'Chester' Tubes
This is the priority action if a chest tube becomes disconnected from the drainage system.
“What is place the tube end in sterile water and notify the provider?”
These findings are assessed in the BEFAST stroke screening tool.
“What are Balance, Eyes, Facial droop, Arm weakness, Speech difficulty, and Timing?”
The NIHSS is primarily used to assess this condition.
“What is stroke severity?”
A patient’s NIHSS worsens while oxygen saturation falls to 82% after chest tube displacement. This physiologic mechanism may worsen neurologic injury.
“What is hypoxia?”
The nurse notes sudden drainage of 400 mL bright red blood from the chest tube in 30 minutes. This complication should be suspected.
“What is active hemorrhage or hemothorax?”
This dressing should be applied if a chest tube is completely removed.
“What is a sterile occlusive petroleum gauze dressing taped on 3 sides?”
This imaging is typically ordered during a stroke alert.
“What is a non-contrast CT scan of the head?”
This NIHSS category evaluates facial symmetry.
“What is facial paralysis?”
A patient with a chest tube develops acute confusion and unilateral weakness. The nurse should prioritize this physiologic system first.
“What is airway and breathing?”
A sudden severe headache and neurologic decline after TNK administration may indicate this complication.
“What is hemorrhagic transformation?”
Tidaling in the water seal chamber generally indicates this.
“What is normal pressure fluctuation with breathing?”
This blood test/result must be checked immediately in suspected stroke patients.
“What is blood glucose?”
This NIHSS component assesses for extinction and inattention.
“What is neglect?”
An NIHSS score rapidly increasing from 6 to 16 most concerningly suggests this clinical event.
“What is stroke progression, cerebral edema, or hemorrhagic conversion?”
This complication can occur 2–5 days after a large ischemic stroke and may cause declining LOC and pupillary changes.
“What is cerebral edema?”
This life-threatening complication may occur if air accumulates in the pleural space and cannot escape.
“What is tension pneumothorax?”
This medication may be considered for eligible ischemic stroke patients within the treatment window.
“What is TNK?”
A patient unable to correctly state the month or age would lose points in this NIHSS category.
“What is level of consciousness questions?”
This blood pressure parameter typically requires management before TNK administration.
“What is blood pressure greater than 185/110 mmHg?”
This cardiac rhythm is strongly associated with embolic ischemic stroke.
“What is atrial fibrillation?”
The nurse notices sudden absent breath sounds, tracheal deviation, and severe respiratory distress after chest tube displacement.
“What are signs of tension pneumothorax requiring emergency intervention?”
This information is critical to determine stroke treatment eligibility.
“What is the last known well time?”
A sudden increase in NIHSS score may indicate this.
“What is worsening neurologic status or stroke progression?”
This stroke type must be ruled out before thrombolytic administration.
“What is hemorrhagic stroke?”
A patient with a large ischemic stroke becomes progressively somnolent with hypertension, bradycardia, and irregular respirations.
“What are signs of increased intracranial pressure and possible herniation?”
This action is contraindicated when a chest tube becomes dislodged.
“What is reinserting the chest tube?”
A patient receiving alteplase develops severe headache and vomiting. The nurse anticipates this immediate order.
“What is STAT head CT?”
The nurse identifies unequal pupils, bradycardia, hypertension, and irregular respirations. These findings may indicate this emergency.
“What is increased intracranial pressure?”
The nurse notes sudden cessation of tidaling in a patient with a chest tube previously demonstrating fluctuation. The priority assessment is for this.
“What is tubing obstruction, lung re-expansion, or kinking?”
A stroke patient develops gurgling respirations and inability to clear secretions. This airway intervention is indicated first.
“What is suctioning the airway?”