Chelsea Ruthrauff

Adult Health II

Sherri Brown

10/1/19

Case Study 24

1. A.B.’s admission vital signs are expected in response to his diagnosis. Currently all vital

signs are elevated. The pleural effusion is causing ineffective breathing. The breathing

itself is described as labored and shallow which means that the breaths are not adequately

oxygenating the body. Lack of oxygen causes the heart to beat faster and more forcefully

in order to attempt to oxygenate the organs. The lack of oxygen also causes A.B. to

breathe more rapidly in an attempt to consume more oxygen. The high fever is expected

with the diagnosis of pneumonia and the decreased SpO2 is also due to the pleural

effusion preventing adequate oxygenation.

2. A pleural effusion is a collection of fluid located in the pleural cavity. The fluid prevents

the lungs from fully expanding, which reduces oxygenation. It also results in the

symptom of chest pain, which is often found to be more painful during inhalation in a pt

with pleural effusion. Cells within the heart trigger increased heart rate and

vasoconstriction in order to push more blood to the rest of the body. The medulla

oblongata signals an increased respiration rate for the same purpose. The dry cough is

another mechanism used in an attempt to clear space in the lungs for expansion, however

this is ineffective.
3. A thoracentesis is a procedure in which fluid is drained from the pleural cavity. A

physician must perform this procedure. The removal of fluid is beneficial for the pt

(allows lungs to expand) and the fluid is then tested for bacteria.

4. (100mL/30min) x (20gtt/mL) = 67gtt/min

5. In order to promote A.B.’s clearing of pulmonary secretions, I would first teach a

beneficial coughing technique. Rather than a shallow cough, I would encourage A.B. to

produce a deep cough by utilizing abdominal muscles. I would also frequently reposition

A.B. in order to allow different areas of the lungs to drain. Finally, I would utilize chest

percussion to assist in clearing the pulmonary secretions.

6. The first thing that I would do is to stop the administration of cefuroxime (Ceftin)

because this medication is not benefiting the pt and may result in harm. The next thing

that I would do is call the physician requesting a new antibiotic to be ordered.

7. While the physician must insert the pleural chest tube, the nurse assists the physician in a

few different ways. Prior to the procedure, the nurse often gathers all equipment and

supplies that will be required. The nurse will also educate the pt and administer

appropriate pain medication to control pain prior to the procedure. During the procedure,

the nurse may help prevent the pt from moving and will assist to keep the head elevated

to 30-60 degrees. After the procedure, the nurse will monitor the pt and care of the tube

and provide pain management.

8. There are many factors involved in managing a chest tube. In terms of the tubing, the

nurse should frequently check to ensure that the tubing is coiled and kept below the level

of the chest. Any compression or kinking of the tubing may affect internal pressures. The

nurse should also check connections along the tubing and observe for tidaling and

bubbling. If the nurse notices an increase in bubbling, she should determine whether the

cause is from the pt or from a leak in the tubing. The nurse should also assess the

drainage every hour and document the amount and the color. In addition to managing the

equipment, the nurse should assess the pt’s vital signs and lung sounds and encourage

deep breathing and use of the incentive spirometer. Finally, when it comes time for

dressing change, the nurse should change the dressing, assess for infection, and clean the

insertion site; all with sterile technique.

9. Evaluate each of the following statements about chest tube drainage systems. Enter

T​ for true or ​F​ for false. State why false statements are incorrect.

__​F​_1. The height of the water in the suction control mechanism limits the amount

of suction transmitted to the pleural cavity.

The height of the water in the suction control mechanism does not limit the amount of

suction. When the amount of water becomes more than 20cm, air enters the chamber and

breaks the suction allowing pressure to be relieved. While the water in the third chamber

does affect the suction, it does not limit the amount of suction.

__​F​_2. A suction pressure of +20 cm H2O is usually recommended for adults.

A suction pressure of -20 cm H2O is recommended for adults.

__​T​_3. Bubbling in the water-seal chamber usually means that air is leaking from

the lungs, the tubing, or the insertion site.

__​T​_4. The rise and fall of the water level with the patient’s respirations reflect

normal pressure changes in the pleural cavity with respirations.

__​F​_5. Because the chamber is a closed system, water cannot evaporate from the

system.

While the chamber is a closed system, water can still evaporate so the levels must be

monitored.

__​F​_6. To declot the drainage tubing, put lotion on your hands, compress the

tubing, and vigorously strip long segments of the tubing before releasing.

Stripping the tubing is no longer recommended as the best practice. It has the potential to

increase pressure in the system and cause damage to the lungs. Alternatively, the tubing

should be hung in a way that prevents the tubing from becoming clogged.

__​F​_7. You lower the bed on top of the drainage system and break it. You

immediately clamp the chest tube, leaving it clamped until you can reestablish the

drainage system.

Leaving a chest tube clamped for an extended period of time may cause internal pressures

to rise causing damage to the pt’s lungs. It is now recommended to place the end of the

tubing in 2 cm of sterile water in order to reinstate the water seal. It is still acceptable

practice to clamp the chest tube briefly in order to connect a new drainage system or to

check the system for leaks.

 __​T​_8. The collection chamber is full, so you need to connect a new drainage system

to the chest tube. It is fine to momentarily clamp the chest tube while you disconnect

the old system and reconnect the new.

10. ​The priority assessment at this time is to assess the chest drainage system to make sure

that none of the tubes are kinked, compressed, or disconnected and to make sure that the

system is functioning properly. I would also listen to lung sounds to determine if there

has been any change.

11. The tube should initially be placed into 2cm of sterile water in order to preserve the water

seal. If the rest of the tubing has become contaminated, the nurse should replace the

tubing with new tubing using sterile technique. If the chest tube itself has become

contaminated, then the nurse should call the physician to insert a new tube.

12. During initial assessment at 0700, A.B. had an SpO2 of 95% with diminished lung

sounds in the right lower lobe. He was stable with no c/o SOB. The chest drainage system

was set to suction at 20mmHg with an air leak present. At 1100 A.B utilized the call

system to inform me that he was feeling short of breath. Upon immediate assessment, it

was determined that the chest drain tube had become disconnected and contaminated. I

initially placed the end of the tubing into 2cm of sterile water and called the physician to

replace the tube. The pt is now stable and is no longer experiencing SOB.

13. One primary discharge instruction is to teach A.B. about signs of infection. Every time he

changes his bandages he should check for redness, warmth, inflammation, drainage, or

fever. If he notices any of these things, he should call his physician. A.B. should not

submerge the wound in water, but may take showers. He should continue resting,
ambulating, and breathing exercises practiced in the hospital. A.B. should also consume

at least 32oz of fluids a day and continue to take medications as prescribed. In order to

prevent a future lung infection, A.B. should practice proper hand washing and avoid

smoking and alcohol consumption. A.B. will return to a follow up appointment with his

physician.