NURS 3370 Exam 3 mosby questions – Flashcards

Assess and auscultate breath sounds, prepare a new drainage system, briefly cross-clamp the chest tube, attach the new system, and unclamp the chest tube.

Clamp the chest tube for a brief period to locate the source of the air leak.

Ensure that the system is maintained at least 0.3 m (1 ft) below the level of the chest tube insertion site

Old pleural blood that was released during the position change

Notify the practitioner regarding the amount of drainage

Place the end of the tubing in a cup of sterile water.

Manipulate the chest tubing to see if the clot can be moved to the collection chamber.

Attempt to keep the tubing horizontal or coiled on the bed or lift and drain the tubing.

This is a normal finding.

Consider hyperoxygenating the patient and then suction secretions from the patient's airway using the closed-system technique.

Stop suctioning and hyperoxygenate the patient for 30 to 60 seconds.

Administer 100% oxygen before suctioning

Hyperoxygenate the patient for 30 to 60 seconds by increasing the FIO₂ on the ventilator to 100% and provide closed-system suctioning until the tube is clear (but less than 15 seconds).

Discontinue suction and hyperoxygenate the patient using ventilator-supplied 100% oxygen.

Reassess the patient to determine the effectiveness of the intervention.

While receiving tracheostomy care, the patient's oxygen saturation drops to 87%. What action should be the nurse's next intervention?

Apply the new tie before removing the old tie

One loose or two snug finger widths of slack

Comfort the patient and explain that blood in the sputum is normal after tracheostomy tube insertion

Clean the inner cannula with saline solution

"A fenestrated tube allows the patient to speak."

Use the dominant hand to maneuver the sterile suction catheter

Hyperoxygenate the patient

The patient and family should use clean technique.

A 47-year-old patient with AIDS

The patient's performance

"Instilling normal saline solution is no longer recommended."

Reusable supplies should be disinfected per the manufacturer's instructions.

While instructing a family member how to suction a child, the nurse correctly teaches that to prevent hypoxemia, each suction pass should last no longer than which time frame?

Tracheoesophageal fistula

An increase in drainage after ambulation is normal but should be monitored closely.

Ensuring that the chest-drainage system is below the thoracic level

The patient may have a pneumothorax.

Ensure that the chest tube is not stripped.

Insert a 20-G needle into the dependent loop after it is cleaned.

Distended neck veins, hypotension, and tachycardia

COPD

Arterial blood gas

Performing mouth care at least four times a day

The ventilator circuit has a leak.

Oropharyngeal suctioning

*Encourages cooperation of the patient during and after the procedure *Minimizes risks to the patient *Identifies teaching needs

*Remain with the patient. *Assist respirations with bag-valve mask as needed. *Assess patient for airway patency, spontaneous breathing, and vital signs. *Prepare for reintubation.

Infection

*Breath sounds are noted in all lobes. *The patient's vital signs and oxygen saturation are within normal limits. *The patient's breathing is nonlabored.

Apical (second or third intercostal space)

6 hours

*Encouraging deep breathing exercises *Assisting patient with early mobility *Providing patient education regarding these practices

5 seconds

Accidental Extubation

Facilitate reinsertion of the outer cannula

Saline

False

Tidaling

An air leak

Hyperoxygenate the patient prior to suctioning for 30 to 60 seconds

Prevent Hypoxia

Air

blood or purulent drainage

33 gtts per minute

Do nothing because this is an expected finding

Place the chest tube end in a bottle of sterile water

a. Apply suction only while withdrawing catheter c. Limit aspiration time to 10 seconds with each suction pass d. Maintain sterile technique throughout suction procedure e. Pre-oxygenate with 100% oxygen

B) Patient in a single room (private) isolation C)Nurse using N95 respirator

Chest tubes are long, semi-stiff, clear plastic tubes that are inserted into the chest, so that they can drain collections of fluids or air from the space between the pleura. If the lung has been compressed because of this collection, the lung can then re-expand

Pneumothorax, Hemothorax, Hemo-pneumothorax, tension pneumothorax, empyema, Pleural effusion,

a collection of air in the pleural space. These can happen spontaneously: I saw a young man walk into the ER once, who "just didn't feel right" - he had a nearly completely collapsed right lung. Pneumos can occur after central line insertion, after chest surgery, after trauma to the chest, or after a traumatic airway intubation. Important to remember: if the air continues to collect in the chest, the pressure in that collection can rise, and push the whole mediastinum over to the other side - this is called a "tension pneumothorax", and is definitely life-threatening. Call the surgeon.

