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Given a scenario in a holding or ward setting, involving a patient with a chest tube, identify procedures for chest tube care and monitoring IAW the
Textbook of Basic Nursing, Lippincott
Introduction
Trauma, disease, or surgery can interrupt the closed negative-pressure system of the lungs, causing the lung to collapse. Air or fluid may leak into the
pleural cavity. A chest tube is inserted and a closed chest drainage system is attached to promote drainage of air and fluid. Chest tubes are used after
chest surgery and chest trauma and for pnuemothorax or hemothorax to promote lung re-expansion
b. Hemothorax – an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae, usually as the result of trauma
c. Chest tubes – a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and
intrapulmonic pressures
(1) One-piece molded plastic unit that duplicates the three-chambered system
(3) There must be bubbles flowing in the suction control portion of the unit to provide suction to the patient
b. Pleur-Evac Set Up
(1) Heimlich valve is a plastic, portable one-way valve used for chest drainage, draining into a vented bag
(2) Equipment
(c) Don gloves. Nonsterile gloves are acceptable as long as sterile technique is maintained while the connection is being made.
(a) Place rubber-tipped Kelly clamps in opposite directions on the proximal end of the chest tube as near to the patient as
possible
(b) Connect the chest tube to the blue end of the Heimlich valve using sterile technique
CAUTION: Only the blue end of the Heimlich valve can be connected to the chest tube. If the clear end is connected, the one-way valve will be in
the wrong position and no drainage will take place.
(c) Tape the connection site at both ends of the valve using 2 inch cloth tape.
CAUTION: When two chest tubes are present, two Heimlich valves must be used to ensure proper functioning of chest tubes.
(d) Monitor and record character of drainage and patency of valve in nursing progress notes.
(e) Record drainage output on I & O graphic every 8 hours. If conditions permit.
a. Assess patient for respiratory distress and chest pain, breath sounds over affected lung area, and stable vital signs
(3) Chest drainage system, which should be upright and below level of tube insertion
d. Provide two shodded hemostats for each chest tube, attached to top of patient’s bed with adhesive tape. Chest tubes are only clamped under
specific circumstances:
(2) To quickly empty or change collection bottle or chamber; performed by soldier medic who has received training in procedure
(3) To change disposable systems; have new system ready to be connected before clamping tube so that transfer can be rapid and
drainage system reestablished
(4) To change a broken water-seal bottle in the event that no sterile solution container is available
(5) To assess if patient is ready to have chest tube removed (which is done by physician’s order); the solider medic must monitor patient
for recreation of pneumothorax
f. Maintain tube connection between chest and drainage tubes intact and taped
(2) Suction-control chamber vent must be without occlusion when suction is used
g. Coil excess tubing on mattress next to patient. Secure with rubber band and safety pin or system’s clamp
h. Adjust tubing to hang in straight line from top of mattress to drainage chamber. If chest tube is draining fluid, indicate time (e.g., 0900) that
drainage was begun on drainage bottle’s adhesive tape or on write-on surface of disposable commercial system
(1) Strip or milk chest tube only per MD/PA orders only
(1) Problem: Continuous bubbling is seen in water-seal bottle/chamber, indicating that leak is between patient and water seal
(2) Problem: Bubbling continues, indicating that air leak has not been corrected
(a) Cross-clamp chest tube close to patient’s chest, if bubbling stops, air leak is inside the patient’s thorax or at chest tube
insertion site
Warning: Leaving chest tube clamped caused a tension pneumothorax and mediastinal shift
(3) Problem: Bubbling continues, indicating that leak is not in the patient’s chest or at the insertion site
(a) Gradually move clamps down drainage tubing away from patient and toward suction-control chamber, moving one clamp at
a time
(b) When bubbling stops, leak is in section of tubing or connection distal to the clamp
(a) Determine that chest tubes are not clamped, kinked, or occluded. Locate leak
(b) Obstructed chest tubes trap air in intrapleural space when air leak originates within patient
(3) Problems: Hyperresonance on affected side, mediastinal shift to unaffected side, tracheal shift to unaffected side, hypotenstion or
tachycardia
(c) Have emergency equipment (oxygen and code cart) near patient
(a) Insert distal end of water-seal tube into sterile solution so that tip is 2 cm below surface
(c) If no sterile solution is available, double clamp chest tube while preparing new bottle
(a) Add sterile solution to water-seal bottle until distal tip is 2 cm under surface
SUMMARY
Caring for a patient with a chest tube requires problem solving and knowledge application. Remember, a chest tubes is a catheter inserted through the
thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures. When caring for and
maintaining a patient with a chest tube, it is important to note the patency of chest tubes, presence of drainage, presence of fluctuations, patient's vital
signs, chest dressing status, type of suction, and level of comfort.
