Problem 9 - Clinical Nursing Skills and Techniques

Question

Mr. Rifas is a 39 -year-old who presented to the emergency department with a tension pneumothorax following a motorcycle accident. He is now on your medical-surgical floor with a chest tube in place at \(20 \mathrm{~cm}\) of suction. The prior shift reported that Mr. Rifas had a total of \(180 \mathrm{~mL}\) serous drainage. When you go to assess Mr. Rifas, you notice \(250 \mathrm{~mL}\) of bright red blood in the chest drainage system. You assess his vital signs: blood pressure, \(102 / 56 ;\) heart rate, 142 ; respiratory rate, \(28 / \mathrm{min} ;\) and oxygen saturation, \(89 \% .\) In addition, Mr. Rifas is complaining of dyspnea. Which of the following actions is the priority? 1 Do nothing; this is normal for a patient following a tension pneumothorax. 2 Continue to monitor Mr. Rifas' vital signs. 3 Notify the health care provider immediately. 4 Notify the charge nurse to let her know that you will need to have a new canister ordered.

Step-by-Step Solution

Answer

Notify the healthcare provider immediately (Option 3).

Step 1: Evaluate the Situation

Mr. Rifas is experiencing a significant change in his condition, indicated by 250 mL of bright red blood in the chest drainage system, which suggests bleeding. Vital signs also indicate hypotension (blood pressure 102/56), tachycardia (heart rate 142), tachypnea (respiratory rate 28), and low oxygen saturation (89%), all of which are signs of potential hemodynamic instability.

Step 2: Determine the Priority Action

Considering the findings, the presence of bright red blood in the drainage system is alarming and might indicate active bleeding or a complication. The hypotension, elevated heart rate, and low oxygen saturation further suggest that Mr. Rifas may be unstable and at risk of deterioration.

Step 3: Make the Clinical Decision

In an emergency or significant change in a patient's condition, the most important step is to ensure the appropriate team is aware and can intervene. Given the potential for rapid deterioration, the priority action is to notify the healthcare provider immediately, as they may need to provide immediate interventions such as further diagnostic tests or surgical evaluation.

Key Concepts

Medical-Surgical Nursing

Medical-surgical nursing involves caring for patients who are in post-surgical recovery or managing complex medical conditions. This specialty requires a broad set of skills as it covers a wide range of illnesses and patient conditions. In Mr. Rifas' case, as a medical-surgical nurse, your role extends beyond just monitoring vital signs. You are responsible for identifying significant changes in health and taking appropriate actions.

• Nurses need to quickly recognize signs of potential complications, such as unexpected changes in drainage or vital signs.
• Understanding surgical procedures and the typical postoperative course is crucial for anticipatory care.
• Collaboration with healthcare teams ensures that necessary interventions can follow a sudden health change.

In situations like Mr. Rifas', where there's evidence of bright red blood in the chest drainage and vital signs indicate instability, your rapid response is key. Recognizing these signs and understanding their potential seriousness means notifying the healthcare provider immediately for further action. The quicker these changes are communicated, the better the chances of avoiding further complications or the need for emergency interventions.

Emergency Nursing

Emergency nursing involves the management and swift intervention of patients in critical or time-sensitive situations. Nurses in this field need to be quick thinkers with strong clinical decision-making skills. For a patient like Mr. Rifas, who presented with a tension pneumothorax due to a motorcycle accident, emergency nurses would have initiated initial life-saving measures.

• Assessing immediate threats to life and identifying priority interventions is a core function.
• Emergency nurses manage stabilizations, such as the insertion of chest tubes, to relieve pneumothorax caused by trauma.
• Close monitoring of vital signs is crucial, alongside ensuring airway stability and oxygen support.

For Mr. Rifas, initially managed in the emergency department, any ongoing or new acute changes, such as the sudden increase in red blood in the drainage system and altered vital signs, would concern the emergency nurse. In such cases, escalation of care by notifying a physician or trauma team would be a priority to engage specialized teams for advanced treatment or surgical interventions. Quick and decisive actions in emergency nursing save lives by keeping ahead of life-threatening developments.

Chest Tube Management

Chest tube management is critical in treating conditions that affect the lungs, such as pneumothorax. A chest tube helps remove air, blood, or fluid from the pleural space, allowing for lung expansion and recovery. Nurses need to be proficient with these devices, monitoring their function and the patient's response.

• Proper setup and maintenance of the chest tube drainage system are vital.
• Observation of the type and amount of drainage is crucial for early detection of complications.
• Immediate reporting of unusual findings, like bright red blood, is necessary for addressing potential emergencies.

In Mr. Rifas' situation, the presence of 250 mL of fresh blood in the drainage system is concerning and suggests new internal bleeding or disruption of tissues. A nurse must act quickly by assessing Mr. Rifas for signs of respiratory distress and altered hemodynamics, like low blood pressure and increased heart rate. Prompt communication with the healthcare team allows for reassessment of the chest tube placement or the need for further surgical intervention. Effective chest tube management ensures complications are caught early and mitigates risks associated with thoracic injuries.