A collection of blood in the pleural space, maybe from surgery, maybe from a traumatic injury

Blood and air

Pus that collects int he pleural space

Fluid, usually serious, maybe from CHF, sometimes from a tumor process, will collect between the pleura

The chest tube is inserted by a surgeon, usually thoracic, but sometimes someone from the general surgical service. The entry point is the fourth or fifth intercostal space, on the mid-axillary line, which is pretty close to the point at which you level a line transducer. The tube is inserted towards the collection: sometimes up and in front, or up and in back, or wherever the collection lies.

We use a device called a pleurevac, a large plastic box with what seems like fourteen separate compartments in it - actually the ideas behind it are not hard to grasp. The box actually imitates an old system that was invented to drain chest tubes, which used three chambers - they were actually glass bottles held by a metal rack - in series. (I remember those glass setups - I must be getting really old.)

Obviously, you need to control the amount of suction applied to the patient. Make sure you have your pleurevac set up correctly. The surgeon who inserts the tube should order a specific water level in the control column - we usually fill it to 20 cm, but sometimes they order less.

Transudates" and "exudates" are descriptive names for types of fluids that can collect in the pleural space. Transudates you might think of as "thinner" - they often result from CHF, and you might think of them as more "watery", being "sweated" into the pleural space when a patient is "wet". Exudates might be thought of as "thicker" - they contain more protein, and usually result from some kind of inflammatory process. They can also be a result of tumor processes - patients with lung Ca or pleural mets often show up with exudative fluid collections. You tell the difference by sending thoracentesis specs to the lab.

Transudates and exudates are types of effusions - the idea being that the collections of fluid are "sweated" from the lung. Recurrent effusions can be a real problem for a patient who is dealing with a long-term illness, but as long as the patient has a reasonable hope for living a while yet, there is good reason to treat the effusion, either with treatment for underlying CHF, or for an underlying tumor process, or for whatever else is causing the problem.

In the short term, with a chest-tube. Some effusions related to CHF can be treated with diuresis - the idea is that decreasing the amount of the water component in the blood will cause the effusion to be re-absorbed. If the effusion is large enough to produce respiratory distress, or tension symptoms, you obviously would think more about inserting a chest tube.

"When it's safe to to do so." This sounds stupid until you stop and think about the underlying reason why the tube was inserted in the first place. Is the effusion just going to re-collect after the original one is drained? Maybe something needs to be done to stop the effusion from recurring, like "pleurodesis".

Pleurodesis is a technique of instilling some substance or other into the pleural space through the chest tube, which is then supposed to "weld" the pleura together by scarring them, preventing the re-collection of fluid between them. This doesn't sound like it would be a very pleasant idea, but it works pretty well for some situations. I remember the old days, when the scarring agents used to cause a lot of pain - I'm sure that they weren't chosen to be painful, but they were - let's forget about those... Nowadays they use sterile talcum powder, which comes up from the pharmacy in large sterile syringes and looks strange - apparently it works very well.

Talcum powder is instilled into the pleural space, right through the chest tube. Then the patient gets rolled around into different positions every which-way so that the scarifying agent gets distributed everywhere.

Sometimes you'll see narrow-gauge chest tubes inserted instead of the large clear ones, and because they're narrow, they get can plugged up with fibrin, which stops the drainage. The tube in this case is usually rigged with a stopcock between the end of the tube and the connector to the pleurevac - the team will instill a dose of streptokinase through the stopcock and into the patient through the chest tube, let it sit for half an hour, and then turn the stopcock back to drain. The dose I see given is 250,000 units. Strepto is also injected if the patient has a "loculated" effusion, which means that it's managed to become surrounded by a fibrin membrane. The drug breaks up the membrane and lets the effusion get to the tube for drainage.

This is a collection of pus in the pleural space, or in a big abscess space in the lung tissue itself. Feh! Pus can collect in large enough quantities to compress the lung, and certainly will act as a septic "focus" until it's drained. Empyema can result from chest trauma - say, a gunshot or knife wound - or necrotizing pneumonia, or any other process that puts bacteria into the chest. And you were wondering why your patient was on pressors? Actually, that's a good question: new ICU nurses, why might this situation make your patient need pressors? Look one paragraph up for the hint.

