NCLEX Style Q
The nurse is handling a client with a chest tube. Suddenly, the chest drainage system is accidentally disconnected, what is the most appropriate action for the nurse to take?
a. Secure the chest tube using a tape
b. Clamp the chest tube immediately.
c. Place the end of the chest tube in a container of normal sterile saline.
d. Apply an occlusive dressing and notify the physician.
c. Place the end of the chest tube in a container of normal sterile saline.
If a chest drainage system is disconnected, the nurse can place the end of the chest tube in a container of normal sterile saline to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. Option A: The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected. Option B: The nurse should not clamp the chest tube because doing so increases the risk of tension pneumothorax. Option D: The nurse should apply an occlusive dressing if the chest tube is pulled out and not if the system is disconnected
What if the chest tube gets pulled out of the patient?
–
Cover the site with a dry, sterile dressing and call the Physician. If you are able to hear air leaking from the chest tube site, tape the dressing on 3 sides to allow air to escape and prevent a tension pneumothorax
How do you know your patient with a chest tube Moving in the Right Direction
•Based on our assessment data, you can determine if the underlying condition is improving and your patient’s lung has fully re-expanded.
–Imaging results • To visualize affected lung
–Amount of daily fluid output • Less than 200 mL/day
–Air leak resolved • On suction and with coughing
ou are providing care to a patient with a chest tube. On the assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding?
A. Reposition the patient because the tubing is kinked.
B. Continue to monitor the drainage system.
C. Increase the suction to the drainage system until the bubbling stops.
D. Check the drainage system for an air leak.
D. Check the drainage system for an air leak
The chest drainage system got knocked over, what should I do?
– Immediately check the patient to ensure chest tubes are still intact and connected to the patient, and then set the chest tube drainage system upright and check the fluid level of the water seal for 2cm of volume. If there is overfill, aspirate water with a 20 gauge needle or smaller from the self-sealing diaphragm. If there is less than 2cm of volume, replace the lost fluid. Mark each chamber to show blood levels after spilling. If blood has entered the water seal, change the drainage system out for a new one
What would you Monitor and Assess with a patient who has a chest tube
Assess Respiratory Function – Rate, depth, pattern, and overall respiratory status of the patient
• Check the Dressing:
– Does not need to be routinely changed
• Can cause air leak to worsen or dislodge the chest tube
Check the Tubing: – No kinks or clots in tubing that would disrupt negative pressure – No dependent loops
• Drainage can’t go uphill – Ensure connection from patient to chest tube and chest tube to chamber is secur
Check the Orders – Suction or water seal? – Do current orders match treatment?
• Check the Suction Regulator – Is wall suction set to a continuous rate of -80mmHg or higher?
• No Stripping or Milking unless ordered by Physician – Can create dangerously high negative pressures inside the chest
• Check the Drainage: – Note the amount, type, and color of fluid – Mark amount since last check directly on collection chamber
Check for bubbling in the Water Seal Chamber – Indicates air is leaving the chest and entering the chest tube system (air leak)
• Check Water Level – Want to maintain a water level of 2cm on the Water Seal Chamber – Replace with Normal Saline if less than 2cm
The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive at the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY?*
A. Place the patient in a supine position and clamp the tubing.
B. Notify the physician immediately.
C. Disconnect the drainage system and get a new one.
D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
It feels like my patient has rice crispies under their skin, what is this and should I be concerned?
– Subcutaneous emphysema (rice crispies under the skin) is a collection of air under the skin that occurs when a chest tube is not in the correct location or the chest tube dressing is not air tight. This air under the skin causes the area to swell and if it travels to the neck or face, the patient’s airway could be compromised, and intubation would be necessary. Report new or increased findings of subcutaneous emphysema to the Physician immediately
What are the Conditions Requiring Chest Drainage
Pneumothorax: Air in the pleural space Caused by blebs, trauma, surgery
Hemothorax: Blood in the pleural space Caused by trauma, surgery
Hemopneumothorax: Air and blood in the pleural space Caused by surgery, disease, or trauma
Tension Pneumothorax: Air enters the pleural space and cannot escape. Build-up of air under pressure can lead to a collapsed lung. Usually caused by a lung laceration.
Mediastinal Shift: Pressure builds up and pushes the mediastinal cavity to the unaffected side. Lung may collapse creating a life threatening situation. May be seen with a large tension pneumothorax.
Pleural Effusion: Accumulation of pleural fluid within the pleural space Caused by malignancy, heart failure or pneumonia
Empyema: Pleural effusion with purulent material (pus) Caused by pneumonia, lung abscess or injury
You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention?*
A. Document your findings as normal.
B. Assess for an air leak due to bubbling noted in the suction chamber.
C. Notify the physician about the drainage.
D. Milk the tubing to ensure patency of the tubes.
A. Document your findings as normal.
What is the purpose of a chest tube?
What is to drain fluid or air from the chest
What is a chest tube removing in the upper anterior chest?
air
If it is lateral and lower, it is for drainage
Patient can have both (they are y connected together attached to a closed chest drainage unit
What are the complications of chest tube?
Complications include bleeding, superficial site infection, deep organ space infection (empyema), dislodgement of the tube, clogging of the tube, re-expansion pulmonary edema, injury to intraabdominal organs such as spleen or liver, injury to the diaphragm, and injury to intrathoracic organs, such as the heart or thoracic aorta
While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention?*
A. Stay with the patient and monitor their vital signs while another nurse notifies the physician.
B. Place a sterile dressing over the site and tape it on three sides and notify the physician.
C. Attempt to re-insert the tube.
D. Keep the site open to air and notify the physician.
B. Place a sterile dressing over the site and tape it on three sides and notify the physician.
What has happened for a client to need a chest tube?
Lung has collapsed (surgery, trauma, tumor, infection)
Mention the 3 Chambers of the Chest Drainage Unit (CDU)
1. Drainage collection chamber
2. Water seal chamber
3. Suction control chamber
What would you do if you noted a new air leak is noted, the chest tube, connecting tubing, pleura-evac?
A patient's wound should be examined for any loose connections or dislodgement of the tube. The fenestrated holes should not be outside of the body. Factors that make a patient high-risk for persistent air leak include steroid use, emphysematous lungs, re-operation with extensive scar tissue, or significant trauma to the lungs.