What color will drainage from a pleural effusion be
lightish yellow
what type of drainage will the nurse notice if a client has empyema
pus or purulent drainage
What is a transudative pleural effusions?
occurs due to increased pressure in blood vessels that cause leakage into the pleural space
What is a exudative pleural effusion
occurs due to inflammation or infection that results in excess fluid production and reduced drainage
what are two causes of transudative pleural effusion
CHF (incr blood hydrostatic pressure)
Liver disease (decr plasma protein, decrease oncotic pressure)
what are four causes of a exudative pleural effusion
- cancer
- infection
- pancreatic disease (leak of enzymes)
- esophageal leak (perforation or complication of surgery)
What are two types pf pneumos
closed (no external wound) and open (opening in chest wall)
what are some causes of a closed pneumothorax
- spontaneous (bleb rupture)
- use of too high pressure in mechanical ventilator
- injury to lung during subclavian central line insertion.
- broken rib injury
What should be done if the nurse notices a penetrating open wound
The wound should be covered with a vented dressing. Occlusive dressing that is taped on three sides.
Signs and symptoms of a pneumo
-increased RR and effort.
- dyspnea
- pleuritic chest pain
- decreased movement on affected side.
- decreased breath sounds.
- falling BP
- rising HR
- tracheal deviation AWAY from affected side.
- cool, mottled skin,
- SubQ emphysema
signs and symptoms of a tension pneumothorax
similar to regular pneumo
-increased RR and effort.
- dyspnea
- pleuritic chest pain
- decreased movement on affected side.
- decreased breath sounds.
- falling BP
- rising HR
- tracheal deviation AWAY from affected side.
- cool, mottled skin,
- SubQ emphysema
What is a pneumonectomy
removal of lung
What is the typical french size of a chest tube for a adult? what about a large adult? what about child and infant?
adult: 24-32
Large adult: 36-40
infant: 8-12
child: 16-20
When are pig tail chest tubes or (small bore) most commonly used
pneumos or small pleural effusions
What are some things the nurse should know about a pig tail catheter drain
- they are smaller and used for little drainage or air.
- they require a doctors order to remove.
- they have a stop cock or clamp that needs to stay open.
IF your patient has a chest tube and you are doing your morning safety check, what will you assess first?
assess patients respiratory system first! RR, breathing depth and effort, SOB and use of O2, pain
Your patient has a chest tube, you have gone in for your morning safety check, you have assessed the patients resp status. What else will you be sure to assess at this time.
start at patient an work down the chest tube.
- check dressing site, if the equipment is working, is suction one? is the needed safety equipment in place?
What should be done to chest tube tubing to prevent kinking or dependent loops?
coil tubing on the bed.
how often should vitals be done on a patient with a CT
Q4H or PRN
how often should deep breathing and coughing exercises be encouraged in a patient with a chest tube
Q1-2H
What is a sign of cardiac tamponade?
muffled or distant heart tones on auscultation
What position should a patient with a chest tube be positioned in
semi to high fowlers
In regards to chest tube drainage, what should be reported to the MRP
Sudden increase or decrease in drainage (>100ml/h). Aswell as if frank blood is noticed or appearance or quality of drainage changes.
In a patient with severe subcutaneous emphysema, which complication should be the HIGHEST concern for the nurse?
A) Decreased cardiac output
B) Airway obstruction
C) Skin breakdown
D) Dysphagia
B) airway obstruction
