Question

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

Options:
A. Keep dry gauze at the bedside
B. Ensure a pair of hemostats are at the bedside
C. Monitor pulse oximetry readings
D. Maintain chest tube bottle in an upright position and below the level of the chest

Answer 1

The nurse should keep dry gauze, ensure hemostats are available, monitor pulse oximetry, and maintain the chest tube bottle position as part of the interventions for a child with a pneumothorax to manage 'Risk for injury related to potential dislodgement of chest tube'. The correct options are A,B,C and D.

Step-by-step explanation:

The nurse planning care for a child with a pneumothorax has included the nursing diagnosis, "Risk for injury related to potential dislodgement of chest tube" in the care plan. When considering interventions for this care plan, the nurse should certainly:

• Keep dry gauze at the bedside in case of chest tube dislodgement, which can be used to cover the site and potentially prevent air from entering the pleural space.
  
  
• Ensure a pair of hemostats are at the bedside, ready to clamp the tube if it becomes disconnected, while causing minimal trauma to the tissue.
  
  
• Monitor pulse oximetry readings to assess the patient's oxygen saturation level and detect any changes indicating respiratory compromise.
  
  
• Maintain the chest tube bottle in an upright position and below the level of the chest to facilitate proper drainage and maintain the necessary negative pressure within the chest cavity, preventing lung collapse.

Each intervention aims to support respiratory function, prevent complications from chest tube dislodgement, and ensure a swift and appropriate response to potential emergencies.