Week 4 Lab Skills
"Some air may leak out of the pleural space and will dissipate over time."
The family member of an intubated patient with a chest tube in place asks the nurse why the patient's neck looks so swollen and why a popping sensation is felt when the neck is touched. What is the nurse's best response? A. "Some air may leak out of the pleural space and will dissipate over time." B. "The anterior placement of the chest tube has caused air to back up." C. "Once your child is off mechanical ventilation, the swelling will go away." D. "The IV may have caused fluid to accumulate."
Tension pneumothorax Rationale: Absent breath sounds on the right side, decreased oxygen saturation, and neck vein distention are signs of a tension pneumothorax. Chylothorax usually occurs from diseases causing obstruction to the thoracic duct, which does not include asthma. An endotracheal tube in the right mainstem bronchus causes decreased breath sounds on the left side (not the right side). A hemothorax is usually associated with blunt trauma or penetrating wounds and presents with hypovolemic shock and respiratory failure.
A 6-year-old patient admitted after an asthma exacerbation is intubated emergently and placed on a ventilator. During assessment, the nurse notices a change in status with absent breath sounds on the right side, decreased oxygen saturation, and neck vein distention. What should the nurse suspect? A. Tension pneumothorax B. Chylothorax C. Right mainstem intubation D. Hemothorax
Tension pneumothorax Rationale: Mechanical ventilation coupled with trauma to the chest increases the risk of a tension pneumothorax. A hemothorax is caused by blood in the pleural space; blood will not enter the pleural space from the abdominal cavity after a splenic rupture as long as there is no communication through the diaphragm. An empyema is pus in the pleural space and is caused by an infection, not by chest trauma. A chylothorax results when chyle from the thoracic duct leaks into the pleural cavity because of thoracic surgery or lymphoma; chest trauma alone would not lead to a chylothorax.
A 3-year-old patient has been admitted to the emergency department after a motor vehicle crash. The patient has increased work of breathing, unequal chest rises, and tachypnea. A chest and abdomen radiograph reveals a small left-sided rib fracture and a small pneumothorax and splenic rupture. The patient is intubated and sent to the intensive care unit for further observation and treatment. The patient is at risk for which complication? A. Empyema B. Hemothorax C. Tension pneumothorax D. Chylothorax
"There are no absolute contraindications for chest tube placement when we need the lung reexpanded." Rationale: There are no absolute contraindications for placement of a chest tube if the patient is in respiratory distress from a closed pneumothorax or has a tension pneumothorax. The benefits outweigh the risks when the lung needs to be reexpanded. Disseminated intravascular coagulopathy and hemophilia A are not contraindications for chest tube placement. If a patient has disseminated intravascular coagulopathy or hemophilia A, laboratory values will need to be monitored and blood products may have to be given for abnormal results.
A patient with a bleeding disorder requires chest tube placement for a closed pneumothorax. The family members are asking if the bleeding disorder would be a contraindication for chest tube placement. Which statement would be the most appropriate response by the nurse? A. "It depends on which bleeding disorder it is; I will have to ask the doctor." B. "There are no absolute contraindications for chest tube placement when we need the lung reexpanded." C. "The only contraindication for chest tube placement is disseminated intravascular coagulopathy." D. "The only contraindication for chest tube placement is hemophilia A."
Ensure that the chest tube is securely taped to the patient's chest or abdomen to prevent dislodgement. Rationale: The chest tube should be securely taped to the chest or abdomen to prevent accidental dislodgement or disconnection. Pinning the catheter prevents it from moving with the patient during position changes. Excess tubing draped below the chest-drainage unit can seal the tubing. Guiding the tubing over a side rail would hinder the gravity flow of the fluid and could cause a clot, sealing the chest tube.
A patient with a chest tube needs assistance with changing positions in bed. What is the best approach by the nurse? A. Ensure that the chest tube is securely taped to the patient's chest or abdomen to prevent dislodgement. B. Pin the catheter to the patient's gown or to the bed sheet to prevent dislodgement. C. Allow the extra tubing to form a loop below the drainage system to facilitate gravity drainage. D. Guide the tubing over the side rail to prevent disconnection of the tube.
Drainage has decreased, indicating an obstruction in the tubing. Rationale: A sudden decrease in drainage may indicate an obstruction in the tubing, causing fluid or air not to be drained, which may lead to a collapsed lung. If the collection chambers of the drainage system are full, it would be difficult for the tube to continue to drain any fluid. However, the nurse would be monitoring the output and would know if the system needed to be changed before noting decreased drainage. PEEP does not interfere with the drainage of pleural air or fluid. Although chest tube drainage should be included when calculating output from a patient, a decrease in the amount of fluid is not a sign of dehydration.
During an assessment of an intubated patient on mechanical ventilation, the nurse observes a sudden decrease in chest tube output. What is most likely the reason for the decrease? A. The drainage system may need to be changed. B. Drainage has decreased, indicating an obstruction in the tubing. C. The PEEP level is too high on the ventilator. D. Drainage has decreased, which is an early sign of dehydration.
