Effective Care for Pneumothorax - Essay Example

? Reflective care for patient with chest drain wound that has caused pneumothorax College Lecturer Introduction Nursing in its broader context is a fast growing profession with a wide range of clinical and ethical challenges emerging each day. According to recent studies, there has been a significant rise in the incidences of medical emergencies and related injuries in the last ten years (Cowen & Moorhead 2011, p.149; Weller et al. 2012, p.594). In all these, trauma and chest injuries from wound, gun shots and thrust injuries among others have critically increased the prevalence of thoracic medical emergencies of different kind. However, the cases of hemothorax and pneumothoraces have dominated the list of recent nursing care emergencies resulting chest injuries as observed by Mowery et al. (2011, p.513). As a senior nurse in the ortho/general surgical department, my healthcare team is bound to encounter such medical emergencies. On the other hand, it is of paramount importance to have relevant expertise in the aforementioned ortho/general surgery portfolio so as to keep an excellent edge in offering the required leadership and professionalism in nursing emergency care. For that reason, this module provides an ideal opportunity to learn and internalize the approved medical manoeuvres in the management of patients with chest drain that has caused pneumothorax. The knowledge will enhance my professional development, nursing competency, clinical exposure and personal confidence in handling similar chest drain cases in the future. This paper focuses on experiential reflection on the effective nursing care management of chest drain patient with pneumothorax with reference to the analytical application of Gibbs Model 1998 (Nicol 2012). Accordingly, the chronology of this reflection examines the details of the case, the resulting personal feeling about it and the professional sense drawn from such clinical experience. Objective application of this model enables the learner to acquire practical insights that will go a long way to improve the fidelity of the portfolio as well as her professional performance in the relevant medical department (Gibbs 1988; Oelofsen 2012, p.22). Case Summary The simulation hitherto involves a 50 year old male patient brought to the ortho/general surgery department with a stub wound on the right side of the chest. From clinical diagnosis, the patient developed chest drain from the stub penetration which has consequently caused pneumothorax. Based on the facts that the chest injury was penetrative with no medical history of spontaneous pneumothorax, this clinical emergency could be classified as open traumatic pneumothorax as reiterated by Sharma and Jindal (2008, p.35). This is the situation at hand for which the medical team seeks to apply the best line of care and treatment to stabilize the patient towards full recovery from traumatic pneumothorax. Reflective Nursing Care Management for Chest Drain Patient Description of what happened The patient presented at the hospital with chest injury sustained from an apparent stub wound. As such, pre-treatment nursing care management required rapid assessment of the situation to accurately diagnose the case and establish the magnitude of the medical emergency. In assessing the chest drain case, it is important to look for signs of anxiety, hyper resonance of the chest wall, tachycardia, pleuritic chest pain, increased heart rate, dyspnoea and diminishing breath sound on the affected side of the chest (Yarmus & Kopman 2012). The oximeter can also be used to assess the level of oxygen demand. It is common to note reducing pulse in pneumothorax patient which normally signifies increased oxygen demand. The patient presented with these signs on which the nursing team based the high suspicion for pneumothorax. The diagnosis of pneumothorax can be confirmed by means of ultrasonography and CT scan of the chest to locate the exact area affected and the magnitude of the pleural disruption (Zhang et al. 2006, p.113). In practice, penetrative chest injuries such as those sustained from stub wounds or gun shots are likely to rapture the mediastinal pleura (Ball et al. 2007, p.451). This results in the formation of a one-valve inflow of air into the pleural space with no outflow route for the trapped air. The mechanism leads to pneumothorax as the penetrative stub wound may also cause hemothorax especially when intervention is delayed. The problem may become fatal within minutes particularly where the threat of total lung collapse is eminent (Paramasivam & Bodenham 2008, p.205; Cerfolio et al. 2005, p.817; Contou et al. 2012, p.1409). In this case, the patient was diagnosed with pneumothorax caused by traumatic stub wound. In order to contain the situation and save the patient, it is a matter of clinical emergency to initiate chest drainage (Henry et al. 2011; Soldati et al. 2008, p.205). This helps to relieve the negative pressure in the pleural space by creating a tubal path for outflow of trapped air. The procedure is also vital for fluid drain out of the pleural space as in the case of hemothorax. The purpose of this intervention is to enhance re-expansion of the lungs and respiratory stabilization as reiterated by Sharma and Jindal (2008, p.36). Personal feeling from the Experience Initially, it seemed like everything went on well and that all reasonable measures were taken to ensure no harm to the patient without compromising the professional code of ethics. From the face value of the scenario, it appears that the patient received competent healthcare. There was need to treat the patient for shock on arrival at the emergency and assure him of good care to stabilize the psychological wellbeing of the patient as suggested by Parrillo and Dellinger (2008, p.51). It is common to find that traumatic experiences such as stubbing may shock the patient and they may become worried by the life-threatening condition of chest drain. On the other hand, thoracostomy is a sensitive and painful surgical procedure which makes me feel that the need for generous analgesic injection cannot be compromised (Yarmus & Kopman 2012). It is important to ensure that no patient undergoes unnecessary pain when such pain can be prevented by medical intervention. For that reason, it was vital to administer analgesia to relieve