the provider

Cool, cold, pale, or pulseless extremity distal to the site.
Bleeding, swelling, or a new/expanding hematoma at the site.
Fever, warmth, or purulent drainage at any surgical/access site.
Significant skin breakdown (for example, severe diaper rash) from prolonged bedrest/immobility in an infant — keep skin clean, dry, and pressure-relieved.

🧠 “Cold, hot, wet, sore — say something.”

✅ General post-op surgical care (open-heart repair)

Elevate the head of the bed after surgery — this reduces the work of breathing.

Manage pain proactively so the child can breathe deeply, cough, and reposition — undertreated pain slows respiratory recovery.

Restrict heavy lifting/strenuous activity for roughly 3–4 weeks after sternotomy while the bone and incision heal — follow the surgeon's specific activity order.

Teach families to report fever, a warm/red incision, or foul-smelling purulent drainage — signs of surgical site infection.

🧠 “Sit up, ease up, watch the wound.” Elevate for breathing, ease into activity, and keep eyes on the incision.

🫧

THE 3-CHAMBER CHEST TUBE SYSTEM

STEP 3 · THE HIGH-YIELD SKILL

Chest tubes drain excess blood, fluid, and air after cardiac surgery so the lungs can fully re-expand and blood doesn't collect around the heart.

🫧 The 3 chambers, in order — patient → collection → water seal → suction control → wall

🧠 “Catch it, seal it, control it.” ① Catch the drainage (collection) → ② Seal the chest so air can't come back in (water seal) → ③ Control how much suction reaches the chest (suction control).

① Collection chamber — what it does

The nearest chamber to the patient. All drainage flows in here first and collects in graduated (marked) columns so you can measure the amount over time.

Every time you round: note the amount, color, and consistency of drainage, and mark the level with the time so trends are visible at a glance.

🧠 “The measuring cup.” This chamber is purely for collecting and measuring — nothing else happens here.

② Water seal chamber — what it does

A tube sits submerged a couple of centimeters under sterile water. This creates a one-way valve: air and fluid can bubble out of the chest, but water blocks air from being sucked back in.

Watch the water level here for tidaling (normal) and bubbling (can be normal or abnormal — see the cards below).

🧠 “The one-way door.” Air can leave through it; nothing gets back in through it.

③ Suction control chamber — what it does

Connected to wall suction. It regulates how much negative pressure actually reaches the chest — turning the wall suction dial up does not increase chest suction; the water level (or a dry-suction dial) sets that.

Gentle, continuous bubbling in this chamber is expected and normal — it just means suction is working.

🧠 “The pressure regulator.” This chamber decides how hard the system pulls — the wall dial doesn't.

⭐ Expected vs alarming drainage

	Expected	Alarming — report
Color	Sanguineous → serosanguineous, getting lighter over time	Sudden return to bright red, frank blood
Rate	Steadily decreasing hour to hour	A sudden increase, or output cited in some protocols as roughly >3 mL/kg/hr sustained (thresholds vary — follow facility policy)
Dressing	Dry to lightly stained	Saturated dressing / visibly pooling blood
Patient	Stable vitals	↑HR, ↓BP, muffled heart sounds — think tamponade

SOURCE NOTE Some course materials also cite roughly >5–10 mL/kg in the first hour after surgery as a concerning drainage rate. Numbers like these vary by facility and by provider order — always follow your unit's specific policy rather than a single memorized cutoff.

🧠 “Sudden red and a lot, fast, is bad.” A big, sudden increase in bright red output plus new instability = possible active bleeding or tamponade — call now.

〰️ TIDALING — what it means, and how to tell why it stopped

Answer first: tidaling is the water level in the water-seal tube rising and falling with breathing — it rises with inspiration and falls with expiration in a spontaneously breathing patient (this reverses on positive-pressure ventilation). Tidaling means the tube is patent and there is still air space to fill — it is normal.

Tidaling stops because…	✅ Lung has re-expanded	❌ Tube is kinked / clamped / obstructed
Breath sounds	Improved, equal, clear	Decreased or absent on that side
Respiratory effort	Comfortable, easy	Increased work of breathing, distress
Drainage trend	Had been steadily decreasing	May suddenly stop despite a recent large amount
Tubing check	No kinks, no dependent loops	Visible kink, dependent loop full of fluid, or a clamp left on
What you do	Expected near tube removal — keep monitoring	Straighten/reposition the tubing, remove any clamp; if tidaling still doesn't return and the patient is distressed, notify the provider immediately

🧠 “Check the patient, then check the tube.” Good breath sounds + comfortable breathing + no kinks = the lung won. Bad breath sounds + distress + a kink you can see = the tubing lost — fix it and call.

