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					1. Given the diagnosis of pneumothorax, explain why the paramedic had difficulty ventilating
   A.W.
    Air escaped from the lung into the pleural space. Eventually, enough air collected in the
      pleural space to cause the mediastinum to shift twoard the right. The collapsed left lung,
      increased intrapleural pressure, and rightward shift make it difficult to ventilate A.W.

2. Interpret A.W.’s ABG’s
     Significant respiratory acidosis with profound hypoxemia. A.W. is near death.

3. What is the reason for A.W.’s ABG results?

      70% of her right lung is collapsed and is not taking part in gas exchange

4. The physician needs to insert a chest tube. What are your responsibilities as the nurse?

   Preinsertion:
    Support patient with comfort and emotional needs – see next question for pain med
       thoughts
    Educate the client and any family that her lung collapsed and that the doctor is going to
       put a tube in her chest to get rid of the air and help her breath on her own again. Even
       though the client is stuporous, you assume she can hear you and needs your calm voice
       and explanations to calm her and provide hope.
    Obtain informed consent for chest tube insertion –
    Set up a chest tube drainage system – fill the water seal to 2 cm and the suction to the
       ordered level, obtain appropriate size chest tube trocars (28 and 32 F is my guess for this
       lady and situation), obtain thoracotomy tray (chest tube insertion tray) found in ER, ICU,
       and materials management department which can be retrieved by the nursing supervisor.
    Baseline assessment of respirations, work of breathing, breath sounds, and oxygenation
       status (O2 saturation)
    Prepare a CXR requisition form for placement check after the insertion is complete
       (doesn’t really matter now or after, but if you have time get it ready now)
   Postinsertion:
    Monitor air leak and any drainage
    Reassess respiratory status as indicated
    Assure portable CXR is done for placement
    Assure proper functioning of drainage system
    Maintain container upright and below the level of the lungs
    Maintain an occlusive and intact dressing
    Provide comfort for the client
    Cough and deep breath to promote expansion of lung
    Report abnormal findings – increased air leak without explanation, deterioration of
       respiratory or patient status
    Document site, presence or absence of air leak, respiratory status as condition indicates
       (could be every 15 minutes, every hour, every two hours, but a minimum of every 4
       hours for anyone with a chest tube)
5. As the nurse, it is your responsibility to ensure pain control. In A.W.s case, would you
   administer pain medication before the chest tube insertion?
    The client is stuporous on arrival to the emergency room and is in a medical emergency;
      you may or may not have time to administer pain medication. Preparing the chest tube
      set-up takes priority because your client is near death and this is what will reverse her
      grave situation. If you do have time after set-up or have other nurses helping you -- the
      quickest and fastest would be IV administration – it is a common order to administer
      morphine 2- 6 mg IV titrated (example: 2 mg at a time assessing each dose after
      approximately 5 minutes to see how the patient is doing; then giving 2 mg more, waiting,
      assessing; etc until pain relief is observed)

6. The ER physician inserts a size 32 chest tube in the 2nd intercostal space, midclavicular line.
   Many chest tubes are inserted in the 6th intercostal space, midaxillary line. What factor
   determines where a chest tube is placed?

   Air is lighter than liquid and tends to rise to the top; therefore, chest tubes inserted to remove
    air are placed close to the 2nd intercostal space along the midclavicular line (high on the
    chest). Fluids are heavier and tend to seek the lowest level, therefore, chest tubes inserted to
    remove fluids are placed lower at around the 5th or 6th intercostal space, midaxillary line.

7. Given the information above, would you expect to observe an air leak when A.W.’s chest
   drainage system is in place and functioning?
 Yes. Since she ruptured a bleb into her pleural space, inspired air would continue to escape
   into the pleural space and into the chest tube drainage system until the hole has healed itself.

8. Would you expect A.W.’s lung to reexpand immediately after the chest tube insertion and
   initiation of underwater suction?

   Not necessarily. It can take hours to days for the lungs to completely reexpand. This time is
    individual for all clients and is assessed by the size of the air leak and by daily chest x-rays.
    (The level of bubbling will diminish over time as the hole in the lung heals and lung
    expands).

9. The clerk tells you A.W.’s husband has just arrived. A.W. will be admitted to the hospital.
   How would you address this issue with her husband?

   Be honest and supportive
   Inform him that his wife is doing much better and is waiting to be transferred to her room
   Explain that one of her lungs collapsed, so the doctor put a tube in her chest to let the air out
    and allow the lung to expand again. Tell him the tube will stay in her chest until the lung
    stays inflated on its own. That means she will have to be admitted to the hospital so she can
    be watched until she is OK again.
   Accompany him into his wife’s room and remain alert to help him into a chair or onto the
    floor if he experiences vertigo or a syncopal episode (faints).
   Explain the tubes and monitoring equipment in very simple terms:
    “This machine allows us to watch her heart”
    “This machine takes her blood pressure”
    “This is the tube that lets the air our of her chest so that she can breath better”
   Provide tissues if he needs them
   Think of things that he might need to use like the telephone, cafeteria, and restroom.

10. You approach A.W.’s bedside and ask about what looks like two healed chest tube sites on
    her left chest. A.W.’s husband informs you that this is the third time she has had a collapsed
    lung. He asks if this trend will continue. How would you respond?
  If she continues to experience spontaneous pneumothoraces in the same area of the lung, the
     doctor may elect to “scar” the surface of the lung in that particular area. The physician
     instills sclerosing medication through the chest tube, and because the medication is very
     irritating to the lung, scar tissue forms on the outside. It is more difficult for the thick scar
     tissue to rupture than the thinner lung tissue. The treatment is effective, but is painful.

11. A.W. recovered and was discharged home 4 days later with a chest tube and Heimlich valve.
    The physician connected a 1-way (Heimlich) valve between the distal end of the chest tube
    and a drainage pouch. Discuss the purpose of this device.
 During inspiration, negative intrapleural pressure closes the valve and prevents air from
    entering the pleural space. During expiration, positive pressure opens the valve and allows
    the air and/or fluid to drain into a plastic pouch. This valve makes it possible to discharge
    patients who have a residual air leak. The chest tube is removed after the air leak heals.
    There is a Heimlich valve in the skills lab to look at!

A.W. developed several more spontaneous pneumothoraces on the left and eventually had
bleomycin instilled over the left lung to induce scarring. She said, “It felt like someone poured
kerosene in and threw a lit match in after it. It was the most painful thing I ever went through.”
 Sclerosing a lung doesn’t have to feel like it is burning; it should be managed with adequate
    pain medication