4335: Midterm-Chest Tubes

Before chest-tube insertion, the patient should be positioned: A. With the head of the bed elevated 90 degrees and nothing between the shoulder blades. B. With the head of the bed elevated 45 degrees and nothing between the shoulder blades. C. Laterally, with a small wedge or bolster between the shoulder blades. D. Flat, with a small wedge or bolster under the shoulder blades.

D, flat, is correct (But many times in real life practice, provider will have them at 45 degrees)

A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? · A. Intermittent bubbling may be noted in the water seal chamber. · B. 200 cc of drainage per hour is expected during recovery of a pneumothorax. · C. The chest tube is positioned at the patient's chest level to facilitate drainage. · D. All of these options are appropriate findings.

The answer is A. It is normal to find intermittent (NOT CONTINUOUS) bubbling in the water seal chamber if the patient is recovery from a pneumothorax. Remember that a pneumothorax is an AIR leak between the lung and chest wall....therefore air will escape into the water seal chamber causing intermittent bubbles. 200 ml drainage is abnormal, esp for a PNEUMOthorax (draining AIR). Chest tube unit should be below chest level

T/F: The nurse would notify the health care provider if drainage from a chest tube unit is greater than 100 mL/h.

True

T/F. Never routinely milk/strip, or clamp a chest tube without provider order

True. You may only clamp chest the with an order. (this may occur prior to removal of chest tube, in order to assess if patient is truly ready for it to be removed)

Is the procedure for removing a chest tube painful for the patient?

Yes, patients describe it as frightening, hot, burning, painful, and a pulling sensation. Consider meds 30 min prior. Encourage Valsalva maneuver as provider removes tube (similar to CVAD removal!). Apply occlusive dressing and monitor for bleeding and respiratory distress. Perform head to toe assessment.

As needed, the suction-control chamber of a chest tube drainage unit should be refilled with: A. Sterile water B. Nonsterile water C. Sterile saline solution D. Nonsterile saline solution

A

With respect to chest tube placement, which of the following is correct? SATA A. Air: anterior 2nd Intra-costal space (ICS) B. Air: anterior 3rd ICS C. Fluid: laterally 5-6th ICS D. Air & Fluid: mid-axillary 4th ICS

A, C, D

Examples of a closed pneumothorax include? SATA A. Spontaneous B. GSW C. Rupture blebs or bullae in COPD D. Broken ribs E. Mechanical ventilation F. Surgical

A, C, D, E Surgical, Stab wound/GSW, and CVC placement are all considered OPEN pneumos

Signs and symptoms of cardiac tamponade. SATA A. Muffled, distant heart sounds B. Hypotension C. Neck vein distention D. Increased CVP

All of the above

Potential complications of chest tubes include: SATA A. Bleeding B. Empyema C. Subcutaneous emphysema D. Cardiac tamponade

All of the above. Empyema is infection; it is the medical term for pockets of pus that have collected inside a body cavity. Cardiac tamponade is an accumulation of blood in the mediastinum; specifically the pericardial sac, it can be life threatening because it can compress the heart and interfere with venous return (prevents filling of ventricles)

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.

B

When placing a chest tube at bedside, what two medications are commonly used? A. Morphine and Epi B. Epi and lidocaine C. Lidocaine and Advil D. Epi and Adenosine

B

Crepitus on palpation of the skin surrounding the chest tube may indicate: A. Deep-tissue emphysema B. Subcutaneous emphysema. C. Excessive drainage. D. Inadequate drainage.

B. subq emphysema

A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? A. The water in the chamber will increase during inspiration and decrease during expiration. B. There will be continuous bubbling noted in the chamber. C. The water in the chamber will decrease during inspiration and increase during expiration. D. The water in the chamber will not move.

C When a patient is receiving mechanical ventilation the water in the water seal chamber will oscillate oppositely than if the patient were breathing on their own. Therefore, the water in the chamber will decrease during inspiration and increase during expiration.

Which statement about the parietal and visceral pleurae is correct? A. A potential space exists between the two. B. A small space separates the two. C. The visceral pleura covers the chest wall and diaphragm. The parietal pleura covers the inside of both lungs. D. The parietal pleura covers the inside of both lungs.