HIV (human immunodeficiency virus) is a virus that attacks the immune system, the body’s natural defense system. Without a strong immune
system, the body has trouble fighting off disease. Both the virus and the infection it causes are called HIV.
White blood cells are an important part of the immune system. HIV invades and destroys certain white blood cells called CD4+ cells. If too
many CD4+ cells are destroyed, the body can no longer defend itself against infection.
The last stage of HIV infection is AIDS (acquired immunodeficiency syndrome). People with AIDS have a low number of CD4+ cells and get
infections or cancers that rarely occur in healthy people. These can be deadly.
But having HIV does not mean you have AIDS. Even without treatment, it takes a long time for HIV to progress to AIDS—usually 10 to 12 years.
If HIV is diagnosed before it becomes AIDS, medicines can slow or stop the damage to the immune system. With treatment, many people with HIV are
able to live long and active lives.
HIV infection is caused by the human immunodeficiency virus. You can get HIV from contact with infected blood, semen, or vaginal fluids.
• Most people get the virus by having unprotected sex with someone who has HIV.
• Another common way of getting the virus is by sharing drug needles with someone who is infected with HIV.
• The virus can also be passed from a mother to her baby during pregnancy, birth, or breast-feeding.
HIV doesn't survive well outside the body. So it cannot be spread by casual contact such as kissing or sharing drinking glasses with an infected person.
HIV may not cause symptoms early on. People who do have symptoms may mistake them for the flu or mono. Common early symptoms include:
• Fever.
• Sore throat.
• Headache.
• Muscle aches and joint pain.
• Swollen glands (swollen lymph nodes).
• Skin rash.
Symptoms may appear from a few days to several weeks after a person is first infected. The early symptoms usually go away within 2 to 3 weeks.
After the early symptoms go away, an infected person may not have symptoms again for many years. But during this time, the virus continues to grow in
the body and attack the immune system. After a certain point, symptoms reappear and then remain. These symptoms usually include:
A doctor may suspect HIV if these symptoms last and no other cause can be found.
The only way to know for sure if you have HIV is to get a blood test. If you have been exposed to HIV, your immune system will make antibodies to try to
destroy the virus. Blood tests can find these antibodies in your blood.
Most doctors use two blood tests, called the ELISA and the Western blot assay. If the first ELISA is positive (meaning that HIV antibodies are found), the
blood sample is tested again. If the second test is positive, the doctor will do a Western blot to be sure.
It may take as long as 6 months for HIV antibodies to show up in a blood sample. If you think you have been exposed to HIV but you test negative for it:
Some people are afraid to be tested for HIV. But if there is any chance you could be infected, it is very important to find out. HIV can be treated. Getting
early treatment can slow down the virus and help you stay healthy.
You can get HIV testing in most doctors’ offices, public health clinics, hospitals, and Planned Parenthood clinics. You can also buy a home HIV test kit in a
drugstore or by mail order. But be very careful to choose only a test that has been approved by the U.S. Food and Drug Administration (FDA). If a home
test is positive, see a doctor to have the result confirmed and to find out what to do next.
How is it treated?
The standard treatment for HIV is a combination of medicines called highly active antiretroviral therapy (HAART). Antiretroviral medicines slow the rate
at which the virus multiplies. Taking these medicines can reduce the amount of virus in your body and help you stay healthy.
It may not be easy to decide the best time to start treatment. There are pros and cons to taking HAART before you have symptoms. Discuss these with
your doctor so you understand your choices.
To find out how much damage HIV has done to your immune system, a doctor will do two tests:
• CD4+ cell count, which shows how well your immune system is working.