Air is entering tissue around the chest tube insertion site. Rationale: Subcutaneous emphysema is the presence of air in the subcutaneous tissue, which creates a crackling sensation on palpation. Subcutaneous emphysema occurs with a chest tube if there is leakage of air from the insertion site or the pneumothorax into the tissue around the tube, including the neck, face, and chest. Accumulating blood in the chest does not cause subcutaneous emphysema. Shallow breathing causes pneumonia and atelectasis, not subcutaneous emphysema. It is not a common or an expected finding after chest tube placement.
During initial assessment of a newly admitted patient who has a chest tube, the oncoming nurse notes a crackling sensation with palpation of the patient's chest and neck. What should the nurse know about this finding? A. Air is entering tissue around the chest tube insertion site. B. Blood is reaccumulating in the chest. C. This is an expected finding after a chest tube is placed. D. This results from shallow breathing associated with pain.
Chest tube size is based on the weight of the patient: Smaller chest tubes are inserted to evacuate air." Rationale: Chest tube size is determined by the weight of the patient, not the height of the patient. Chest tubes inserted to drain blood are larger than chest tubes inserted to evacuate air.
Family members are concerned about the size of the chest tube that will be used on their 6-year old child. Which statement made by the nurse correctly describes the size and intended use of chest tubes? A. "Chest tube size is based on the height of the patient: Larger chest tubes are inserted to drain blood." B. "Chest tube size is based on the height of the patient: Smaller chest tubes are inserted to drain blood." C. "Chest tube size is based on the weight of the patient: Larger chest tubes are inserted to evacuate air." D. "Chest tube size is based on the weight of the patient: Smaller chest tubes are inserted to evacuate air."
"Yes, as long as the closed system is kept below the level of the chest." Rationale: The drainage system should be kept below the level of the patient's chest. Coiling the tubing on the chair would cause dependent looping, and the tube should not be secured to clothing or bedding to prevent dislodgement. Chest tubes are only clamped in emergencies.
The family member of an awake and alert patient who has a chest tube in place after cardiac surgery is requesting to hold the patient. What is the most appropriate response by the nurse? A. "Yes, as long as you keep the tubing coiled on the chair next to you." B. "Yes, when the chest tube is clamped before or after the upcoming scan." C. "Yes, as long as the closed system is kept below the level of the chest." D. "Yes, after the tube and tubing are secured to the hospital gown."
Continuous bubbling in the water-seal chamber Continuous bubbling in the water-seal chamber indicates an air leak from the chest cavity or the system. Intermittent bubbling indicates that air is draining, which is normal for a patient with a pneumothorax. Tidaling, the rise of water in the water-seal chamber with inspiration and the fall of water with expiration, is normal. The pattern would be reversed in a mechanically ventilated patient. Air would be immediately evacuated when the chest tube was placed. However, the leak in the chest would not immediately seal, so there would still be an air leak until the lung healed.
The nurse is assessing a patient with a chest tube on the left side for a pneumothorax. What assessment finding would cause suspicion of an air leak? A. Continuous bubbling in the water-seal chamber B. Water in the water-seal chamber rising with inspiration and falling with expiration C. All the air being immediately evacuated with a chest tube in place D. Water in the water-seal chamber falling with inspiration and rising with expiration
thoracostomy tube placed posteriorly and inferiorly Rationale: A hemothorax is best treated by a thoracostomy tube placed posteriorly and inferiorly. Pigtail catheters are typically placed anteriorly toward the apex and work best for removing air from the thoracic cavity.
The nurse is preparing to assist with chest tube insertion to treat a patient for a hemothorax. What approach by the practitioner should the nurse anticipate? A. A pigtail catheter placed anteriorly toward the apex B. A thoracostomy tube placed posteriorly and inferiorly C. A pigtail catheter placed posteriorly and inferiorly D. A thoracostomy tube placed anteriorly toward the apex
Clamp the tubing between the chest tube and the closed system Rationale: Clamping the tubing between the chest tube and the closed system allows the nurse to see if there is an air leak within the system. Clamping the suction would not help the nurse discover any issues. Tidaling is normal and decreasing the suction would not assist with the diagnosis.
The nurse notices continuous bubbling in the water-seal compartment of the chest-drainage system on a patient with a pneumothorax. What is the best way for the nurse to assess for an air leak? A. Clamp the tubing between the closed system and the suction setup. B. Clamp the tubing between the chest tube and the closed system. C. Turn off the suction and monitor the system for tidaling. D. Decrease the suction and monitor the insertion site for leaking
Turn on the ordered suction. Rationale: Once the chest tube has been inserted and attached to the closed drainage system, the ordered suction needs to be turned on to maintain negative pressure within the pleural space. Assisting with suturing the chest tube in place, applying a sterile dressing, and obtaining an order for a chest radiograph are all important, but establishing suction is the priority.
