A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?
A.
Crepitus in the area above and surrounding the insertion site
B.
Bubbling of the water in the water seal chamber with exhalation
C.
Eyelets are not visible
D.
Movement of the trachea toward the unaffected side
The correct answer and Explanation is:
The correct answer is D. Movement of the trachea toward the unaffected side.
Explanation:
In the case of a pneumothorax with a chest tube in place, it’s crucial for the nurse to carefully monitor the patient for signs of complications or worsening conditions.
A. Crepitus in the area above and surrounding the insertion site could indicate subcutaneous emphysema, which occurs when air becomes trapped under the skin. While this is not uncommon and may not be immediately life-threatening, it should still be monitored. It’s not as critical as the movement of the trachea.
B. Bubbling of the water in the water seal chamber with exhalation is generally expected in the case of a pneumothorax, as it indicates air is being drained from the pleural space. However, continuous bubbling can indicate an air leak, which should be monitored but isn’t as immediately critical as tracheal deviation.
C. Eyelets are not visible means the eyelets (the small holes on the end of the chest tube) are not seen in the chest tube drainage system, which could be a sign of a dislodged or malfunctioning tube. While this is a concern, it is not as urgent as tracheal deviation.
D. Movement of the trachea toward the unaffected side is a critical finding. This phenomenon, known as tracheal deviation, can indicate a mediastinal shift. In the case of a pneumothorax, it suggests that there is increasing pressure in the pleural space or a tension pneumothorax, which could be life-threatening. This condition requires immediate intervention to prevent respiratory and cardiovascular collapse. The trachea should ideally be midline; deviation away from the affected side indicates a need for urgent medical evaluation and intervention.