Correct: A Pleural "potential" space separate the two section of your body. It should be a negative space. If this space is interrupted [by a knife wound] it becomes positive (sucking chest wound)

Which finding best indicates that the chest tube for a client with a pneumothorax may be discontinued? A. Clear breath sounds heard in both lungs B. Oxygen saturation reading is higher than 90% C. Absence of bubbling in the water-seal chamber D. Full re-expansion of the lungs seen on chest x-ray

D Chest x-ray films reveal the degree to which the lung fills the pleural cavity and also the presence or absence of pneumothorax. Clear breath sounds heard bilaterally do help indicate that the lung has re-expanded, but a chest x-ray is needed to confirm lung re-expansion. Oxygen saturations improve with resolution of pneumothorax, but a chest x-ray is needed for confirmation. Because intrapleural air is expelled into the water-seal chamber, lack of bubbling in the water-seal chamber indicates possible resolution of the pneumothorax, but a chest x-ray is needed for confirmation.

The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

D Option D is the best choice. A new system needs to be obtained, however, in order to maintain a water seal until the new system arrives you will need to place the tubing 1 inch in sterile water or sterile saline to regain a water seal.

In the occurrence of a tension pneumothorax, the increase in positive pressure will continue to collapse the lung further, eventually causing a shift of which part of the body?

Trachea. A mediastinal/tracheal shift can occur in untreated tension pneumo, which may lead to cardiac tamponade

You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? · A. Document your findings as normal. · B. Assess for an air leak due to bubbling noted in the suction chamber. · C. Notify the physician about the drainage. · D. Milk the tubing to ensure patency of the tubes.

A The assessment findings are normal. All the other options are incorrect: Bubbling in suction control chamber is normal, no need to assess for leak. 50 cc is an acceptable amount of drainage (Report >100 ml/hr). Do not milk/strip chest tube tubing.

What should be included in patient teaching for a patient with a chest tube?SATA A. Patient should cough and deep breathe to help drain pleural space and expand lungs. B. Have the patient sit upright for optimal lung expansion. C. Have the patient lie down for maximal comfort D. Splint insertion site while coughing to minimize pain. E. Tell patient to report an increase in difficulty breathing immediately. F. Make sure the patient stays in bed and does not ambulate for their safety.

A, B, D, E Tell patient to cough a deep breathe, sit upright for maximal chest expansion, encourage ambulation (medicate 30 min prior for comfort), and splint insertion site when coughing. Make sure patient reports any SOB, dyspnea, sense of 'doom', nervousness, or feelings similar to when they first arrived to the hospital/ED (could be sign of tension pneumo)

The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider? 1. New, vigorous bubbling in the water seal chamber. 2. Scant amount of sanguineous drainage noted on the dressing. 3. Clear but slightly diminished breath sounds on the right side of the chest. 4. Pain score of 2 one hour after the administration of the prescribed analgesic.

Answer: 1. The bubbling in the water seal chamber can mean a new pneumothorax or tube dislodgment. The drainage could be related to the insertion procedure and is scant, so it does not require an immediate phone call to the provider. Answers 3 and 4 are expected findings for a patient with a chest tube

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, which type of pressure will be reestablished? A. Neutral pressure in the pleural space B. Negative pressure in the pleural space C. Atmospheric pressure in the thoracic cavity D. Intrapulmonic pressure in the thoracic cavity

Answer: B Removal of air and fluid from the pleural space reestablishes negative pressure, resulting in lung expansion. Neutral pressure in the pleural space will cause collapse of the lung. Atmospheric pressure in the thoracic cavity will cause collapse of the lung. Intrapulmonic pressure refers to pressure within the lung itself, not the pressure within the thoracic cavity.

If the nurse finds the chest tube has come out of the patient, what is the order of the correct steps to take? A. Place a 4x4 gauze over site and tape three sides B. Instruct patient to immediately Exhale and cough C. Call provider D. Assess patient

B, A, D, C (A and B can be done at the same time.) Normally, we assess patient first. However, a chest tube coming out of patient requires immediate intervention. Patient should exhale and cough immediately to keep air from rushing into pleural space and causing tension pneumothorax. The nurse should also place an occlusive petroleum gauze pad over site and tape three sides to allow air to escape upon exhalation, but does not allow air to enter in. Assess the patient to ensure they are stable. Then call the provider with SBAR report.