• Viral load, which shows the amount of virus in your blood.
If you have no symptoms and your CD4+ cell count is at a healthy level, you may not need treatment yet. Your doctor will repeat the tests on a regular
basis to see how you are doing. If you have symptoms, you should consider starting treatment, whatever your CD4+ count is.
After you start treatment, it is important to take your medicines exactly as directed by your doctor. When treatment doesn't work, it is often because HIV
has become resistant to the medicine. This can happen if you don't take your medicines correctly. Ask your doctor if you have questions about your
treatment.
Treatment has become much easier to follow over the past few years. New combination medicines include two or three different medicines in one pill.
Many people with HIV get the treatment they need by taking just one or two pills a day.
Learn all you can about HIV so you can take an active role in your treatment. Your doctor can help you understand HIV and how best to treat it. Also,
consider joining an HIV support group. Support groups can be a great place to share information and emotions about HIV infection.
HIV can be spread by people who don't know they are infected. To protect yourself and others:
• Practice safe sex. Use a condom every time you have sex (including oral sex) until you are sure you and your partner are not infected with HIV.
• Don't have more than one sex partner at a time. The safest sex is with one partner who has sex only with you.
• Talk to your partner before you have sex the first time. Find out if he or she is at risk for HIV. Get tested together and retested 6 months later.
Use condoms in the meantime.
• Don't drink a lot of alcohol or use illegal drugs before sex. You might let down your guard and not practice safe sex.
• Don't share personal items, such as toothbrushes or razors.
• Never share needles or syringes with anyone.
What is thyroidectomy?
Thyroidectomy is an operation in which one or both lobes of the thyroid gland are removed. The most common indications for thyroidectomy
include a large mass in the thyroid gland, difficulties with breathing related to a thyroid mass, difficulties with swallowing, goiter, suspected or proven
cancer of the thyroid gland and hyperthyroidism (overproduction of the thyroid hormone, Graves' disease). The need for thyroidectomy is based on
your history, the results of a physical examination and tests. The most common tests to determine whether a thyroidectomy is necessary include a fine
needle aspiration biopsy, thyroid scan, ultrasound, x-rays and/or CT scan, and assessment of thyroid hormone levels. The procedure is usually done
under general anesthesia. The extent of surgery (removal of one or both lobes) may sometimes be determined in the course of surgery after microscopic
examination of tissue removed during the surgery.
If you have not been assigned a room, you would be asked to go to the second floor registration and from there, you would be directed to Day
Surgery pre-op holding.
In pre-op holding, the nurses will start an IV line and review your history and medications. They will ask you questions to make sure you
understand what is going to be done and that you have consented. They may make you sign the consent forms if you have not signed them during
assessment. They will also mark the operative site with ink and if applicable, write on your neck LEFT or RIGHT so that there will be no confusion as to
which side is being operated on. You may request a tranquilizer if you are very anxious.
You will be asked to speak to find out if your voice is hoarse. Many patients, especially smokers, have a raspy or hoarse voice when they
wake up from anesthesia. Smokers have a tendency to cough.
You will notice that the wound is not covered with a dressing; it is just sealed with acrylic glue (Dermabond). Occasionally, however,
dressings or drains are needed and you may notice a dressing wrapped around your neck and drain tubes attached to your clothes or a necklace.
These are usually removed the next day. Please do not pull on them or try to empty the attached plastic bulbs.
For 2 – 3 days after the surgery, it is not unusual to have pain or difficulty on swallowing.
The nurses have standing orders to give you antibiotics, pain killers, thyroid replacement hormone and medications for nausea and
vomiting. If there are no contraindications, you will also receive your usual home medications.
Most patients develop a transient hypocalcemia (low calcium) in the immediate post-operative period. That is why your calcium,
phosphorus and magnesium levels will be monitored every six hours and sometimes more frequently. If you develop hypocalcemia, you will be given
calcium by mouth and / or intravenously. Tingling around the mouth and face, muscle spasms of the hands and feet, involuntary grimacing and
sometimes difficulty in breathing and gasping for air (stridor) are signs of hypocalcemia.
