A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
A.
Monitor for at least 150 mL of drainage every hour.
B.
Clamp the tube for 30 min every 8 hr.
C.
Pin the tubing to the client’s bed sheets.
D.
Replace the unit when the drainage chamber is full.
The Correct Answer and Explanation is:
Correct Answer: D. Replace the unit when the drainage chamber is full.
Explanation:
In managing a client with a closed-chest tube drainage system, the primary goal is to ensure effective drainage of pleural or mediastinal fluid and to maintain the integrity of the drainage system. Here’s an explanation of why option D is the correct action and why the other options are not appropriate:
1. Replace the unit when the drainage chamber is full:
The closed-chest tube drainage system is designed to collect fluid or air from the pleural space. The system typically consists of a collection chamber, a water-seal chamber, and a suction control chamber. When the drainage chamber reaches its maximum capacity, it must be replaced to prevent overfilling, which could compromise the system’s ability to effectively drain and manage pleural fluid or air. An overfilled drainage chamber can lead to inaccurate measurements of drainage output and an increased risk of infection or malfunction. Therefore, the drainage unit should be replaced promptly when the collection chamber is full, following standard protocols to ensure proper functioning.
2. Monitor for at least 150 mL of drainage every hour:
This is not a standard guideline. The amount of drainage can vary based on the patient’s condition and the type of surgery or pathology being managed. Monitoring should be based on the patient’s specific needs and the clinical situation. Excessive or insufficient drainage could indicate complications, and the nurse should follow the specific parameters set by the healthcare provider rather than a fixed volume.
3. Clamp the tube for 30 min every 8 hr:
Clamping a chest tube is generally avoided unless directed by a healthcare provider for specific reasons, such as to check for an air leak or to assess if the lung has re-expanded. Regularly clamping the tube can lead to complications such as tension pneumothorax, which is a medical emergency. Therefore, clamping should only be done as directed and for specific purposes.
4. Pin the tubing to the client’s bed sheets:
Pinning the tubing to the bed sheets can cause kinks or occlusions in the tubing, which can impede drainage and lead to complications. The tubing should be secured properly but not in a way that could cause blockage. It’s essential to ensure the tubing is free from kinks and that it allows for adequate drainage and movement.
In summary, the correct action is to replace the unit when the drainage chamber is full to maintain the efficacy and safety of the closed-chest tube drainage system.