Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
A. The system is functioning normally.
B. The client has a pneumothorax.
C. The system has an air leak.
D. The chest tube is obstructed.
Correct Answer: C. The system has an air leak.
Constant bubbling in the chamber indicates an air leak and requires immediate intervention. With suction applied, this indicates a persistent air leak that may be from a large pneumothorax at the chest insertion site (patient-centered) or chest drainage unit (system-centered).
Option A: Clients without a pneumothorax should have no evidence of bubbling in the chamber. Absence of bubbling may indicate complete lung re-expansion (normal) or represent complications such as obstruction in the tube.
Option B: The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Bubbling during expiration reflects venting of pneumothorax (desired action). Bubbling usually decreases as the lung expands or may occur only during expiration or coughing as the pleural space diminishes.
Option D: If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber. Monitor water-seal chamber “tidaling.” Note whether the change is transient or permanent. Tidaling of 2–6 cm during inspiration is normal and may increase briefly during coughing episodes. Continuation of excessive tidal fluctuations may indicate the existence of airway obstruction or the presence of a large pneumothorax.
No comments:
Post a Comment