Flashcards in Chest Tubes Chap 26 and Chap 43 Deck (75)
The nurse is caring for a patient who is comatose and on a ventilator. When she enters the room, she notices that the patient’s trachea has shifted toward the left side of the patient’s neck, and he has become tachycardic. She assesses the patient’s blood pressure and notes that it is 84/38. The nurse calls for help, having recognized that the patient has developed which of the following conditions?
b. Pneumothorax on the left side
c. Pneumothorax on the right side
d. Myocardial infarction
A tension pneumothorax occurs from rupture in the pleura when air accumulates in the pleural space more rapidly than it is removed. If left untreated, the lung on the affected side collapses, and the mediastinum and the trachea shift to the opposite (unaffected) side. The patient has sudden chest pain, a fall in blood pressure, and tachycardia, and cardiopulmonary arrest can occur. Patients with chest trauma, fractured ribs, and invasive thoracic bedside procedures (such as insertion of central lines) and those on high-pressure mechanical ventilation are at risk for tension pneumothorax. A hemothorax is a collapse of the lung caused by an accumulation of blood and fluid in the pleural cavity between the chest wall and the lung, usually as a result of trauma. Nothing in this scenario would suggest myocardial infarction.
For a patient with a pneumothorax, where does the nurse anticipate that the chest tube will be located?
a. Second to third intercostal space (apical), anterior
b. Fifth to sixth intercostal space, posterior
c. Fifth to sixth intercostal space, lateral
d. Mediastinal area
Apical (second or third intercostal space) and anterior chest tube placement promotes removal of air, which is necessary in the case of a pneumothorax. Chest tubes are placed low (usually in the fifth or sixth intercostal space) and posterior or lateral to drain fluid. A mediastinal chest tube is placed in the mediastinum, just below the sternum. This tube drains blood or fluid, preventing its accumulation around the heart. A mediastinal tube commonly is used after open heart surgery.
The patient’s chest tube is attached to a one-way flutter valve that allows air to escape the chest cavity and prevents air from reentering. How does the nurse document this finding?
a. Heimlich chest drain valve
c. Water seal
The device described is a Heimlich chest drain valve. Pneumovax is a pneumococcal vaccine that is effective against 23 common strains of Pneumococcus. A Pleurovac is the brand name of a water-seal set.
The nurse is caring for a patient who has a chest tube connected to a water seal. The patient is not on a ventilator. Which of the following would the nurse consider normal?
a. The fluid level in the water seal rises with inspiration.
b. The fluid level in the water seal falls with inspiration.
c. Constant bubbling occurs in the water seal.
d. The fluid level in the water seal falls with expiration 3 days after insertion.
Observe the water seal for intermittent bubbling from its U tube or for a rise and fall of fluid that is synchronous with respirations. (For example, in a nonmechanically ventilated patient, the fluid rises during inspiration, and the fluid level falls during expiration. When a patient is on a mechanical ventilator, the opposite occurs.) In a nonmechanically ventilated patient, the fluid rises during inspiration, and the fluid level falls during expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. After 2 to 3 days, tidaling or bubbling on expiration is expected to stop, indicating that the lung has reexpanded.
The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices that the drainage contains a large amount of pus. What does the presence of the pus indicate?
b. Pulmonary infarction
Pus indicates an empyema, which is a collection of pus in the pleural cavity, and the drainage is pus colored. Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Frank blood indicates a hemothorax.
What is indicated by continuous bubbling in the water-seal chamber with no bubbles noted in the suction control chamber of the drainage system?
a. A leak in the system
b. Normal functioning
c. A drainage obstruction
d. Insufficient suction pressure
Continuous bubbling in the water-seal chamber with an absence of bubbles in the suction control chamber indicates that there is a leak in the system. Normal functioning is indicated by gentle, continuous bubbling in the suction chamber and occasional bubbling in the water seal, with fluctuations on inspiration and expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. Insufficient suction pressure has little to no bubbling in the suction chamber.
What condition is indicated when a patient with a chest tube experiences sharp, stabbing chest pain without a change in pulse or blood pressure?
b. Tube displacement
c. A myocardial infarction
d. A tension pneumothorax
Sharp, stabbing chest pain with or without decreased blood pressure and increased heart rate may indicate a tension pneumothorax. A chest tube is not an expected treatment for pneumonitis. Tube displacement is an unexpected outcome and can lead to increased pneumothorax. Immediately apply pressure over the chest tube insertion site. Myocardial infarction pain is expressed as “crushing” or “pressure” over the sternal area.
Which of the following is an expected outcome of chest tube insertion?
a. Mild chest pain is maintained.
b. Breath sounds are auscultated in all lobes.
c. Drainage from the pleural cavity increases over time.
d. Lung expansion is increased beyond the unaffected side.
