Chest tube NC
The patient asks you, the nurse, where does my chest tube go in my body?
What is the pleural space?
The nurse knows that the patient who breathes shallowly is at risk for atelectasis and pneumonia. After the nurse administers pain medication, it is important to help the patient to...
What is deep breathe and cough?
A patient who has experienced brain death has no drive to breathe on her own. The nurse anticipates what type of mechanical ventilation?
Along with other risk factors, patients on mechanical ventilation have an oral airway or tracheostomy tube that bipasses some of the natural defenses against this type of infection. What is the name of this ventilator assisted or acquired infection?
What is VAP?
The nurse is assisting a physician intubate a patient in the ED with an oral ET tube. The nurse anticipates the patient's neck should be...
What is extended?
When setting up the chest tube system, the nurse will add water to the compartment that allows air to leave the pleural space, but won't allow air to enter the pleural space. What is this compartment?
What is the water seal?
The patient's daily chest x-ray report indicates that the right lung is still not fully expanded, but the nurse notes tidaling has stopped. What is a common cause of this?
What is the tubing is kinked or blocked or the patient is lying on tubing?
A patient is confused and is trying to grab at or pull on her oral ET tube. The nurse anticipates what?
What are restraints?
What is cardiovacular system? Or Cardiac output?
The patient's chest tube output on the previous count was 50 ml of serous drainage. In the 3 hours since that count, the chest tube has drained 120 ml of sanguinous drainage. The nurse will...
What is notify the provider? Call the doctor?
A patient is scheduled to have his chest tube removed later in your shift. It is disconnected from the wall suction. In what position should he carry the chest tube as he ambulates?
What is lower than the chest?
The nurse notes a constant bubbling in the water seal chamber. After checking for loose connections, and finding none, the nurse suspects what?
What is an air leak?
The nurse is caring for a patient with an oral ET tube and mechanical ventilation. The nurse anticipates providing what care every two hours to decrease the risk of VAP?
What is oral care?
The nurse notes the patient's bowel sounds are hypoactive and asks if what type of feeding can be started to increase perfusion to the patient's gut?
What is enteral feeding?
The nurse need to change the dressing on a patient who is on a mechanical ventilator and appears to be deeply asleep. How should the nurse address this patient, if at all?
What is as if the patient were fully awake?
In a wet chest tube system, the nurse adds water to the suction compartment and connects the system to wall suction. The nurse knows the system is working properly when the nurse hears what in the suction compartment?
What is gentle bubbling?
The nurse notes the patient's Atrium chest tube system is nearly full of drainage. The nurse prepares a new system and before disconnecting from the old system and attaching to the new system, the nurse...
What is clamps the chest tube?
The nurse auscultates course rhonchi in the upper lobes of the lungs and the patient has a weak, unproductive cough. Before the nurse suctions, the nurse does what?
What is hyperoxygenates?
The patient's ventilator is alarming for low pressure. The nurse anticipates what?
What is the ET tube is out or the tubing is disconnected?
Because of low ANF, high ADH, high cortisol and high levels of ________, patients generally experience fluid retention after 48-72 of mechanical ventilation.
The nurse notes that the patient with a left sided chest tube is breathing 28 times per minute with a saturation of 91% on 2L oxygen at 2L/min NC. The patient is grimacing and guards the left chest with a clenched shoulder. What is the priority nursing intervention at this time?
What is administer pain medication?
The patient is experiencing delirium and tears his chest tube tubing. The patient is quickly restrained and medicated and the nurse does what to prevent further pneumothorax?
What is places the end of the chest tube in 2 cm of sterile water or saline.
The patient on mechanical ventilation is on a paralytic drug called vecuronium. The nurse anticipates what other drug class the patient will be receiving?
What are sedatives or sedating drugs?
The nurse is performing an assessment on a ventilated patient and notes the skin over the middle anterior chest is "crunchy" and spongy. The nurse anticipates this is caused by...
What is barotrauma or injury to alveoli?
A nurse is caring for a patient with a large ascites related to liver failure. The nurse understands this does what to the patient's intrathoracic pressure?
What is increases it?