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22 Cards in this Set
- Front
- Back
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reasons for a chest tube |
pneumothorax
hemothorax pleural effusion empyema |
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s/s of pneumo
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resp distress
decreased/absent breath sounds decreased chest expansion increased HR/RR/breathing pain hyper-resonance |
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s/s of tension pneumo
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severe resp distress
tracheal deviation cyanosis/hypoxia hypotension muffled heart sounds potential cardiac arrest |
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s/s of hemothorax
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resp distress
decreased/absent breath sounds dullness on percussion |
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what is most common iatrogenic hemothorax caused by
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placement of CVC
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s/s of pleural effusion
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labored resp
paradoxical breathing decreased chest movement decreased/absent breath sounds tachycardia fever pleuritic pain dry cough |
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goal of chest tube
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restore negative pressure
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name some chest tube placement pre-reqs
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size/extent of pneumo/effusion
AP & lateral x-rays chest CT |
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common chest tube sizes
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small - 24FG - air
medium - 28FG - serous fluid large - 32-36FG - blood/pus |
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where is chest tube drainage documented
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directly on container
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3 reasons to clamp chest tubes
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changing drainage system
searching for leaks assess for removal potential |
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most common complication of chest tubes
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air leaks
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constant bubbling in the water seal chamber indicates what
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air leak
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no bubbling in water seal chamber indicated what?
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tube occlusion
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name a MAJOR complication of chest tubes
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penetration of lung bulla
penetration of heart/major vessels pleural sepsis |
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s/s of pleural sepsis following chest tube insertion
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fever
drain site infected purulent drainage |
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how long should chest tube be left in
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< 3 weeks
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when will chest tubes be removed
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no air leaks for 24 hours
drainage <100 ml/day CXR shows complete lung re-expansion |
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what does STOP stand for
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S - site
T - tube O - output P - patient/patent |
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what should nurse tell pt while removing chest tube
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take a deep breath and perform valsalva
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if the level of water in the water-seal chamber is rising, what should the nurse do
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vent the neg pressure with the valve on top of the pleur-evac
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what should be kept at bedside of pt w/ chest tube
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padded clamps
vaseline guaze 4x4s sterile water |