When breath sounds are auscultated in all lobes, lung expansion is symmetrical, oxygen saturation (SaO2) is stable or improved, and respirations are nonlabored. Chest pain is not an expected outcome. Treatment is effective when the patient reports no chest pain. Drainage from the pleural cavity decreases over time with reexpansion of the lung. Lung expansion would be equal to preinjury status.
What should the nurse do to establish a two-chamber waterless chest tube system?
a. Add sterile water to the suction chamber
b. Add sterile solution to the water seal
c. Set the float ball to the correct drainage pressure
d. Connect directly to the chest tube and add nothing
The waterless two-chamber system is ready for connecting to the patient’s chest tube after the wrappers have been opened. The waterless system’s principles are similar to those of the water-seal system, except that fluid is not required for setup. Because water is not used, accidentally tipping over the system does not compromise the patient’s condition. The suction chamber does not depend on water. Instead, it contains a float ball, which is set by a suction control dial after the suction source is turned on.
Which of the following represents appropriate technique when providing care for a patient with chest tubes?
a. Applying an occlusive dressing over the site
b. “Stripping” the tube on a regular basis
c. Assessing the patient hourly after insertion
d. Keeping excess loops of tubing from hanging over the side of the bed
Lay excess tubing horizontally on the mattress next to the patient. Secure with a rubber band and safety pin or with the system’s clamp. This prevents excess tubing from hanging over the edge of the mattress in a dependent loop. Drainage could collect in the loop and occlude the drainage system. Physician responsibility in chest tube placement includes covering the insertion site with sterile petroleum gauze, 4 × 4-inch gauze, and a large dressing to form an occlusive dressing supported with an elastic bandage. Strip or milk the chest tube only if indicated (this means compressing the tube to encourage clots to press through the tube). Stripping may cause complications because it creates excessive negative intrapleural pressure. Check agency policy. Monitor vital signs, SaO2, and the insertion site every 15 minutes for the first 2 hours.
Which of the following is the correct positioning for a patient after a chest tube has been inserted for a hemothorax?
After the tube is placed, assist the patient to a comfortable position. Supine does not facilitate drainage or removal of air or fluid, and side-lying does not facilitate lung expansion. The high-Fowler’s position is used to evacuate air (pneumothorax).
What is the expected amount of drainage for an adult patient with a mediastinal chest tube?
a. Less than 100 mL/hr during the immediate postoperative period
b. Less than 10 mL/hr during the immediate postoperative period
c. 1000 mL/hr during the first 24-hour period
d. 200 mL/hr during the first 24-hour period
In the adult, less than 50 to 200 mL/hr is drained immediately after surgery in a mediastinal chest tube. No standard is known for 10 mL/hr in the immediate postoperative period. Expected drainage in the adult with a mediastinal chest tube is approximately 500 mL in the first 24 hours.
What is the expected amount of drainage for an adult patient with a posterior chest tube?
a. 100 to 300 mL during the first 3 hours
b. 10 to 50 mL during the first 2 hours
c. 200 mL during the first 24 hours
d. 400 to 500 mL during the first 24 hours
In the adult, between 100 and 300 mL of fluid may drain from a posterior tube during the first 3 hours after insertion. The 24-hour rate is 500 to 1000 mL.
A nurse determines that there may be a leak in the chest tube system. Clamps are applied near the patient’s chest, and the nurse finds that the bubbling stops. What should the nurse do next?
a. Change the tubing.
b. Change the drainage container.
c. Move the clamps farther down the chest tube.
d. Reinforce the dressing and notify the physician.
Assess for the location of the air leak by clamping the chest tube close to the chest wall with two shodded hemostats. If the bubbling stops, the leak is inside the thorax or insertion site. Unclamp the tube, reinforce the dressing, and notify the physician immediately. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down the tubing toward the patient. If bubbling stops, replace the tubing or secure the connections. If bubbling continues, replace the drainage system.
During assessment of a patient, the chest tube becomes dislodged. What should the nurse do first?
a. Have an assistant apply an occlusive gauze dressing and tape on all four sides.
b. Clamp the chest tube.
c. Attempt to gently reinsert the tube.
d. Apply pressure over the insertion site.
If the chest tube becomes dislodged, immediately apply pressure over the chest tube insertion site. The nurse should first stabilize the patient to the best of his or her ability before calling the physician. Applying gauze to all four sides of an occlusive dressing would not allow for the escape of any air from the pleural space and could lead to a tension pneumothorax. Because the chest tube has become dislodged, it is outside of the body. Clamping the tube at this point would be useless. Nurses are not allowed to reinsert chest tubes. Immediately apply pressure over chest tube insertion site. Have an assistant apply gauze dressing and tape three sides. Notify the health care provider.
