Acute Care Nursing Assessment Task 5:Clinical Episode of Practice
Acute Care Nursing: Nursing management of patients with underwater seal
drain
The focus of this assignment is to look at the rationale behind chest Insertions and to explore
the role of nurses in the administration of these procedures. That includes assessing and
planning the nursing care while considering the patient’s safety and implementing and
evaluating the care aspect of pain management, drain functioning. and safely drain removal.
The patient discussed in this paper is Mr Smith (pseudonym), who gave his verbal consent
for his condition to be described in this paper.
Mr Smith is a 48-year-old man, born in Vietnam, who presented to the emergency department
on 22/1 1/2010 with progressively worsening dyspnoea on exertion and acute stabbing pain
in his right chest. Mr Smith was injured in a motor vehicle collision at the end of October 2010,
suffering three right rib fractures and a fracture of his left clavicle. According to Sidebotham
et al. (20 1 0), rib fractures are the most common significant injury to the thorax. He also
complained of a non-productive cough with increasing left chest pain developing over the
previous 2 weeks. Rib fractures are extremely painful, and they may have a major impact on
a patient's ability to breathe and cough (Sidebotham et al., 2010). Mr Smith's appetite has
also been poor for the same period causing him to lose approximately 4kg. He had no history
of respiratory conditions and no known allergies.
Typical signs and symptoms of pleural effusion are dyspnoea which indicates large effusion,
cough, and chest pain as a result of pleural irritation, dullness around the chest wall, and
sharp pain on inspiration (McGrath et al.2009). Mertin et al. (2009) state that the size and
characteristics of the effusion are the main factors influencing the severity of dyspnoea.
On examination, Mr Smith's pressure was 1 16/75 nun I (g, his respiratory rate was 24 breaths
per minute, his heart rate was 71 beats per minute, and his temperature was 36.4 C. His
haemoglobin oxygen saturation was determined by pulse oximetry to be 94 percent while
breathing room air. He had dullness to percussion from the fifth thoracic vertebrae to the base
of the right lung and diminished breath sounds over the right hemithorax.
Mr Smith described his chest pain as mild and sharp, and his cough was irritable and dry,
accompanied by minimal sputum production. He exhibited tenderness over the right
abdominal area. He was alert and orientated and able to speak in full sentences. Tactile
1
, Acute Care Nursing Assessment Task 5:Clinical Episode of Practice
fremitus was reduced, and asymmetric expansion to the thoracic cage was noted. Mr Smith's
diagnosis was unilateral pleural effusion secondary to haemothorax.
‘A pleural effusion is not a disease, but rather it is a sign of underlying pathology and is
defined as an abnormal accumulation of fluid between the layers of the membrane that lines
the lungs and thoracic cavity' (Chapman et al. 2005). Pleural effusions typically occur at the
base of the pleural area as a result of gravity (Bourke 2003). In Mr Smith's case, there was
a notable accumulation of fluid in his thoracic cavity secondary to the rib fracture and
possible intercostal artery ruptures, which can be associated with underlying blood
accumulation or haemothorax (Crisp & Taylor 2001). Haemothorax is a blood collection
within the thoracic cavity as a result of blunt or traumatic thoracic injury (Mertin et al. 2009).
Haemothorax 'should be suspected in any patient with blunt or penetrating chest trauma
with a pleural effusion on chest radiograph' (Jantz 2008). If left untreated, haemothorax can
lead to shock from haemorrhage, severe pain, or respiratory failure (SGHCHS 2010).
In normal cases, pleural fluid is formed in small amounts of between 20-30 ml to lubricate
the visceral and parietal pleura (Dunne et al.2010). This fluid is constantly produced by the
cells in the parietal pleura and absorbed back through the lymphatic ducts keeping retaining
fluid balance without any net accumulation (Bourke 2003). A pleural effusion occurs when
extra fluid moves into 'the pleural space than is removed' (Totaro 2004). There is a small
negative pressure (-4 mmHg) between the two layers, which sucks the visceral pleura onto
the parietal pleura (Chamnan et al. 2005). When trauma to the lung occurs, intrathoracic
pressure is increased, resulting in reduced lung expansion and accordingly, gas exchange
cannot take place efficiently (Mertin et al. 20()9). This results in under-perfusion of tissues,
leading to dyspnoea (Bourke 2003).
In Mr Smith's care, diagnosis of pleural effusion was confirmed via a CT Pulmonary
Angiogram with contrast performed on 22 November 2010. A CT scan was used due to
its sensitivity and the fact that it can detect even the smallest amount of effusion (2-10 ml)
and also in distinguishing between a range of benign and malignant conditions (SGHCHS
2010; Mertin et al. 2009). The results of Mr Smith's test showed a large right-sided pleural
effusion underlying the lower posterior 10th -12th right rib fractures accompanied by a
mild associated collapse of the near right lower lobe.