The idea of using chest tubes to remove air from the pleural cavity means that there has to be some way to tell that air is actually coming out. The smaller bubble chamber in the pleurevac shows an air leak very simply - if there are bubbles coming through it, then air is coming down the tube and being evacuated. It's important to remember that this does not mean automatically that air is coming out of the chest. If there's a leak in the tubing, or if a chest tube suction port (the openings along the lumen of the tube inside the chest that draw in the air and fluid for drainage) is outside of the chest wall, then air will be sucked in there - instead of being pulled out of the chest. So bubbles are a good sign, but you have to check everything else too

Sometimes you'll suddenly hear a new sound in your room. Hunting around, you may find that your patient's chest tube has inadvertently taken a yank - and it's whistling at the insertion site. A port has come outside the skin, and it's continuously sucking in air from the atmosphere around it. You can put your stethoscope on the dressing over the site if you're suspicious, and you'll hear it clearly there. Take a look at this picture - one of these chest tubes isn't quite right. See the radio-opaque lines going along the tubes? Look at the one on the patient's left. See the break in the line? That's the drainage opening. Nicely inside the chest? So what about the one on the other side?

If you take the site dressing down, you can wrap the port with sterile vaseline gauze and apply an occlusive dressing, but usually this situation means that the tube will need to be replaced. You'll also need a stat x-ray - air may be dangerously re-accumulating in the chest!

It depends on the situation. (Everything always depends on the situation!) If a patient has a chest tube put in for a pneumothorax, then at least initially an air leak is a very good thing - because you certainly want that air out of there. If you don't see bubbles coming out through the air leak chamber after a tube is placed for a pneumo - then you may have a non-functioning chest tube on your hands; it might not be in the right place. Get a look with the team at the followup x-ray immediately to see if the pneumo has shrunk at all - if not, the patient may need another tube put in. Same thing is true for a number of postop situations involving chest surgery: open lung biopsies, lobectomies, pneumonectomies - all these leave an area of lung tissue that will leak air into the pleural space until they heal, and so require chest tubes to get rid of that air. So air leaks in those cases are also good. But say a patient still had an air leak two weeks after an open lung biopsy - what then?

It depends on the situation. (Everything always depends on the situation!) If a patient has a chest tube put in for a pneumothorax, then at least initially an air leak is a very good thing - because you certainly want that air out of there. If you don't see bubbles coming out through the air leak chamber after a tube is placed for a pneumo - then you may have a non-functioning chest tube on your hands; it might not be in the right place. Get a look with the team at the followup x-ray immediately to see if the pneumo has shrunk at all - if not, the patient may need another tube put in. Same thing is true for a number of postop situations involving chest surgery: open lung biopsies, lobectomies, pneumonectomies - all these leave an area of lung tissue that will leak air into the pleural space until they heal, and so require chest tubes to get rid of that air. So air leaks in those cases are also good. But say a patient still had an air leak two weeks after an open lung biopsy - what then?

This is actually pretty important. Go back to the picture on page 5, and look at item D. See that button? The air leak chamber of a pleurevac, just like the first bottle of a drainage set, needs to be partly filled with water - that's how the bubble-trap idea works, like putting the end of the chest tube in a cup of water, like a one-way valve. You put that water into that chamber when you set up the pleurevac, through a filling column that has an opening on the top of the box. If you remember to look at the air leak chamber at various times during the course of your shift, you'll notice that the water in it can sometimes rise up the filling column towards the top of the box. This usually happens if the patient is "pulling" very hard with inspiration - what they call "excess negative pressure". Kind of like what high school teachers do...in other words, not only is the patient trying to pull in air through his airway, but also from the pleurevac itself, which actually he can't, because that's what the air leak chamber prevents, right? But the water in the trap chamber will rise up in the filling column after a while, and the air that's trying to escape from the chest won't be able to get out because of the increased weight of that column. The resistance of the air trap, or leak chamber filled with water to the proper level, is only supposed to be tiny - about 2cm of water - not like the 20cm in the control column. So what you have to do is lower that column of water back down to the level indicated on the chamber - there's a line marked on the box. Holding down the black button is the thing to do - hold the button down, and the column will slowly sink down towards the correct level - let go when it gets there. This problem also happens very often with tube "stripping".