What does the expected role of the nurse include during chest tube removal?
a. Prepares an occlusive dressing
b. Performs clipping of the sutures
c. Provides support and assessment of the patient
d. Removes the chest tube firmly and quickly
The nurse supports the patient physically and emotionally while the physician or an advanced practice nurse (APN) removes the dressing and clips the sutures. A physician or an APN prepares an occlusive dressing of petroleum gauze on a pressure dressing, sets it aside on a sterile field, and applies sterile gloves; removes the dressing and clips the sutures; and pulls out the chest tube.
Appropriate intervention for the patient who is having a reinfusion of chest tube drainage is noted when the nurse:
a. Hangs the reinfusion lower than the usual intravenous (IV) bag
b. Uses a microaggregate filter on the reinfusion bag
c. Maintains 500 mm Hg pressure in the gravity blood cuff
d. Keeps the clamps open on the drainage tubing during bag transfer
Use a new microaggregate filter to reinfuse each autotransfusion bag. Hang the bag on an IV pole and continue to prime the tubing until all air is gone. Clamp the tubing, attach it to the patient’s IV access, and adjust the clamp to deliver the reinfusion at the appropriate rate. Reinfusion is delivered by gravity or by application of a blood cuff (not to exceed 150 mm Hg pressure) or a blood-compatible IV pump. Connect the red and blue connectors on top of the initial collection bag, and remove it by lifting it from the side hook and then from the foot hook. This maintains a closed system within the bag and removes it for use in autotransfusion.
Of the following nursing assessments, which should be reported to the primary care provider immediately by the nurse?
a. Bloody drainage from a patient with a hemothorax
b. Subcutaneous emphysema is noted on assessment
c. Bubbling in the water seal stops on a patient with a pneumothorax
d. Over 300 mL of drainage has been collected in the system in the past hour
Drainage exceeding 100 mL/hr should be reported immediately because this would be considered abnormal. Drainage would be expected to be bloody if the patient has a hemothorax. Cessation of bubbling in the water seal indicates that the air has been evacuated in the patient with a pneumothorax. Although the finding of subcutaneous emphysema should be reported, documented, and monitored, it is not an emergency.
The nurse is providing care for a patient with a pneumothorax. She anticipated removal of the chest tube because of the absence of an air leak for the past _____ hours.
a. 6 to 8
b. 12 to 16
c. 18 to 24
d. 48 to 72
One of the signs that indicate that the chest tube may be removed is lack of an air leak for 24 to 48 hours. Lack of an air leak for less than 24 hours is usually not long enough, and there is no need to wait 4 days. Other findings that indicate that the chest tube may be removed include a chest x-ray showing lung reexpansion, minimal tube drainage, and lack of water-seal tidaling.
The nurse is caring for a patient with blood collecting in the pleural space. The nurse documents this as:
a. pleural effusion.
c. pulmonary hemorrhage.
A hemothorax is a collection of blood in the pleural space. A pneumothorax is the collection of air in the pleural space. A pulmonary hemorrhage is bleeding inside the lung. A pleural effusion is the collection of fluid within the pleura.
The nurse knows that _______________ is the proper term to describe that the patient’s water seal is fluctuating up and down with each breath.
The term for the fluctuation of the water-seal chamber when the patient breathes is tidaling. Bubbling is different from tidaling, because bubbling is the presence of gas moving through the chamber, whereas tidaling is an up and down movement that correlates with the patient’s breathing. Fluttering and alternating reflect incorrect terminology.
The nurse is caring for a patient with a chest tube connected to water-seal drainage. The nurse may delegate which of the following tasks to nursing assistive personnel (NAP)?
a. Changing the chest tube drainage system
b. Milking the chest tube
c. Measuring chest tube output
d. Turning and positioning the patient
The NAP may turn and position the patient as long as the nurse ensures that the NAP understands how to manipulate the tubing safely and what signs and symptoms should be reported immediately. Care of the chest tube, including milking the tube if ordered, measuring chest tube output, and changing the chest tube drainage system, should never be delegated to unlicensed assistive personnel.
The patient has a chest tube for a pneumothorax. Assessment revealed no continuous bubbling in the water-seal chamber. The nurse finds no loose connections. After the chest tube near the patient is clamped, the bubbling stops. The nurse’s first action should be to:
a. apply pressure to the dressing around the chest tube insertion site.
b. move the clamp farther down the tube and note whether bubbling resumes.
c. replace the entire collection tubing and system.
d. increase suction control until bubbling does not resume when the clamp is removed.