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include a petroleum gauze dressing per physician preference. C. Have the patient take a deep breath, exhale, and bear down during removal of the tube. D. Pre-medicate prior to removal as ordered by the physician. E. Place the patient is prone position after removal.

B, C, D Option A is wrong because this is not how the Valsalva Maneuver is performed (the correct way is detailed in option D). Option E is wrong as well because this position would not facilitate breathing...Fowler's position (or supine) is best after removal.

When evaluating a post-thoracotomy patient with a chest tube, the best method to properly maintain the chest tube would be to: A. Strip the chest tube every hour to maintain drainage. B. Place the device below the patient's chest. C. Double clamp the tube except during assessment. D. Remove the tubing from the drainage device to check for proper suctioning.

B. Avoid stripping or clamping chest tubes. Do not remove tubing from drainage device to check suctioning; instead look at the suction control chamber for continuous bubbling.

While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? · A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. · B. Place a sterile dressing over the site and tape it on three sides and notify the physician. · C. Attempt to re-insert the tube. · D. Keep the site open to air and notify the physician.

B. Immediately place sterile dressing and secure on three sides/ have patient exhale and cough to keep from sucking in air through hole. Then stay with patient, monitor VS, and notify provider. Do not reinsert tube, do not leave site open to air

What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. · A. Mediastinal chest tube system · B. Dry suction chest tube system · C. Wet suction chest tube system · D. Dry-Wet suction chest tube system

B. This describes a Dry suction system (e.g., Atrium Oasis brand)

Which action would the nurse take to determine patency of the chest tube and closed chest drainage system in a client after left lower lobectomy? A. Milk the chest tube toward the drainage unit. B. Check the amount of bubbling in the suction control chamber. C. Observe for fluctuations of the fluid in the water-seal chamber. D. Assess for extent of chest expansion in relation to breath sounds.

C Fluctuations of the fluid in the water-seal chamber indicate effective communication between the pleural cavity and the drainage system. Milking the chest tube toward the drainage unit should be avoided because it raises pressure in the pleural space, which can result in a tension pneumothorax. Bubbling in the suction control chamber occurs whenever the chest drainage system is connected to suction and is not a sign that the chest drainage system is patent. Extent of chest expansion in relation to breath sounds does not directly reflect the patency of the chest tube.

When a client has a chest tube placed in the second intercostal space, how will the nurse evaluate for the effectiveness of the chest tube? A. Check for bubbling in the suction control chamber. B. Measure the amount of drainage in the collection chamber. C. Inspect the amount of bubbling in the water-seal chamber D. Observe for the presence of clots in the tubing.

C Rationale: A chest tube is placed in the second intercostal space to treat pneumothorax. The chest tube will remove air from the intrapleural space, causing bubbling in the water-seal chamber. Bubbling in the suction control chamber indicates only that suction is turned on. Only a few milliliters of drainage are expected with a chest tube placed in the second intercostal space; a tube would be placed at the base of the lung to drain fluid from the pleural space. Clotting in the tubing would not be expected for a chest tube placed at the second intercostal space because there should be only a few milliliters of bloody drainage.

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber. Which of the following is the CORRECT nursing intervention for this type of finding? A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops. D. Check the drainage system for an air leak.

D Continuous bubbling in the water seal chamber is NOT normal and indicates there is an air leak. However, oscillation ("tidaling") of the water in the water seal chamber is normal.

T/F. It is normal for the water seal chamber to be continuously bubbling.

False. The water seal chamber should not continuously bubble. Constant bubbling in the water-seal chamber is indicative of an air leak. Instead, it should tidal/fluctuate with patient respirations. These fluctuations of the fluid in the water-seal chamber indicate effective communication between the pleural cavity and the drainage system. If it has stopped tidaling, assess patient. This may indicate a problem, OR it may indicate the lung is fully re-expanded. The only place there should be continuous bubbling (but not vigorous bubbling) is in the suction control chamber; there is bubbling when the unit is turned on.