Question

The nurse is planning care for a child with a pneumothorax. The nurse adds the nursing diagnosis, "Risk for injury related to potential dislodgment of chest tube" to the care plan. When writing the care plan, what should the nurse be sure to include as interventions?

A. Keep dry gauze at the bedside.
B. Ensure a pair of hemostats is at the bedside.
C. Monitor pulse oximetry readings.
D. Assess lungs as directed by the physician or as the client's condition warrants.
E. Maintain chest tube bottle in an upright position and below the level of the chest.

Answer 1

For a child with a pneumothorax, nursing interventions to prevent chest tube dislodgment include keeping dry gauze and hemostats at the bedside, monitoring pulse oximetry, assessing lungs regularly, and maintaining the chest tube drainage system in the correct position.

Step-by-step explanation:

When planning care for a child with a pneumothorax and a chest tube in place, the nurse's interventions should focus on preventing injury related to potential dislodgment of the chest tube. Key interventions to include in the care plan are:

• Keeping dry gauze at the bedside, to provide a quick dressing in case of accidental dislodgment.
• Ensuring a pair of hemostats is at the bedside, which can be used to clamp the tube temporarily if it becomes disconnected.
• Monitoring pulse oximetry readings regularly to assess the patient's oxygenation status.
• Assessing the lungs as directed by the physician or as the client's condition warrants, ensuring effective lung re-expansion and identifying potential complications early.
• Maintaining the chest tube bottle in an upright position and below the level of the chest to facilitate drainage and maintain the necessary negative pressure within the chest cavity.

These steps are essential to ensure the chest tube remains functional, to quickly identify and respond to any issues, and to maintain the patient's respiratory status.