UNIT FOUR
588
Clinical Skills and Care
Skill 28.9 (continued) 10. Ensure that Vaseline and gauze 4 × 4s are at the bedside in case of air leakage or other emergency. Follow your facility’s policy for appropriate action to take if the chest tube is dislodged. 11. Assess output in the collection chamber. Be aware of the color and amount draining each hour. Safety: Notify the phy- sician immediately if the drainage changes to a bright red color or is greater than 100 mL/hr. 12. Assess for air leaks in the drainage system. Remember that wet suction will bubble gently in the suction chamber. If the patient has a pneumothorax, expect to see air in the water- seal chamber and tidaling in the chamber. As the pneu- mothorax resolves and the lung reinflates, the air in the water-seal chamber and the tidaling in the chamber will cease. 13. Mark output for your shift on the writable surface of the col- lection chamber. Mark the level of the output and then write the date, time, and your initials. Calculate drainage out- put for your shift by subtracting the amount in the drainage chamber when you started your shift from the amount in the chamber at the end of your shift. 14. Assist the patient to a comfortable position and reassure them regarding the chest tubes. Encourage the patient to change position, cough, and deep breathe every 2 hours to help re-expand the lung and remove drainage from the chest cavity. 15. Follow the Ending Implementation Steps located on the inside back cover.
Evaluation Steps 1. Evaluate the effectiveness of the chest tubes. Is the patient breathing with less difficulty? Is the suction set correctly? Is the water seal at 2 cm of water? Are there signs of escaping pneumothorax? Are there any signs of additional air leaks? 2. Evaluate the patient’s response to the procedure. Is the patient resting comfortably? Is pain medication needed for the incision site? Is the patient complaining of any other problems? 3. Evaluate the insertion site dressings. If there is a hemothorax, is the dressing dry and intact? Does it need to be reinforced or changed? Follow your facility’s policy for changing the dress- ing to the chest tube insertion site.
Sample Documentation
10/12/28 1825 Dr. Chapman inserted one chest tube for hemothorax. Attached to Pleuravac drainage system with wet suction at –20 cm. Water seal established with 2 cm water. Chest tube draining mod amt of dark red fluid, less than 100 mL/hr. All connections double-taped. Drsg at insertion site clean, dry, and intact. Resting quietly in bed in semi-Fowler’s position eating ice chips. States he “can breathe better” after chest tube insertion. Requests pain med for incisional pain. _________________________________________________________________________ ___________________________________________________ Nurse’s signature and credentials
CRITICAL THINKING CONNECTIONS: POST CONFERENCE
You were really worried when you walked into your patient’s room the first morning and saw him with his tra- cheostomy, sounding all bubbly and coughing frequently. He pointed to the tracheostomy and mouthed the word “suction.”Without much time to think, you grabbed a suc- tion catheter and glove kit and set up quickly but with- out contaminating your sterile field or sterile supplies. You remembered as you suctioned to hold your own breath and not suction for longer than 10 seconds. It was obvious to you that the suctioning procedure tired Key Points • Muscles, nerves, and chemicals all play a role in causing and controlling respirations. • Impaired oxygenation may be the result of hypoxia or hypoxemia caused by airway obstruction, secretions in the alveoli, chronic lung disease, and trauma. • Respiratory assessment of the patient with impaired oxy- genation must be very thorough to avoid missing subtle signs of hypoxia or hypoxemia.
your patient and made him a little short of breath. How- ever, once you had suctioned his tracheostomy several times, he could breathe considerably better and mouthed “thank you.” After that, you weren’t afraid to suction him. His tracheostomy collar stayed in place pretty well, and you were able to replace his inner cannula the first day with your instructor’s guidance. By the second day, you were feeling far more confident about all of his care. By the third day of clinicals, you were showing other students how to suction him.
• Crepitus indicates air under the skin, or subcutaneous emphysema, and the source of the leaking air must be found and treated. • Diagnostic tests for which you will obtain specimens include sputum testing and throat cultures. • Patients with impaired oxygen need to expand the lungs fully, which can be accomplished by turning, coughing, and deep breathing; use of an incentive spirometer; and nebulizer treatments with bronchodilators.
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