If you feel up to it, you are allowed to stand up, walk and go to the bathroom, with assistance and always, with someone present in the
room. Do not attempt at walking or going to the bathroom if you are alone in the room. You may be too groggy from the pain killers or you may pass-
out and fall down.
In general, the wound is sealed with a thin clear acrylic layer (Dermabond) and the sutures are buried under the skin. There is no need to
apply antibiotic ointment on the wound. You are allowed to take a shower without covering the wound. This acrylic film will peal off in a couple of
weeks. When you go home, please keep the wound exposed and do not hide it with a dressing or scarf. A little antibiotic ointment may be used at the
site of the drains for a day or two. In general the drain wound heals and stops oozing in 24 hours.
When do I go home?
Most patients are discharged the day after the operation. By then, they should be able to eat, walk and go to the bathroom. Occasionally,
however, some patients may run a temperature or continue to have hypocalcemia, nausea or excessive drainage. It is not uncommon for older men,
especially those with large prostates, to develop urinary retention after general anesthesia. In all these instances, discharge is delayed a day or two,
until the problem is resolved.
Complications
Bleeding or infection are possible short term complications. Although rare in thyroid surgery, some patients may develop a thick scar or keloid.
Two complications specific to thyroid surgery are hypocalcemia and vocal cord weakness or paralysis.
Hypocalcemia, or low blood levels of calcium, may occur after complete removal of both thyroid lobes. This condition is caused by interference with
four tiny glands called parathyroid glands, which are located within or very close to the thyroid gland. Hypocalcemia is usually temporary, but
sometimes may require calcium supplements if sufficiently pronounced. Permanent hypocalcemia is fortunately rare.
Vocal cord weakness or paralysis may be caused by swelling, stretching, or injury to the recurrent laryngeal nerve which passes very close to the
thyroid gland. Temporary hoarseness may result. Again, this is an uncommon, usually temporary complication. Permanent vocal cord paralysis is rare
COLOSTOMY
What is a colostomy?
A colostomy is an incision (cut) into the colon (large intestine) to create an artificial opening or "stoma" to the exterior of the abdomen. This
opening serves as a substitute anus through which the intestines can eliminate waste products until the colon can heal or other corrective surgery can
be done. The bowel movements fall into a collection pouch. Our ostomy nursing staff will teach you skin care and how to change the bag.
A colostomy may be needed to divert intestinal contents in conditions such as necrotizing enterocolitis ( an acute inflammatory disease of the
bowel), imperforate anus (absence of anal opening) or Hirschsprung's Disease (a condition in which the nerves controlling bowel function are abnormal).
Each one of these conditions will be explained in detail by your pediatric surgeonHow is a colostomy created?
If the child has measles now or within the last 3 months, assess for:
-mouth ulcers – painful open sore on the inside of the mouth and lips or tongue
-pus draining from the eye
-clouding of the cornea – hazy area in the cornea
Assess for Dengue Hemorrhagic Fever all children two months of age or older.
- Look and feel for signs of bleeding and shock:-bleeding from the nose and gums
-skin petechiae – small hemorrhages in the skin; look like small dark red spots or patches in the skin; not raised, not tender; if you stretch the
skin they
do not lose their color.
-Cold and clammy extremities
-If with cold and clammy extremities, check for slow capillary refill ( longer than 3 seconds)
-Perform the tourniquet test if: there are no signs in the ASK or LOOK and FEEL, the child is 6 months or older, and the fever is present for
more than 3
days.
CLASSIFY FEVER
8. Assess Ear Problem
Assess the child for:
-Ear pain
-Ear discharge; Present less than 2 weeks – Acute ear infection
Present 2 weeks or more – Chronic Ear Infection
-Tender swelling behind the ear
CLASSIFY EAR PROBLEM
9. Check for malnutrition and anemia:
*Look for visible severe wasting – a child with visible severe wasting has marasmus, a form of severe malnutrition..
A child has this sign if he is thin, has no fat, and looks like skin and bones.
Look for ulcers or white patches in the mouth (thrush). Thrush looks like milk cuds on the inside of the cheek, or thick white coating of the tongue. Try
to wipe it off. Milk curds will be removed but thrush will remain.
Check the Young Infant’s Immunization Status
Assess Other Problems