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Outline
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.
What nursing assessments should be performed at this time for Mr. Jones?
- Auscultate Lung Sounds
- Full set of Vital Signs, including SpO2
- Determine further details of symptoms if needed (OLDCARTS)
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.
What might be occurring physiologically? How would this be diagnosed?
- Because of his rib fractures, he may have developed a pneumothorax – this would cause air to begin filling the space around his lung and cause it to collapse
- The quickest way to diagnose this is with a chest x-ray, though it can also be diagnosed with a CT, ultrasound, or MRI – though that would be too time consuming.
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.
What output would you expect to see on initial placement of Mr. Jones’s chest tube?
- Because this is a pneumothorax, we shouldn’t see any drainage or blood. It’s possible there may be a very small amount of pleural fluid, but mostly it is just draining air.
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.
Describe how ‘water seal’ works.
- It’s like blowing bubbles through a straw, the air can go out, but it can’t come back in.
What safety considerations should you take for the tubing and drainage system?
- Should have no dependent loops – loop the tubing on the bed to prevent dependent loops from forming – this could lead to clots in the tubing and occlusions.
- Drainage system should be kept upright at all times .
- Never clamp the tubing of a chest tube unless searching for an air leak or unless specifically instructed to do so by a provider.
- Ensure that the tubing is covered with an occlusive dressing and taped securely to the patient’s chest.
- Ensure that all connections are tightly secured.
What assessments would you perform to monitor the effectiveness of the chest tube?
- Tidaling – should see tidaling of any fluid in the tubing with reservations
- Water seal – verify that the level of fluid in the water seal is appropriate (2 cm)
- Output – assess the character, quality, and volume of output from the chest tube
- Air leak – assess for air leak – continuous bubbling in the water seal chamber
- Ability to breathe – assess the patient’s symptoms, ensure they aren’t SOB
- SpO2 – assess oxygenation to ensure the lung is inflating well
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.
What could be the possible causes of an air leak?
- Dislodgement of the tube
- Disconnection of tubing/system
- Equipment failure (hole in the tubing)
- Pneumothorax
What should you do if you discover there is a hole in the drainage system tubing?
- The entire drainage system and tubing (not the chest tube) should be changed. This can be done by a nurse without a provider order. Prepare the new system, clamp the chest tube, remove the old tubing, connect the new tubing. This should be done with sterile technique. Document the amount of drainage in the old system before discarding.
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.
What should your first nursing action be? Explain.
- This creates a one-way valve to prevent the patient from developing a tension pneumothorax while we wait for the provider to arrive
- Cover the site with an occlusive dressing taped on 3-sides.
- Then, notify the provider immediately – stay with the patient and monitor their respiratory and hemodynamic status.
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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