Medical Surgical Chest tube #5

Question

While providing care to a client with a chest tube drainage system, the nurse detects redness around the insertion site of the tube along with subcutaneous crepitus. Upon palpation, the client denies any pain. Which action is best?

Answers

  1. Use a skin marker to identify the borders of the redness and continue to monitor.
    • Rationale:

      This answer is correct because these are signs of subcutaneous emphysema (SCE). SCE occurs when CO2 is trapped in the subcutaneous tissues of the skin. Assessment reveals a “rice crispyâ€ crackling sound under the skin during palpation. This is called crepitus. SCE is self-liming requiring no treatment. The nurse will notify the provider if the client reports pain or if there is purulent drainage or odor coming from the insertion site.

  2. Notify the client's provider of this new development.
    • Rationale:

      This answer is not correct because the nurse needs to document the findings and continue to monitor. The nurse will only notify the provider if the client reports pain or if there is purulent drainage or odor coming from the insertion site.

  3. Document the findings and change the dressing.
    • Rationale:

      This answer is not correct because although documenting the findings and changing the dressing is an appropriate action, the question asks which action would be “best”. The best action is for the nurse to identify the borders with a skin marker and continue monitoring.

  4. Tape all the connections from the insertion site to the unit.
    • Rationale:

      This answer is not correct because although taping all the connections from the insertion site of the client to the chest drainage unit will keep the dressing occlusive, this is not the “bestâ€ action by the nurse at this time. But by avoiding an air leak, the chest drainage system will be successful.

Overview

Maintaining skin integrity is an important part of care of the client with a chest tube. Redness around the insertion site and crepitus indicates subcutaneous emphysema.

Explanation

Learning Outcomes

Maintaining skin integrity is an important part of care of the client with a chest tube. Redness around the insertion site and crepitus indicates subcutaneous emphysema. (SCE). SCE is self-liming and resolves on its own. The CO2 trapped underneath the skin creates a crackling sound (crepitus). This sensation is painless. At this point, the nurse will only continue monitoring by identifying the borders with a skin marker. If the client complained of pain on palpation or if there was purulent drainage or odor coming from the insertion site, the nurse would then want to notify the provider.

Test Taking Tip

Do not forget about the importance of skin integrity!

Video Rationale