Fundamentals of Nursing Q 39
The nurse is assessing the functioning of a chest tube drainage system in a client with hemothorax. Which of the following findings should prompt the nurse to notify the physician?
A. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation.
B. Drainage system maintained below the client’s chest.
C. Drainage amount of 100ml in the drainage collection chamber.
D. Occlusive dressing in place over the chest tube insertion site.
Correct Answer: C. Drainage amount of 100ml in the drainage collection chamber.
Drainage of more than 70 to 100 mL/hour is not normal and requires the immediate notification of the physician. Measure date and time, and the amount of drainage, and mark on the outside of the chamber. Record amount and characteristics of the drainage on the fluid balance sheet and patient chart. Drainage that is red and free-flowing indicates a hemorrhage. A large amount of drainage, or drainage that changes in color, should be recorded and reported to the primary health care provider.
Option A: The water in the water seal chamber will rise and fall (swing) with respirations. This will diminish as the pneumothorax resolves. Watch for unexpected cessation of swing as this may indicate the tube is blocked or kinked. Cardiac surgical patients may have some of their drains in the mediastinum in which case there will be no swing in the water seal chamber.
Option B: Collection chamber (drainage system) is below the level of the chest and secured to prevent it from being accidentally knocked over. The drainage system must remain upright for the water-seal chamber to function correctly. The chest drainage system must be lower than the chest to facilitate drainage and prevent backflow.
Option D: The classic dressing for chest thoracostomy tube (CTT) insertion sites is petroleum gauze held in place by a secondary dressing of sterile, 4? x 4? sponge gauze secured with tape. Studies suggest that petroleum gauze macerates skin over time.