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Chest Tube Care & Infection Prevention

1) The 3-year-old client accidentally pulled out their chest tube while sleeping, traumatizing the tissue and breaking the skin at the insertion site on their right lateral intercostal space. 2) Chest tube insertion is a minimally invasive procedure to drain fluid from the pleural space, but unplanned removal can cause infection or recurrence of pneumothorax. 3) The nursing care plan includes assessing for signs of infection, monitoring vital signs and lab values, providing wound care and nutrition, administering antibiotics if needed, and consulting other healthcare providers to improve the client's condition and recovery.

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Jhem Reyes
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293 views2 pages

Chest Tube Care & Infection Prevention

1) The 3-year-old client accidentally pulled out their chest tube while sleeping, traumatizing the tissue and breaking the skin at the insertion site on their right lateral intercostal space. 2) Chest tube insertion is a minimally invasive procedure to drain fluid from the pleural space, but unplanned removal can cause infection or recurrence of pneumothorax. 3) The nursing care plan includes assessing for signs of infection, monitoring vital signs and lab values, providing wound care and nutrition, administering antibiotics if needed, and consulting other healthcare providers to improve the client's condition and recovery.

Uploaded by

Jhem Reyes
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Holy Angel University

School of Nursing and Allied Medical Sciences


2nd Semester , 2022 - 2023
Nursing Care Management 109

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


DIAGNOSIS EXPLANATION
Subjective: - Risk for Chest tube insertion is Objective #1: Independent: Objective #1:
Client s/o infection aeb a minimally invasive After 15 minutes of Assess the previous Signs of infection like Goal Met:
verbalized that traumatized procedure that nursing chest tube insertion site. redness, warmth, After 15 minutes of
the 3-yr-old tissue and requires making an interventions the bleeding, inflammation, nursing
client broken skin incision and inserting client’s s/o will: drainage, and abscess interventions, the
accidentally from previous a thin plastic tube into - Identify 3 ways can occur in the chest client’s s/o was able
pulls the chest CT insertion pleural space. There to reduce the tube insertion site. to identify 3 ways to
tube out while on R lateral is a proper and safer risk for infection reduce the risk for
sleeping. intercostal procedure to remove such as Assess and monitor An elevated white blood infection.
space and as a chest tube as it providing laboratory values. cell count can indicate a
Objective: verbalized by requires a sterile protein-rich and systemic infection.
- Traumatized the s/o environment and calorie-rich
tissue and skilled professional. foods, change Monitor and record vital Tachycardia, dropping Objective #2:
broken skin Unplanned chest tube dressing and signs oxygen saturation, Goal Met:
from removal can cause bandage that tachypnea, fever, and After 3 hours of
previous CT recurrence of are soiled or changes in blood nursing
insertion on previously resolved wet, assist client pressure signal an interventions, the
R lateral pneumothorax that in carrying out infectious process. client has no signs of
intercostal can be associated appropriate skin infection.
space with premature CT hygiene,
removal, an occult air adequate fluid Dependent:
leak, or air entering intake, etc. Administer medication IV antibiotics can be
the pleural space as prescribe by the administered to prevent
during removal Objective #2: doctor. or treat an infection.
(Kwiatt, M., wt al., After 3 hours of
2014). nursing
interventions the

Name:REYES, JHEREMY LOUIESE Section: NU 201


Holy Angel University
School of Nursing and Allied Medical Sciences
2nd Semester , 2022 - 2023
Nursing Care Management 109

client will:
- Display no signs Collaborative:
of infections Consult with a A respiratory therapist
such as bloody respiratory therapist can determine if the
drainage, patient still needs a CT.
warmth, or pus
at the insertion
site. Consult with a Pediatrician is the
Pediatrician doctor for children and
can suggest ways to
improve the condition of
the patient.

Name:REYES, JHEREMY LOUIESE Section: NU 201

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