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Chest Tube Management Case Study (60 min)

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Mr. Jones is a 19 year old male who was in a motor vehicle collision yesterday. He sustained a fractured left radius and fractures to ribs 4-7 on the left side.  He was admitted to the trauma med-surg floor last night. This morning, he suddenly develops shortness of breath and ‘chest tightness’. He says “I feel like I can’t get a deep breath” and appears very anxious.

Critical Thinking Check
Bloom's Taxonomy: Application

What nursing assessments should be performed at this time for Mr. Jones?

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You assess Mr. Jones to find his SpO2 is 90%, his RR is 32, HR 108, and BP 117/72. You auscultate his lungs but find that lung sounds are diminished and almost absent over the left upper lobe.

Critical Thinking Check
Bloom's Taxonomy: Analysis

What might be occurring physiologically? How would this be diagnosed?

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You notify the provider who orders a STAT Chest x-ray.  The chest X-ray confirms the patient has a moderate sized pneumothorax on the left side, with no shifting of the mediastinum or trachea. The provider determines the patient needs a chest tube placed. You gather supplies, set up the drainage system and assist with placement of the chest tube on the left side.

Critical Thinking Check
Bloom's Taxonomy: Analysis

What output would you expect to see on initial placement of Mr. Jones’s chest tube?

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You secure the chest tube with an occlusive dressing and place the drainage system at the foot of the bed. The provider orders the chest tube to be placed to water seal, without suction.

Critical Thinking Check
Bloom's Taxonomy: Comprehension

Describe how ‘water seal’ works.

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Critical Thinking Check
Bloom's Taxonomy: Application

What safety considerations should you take for the tubing and drainage system?

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Critical Thinking Check
Bloom's Taxonomy: Application

What assessments would you perform to monitor the effectiveness of the chest tube?

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You note intermittent bubbling in the air leak chamber and no output in the drainage chamber. The patient’s lungs sound clear, though still slightly diminished in the left upper lobe. SpO2 is has risen to 96% on 2L nasal cannula.  Four hours later, you are checking the chest tube system again and notice continuous bubbling in the air leak chamber.

Critical Thinking Check
Bloom's Taxonomy: Analysis

What could be the possible causes of an air leak?

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Critical Thinking Check
Bloom's Taxonomy: Application

What should you do if you discover there is a hole in the drainage system tubing?

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You notice the connections had come loose, so you tighten them, which fixes the air leak.  Later that evening when turning the patient, the chest tube becomes accidentally dislodged from the patient’s chest.

Critical Thinking Check
Bloom's Taxonomy: Analysis

What should your first nursing action be? Explain.

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Mr. Jones remained stable even without the chest tube, therefore the provider decided that his pneumothorax had resolved and there was no need to replace it. You continue to monitor for any possible complications or redevelopment of a new pneumothorax.

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