UNIT FOUR
574
Clinical Skills and Care
fl uid to reestablish the water seal. You can then connect the tube to a new drainage system. Chest tubes may be clamped for very short periods in speci fi c circumstances, such as to change the drainage unit or to test the patient’s ability to tol- erate the removal of the chest tube. If the drainage unit is a wet suction setup, it must be kept upright at all times. Inspect tubing to be sure that there are no kinks and that the fl uids are draining to gravity. Eliminate any loops that would require drainage to run uphill. Always check for leaks. Keep all connections securely taped. Keep all dressings around the insertion site intact. These are petro- leum gauze dressings covered with regular gauze. Check the patient for subcutaneous emphysema, the feeling of
crepitus under the skin, to detect any air leaks into the tissue. Skill 28.9 gives the steps for maintaining chest tubes.
KNOWLEDGE CONNECTION Why is the chest tube for a pneumothorax placed in the upper area of the chest? List the three chambers of a stan- dard chest tube drainage system. How is a digital chest tube system different from the standard three-chamber system? What might indicate hemorrhage in a patient with chest tubes?
Nursing Care Plan for a Patient With COPD and Pneumonia
• Impaired gas exchange related to chronic lung changes as evidenced by dyspnea and decreased oxygen saturation • Decreased activity tolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea with exertion Planning You will now plan your interventions and the outcomes for this patient. You decide that the outcomes for him will be that he will cough more effectively to remove secretions before discharge, that his gas exchange will then improve when the secretions are removed, and therefore his oxygen saturation will also improve. You determine that his activity tolerance can be increased when his oxygenation improves. You begin to think of a number of nurs- ing interventions to help him accomplish these outcomes, includ- ing ways to help him conserve his energy and ways to help him expectorate sputum and keep his lungs expanded. Figure 28.11 presents a concept map care plan for a patient with COPD and pneumonia. Implementation You are now at the stage of the nursing process to implement, or actually perform, the interventions that you have planned. Refer to the interventions listed later. Evaluation Once the interventions, or nursing actions, have been performed, you will need to evaluate whether or not they were effective. Did they accomplish what you intended? Did they help the patient’s problems? Refer to the evaluations that follow.
You are planning care for a 60-year-old male patient with a diag- nosis of bilateral pneumonia and chronic obstructive pulmo- nary disease (COPD). He lives with his wife, who is also having health problems, but she is his primary caregiver. He has had pneumonia several times in the past 2 years, but this is the most severe case. The following are questions you might ask yourself as you assess him and collect data: • What are his lung sounds like? • Is he hypoxemic? • Does he have a productive cough? • What is the amount, color, and consistency of the sputum? Assessment When you research his chart and perform your assessment, you discover that your patient is 5 feet 10 inches (177.6 cm) tall and weighs 135 pounds (61.2 kg). His skin color is pale, with a blu- ish tinge to his lips and nailbeds. His temperature is elevated at 102.2°F (39°C), his pulse is 108, respirations are 26, and blood pressure is 144/86. His SaO 2 using a pulse oximeter is 89%. He is short of breath with any movement and has oxygen on at 2 L/min per nasal cannula (2L/NC). He has a history of smoking two packs per day for 20 years. He has a weak cough that often is nonproductive. When he does expectorate sputum, it is a small amount of rust-colored spu- tum. He appears anxious and is sitting in the high Fowler’s posi- tion in bed. His activity orders are for bedrest with bathroom privileges. When you assist him to the bathroom, he is extremely short of breath with exertion. When you auscultate his lungs, you hear coarse crackles in the lower lobes bilaterally that do not clear with coughing. Nursing Diagnoses The highest-priority nursing diagnoses given for this patient are the following: • Ineffective airway clearance related to secretions in the air- ways as evidenced by ineffective cough and adventitious breath sounds
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