Nursing of the adult with a chest tube
Help!
|
|
||||
|---|---|---|---|---|---|
| Define pneumothorax. | show 🗑
|
||||
| show | traumatic chest injury, thoracotomy,and spontaneous in tall thin people
🗑
|
||||
| Define pleural effusion. | show 🗑
|
||||
| show | impaired lymphatic drainage/malignancy; changes in colloidal osmotic pressure/heart failure
🗑
|
||||
| Define empyema (Say ‘M’ Pie ‘E’ mah). | show 🗑
|
||||
| show | lung abscess or pneumonia
🗑
|
||||
| show | anteriorly through the second intercostal space – usually on the anterior aspect of the midclavicular line, second or third intercostal space
🗑
|
||||
| show | posteriorly through the 8th or 9th intercostals space midaxillary line
🗑
|
||||
| Why do some clinicians use the 4th and 5th anterior or midaxillary intercostal space for chest tube insertion? How does this work for fluid or air removal? | show 🗑
|
||||
| show | to collect drainage from the patient’s pleural space, allow for visual inspection of the nature of drainage, and measure output
🗑
|
||||
| show | The tube in this chamber is submerged to prevent air from flowing back toward the patient. The water acts like a one way valve.
🗑
|
||||
| What is the function of the suction chamber of a chest drainage unit? | show 🗑
|
||||
| show | no
🗑
|
||||
| What education should the RN provide to assistive personnel regarding care of the client with a chest tube? (P,BBCCEDSV) | show 🗑
|
||||
| What will the nurse check during assessment of the patient with a chest tube?(BCDDubILPSSTkdcV) | show 🗑
|
||||
| show | asymmetrical chest movements, cyanosis, decreased breath sounds, hypotension, subcutaneous emphysema at insertion site/neck, tachycardia
🗑
|
||||
| What signs/symptoms would alert the nurse to the possibility that her patient with a chest tube has developed a pneumothorax? | show 🗑
|
||||
| show | notify physician immediately
🗑
|
||||
| Why monitor the chest tube patient’s pulse and BP? What might changes in these values mean? (IRP) | show 🗑
|
||||
| What is the nurse looking for when she assesses the insertion site of the chest tube patient? | show 🗑
|
||||
| show | increases patient’s risk for infection, atelectasis, and tension pneumothorax
🗑
|
||||
| show | Usually not, only with physicians order (usually to assess patient’s readiness for chest tube removal) or very briefly to assess air leak, or to empty/change disposable drainage system (requires special training).
🗑
|
||||
| show | 2 shodded (to prevent puncture) hemostats per tube
🗑
|
||||
| What would be a sign of leaking at the insertion site, connection between tube and drainage, or within the drainage device? | show 🗑
|
||||
| How do we find the location of a leak? | show 🗑
|
||||
| What are the expected drainage amounts and characteristics after placement of a pleural drainage system? | show 🗑
|
||||
| What is the nurses responsibility if ther is more than 100mL/hour of blood drainage (except for 1st 3 hours preoperative)? | show 🗑
|
||||
| show | large bore usually 34 -36 French)
🗑
|
||||
| show | the tube collapses on inspiration and opens on expiration (or when chest pressure exceeds atmospheric pressure)
🗑
|
||||
| Name 4 disposable water seal drainage systems. | show 🗑
|
||||
| Name the three chambers of a pleural drainage system. | show 🗑
|
||||
| What is the collection chamber for? | show 🗑
|
||||
| When are there bubbles in the water seal chamber? | show 🗑
|
||||
| What does fluid rising with inhalation and falling with expiration mean if seen in the waterseal chamber? Describe how observations would differ if client is on a ventilator. | show 🗑
|
||||
| What does no bubbling in the water seal chamber mean? | show 🗑
|
||||
| show | 48-72 hours
🗑
|
||||
| show | reexpanded lung or kinked/clogged tube
🗑
|
||||
| What is the usual amount of suction ordered? | show 🗑
|
||||
| Where and when would an open thoracotomy take place? Closed thoracotomy? | show 🗑
|
||||
| show | sitting or lying with the affected side up
🗑
|
||||
| show | after the area is prepped and local anesthesia is injected a small incision is made or in case of emergency a removable trocar (metal guide in the middle of the chest tube) is used
🗑
|
||||
| show | the tube is connected to the chest drainage system and the MD sutures the tube to the chest wall
🗑
|
||||
| show | all connection are securely taped to maintain airtight system; occlusive sterile dressing is applied to the insertion site; pneumothorax- petroleum gauze is often used to prevent air from being sucked into the pleural space
🗑
|
||||
| Discuss the use of Chest X-ray for the client with a chest tube. | show 🗑
|
||||
| show | abnormal chest movements;anxiety, bilateral breath sounds > q 2hours; cyanosis; quality of respirations;VS > q 4hr;
🗑
|
||||
| What signs and symptoms would alert the nurse to potentially worsening pneumothorax (CCHRIIST)? | show 🗑
|
||||
| show | diminished or absent breath sounds, dyspnea, cyanosis
🗑
|
||||
| How often do we assess the chest drainage system? | show 🗑
|
||||
| What do we check when assessing the chest drainage system (5)? | show 🗑
|
||||
| What is the nurse’s responsibility if the drainage changes from dark to bright sanguineous or if the amount of drainage exceeds 200mL/hr for 2 hours | show 🗑
|
||||
| show | Ineffective breathing pattern; Impaired gas exchange rt decreased lung expansion; anxiety r/t perceived risk of CT dislodgement, system disruption, inability to breathe
🗑
|
||||
| What are some nursing goals or signs of success for impaired gas exchange and ineffective breathing (6)? (ABCCERS) | show 🗑
|
||||
| Name 2 nursing goals for the anxiety a patient with a chest tube may have. | show 🗑
|
||||
| What are some nursing interventions that help with ineffective breathing pattern and impaired gas exchange(8)? | show 🗑
|
||||
| show | Place end of tube in sterile H2o or Saline; hold below chest level; immediately replace system; momentary clamping okay if air entering pleural cavity
🗑
|
||||
| show | Air is trapped and creates pressure that works against lung expansion
🗑
|
||||
| show | deviation
🗑
|
||||
| show | cover wound with occlusive dressing (in an emergency a gloved hand will work); tape 3 sides, leave one open to avoid tension pneumothorax
🗑
|
||||
| What can be done to avoid placing pressure on the chest tube if the client wants to lie on the side of the insertion site? | show 🗑
|
||||
| show | CXR confirms full re-expansion, no fluctuation of fluid, cessation bubbling in water seal chamber, adequate gas exchange
🗑
|
||||
| show | provide medication 30 minutes before procedure, patient is instructed to bear down and cough while tube is quickly removed, Vaseline gauze and sterile dressing placed over site, monitor for respiratory distress after; usually takes about a week to heal
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
Perseverandovercome
Popular Nursing sets