🚨 Continuous bubbling in the WATER SEAL chamber = an AIR LEAK

Intermittent bubbling in the water seal chamber — for example, with a cough or forceful exhale — can be a normal transient finding as trapped air escapes.

Continuous, vigorous bubbling in the water seal chamber is abnormal — it means air is continuously entering the system, either from the patient's pleural space (an air leak in the lung) or from a loose connection or crack somewhere in the tubing/system.

FIRST STEP Check every connection along the tubing for a loose fitting before assuming the leak is coming from inside the patient. Then notify the provider.

Never confuse water-seal bubbling with suction-chamber bubbling — gentle continuous bubbling in the SUCTION CONTROL chamber is normal; continuous bubbling in the WATER SEAL chamber is not.

✅ Routine chest tube care — do this every shift

⬇️Keep the unit below chest levelalways

📏Keep it uprightnever on its side

🌀Keep tubing free of kinks/loopscheck every round

🩹Keep dressing occlusivereinforce, don't remove

🧰Bedside kit: sterile gauze, tape, sterile water, clampready before you need it

🚶Encourage deep breathinghelps re-expansion

POLICY VARIES Routine stripping/milking of chest tube tubing and routine clamping are generally avoided outside of specific ordered situations — both practices vary by facility policy, so follow your unit's protocol.

🚨

THE 2 CHEST TUBE EMERGENCIES

STEP 4 · ACT FAST

Both are rare, both are tested, and they are NOT the same problem — know which one you're looking at before you act.

🚨 Emergency 1 — the chest tube comes OUT of the patient

🩹 Cover the insertion site immediately with sterile occlusive gauze, taped on 3 sides only. The open 4th side acts like a one-way flutter valve — air can escape but is less likely to be pulled back in.

🧍 Stay with the patient and assess breathing/color continuously.

📞 Call for help immediately — this needs provider evaluation and likely a new tube.

🧠 “3 sides, not 4.” Taping all 4 sides can trap air inside the chest and cause a tension pneumothorax — always leave one side open.

🚨 Emergency 2 — the tubing DISCONNECTS from the drainage unit

Here the tube is still in the patient — only the connection to the collection unit came apart. Two approaches are taught; follow your instructor/facility's specific policy:

	Submerge in sterile water	Clamp near the chest
What you do	Put the open tubing end ~2 cm under sterile water	Briefly clamp the tubing close to the chest wall
Why	Recreates the one-way water-seal effect right away	Temporarily stops air from moving through the open tube
Watch for	Get a new sterile system connected as soon as possible	Unclamp the moment a new system is attached — prolonged clamping risks a tension pneumothorax

🧠 “Different hole, different answer.” Tube out of the patient → cover the site. Tubing disconnected from the unit → water or a brief clamp, per policy. Either way: call for help and don't leave the patient.

🧠 Both emergencies, side by side

	Tube pulled OUT of patient	Tubing disconnects from unit
Where's the break?	At the chest wall / insertion site	Somewhere along the tubing, away from the chest
Immediate action	Sterile gauze, taped on 3 sides	Submerge end in sterile water or clamp, per policy
Shared steps	Stay with the patient · assess airway/breathing/color · call for help right away

⚡

QUICK RECALL

SAY IT OUT LOUD

🩸 Pulses first, after a cathWeak = expected. Cool/pale/pulseless = call. Straight leg, no baths on the site.

🫧 Catch → Seal → ControlCollection measures it, water seal keeps air from re-entering, suction control sets the pressure.

〰️ Tidaling stops = check WHYGood breath sounds + no kink = lung re-expanded. Bad breath sounds + a visible kink = fix the tube, then call.

🚨 Continuous bubbling ≠ suction chamberWater seal chamber bubbling continuously = air leak. Suction chamber gentle bubbling = normal.

⭐ One last time — the 2 emergencies

	Tube OUT of patient	Tubing disconnects from unit
Do this first	Sterile gauze taped on 3 sides	Submerge in sterile water or clamp — per your policy
Then	Stay with the patient · call for help immediately

🧠 “3 sides for a hole, water or a clamp for a break.”