CASE STUDY
Scenario
A.W., a 72-year-old woman with severe emphysema, was walking at a mall when she suddenly grabbed her right side and gasped, “Oh, something just popped.” A.W. whispered to her walking companion, “I can’t get any air.” Her companion yelled for someone to call 911 and helped her to the nearest bench. By the time the rescue unit arrived, A.W. was stuporous and in severe respiratory distress. She was intubated, started on intravenous lactated Ringer’s at KVO (keep vein open), and transported to the nearest emergency department (ED).
On A.W.’s arrival at the ED, the physician auscultates muffled heart tones, no breath sounds on the right, and faint sounds on the left. A.W. is stuporous, tachycardic, and cyanotic. The paramedics inform the physician that it was difficult to ventilate A.W. A portable chest x-ray (CXR) examination shows an 80% pneumothorax on the right.
Chart View
Arterial Blood Gases (ABGs; 100% O2)
PH 7.25
Paco2 92 mm Hg
Pao2 32 mm Hg
HCO3 27 mmol/L
Spo2 53%
1. Given the diagnosis of pneumothorax, explain why the paramedics had difficulty ventilating A.W.
2. Interpret A.W.’s ABGs.
3. What is the reason for A.W.’s ABG results?
4. The physician needs to insert a chest tube. What are your responsibilities as A.W.’s nurse?
5. As the nurse, it is your responsibility to ensure pain control. In A.W.’s case, would you administer pain medication before the chest tube insertion?
6. The ED physician inserts a size 32 Fr chest tube in the sixth intercostal space, midaxillary line. Would you expect to observe an air leak when A.W.’s chest drainage system is in place and functioning?
7. Would you expect A.W.’s lung to re-expand immediately after the chest tube insertion and initiation of underwater suction? Explain.
8. Part of your responsibilities after the chest tube has been inserted is to assess for fluctuation in the water-seal chamber and bubbling in the suction-control chamber. Label the areas on the chest drainage system that you would be monitoring.
9. What do you need to document regarding A.W.’s chest drainage system?
10. While A.W. has a chest drainage system, what instructions do you need to give to the nursing assistive personnel (NAP) who is working with A.W.?
11. The secretary tells you A.W.’s husband has just arrived. What will you discuss with him about A.W.’s status and her hospital admission?
12. You approach A.W.’s bedside and ask about what look like two healed chest tube sites on her right chest. A.W.’s husband informs you that this is the third time she has had a collapsed lung. He asks whether this will continue to happen. How will you respond?
13. It is now the end of your shift and A.W.’s condition has stabilized. Using the SBAR framework, describe the bedside change-of-shift report you will give the oncoming nurse.
Case Study Progress
Because A.W. has a history of spontaneous pneumothoraces on the right side, the physician elects to perform chemical pleurodesis on A.W. after her condition stabilizes.
14. A.W. asks what a pleurodesis is. How would you describe this procedure and what will happen?
Case Study Progress
A.W. recovers uneventfully and is discharged home 4 days later with a chest tube and Heimlich valve. The physician connects the one-way (Heimlich) valve between the distal end of the chest tube and a drainage pouch.
15. Discuss the purpose of this device.
16. You teach A.W. and her husband about the care of the chest tube and Heimlich valve. Which of these statements would indicate that further teaching is necessary? Select all that apply.
a. “I will maintain a water-tight dressing around the chest tube site.”
b. “I can shower if the device is completely covered in plastic.”
c. “When I am moving around I must keep the collection system below the insertion site.”
d. “I will notify the physician if there is a change in the color or amount of drainage.”
e. “The arrow on the flutter valve should always point toward me.”
f. “I will check the insertion site twice daily for swelling, redness, and drainage.”