Problem 7 - Clinical Nursing Skills and Techniques

Question

A patient comes through the emergency department after an automobile accident 6 hours ago. He has had a chest tube inserted at a small community hospital. He is transferred immediately to the intensive care unit. The nurse's assessment finds that the \(18 \mathrm{Fr}\) chest tube is draining serosanguineous fluid, with approximately 75 mL draining over the last hour. The medical record indicates the patient has a hemothorax. The patient's \(\mathrm{SpO}_{2}\) is \(90,\) and respirations are 18 per minute. Based on the nurse's findings the most important action would be: 1 Monitoring the patient's vital signs 2 Notifying the health care provider about the appearance of the drainage 3 Providing analgesic for the patient's pain 4 Frequently checking the position of the chest drainage tube and note if it stays patent

Step-by-Step Solution

Answer

Frequently check the chest tube position and patency to ensure proper drainage.

Step 1: Understand the Situation

The situation involves a patient with a chest tube inserted due to a hemothorax and an automobile accident 6 hours ago. The chest tube is draining serosanguineous fluid at 75 mL/hour. Patient's SpO2 is at 90%, indicating low blood oxygen, and respiratory rate is 18 per minute.

Step 2: Analyze the Condition

Hemothorax suggests blood in the pleural cavity. The chest tube drainage and SpO2 levels need careful monitoring. SpO2 of 90% indicates hypoxemia, which requires attention to ensure adequate oxygenation.

Step 3: Evaluate the Options

1. Monitoring vital signs is crucial but may not be the most actionable priority given the current info. 2. Notifying the healthcare provider about the drainage is important but not urgent since hemothorax is already known. 3. Providing analgesics addresses pain, but doesn't address potential oxygen deprivation or tube blockage. 4. Frequently checking the position and patency of the chest drainage tube ensures continued drainage and helps prevent respiratory complications.

Step 4: Determine the Most Important Action

Given the situation, ensuring the chest tube remains patent to continue effective drainage is crucial in managing a hemothorax and preventing respiratory distress. Therefore, maintaining tube patency is a direct intervention in this emergency context.

Key Concepts

Chest Tube Care

Chest tube care is vital in managing a hemothorax, which involves collecting blood in the pleural cavity. First, it's essential to ensure the chest tube remains patent, allowing continuous drainage. A blocked chest tube can lead to increased pleural pressure, worsening respiratory distress.

• Regularly assess the tube's position to confirm it hasn’t been dislodged.
• Check for kinks and pieces of debris that might impede the flow.
• Document the color and amount of drainage hourly to spot any changes.

Consistent maintenance prevents complications, ensuring proper therapeutic outcomes for patients with thoracic injuries.

Patient Assessment in Emergency Care

Assessing a patient efficiently in an emergency setting can be life-saving. It involves a rapid evaluation of the patient's condition, especially when dealing with injuries such as hemothorax.
Start with the primary survey: check the airways, breathing, and circulation. In cases like these:

• Observe breathing patterns and note any irregularities.
• Assess the level of consciousness using the AVPU scale (Alert, Verbal, Pain, Unresponsive).
• Take a brief but thorough medical history, focusing on recent trauma events.

Incorporating these steps into your patient assessment helps prioritize urgent care needs.

Oxygen Monitoring and SpO2 Levels

Monitoring oxygen levels in patients with respiratory issues is crucial. SpO2, which stands for peripheral capillary oxygen saturation, indicates the percentage of oxygen-carrying hemoglobin in the blood.
Ideal SpO2 levels range from 95% to 100%. In this case, the patient's SpO2 is 90%, highlighting the risk of hypoxemia. This necessitates:

• Regular oxygen saturation monitoring using a pulse oximeter.
• Evaluating the need for supplemental oxygen to maintain adequate levels.
• Ensuring oxygen delivery systems are functioning correctly.

Consistent attention to oxygen levels helps prevent further deterioration of respiratory function.

Nursing Interventions for Respiratory Complications

Nurses play a crucial role in managing respiratory complications. Prompt interventions for patients with conditions like hemothorax can prevent escalation.
Key actions include:

• Ensure continuous monitoring of the patient's breathing and SpO2 levels.
• Administer oxygen therapy as per the healthcare provider's order, adjusting it according to the patient's needs.
• Encourage the patient to practice deep breathing exercises to enhance lung expansion and facilitate aeration.
• Watch for signs of distress that might suggest complications, such as increased pain or changes in vital signs.

These interventions help manage complications and improve recovery outcomes.