2
Acute Care Nursing: Nursing management of patients with underwater seal
drain
The focus of this assignment is to look at the rationale behind chest Insertions and to explore
the role of nurses in the administration of these procedures. That includes assessing and
planning the nursing care while considering the patient’s safety and implementing and
evaluating the care aspect of pain management, drain functioning. and safely drain removal.
The patient discussed in this paper is Mr Smith (pseudonym), who gave his verbal consent
for his condition to be described in this paper.
Mr Smith is a 48-year-old man, born in Vietnam, who presented to the emergency department
on 22/1 1/2010 with progressively worsening dyspnoea on exertion and acute stabbing pain
in his right chest. Mr Smith was injured in a motor vehicle collision at the end of October 2010,
suffering three right rib fractures and a fracture of his left clavicle. According to Sidebotham
et al. (20 1 0), rib fractures are the most common significant injury to the thorax. He also
complained of a non-productive cough with increasing left chest pain developing over the
previous 2 weeks. Rib fractures are extremely painful, and they may have a major impact on
a patient's ability to breathe and cough (Sidebotham et al., 2010). Mr Smith's appetite has
also been poor for the same period causing him to lose approximately 4kg. He had no history
of respiratory conditions and no known allergies.
Typical signs and symptoms of pleural effusion are dyspnoea which indicates large effusion,
cough, and chest pain as a result of pleural irritation, dullness around the chest wall, and
sharp pain on inspiration (McGrath et al.2009). Mertin et al. (2009) state that the size and
characteristics of the effusion are the main factors influencing the severity of dyspnoea.
On examination, Mr Smith's pressure was 1 16/75 nun I (g, his respiratory rate was 24 breaths
per minute, his heart rate was 71 beats per minute, and his temperature was 36.4 C. His
haemoglobin oxygen saturation was determined by pulse oximetry to be 94 percent while
breathing room air. He had dullness to percussion from the fifth thoracic vertebrae to the base
of the right lung and diminished breath sounds over the right hemithorax.
Mr Smith described his chest pain as mild and sharp, and his cough was irritable and dry,
accompanied by minimal sputum production. He exhibited tenderness over the right
abdominal area. He was alert and orientated and able to speak in full sentences. Tactile
1
, Acute Care Nursing Assessment Task 5:Clinical Episode of Practice
fremitus was reduced, and asymmetric expansion to the thoracic cage was noted. Mr Smith's
diagnosis was unilateral pleural effusion secondary to haemothorax.
‘A pleural effusion is not a disease, but rather it is a sign of underlying pathology and is
defined as an abnormal accumulation of fluid between the layers of the membrane that lines
the lungs and thoracic cavity' (Chapman et al. 2005). Pleural effusions typically occur at the
base of the pleural area as a result of gravity (Bourke 2003). In Mr Smith's case, there was
a notable accumulation of fluid in his thoracic cavity secondary to the rib fracture and
possible intercostal artery ruptures, which can be associated with underlying blood
accumulation or haemothorax (Crisp & Taylor 2001). Haemothorax is a blood collection
within the thoracic cavity as a result of blunt or traumatic thoracic injury (Mertin et al. 2009).
Haemothorax 'should be suspected in any patient with blunt or penetrating chest trauma
with a pleural effusion on chest radiograph' (Jantz 2008). If left untreated, haemothorax can
lead to shock from haemorrhage, severe pain, or respiratory failure (SGHCHS 2010).
In normal cases, pleural fluid is formed in small amounts of between 20-30 ml to lubricate
the visceral and parietal pleura (Dunne et al.2010). This fluid is constantly produced by the
cells in the parietal pleura and absorbed back through the lymphatic ducts keeping retaining
fluid balance without any net accumulation (Bourke 2003). A pleural effusion occurs when
extra fluid moves into 'the pleural space than is removed' (Totaro 2004). There is a small
negative pressure (-4 mmHg) between the two layers, which sucks the visceral pleura onto
the parietal pleura (Chamnan et al. 2005). When trauma to the lung occurs, intrathoracic
pressure is increased, resulting in reduced lung expansion and accordingly, gas exchange
cannot take place efficiently (Mertin et al. 20()9). This results in under-perfusion of tissues,
leading to dyspnoea (Bourke 2003).
In Mr Smith's care, diagnosis of pleural effusion was confirmed via a CT Pulmonary
Angiogram with contrast performed on 22 November 2010. A CT scan was used due to
its sensitivity and the fact that it can detect even the smallest amount of effusion (2-10 ml)
and also in distinguishing between a range of benign and malignant conditions (SGHCHS
2010; Mertin et al. 2009). The results of Mr Smith's test showed a large right-sided pleural
effusion underlying the lower posterior 10th -12th right rib fractures accompanied by a
mild associated collapse of the near right lower lobe.
2
