Procedures, Delegation, and

Ethics
CHEST TUBES
What is it?

- sterile drainage system to remove air/fluid/blood from pleural space

Why do we need them?

- pleural effusion, pneumothorax, hemothorax, post op cardiac/lung surgery

Chest Tube Drainage system
parts of chest tube drainage system
Collection Chamber (D)
- Collects fluid/blood/air
- assess every hour for the 1st 8 hours of insertion and then
every 8 hours after that
- notify dr if: bright red blood over 100ml/hour after first hour
of placement

Water-Seal Chamber (B)

- allows air to exit pleural space and ensures its not going to go
back into the body again
- Tidaling = normal
- intermittent bubbling = ok
- No fluctuation = lung re expanded/kink
- Excessive/continuous bubbling = air leak

Wet/Dry Suction Control Chamber (A)

- Wet suction: controlled by level of water in suction control
chamber
- Dry suction: regulates suction pressure mechanically rather than
with a column of water
- gentle steady continuous bubbling = good
- Vigorous bubbling = suction too high

Air leak Monitor (C)

- Part of water seal chamber
- bubbling = air leak in chest tube
- If a patient has pneumothorax there may be intermittent bubbling
here which would be normal
dos & donts
DOS DONTS

- Monitor lung sounds - CLAMP THE CHEST TUBE

- Monitor insertion site - LEAVE DRAIN ABOVE CHEST LEVEL
- Have patient cough and deep - KNOCK IT OVER
breath - MILK THE CHEST TUBE
- Repositioning
- HAND HYGIENE
- PATIENT ASSESSMENT
- CHEST TUBE ASSESSMENT
- KEEP BELOW CHEST
- HAVE A DOCTOR REMOVE IT
- ENSURE ALL TUBING HAS NO
KINKS/OBSTRUCTIONS
!!!!!!!
If the chest tube is removed from patient by accident:

- add 3 sided dressing

If there is accidental disconnection from drainage system without

contamination:

- Wipe the end of chest tube with antiseptic and immediately reconnect

If there is accidental disconnection from drainage system with contamination

and can’t be reattached OR if the drainage system breaks:

- insert 1 inch of tubing in bottle of sterile water and get a new system
drainage
- check color
- report if >100ml/hour (exception: thoracotomy)
- Dark blood = normal
- Bright blood = not normal
- If it suddenly stops = check for clot/kink/obstruction
a Few important things:
- chest tube insertion is always performed by a HCP
- Monitor every 15 minutes for the first hour after
insertion
- ensure chest xray to make sure it is properly placed
nursing interventions
- Deep breathing
- Coughing exercises
- Position changes
- Incentive spirometry
- Ambulation
tRansporting with a chest tube
- Suction can be disconnected
- Ensure chamber is below chest
- Ensure chamber is secure on patient bed on an immovable
part
delegation
RN LPN UAP
- ADL’s
- Monitor RN - Hygiene
- Clinical - Linen changes
findings
assessment - Routine, stable vitals
- Reinforce - I/O - record and doc
- Initial client education - Glucose checks
education - Routine procedures - positioning
- Med administration - delegate comfort
- Discharge
measures
education - Ostomy care - Set up equipment
- Enteral feeding - Get supplies
- Clinical judgement
- Initial vitals - Foley care
- Initiating blood - Sterile dressing - Reorient and reassure
transfusion changes - Remind/reinforce
- Postmortem care
- Focused - CAN’T feed clients with
assessments dysphagia
- CANNOT do initial - CAN’T do vitals few
assessments but hours after birth on
newborn
CAN do initial
- CAN’T get urine from
vitals infant
- CAN‘T get urine from a
person with a foley
LET’S PRACTICE!!!!

1. Assisting the client to the bathroom

2. Deciding if supplemental oxygen is necessary when the client is
ambulating
3. Documenting vital signs in the electronic medical record
4. Notifying the nurse immediately if the client’s respirations exceed
20/min
5. Reapplying the nasal cannula if it accidentally comes off

UWORLD QID #30246

ANSWER
1. Assisting the client to the
bathroom
3. Documenting vitals in
electronic medical record
4. Notifying nurse immediately if
client’s respirations exceed
20/min
5. Reapplying the nasal cannula if
it accidentally comes of
Meeting hygiene and
elimination needs,
documenting observations
made during usual care
(SOB) in the section of
the medical record
designated for the UAP,
taking vitals, and
reapplying an oxygen
delivery device at the
preset liter flow are
tasks appropriate for an
experiences UAP.
blood transfusions
- you need full vitals before, 15 minutes after and after
completion
- UAP/LPN can do vitals BEFORE and anytime after the first
15 minutes of infusion
- RN needs to stay with patient for the first 15 minutes
after completion and record vitals, after that then
LPN/UAP can take vitals
5 Rights of delegation
1. Right task
2. Right circumstance
3. Right person
4. Right communication/direction
5. Right supervision
LET’S PRACTICE!!

