STATION C CHEST TUBE CHALLENGE

Front

Based on the fact that the client has both a hemo and pneumothorax, where will the chest tube(s) be placed?

Back

2ND ICS AND 5TH ICS

Answer explanation

​The client will require two chest tubes. The inferior tube typically is inserted midaxillary at the fifth or sixth intercostal space and will draw the blood from the hemothorax. The superior tube is typically inserted anteriorly, at the second intercostal space, and will draw air from the pneumothorax. Remember: Air rises and blood falls, so it is critical that the tubes are placed accordingly.

Front

The chest tubes have been inserted and are now connected to the wet drainage system. Prepare to dress the tube insertion sites and stabilize the drainage tube system. Which dressing would be applied?

Back

OCCLUSIVE

Answer explanation

​The dressing used for a chest tube is an occlusive one, usually using 4 x 4 dressings. The dressing is covered completely by tape such that all edges are sealed. By using a fully occlusive dressing, air is prevented from leaking into the chest at the insertion site, which could cause a tension pneumothorax. The chest tubes are generally sutured to the skin near their insertion site to minimize the risk of accidental dislodgment. Additional stabilization with taping each tube to the skin may be desirable. All tube connections should be taped to prevent unintentional breaking of the negative seal.

Front

What should the nurse do to ensure safe and effective use of the drainage system?

Back

Make sure that the drainage apparatus is always below the client's chest level.

Answer explanation

​The drainage apparatus is always kept below the client’s chest level to prevent back flow of fluid into the pleural space. The air vent must always be open in the closed chest drainage system to allow air from the client to escape. Stripping a chest tube causes excessive negative intrapleural pressure and is not recommended. Clamping a chest tube when moving a client is not recommended.

Front

If the chest tube is accidentally removed, which of the following is the priority?
Options:
Reinsert the tube and attach it to the wet drainage device.
Notify the primary health care provider.
Create a pressure dressing out of petroleum gauze.
Clean the wound with povidone-iodine and apply a gauze dressing.

Back

Notify the primary health care provider.

Answer explanation

​If a chest tube is accidentally removed, a 3 sided dressing should be placed and the primary health care provider should be notified. Do not use an occlusive pressure dressing as this could lead to a tension pneumo since the air cannot escape. It is not within the scope of nurse to routinely insert a chest tube. The nurse should have another staff member call the primary health care provider so another tube can be introduced by the provider under sterile conditions.

Front

The chest tube is connected to a water drainage system. The nurse notes that the fluid in the water seal chamber is fluctuating with each breath that the client takes. What is the significance of this finding?

Back

The chest tube system is functioning properly.

Answer explanation

​Fluctuation of fluid (also referred to as tidaling) with respirations in the water seal chamber indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client’s skin around the chest tube insertion site. An air leak in the system is indicated when CONTINUOUS or VIGOROUS bubbling occurs in the WATER SEAL CHAMBER

Front

There is noticeable edema and crepitus upon palpation of the chest tube insertion site. Which of the following is the priority concern? SUBCUTANEOUS EMPHYSEMA, PNEUMONIA, TIDALING OF THE DRAINAGE DEVICE, DRAINAGE OF 20ML/HR

Back

SUBCUTANEOUS EMPHYSEMA

Answer explanation

​The client is experiencing subcutaneous emphysema. This would need to be monitored to prevent airway constriction. The subcutaneous emphysema will be absorbed by the body over time. Drainage of less than 150 mL/hr is considered normal.

Front

The client begins breathing with a little more effort and at a faster rate than 1 hour ago. The client’s heart rate is also increased. Which of the following is the priority? Options: Check the tubing to ensure that the client is not lying on it or kinking it., Increase the suction., Raising the drainage device 2 to 3 feet (61 to 91.4 cm) above the level of the client's chest., Ensure that the chest tube has two clamps on it to prevent air leaks.

Back

Check the tubing to ensure that the client is not lying on it or kinking it.

Answer explanation

​In this case, there may be some obstruction to the flow of air and fluid out of the pleural space, causing air and fluid to collect and build up pressure. This prevents the remaining lung from re-expanding and can cause a mediastinal shift to the opposite side. The nurse’s first response is to assess the tubing for kinks or obstruction. Increasing the suction is not done without a primary health care provider’s prescription. The normal position of the drainage device is 2 to 3 feet (61 to 91.4 cm) below chest level. Clamping the tubes obstructs the flow of air and fluid out of the pleural space and should not be done.

Front

What is the priority action after a client is extubated, with no bubbling in the water seal chamber, vesicular breath sounds in the left lower lung, and 100% oxygen saturation on room air? Options: Increase the suction level of the chest tube, Connect the client to a new chest tube system, Clamp the chest tube and document the response, Ensure a chest xray is taken to check for re-inflation of the lung.

Back

Ensure a chest xray is taken to check for re-inflation of the lung.

Answer explanation

​A lack of bubbling in the water chamber and normal lung sounds are an indication that lung re-inflation has occurred. The nurse can further assess the client in relation to pulse oximetry, respiratory rate, and other signs that indicate improvement and can be relayed to the provider for possible removal of the chest tube.

Front

A client is connected to a wet drainage system. Continuous bubbling in the wet seal chamber can indicate an air leak within the tubing system.

Back

TRUE

Front

A client is connected to a wet drainage device. Bubbling in the suction control chamber is concerning.

Back

FALSE