The Emergency Department

Joe came into the Emergency Department after falling from a ladder while trimming trees.  He states that he “landed on his right side when he fell”.  He is complaining of Shortness of Breath and right-sided chest pain.  Upon assessment the nurse finds HR 115, RR 28, T 99.2, BP 88/52, O2 86% rates his pain at an 8 on a 0-10 scale.  The nurse notes absent breath sounds on the right side when completing the lung assessment.  The physician is notified and Joe is sent to Radiology for a Chest X-ray.  The Chest X-ray results show that Joe has a hemothorax.

1. As the nurse, what procedure can you anticipate preparing for?
2. Write a statement on how you would teach Joe and his wife about this procedure. (Keep in mind they need to get the procedure completed quickly).  Use complete sentences.
3. His wife asks, “How will that tube help his breathing?”  You respond:
4. The physician inserts the chest tube and connects to the closed chest tube drainage system. The physician orders -20cm wall suction for the chest tube. Write a sample post-chest tube insertion documentation note.  You can “make-up” assessment finding values.
5. During report hand-off at change of shift, you notice the following changes in your patient:
   1. What would you do?
6. Joe’s RR has increased from 16 breaths/minute to 28 breaths/minute
7. You notice an increased sanguineous drainage of 200mLs in the last hour.
8. The following morning you are assigned Joe as one of your patient’s. You arrive to his room to complete your first assessment and discover the chest tube is no longer connected to the closed drainage system.  Identify your next actions:
9. The physician places the order to “Place chest tube to water seal”, he also notifies you to keep him updated regarding Joe’s tolerance of this. 

1. How will you explain this order to Joe (write your specific words used)?

1. What will you do to enact this order?

1. What will you specifically assess to learn about Joe’s tolerance of this intervention?

1. State two findings that would require you to call the physician?

1. The physician calls and asks if Joe’s chest tube appears ready for removal. In preparing to respond, the nurse needs to find out the following assessments/information.  (1 pt)

1. The physician has decided to remove Joe’s chest tube.  How will you prepare, as well as prepare Joe for the removal?  (1 pt)

1. You are assisting a co-worker in changing the chest tube dressing of a different patient.  When the dressing is removed you see that the bottom eyelets of chest tube are visible. Your next action includes:  (1 pt)