1. ” I need for you to take vitals on all patients in rooms 1-10

this morning”
2. ”Mr. Wu’s blood pressure has been low. Please take his vitals
first and let me know if his systolic blood pressure is <100”
3. Mrs. Jones fell out of bed during the night. Be sure to keep a
close eye on her this shift.”
4. Would you please makes sure MR. Garcia in bed 8 ambulates
several times?”
ANSWER
2. “Mr. Wu‘s blood pressure has
been low. Please take his vital Generally, you need
signs first and let me know if
clear
his systolic blood pressure is
<100” communication,
specific
instructions,
Why this is correct: specific time
frame, follow up
It’s communicated clearly
instruction, clear
There are specific instructions expectations
legal ethics
- Beneficence: to do good
- Nonmaleficence: to do no harm
- Autonomy: let patient make decisions for themselves
- Justice: fair
- Veracity: truth
- Fidelity: loyalty, fulfilling commitments, meeting
expected responsibilities
- Assault: threat
- Battery: physical contact without permission
LET’S PRACTICE!!!
Which statements related to ethical nursing practices are
correct?

UWORLD QID #: 31202

ANSWER
3. Fidelity is administering medication as prescribed to
the client

5. Nonmaleficence is refusing to give report to a nurse

who is impaired

Fidelity: loyalty, fulfilling commitments, accountability

Nonmaleficence: to do no harm, protecting patient from danger
Autonomy: right to make decisions for one‘s self
Beneficence: to do good
Justice: treating all patients fairly
Veracity: telling the truth
nEgligence versus malpractice
Negligence: Malpractice

- unintentional - intentional
advance directives
- Living will
- Healthy Care proxy
- Medical power of attorney
restraints
- Belt Restraint
- Soft Limb Restraint
- 1 point, 2 point, 3 point
- Mechanical: mitts, wrist, leather, full body, all 4 bed
rails up
- Chemical
- CANNOT have PRN orders, orders only good for 24 hours
then doctor need to reassess
- check every 2-4 hours
- Restraints are a last resort!!!
safety/infection control
Universal/Standard Precautions

- Hand hygiene
- Appropriate PPE as needed
- Handling patient equipment
- Infection safety practices
- Environmental cleaning
- Handling of laundry
- Patient room placement
Airborne precautions
- Coughs/sneezes
- These droplets survive
- Distance does not matter
- Mneuomonic: airS MTV

Shingles (disseminated)

Measles

TB (active)

Varicella (uncrusted)

- PPE: N 95 MASK plus standard precautions and other PPE as needed

- Negative pressure room
- Keep door closed at all times
- If patient leaves room: surgical mask
droplet precautions
- sneezing, coughing, talking
- Droplets are large and travel up to 6
feet then fall PPE: surgical mask, standard
- Enter through nose/mouth precautions and other PPE as
- Mnemonic: SPIDERMAN necessary
Sepsis, streptococcal pharyngitis
Patient wears surgical mask
Pneumonia, pertussis
when being transported
Influenza A + B
Door can stay open
Diphtheria

Epiglottitis Private room

Rubella

Mumps,meningitis, meningeal pneumonia

Adenovirus
**Scarlet Fever is droplet
Neisseria Meningitis
contact precautions
- PPE: gown and gloves,
- transmitted through direct standard precautions and
contact with patient or by
other PPE as needed
touching something that they
- Private room or you can
touched
- Mnemonic: DORMS group patients together who
have the same infection
Diarrhea: C DIFF, rotavirus,
diarrhea, E Coli

Other: conjunctivitis, salmonella

Respiratory infections: RSV, **Ebola is contact precautions

adenovirus, parainfluenza
Multi drug resistant: MRSA, VRE
Skin and wound infections
**C DIFF: soap and water when
leaving room, bleach wipe
equipment
LET’S PRACTICE!!!

1. Gown
2. goggles or face shield
3. Hand washing
4. N95
5. Surgical Mask
ANSWER
3. Hand washing

4. N95
rooming patients
LOOK OUT FOR:

- Pregnant people
- Immunocompromised
- Elderly

YOU DON’T WANT TO ROOM THESE PEOPLE WITH

PEOPLE THAT ARE INFECTIOUS!!!!

IN AN EMERGENT SITUATION, you can room patients with same

exact diseases together
EMERGENCY RESPONSE PLAN
- ALWAYS PROTECT YOURSELF BEFORE YOU PROTECT YOUR PATIENT
- CHEMICAL EMERGENCY: PROTECT OTHER STAFF AND MOVE EVERYONE
AWAY, PPE, TREAT PATIENTS THAT WERE FURTHER AWAY FROM
CHEMICAL SPILL FIRST, THEN TREAT THE CHEMICAL SPILL
IN CASE OF A FIRE