Medical Surgical Hemothorax vs Pneumothorax #1
The nurse contacts the healthcare provider about a client’s assessment following chest tube removal and reports tracheal deviation away from the affected side, agitation, and neck vein distention, all signs of a tension pneumothorax. Which action will the nurse perform while waiting for re-insertion of the chest tube?
- Release the dressing covering the open chest wound.
This answer is correct because the nurse should immediately release the covering where the previous chest tube was placed. This may become a medical emergency because of build-up of intrathoracic pressure in the pleural space and air cannot escape.
- Administer oxygen at 80% FiO2.
This answer is not correct because administration of oxygen is not the priority action. The most important intervention is to prevent expansion of the tension pneumothorax by removal of the occlusive dressing covering the chest tube insertion site.
- Place the client in trendelenburg position.
This answer is not correct because it is not appropriate to place the client in the trendelenburg position. This action will not prevent expansion of the tension pneumothorax which is the nurse’s priority.
- Perform arterial blood gas.
This answer is not correct because, while arterial blood gases (ABG) may be ordered to assess the client’s oxygenation status, this is not the priority. ABGs may be ordered and drawn once the client is stabilized and actions have been taken to prevent expansion of the tension pneumothorax.
The focus of this question is choosing the priority action for a client experiencing a severe complication following chest tube removal. Removal of the dressing covering the open chest wound allows air to exit the pleural space preventing worsening of the tension pneumothorax.
Tension pneumothorax is a critical potential complication of chest tube insertion and can occur if a lung is punctured during insertion. If a pneumothorax is suspected after chest tube removal, the nurse should take immediate action to prevent the entry of air through the insertion site. The nurse should immediately remove the occlusive dressing covering the opening and cover the insertion site with a dressing taped on 3 sides which allows air to escape but prevents it from re-entering.
Test Taking Tip
It is essential to understand the pathophysiology of a tension pneumothorax in order to answer this question correctly. The nurse’s priority is to perform interventions that will allow for escape of air to prevent worsening of the tension pneumothorax.