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 nigh
...
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’
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