The practitioner has just inserted a chest tube into a patient, and the tube is connected to a closed drainage system. What would be the next appropriate intervention? A. Place a sterile dressing over the chest tube site. B. Assist with suturing the chest tube in position. C. Turn on the ordered suction. D. Obtain an order for a chest radiograph.
Ensure that the chest tube drainage system is below the patient's chest. Rationale: The collection drainage system should be kept below the patient's chest to ensure gravity flow. Clamps may be necessary to determine the source of an air leak but should not be used during the transport of the patient to another department. Clamping the chest tube places the patient at risk of tension pneumothorax because air or fluid is not able to escape the pleural cavity. Aggressively milking the pleural tube increases the negative pressure in the chest cavity and may also dislodge or occlude the tube.
What action should be taken before transporting a patient with a chest tube to the radiology department? A. Place the collection drainage system in the bed with the patient to ensure that the chest tube is not dislodged. B. Clamp the chest tube and secure it to the bed during transport. C. Ensure that the chest tube drainage system is below the patient's chest. D. Strip or milk the tube aggressively to ensure the patency of the tube until the patient returns to the unit.
Restore negative pressure in the pleural space Rationale: Chest tubes are inserted into the pleural space to restore negative pressure and reestablish lung expansion. Positive pressure ventilation is used with mechanical ventilation. The lung alveoli open when there is negative pressure, which allows the pleura to adhere to the chest wall.
What is the physiologic goal of chest tube insertion? A. Restore positive pressure in the pleural space B. Restore positive pressure in the lung alveoli C. Restore negative pressure in the pleural space D. Restore negative pressure in the lung alveoli
Suction should be turned on after the tubing has been connected to the chest tube. Rationale: Suction should be turned on after the tubing has been connected from the drainage system to the chest tube. Changing the system during inspiration or expiration will not make a difference and is not required. There is no need for additional pain medication before clamping the chest tube. Milking or stripping the tube is not recommended and is not a precursor to changing out the closed drainage system.
What should the nurse consider when preparing to change out a closed drainage system? A. The system should only be changed if milking the tube is ineffective. B. The nurse should wait until inspiration to reduce the negative pressure. C. Pain medication should be given before clamping the chest tube before the change. D. Suction should be turned on after the tubing has been connected to the chest tube.
This is a normal process. Rationale: Tidaling or swinging, the rise of water in the water-seal chamber with inspiration and the fall of water with expiration, is a normal process. For a mechanically ventilated patient, the pattern is reversed. Continuous bubbling in the water-seal chamber indicates an air leak. Tension pneumothorax would result in no fluctuation. If a drainage system is connected to suction, fluctuation does not occur. The suction should be temporarily stopped to assess fluctuation in the water-seal chamber
When assessing a patient with a chest tube, the nurse notes fluctuation in the water-seal chamber with spontaneous respiration. What should the nurse conclude? A. This is a normal process. B. Air is leaking from the drainage system. C. There is a tension pneumothorax. D. Suction is attached to the drainage system.
Look for kinks in the chest tube and connecting tubing. ationale: A sudden decrease in drainage could indicate that a clot is blocking the fluid and that the practitioner should be notified; keeping the tubing free of kinks facilitates drainage and prevents reaccumulation of the hemothorax. A chest radiograph may be necessary, but other problems, such as blockage of the tube, should be ruled out first. The nurse should not assume that the sudden decrease of drainage indicates that the hemothorax has resolved. It may be resolved, but more information is needed before documenting that is possible. Milking chest tubes is not recommended. Placing the patient in lateral position with the affected side slightly elevated (not down) assists in reexpansion of the lung and promotes fluid drainage.
When assessing the chest tube drainage system 6 hours after chest tube placement for a hemothorax in a 6-year-old patient, the nurse notices that the drainage has stopped. What should the nurse do? A. Request an order for an immediate portable chest radiograph. B. Look for kinks in the chest tube and connecting tubing. C. Milk the chest tube to dislodge a clot that is blocking drainage. D. Place the patient in a lateral position with the affected side down.
Semi-Fowler Rationale: The semi-Fowler position is best for a hemothorax. The lateral supine position is for a pneumothorax. For either condition, the arm on the affected side should be above the head, not adducted. A prone position places the insertion side under the patient.
When preparing a patient for chest tube placement for a hemothorax, how should the nurse position the patient? A. Semi-Fowler B. Lateral supine C. Supine with both arms adducted D. Prone
Patient's chest Rationale: Chest tubes are initially secured with sutures and an occlusive dressing at the insertion site; additional taping of the tubing to the patient's chest below the dressing will prevent pulling on the sutures and dislodgement. Securing the tube to the patient's gown may cause the tube to kink or dislodge with repositioning or change of gown. Repositioning may cause dislodgement if the tube is secured to the bed. Draping the tube over the side rail inhibits the flow of drainage and could cause dislodgement if the rail is lowered without releasing the chest tube first.
Where should the nurse secure the chest tube to avoid dislodgement? A. Bed B. Patient's gown C. Patient's chest D. Side rail