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JONES GUIDED CASE STUDY

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Mr. Jones is a 19 year old male who was in a motor vehicle collision yesterday. He sustained a fractured left radius and fractures to ribs 4-7 on the left side. He was admitted to the trauma med- ... surg floor last night. This morning, he suddenly develops shortness of breath and ‘chest tightness’. He says “I feel like I can’t get a deep breath” and appears very anxious. What nursing assessments need to be performed for Mr. Jones?  Auscultate Lung Sounds  Full set of Vital Signs, including SpO2 You assess Mr. Jones to find his V/S: HR 108 RR 32 BP 117/72 SpO2 90% on Room Air You auscultate his lungs but find that lung sounds are diminished and almost absent over the left upper lobe. What might be occurring physiologically? How would this be diagnosed?  Because of his rib fractures, he may have developed a pneumothorax – this would cause air to begin filling the space around his lung and cause it to collapse  The quickest way to diagnose this is with a chest x-ray, though it can also be diagnosed with a CT, ultrasound, or MRI You notify the provider who orders a STAT Chest x-ray. The chest X-ray confirms the patient has a moderate sized pneumothorax on the left side, with no shifting of the mediastinum or trachea. The provider determines the patient needs a chest tube placed. You gather supplies, set up the drainage system and assist with placement of the chest tube on the left side. You secure the chest tube with an occlusive dressing and place the drainage system at the foot of the bed. The provider orders the chest tube to be placed to water seal, without suction. What output would you expect to see on initial placement of Mr. Jones’s chest tube? Because this is a pneumothorax, we shouldn’t see any drainage or blood. It’s possible there may be a very small amount of pleural fluid, but mostly it is just draining air. Describe how ‘water seal’ [Show More]

Last updated: 3 years ago

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