Medical Surgical Hemothorax vs Pneumothorax #2
The nurse is assessing the chest tube drainage of a client with a hemothorax following a motor vehicle accident. Which findings will be expected in a normally functioning chest tube system? Select all that apply.
- Presence of an occlusive dressing over the insertion area.
This answer is correct because a functioning chest tube system includes having an occlusive dressing over the chest tube insertion site. The insertion site must be covered in order to prevent infection and form an airtight seal around the opening.
- Tidaling in the water-seal chamber with respirations.
This answer is correct because tidaling in the water-seal chamber with respirations is a normal finding. As the client inhales, the fluid level will rise and the fluid level will fall as the client exhales.
- Continuous bubbling in the water-seal chamber.
This answer is not correct because continuous bubbling indicates a leak in the system and is not a normal finding. Intermittent bubbling may occur with a pleural air leak and will resolve as the lung re-expands, but continuous bubbling is not normal.
- 100mL sanguineous blood in the drainage collection chamber.
This answer is correct because 100mL of sanguineous drainage within the collection chamber is a normal finding in a chest tube that is being used to drain a hemothorax. The drainage in the collection chamber should be included in the client’s intake and output. Chest tube removal is typically indicated when drainage is 200mL/day or less.
- The chest tube secured to the floor beside the client's bed.
This answer is correct because the chest tube should be kept below the level of the client at all times to prevent back flow of fluid into the pleural space.
The focus of this question is choosing the correct findings which are expected in a chest tube that is being used to drain a hemothorax. Chest tubes are typically inserted for the purpose of draining excess fluid/ blood or air from the pleural space.
Chest tubes are inserted to drain fluid (pleural effusion/hemothorax) or air (pneumothorax) from the pleural space in order to allow for lung reexpansion. It is essential to to understand the mechanics of a chest tube when assessing for signs of a malfunctioning tube or client complications. The insertion site of a chest tube should be covered with an occlusive dressing to prevent the entry of air into the pleural space. Normal tidaling with respirations is an expected finding in a properly functioning chest tube. 100mL serosanguineous blood in the collection chamber is an expected finding for a chest tube that was recently inserted to drain a hemothorax. The chest tube should always remain below the level of the clients chest which can be ensured by taping the system to the floor.
Test Taking Tip
When answering, select all that apply questions, look at each individual answer choice separately while covering the remainder of answer choices.