Chest tubes MEd Surgical Unit

1.     How do the patient’s vital signs reflect his current situation?  Do any of them concern you and if so, why?

For a healthy adult the normal vital signs includes RR 12-16 breaths per minute, BP 120/80, HR 60-100 beats per minute, and SpO2 95%-100%.  The vital signs presented by the patients include HR 102, BP 142/88, RR 32, and SpO2 97% on room air, chest pain (8/10). His HR, RR, and BP are higher than the normal range as well as increased chest pain. These vital signs demonstrate that the patient has tachycardia because the heart beats faster than the normal rate while at rest resulting in these symptoms.

2.     What should be the focus of your assessment of this patient?  What specific abnormal findings might you notice?

The focus of assessment of this patient is pneumothorax and head laceration. Pneumothorax is a life-threatening condition and assessment of its cause is crucial in fostering appropriate treatment to the right type of pneumothorax. Pain in the head laceration areas, which may raise concerns of damage to the structure below the skin, bleeding, or infection (Huang, Ahmed, D'Souza & Awad, 2018).

The abnormal findings noticed include the elevated blood pressure.  Patients with pneumothorax usually have low blood pressure, which is contrary in John’s case. Although uncommon, some patients with pneumothorax present high blood pressure level. Tension pneumothorax is commonly found among individuals with high blood pressure, which is an indication that John has tension pneumothorax. A tension pneumothorax can lead to a collapse of the nearby lung completely and push the major blood vessels and the heart to one of the chest thus leading to elevated blood pressure in a patient (Huang, Ahmed, D'Souza & Awad, 2018).

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3.     What is the priority nursing diagnosis for this patient?

 The nursing assessment will include collecting data on:

•         Pain/anxiety
•         Chest expansion
•         Breath pattern

The nursing diagnosis based on the assessment data include:

•         Acute pain related to chest pain when taking deep breaths and coughing
•         Anxiety associated with difficulty in breathing
•         Ineffective breathing pattern associated with respiratory problems

The nursing care planning and goals for the patient include:

•         Ensuring the patient is relaxed to minimize anxiety to manageable level
•         Relief pain
•         Create a normal and effective respiratory pattern for the patient evidenced by normalized respiratory rate and ease in breathing.

Nursing Interventions

•         Supporting the patient’s abdominal muscles and chest to make breathing and coughing less traumatic and more effective.
•         Assist the patient to minimize anxiety or fear through helping them to take deeper and slower respirations.
•         Inserting the chest tube to facilitate optimum fluid drainage and lung expansion.
•         Monitoring the progress of re-expansion of lung and addressing pneumothorax (Lewis, Dirksen, Heitkemper & Bucher, 2014).

4.     The patient is ordered Percocet (Oxycodone 5mg/Acetaminophen 325 mg) 2 tablets for pain <8/10 and morphine 4 mg IVP for pain >8/10.  Which would you administer? 

Both Percocet and morphine are pain relief medication used in emergency department.  They relief moderate to severe pain in patients. Percocet was ordered because it is an orally therapy medication while morphine IV was ordered because it is intravenous medication. I would administer Percocet because it is 1.5 times more effective than morphine in relieving pain. According to Hovda, Brutlag, Poppenga and Peterson (2016), oral administration route is regarded as the most acceptable and economical route of medication administration. I will not administer morphine IV because it is a narcotic and giving 4mg of morphine medication to John who has a higher blood pressure can cause it to drop to 50 -60 systolic and thus cause the patient become unresponsive. If morphine is given, the patient blood pressure, breathing, allergic reaction, and respiratory arrest should be monitored.

5.     What would be important to monitor after giving this medication based on this patient’s diagnosis?

The aim of administering the medication was to relieve pain. Therefore, following the administration of these medications, the patient can be monitored for pain to determine if there is any change.

6.     How do you know that the pain medicine was effective?

I can know that the pain medication was effective by asking the patient himself because pain is subjective.

The chest tube is inserted without difficulty and 50 mL sanguineous drainage is removed.  The chest tube is attached to low continuous suction as ordered. 

7.     Upon connecting, you notice some bubbling in the water seal chamber of the chest tube.  What would be your next action?

Bubbling could be an indication of an air leak. I would identify the area of air leak, I will clamp the thoracic catheter next to the exit from chest. If air leak continues, I will clamp the chest tube with the physician’s order since clamping could result in tension pneumothorax.

8.     What outcomes would you anticipate to see in the patient if the chest tube insertion has been effective?

To determine if the chest tube insertion has been effective, I would anticipate to see the patient with an effective or normal respiratory pattern.