If bubbling stops when the chest tube is clamped between the collecting system and the body, the leak is at the insertion site or inside the patient. Applying pressure to the dressing will determine which of the sites is leaking. If bubbling continues after the chest tube is clamped, the leak is below the clamp, and the next step would be to move the clamp farther away from the patient and reassess. Only if the bubbling never stops after the clamp is moved all the way down the tubing should the collection system be replaced. Turning the suction device higher will increase bubbling in the suction chamber and will not affect bubbling in the water-seal chamber.
A pneumothorax can be caused by which of the following? (Select all that apply.)
b. Rupture of a blister
ANS: A, B, C
A variety of mechanisms can cause a pneumothorax. A traumatic pneumothorax develops as a result of penetrating chest trauma, such as a stabbing or a case of the chest striking the steering wheel in an automobile accident. A spontaneous or primary pneumothorax sometimes occurs from the rupture of a small bleb (blister) on the surface of the lung or from an invasive procedure, such as insertion of a subclavian IV line. Secondary pneumothorax occurs because of underlying disease, such as emphysema. A patient with a pneumothorax usually feels pain as atmospheric air irritates the parietal pleura. Dyspnea is a symptom of pneumothorax, not a cause.
The nurse is caring for a patient with a chest tube connected to wall suction. To keep the tube patent, the nurse should implement which of the following? (Select all that apply.)
a. Routinely “milk” the drainage tubing.
b. Avoid dependent loops of the drainage tubing.
c. Lift and clear the tube every 15 minutes.
d. Coil the drainage tubing to prevent dependent loops.
ANS: B, C
Chest tube milking or stripping usually is contraindicated because it does not improve catheter patency. Careful management of chest tube drainage prevents the need to milk the chest tube. Institute nursing interventions to maintain tube patency. These interventions include avoiding dependent loops of the drainage tube, or, when these loops cannot be avoided, such as when the patient is sitting, lifting and clearing the tube every 15 minutes. If the tubing is coiled, looped, or clotted, drainage is impeded, and this can result in a tension pneumothorax.
The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices that the drainage is blood-tinged. What might this indicate to the nurse? (Select all that apply.)
b. Pulmonary infarction
ANS: A, B
Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Pus indicates an empyema, which is a collection of pus in the pleural cavity, and the drainage is pus-colored. Frank blood indicates a hemothorax.
The nurse is preparing to assist the physician in removal of a chest tube. What should the nurse do to prepare the patient? (Select all that apply.)
a. Assess the patient’s need for pain medication.
b. Instruct the patient about the process.
c. Teach the patient to take a deep breath and hold it.
d. Clamp the chest tubes.
ANS: A, B, C
The nurse should prepare the patient for chest tube removal by (1) assessing the need for pre-removal analgesia and obtaining the required medication orders, and (2) instructing the patient about the process and what will be requested of the patient. During removal of the chest tube, it is important to instruct the patient to take a deep breath and hold it until the tube is removed. This maneuver prevents air from being sucked into the chest as the tube is pulled out and an occlusive dressing is applied. Although clamping of the chest tubes is done to determine whether the chest tube can be eliminated, this is not part of the immediate chest tube removal procedure.
The nurse is caring for a patient who has a chest tube. Attached to the top of the patient’s bed are two shodded hemostats. In which situations would these be used? (Select all that apply.)
a. To assess an air leak
b. To quickly empty or change disposable systems
c. To quickly seal off the lungs if the system becomes disconnected
d. To assess whether the patient is ready to have the chest tube removed
ANS: A, B, D
Chest tubes are clamped only under the following specific circumstances, per health care provider order or nursing policy and procedure: to assess air leak, to quickly empty or change disposable systems, or to assess whether the patient is ready to have the chest tube removed (which is done by a health care provider’s order). Clamping an open system could lead to a tension pneumothorax.
The nurse is performing an initial assessment of a patient with a chest tube placed in the eighth intercostal space. Which of the following findings would the nurse need to assess further? (Select all that apply.)
a. Respiratory rate of 18 breaths per minute
b. Continuous bubbling in the water-seal chamber
c. The presence of subcutaneous emphysema
d. Complaints of pain at the insertion site
e. Serous drainage on the chest tube dressing the size of a bean
ANS: B, C, D
Continuous bubbling in the water-seal chamber could indicate a leak in the system and should be assessed further. The presence of subcutaneous emphysema must be assessed further because it can be caused by a poor seal at the chest tube insertion site. Complaints of pain at the insertion site can be expected but should be fully assessed before analgesics are administered. A respiratory rate of 18 breaths per minute falls within the normal range and does not, by itself, indicate a need for further assessment. A small amount of drainage on the chest tube dressing can be expected and serous drainage would be normal; however, it should be monitored for any change in appearance.