Stripping is something people argue about a lot. The idea is that if a chest tube is "milked" every couple of hours after, say, a surgical procedure, then it won't get plugged up by clots, which only makes sense, since if the tube gets plugged, then the air and fluid that it's supposed to remove will not get removed, and a tension situation could develop in the chest. Definitely a bad thing. But stripping and milking can pull too hard suction-wise on the chest cavity, possibly causing tissue injuries to the lung. Also a bad thing. So the only thing to do is to ask the surgeon what she wants done. If you're instructed not to strip, watch carefully for signs that the chest tube is still working properly: draining air, fluid, or blood. If air were to stop coming out three hours postop a lobectomy - I'd page that surgeon right away.

Sometimes the signs and symptoms are obvious, sometimes not. The first thing to do if you suspect this is to get the team to order a stat chest film - and then get it promptly read! Observing the patient, you might see hypotension, cyanosis, general signs of respiratory distress - maybe even tracheal deviation to the opposite side as the mediastinum gets pushed across the chest. If the patient has an arterial line, look for a pulsus paradoxus.

The idea here is that blood pressure varies as the patient inhales and exhales: literally goes up and down, maybe by 50 points, systolic. Maybe more. There are three main situations where you see this: tension pneumothorax, pericardial tamponade, and (maybe) severe hypovolemia. Let's take the first one, which is the relevant one here: what happens is that as the patient gets a breath, the intrathoracic pressure rises. The tension gets worse - maybe there's already some mediastinal compression. The heart is squeezed tightly, and compressed, and literally doesn't have room in the chest to pump. This makes sense if you think about tension pneumothorax - a lung may go all the way down, and as the pressure in the chest continues to rise and rise, with every breath, the mediastinum gets pushed over harder and harder. So now when the patient gets a breath, the small addition of positive pressure (assuming they're vented - in which case positive pressure happens on inspiration because the vent is pushing the air in) the heart gets squeezed just a little more, is able to move just a little less - can't pump well - and the blood pressure drops. When the patient exhales (on the vent, this is when intrathoracic pressure is released - after the breath is pushed in) - then the intrathoracic pressure drops again, and the heart is un-squeezed a bit, the heart can move just a little better, and the blood pressure rises again. This can sometimes be clearly seen if the patient has an arterial line - watch the tops of the blood pressure waves on the A-line as the breaths go in and out - if they drop more than 15-20 points per breath, you've got a "clinically significant" pulsus paradoxus - often a very clear classic sign of pneumothorax. Think about it - did the patient just have a central line put in...? You can measure this by using the arterial line cursor - there is one there, although we hardly ever use it. Chase the wave tops up and down, measuring the distance between the tops at inspiration and the tops at expiration, and find the difference. You might see a dramatic change - in a severe situation, maybe a systolic of 150 dropping to 80.

Aside from changing the pleurevac, it sounds like a bad idea to me. If the pleurevac tubing comes disconnected from the chest tube itself, then I would clamp the tube only long enough to hook up another one, to prevent air from being sucked back into the chest. But only that long! Did the tube get contaminated?

That's what you keep vaseline gauze at the bedside for. You would slap that gauze right onto the site, (don't really slap the patient, right?) and occlude the opening - you don't want air going back into the patient's chest - for the same reason why you'd (briefly!) clamp a chest tube in the question above. Again, you'd want to stat page a surgeon if the patient needed the tube back in, and get a CXR ordered right away.

"Water seal" means that you've disconnected the wall suction line from the pleurevac (on purpose). Usually this is ordered when the air and/or fluid draining from the patient is assumed to be pretty much over and done with - several days after surgery - maybe not in the case of recurrent effusion - maybe a day or so after pleurodesis when you'd expect the drainage to have stopped. You'd want to watch carefully for signs of re-accumulating air or fluid in the chest - daily, or sometimes twice-daily x-rays will help determine this. It's done as a maneuver when you're thinking about pulling the tube after it's served its' purpose.

Subcutaneous emphysema is the collection of air in the tissues just under the skin - once you feel it, you'll never forget it: as though Rice Krispies had been spread around under the patient's skin. If a chest tube isn't properly placed, or maybe if the site dressing isn't airtight, air can leak into the tissue around the insertion site. Eventually it can track up and down the body, sometimes causing the neck and face to swell, sometimes threatening the airway. In that case the patient should be immediately assessed for intubation - there may be no time to waste! Correcting the position of the chest tube usually stops the leakage of air into the tissues, and the air itself is almost always very rapidly reabsorbed - a matter of several days at most, in my experience.