Answers to Case Study, Chapter 25, Respiratory Care Modalities
Objective: 8
April Long, a 60-year-old client is admitted with the diagnosis of small cell carcinoma of the left lower lobe. She had a left lower lobectomy removing the cancerous mass. After surgery, the client has a chest tube to a closed water-seal drainage system, the Atrium Ocean at 20-cm H2O.The nurse has a quick view sheet to help guide the nurse with managing the drainage system: http://www.atriummed.com/PDF/OceanSetupLetterSize.pdf .
What are the nursing responsibilities when caring for a client with a chest tube to a drainage system?
• Look at the client first- (color, level of consciousness, airway patency, respiratory rate, depth, rhythm, chest movement- symmetry, lung sounds, lips/ nailbeds).
• Assess the chest tube insertion site- for intactness; dressing occlusive; check for crepitus at site; listen for air leak at chest tube site.
• Assess connections- taped, intact.
• Assess for tidaling in the waterseal chamber. The fluid fluctuates in the tubing with breathing (rises with inspiration and falls with expiration). If the client is on wall suction, the nurse will have to disconnect the suction temporarily to assess. If the nurse doesn’t observe tidaling, then check to see if the chest tube is kinked or maybe the lung is re-expanded.
• Examine the drainage coming from the client, the color, consistency, amount, and if there are any clots present.
• Make sure there are no dependent loops, which leads to back pressure and does not promote drainage. The chest tube drainage system must always be kept below the level of the chest to properly drain.
• Mark the drainage on the collection chamber. Drainage should decrease over 2-3 days and change from sanguineous to serosanguinous to serous.
• Observe for continuous bubbling in the water seal, which is an indication of an air leak. The chest tube drainage systems have air leak indicators that rate the air leak on a scale, so the nurse may evaluate the extent and progress of the air leak. Checking for the source for the air leak involves a brief clamping at the chest tube insertion site, as close to the dressing as possible with a padded clamp.
• If the bubbling continues, the air leak is farther down the system. Keep moving the clamp, and see if it is a hole in the drainage tubing, a connection that is loose, or a hole in the system. Fix the problem.
• If when you clamped the chest tube the bubbling stopped, then remove the dressing carefully and see if the eyelet of the chest tube is exposed- apply Vaseline gauze, and a dry sterile dressing and call the physician. Suspect pneumothorax.
• Make sure in report to pass on that the client developed an air leak and what was done, so the next nurse will know.
• Check the amount of suction per order. Make sure that the dial and float at the chest tube system is at the correctly ordered level.
• Keep Vaseline gauze, 4x4s, padded hemostat, and sterile water (according to your facility policy and procedure) at the bedside at all times.
• Keep the head of the bed elevated to help with lung re-expansion. Instruct the client to call for help and not try to get up on own to decrease the risk of accidentally pulling out the chest tube.
• Assess for pain.
How should the nurse reposition the client in this case study?
The nurse should not position the client on her left side because lying on the chest tube will increase pain and can kink the tubing, limiting drainage. The client should be positioned either supine or to the right-side. Positioning to the non-operated side allows for optimal ventilation and perfusion of the lung tissue.
The chest tube accidently is disconnected from the drainage system and the drainage system is cracked. What should the nurse do?
Place the chest tube immediately in a bottle of sterile water kept at the bedside (at 2 cm). The client will need a new drainage system; the bottle of sterile water is a temporary measure. Assess vital signs and breath sounds in all fields. Assess for dyspnea, anxiety, skin temperature and moisture level, complaint of pain, and dysrhythmias. Notify the doctor of any abnormal findings and the incidence. Fill out an incident report according to the hospital policy and procedure.