the patient of pain during the process of treatment. Evaluation In evaluating the process of nursing care management of chest drain patient, it is essential to use a systematic approach as reiterated by Howatson (2010). It makes clinical and learning sense to evaluate the process of chest drain insertion. As utilized in the nursing care management of the patient herein, the use of chest radiography, CT scan and ultrasonography imaging to ascertain the presence, position and size of the pneumothoraces within the pleural space is often reliable (Ball et al. 2007, p.452; Henry et al. 2011, Mowery et al. 2011, p.515). The concept enhanced the diagnostic sensitivity and specificity with modern ultrasonography giving an impressive 100% specificity of the presumed pneumothorax in penetrative chest injuries. Based on the NICE guidelines, nursing care during chest drain insertion comprises a number of procedural steps. The fist step in the pre-insertion procedure involve careful gathering of all the required surgical equipment and chest drain units. Besides, it is at this point that the nurse should brief the patient on the upcoming procedure as well as the expected outcome of the clinical intervention as ascertained by Luh (2010). The nurse should then check if the patient has any allergies that might compromise medical intervention. Once this is done, inject appropriate amount of analgesic sedation as directed by the physician (NMC 2008). This will take effect within three to five minutes after which patient is place in the insertion position in readiness for the creation of the sterile field. According to Mower et al. (2011, p.514), it is crucial to accurately locate the precise triangle site for the placement of chest drain. Insertion should be made around the second intercostals space within the mid-clavicular line on the placement site. In this reflective case, the team correctly demarcated the upper aspect on the right side of the thoracic cage as the ideal site of chest drain insertion. Nursing care management of chest drain patient requires that the nursing care team ought to know the correct positioning site for accessing the pleural space. Incorrect chest drain insertion can cause laceration of the peripheral lung which might cause diaphragmatic paralysis especially among the elderly patients (Hwang et al. 2005, p.129; Dente et al. 2010, p.254). The use of pleur-evac chest drain system is adequate in routine nursing care management of chest drain patients. Pleur-evac system is a portable and calibrated single lightweight chest drainage unit. The system has both the suction chamber and the water seal chamber which allows controlled outflow of trapped air and fluid from the pleural space. Once the doctor has inserted the pleur-evac chest drain, the nurse should place Vaseline gauze around the chest tube at the insertion site. Then dress the site with a sterile occlusive gauze to keep off any contaminants as accentuated by Monaghan and Swan (2008, p.2021). It is advisable for the nurse to watch out for any colouration on the dressing or odour during the chest drain procedure and keep changing the dressing as needed in accordance with the hospital policies for the nursing care management of chest drain patients (Luh 2010). At the same time, the nursing team should pay attention in monitoring changes in breath sound, Blood pressure and body temperature. In addition, constantly check for heart rate as well as the respiratory rate, as the patient’s oxygen concentration. According to Yarmus and Kopman (2012, p.1103), it is ideal to put traumatic chest drain patients on 100% oxygen especially in critical conditions to keep an level optimal of oxygen concentration. In the post-insertion stage, chest x-ray should be taken soon after the insertion procedure is complete to ascertain that the chest drain was correctly inserted and that the lungs were not lacerated during the process. Secondly, this phase of nursing care management of chest drain patient should include an amicable way of encouraging the patient to report any increase in pain. The nursing team also needs to confirm that the patient comprehends potential chest drain complications and thereby advising the patient to promptly report any signs of dyspnoea or haemoptysis (Kelly 2009, p.378; Emeka et al. 2012). If need be, turn the patient after two to three hours and ensure that the drainage unit is kept below the heart level. CXR is recommended if the patient’s condition begin to show drastic deterioration (Vincent 2011). During the chest drain procedure, the need for hemodynamic monitoring is always imperative. A trained nurse can use USCOM to closely monitor the hemodynamic of the chest drain patient. The most critical components to check include cardiac output and blood pressure. These depend on the stroke volume SV, systemic vascular resistance SVR and the heart rate HR. On one hand, the interaction between cardiac output and hear rate would give the patient’s blood pressures. On the other hand, the hemodynamics of Hb, SpO2 and cardiac output would give the amount of oxygen delivery DO2 of the patient as reiterated by Vincent (2011). Any abnormalities in the SV graph should be reported to the physician immediately. From a different perspective, chest drain patients require keen respiratory assessment to ensure effective breathing. This can be assessed by observing consistent tidal movement in the water seal chamber. The consistency reflects normalcy in patient’s rate of inhalation and exhalation as noted by Paramasivam and Bodenham (2008, p.207). The suction chamber should also show gentle bubbling from the 20cm under water vent which in essence applies a controlled negative atmospheric pressure on the chest tube suction predetermined at -20cm Hg. As such, irregular tidal or sudden stop of tidal movement could be a sign of breathing obstruction or failing respiration and should be addressed as a medical emergency in order to prevent potential pneumothorax complications. Conversely, the nursing care should regularly monitor the chest drain patient to maintain fluid balance. This can be done be controlling the inotropy by keeping the ventricular loading at an optimal level of 2mls/Kg. This will correspond to an optimum hemodynamic stroke volume of about 110mls (Sharma & Jindal 2008). It is however, essential to maintain fluid balance between the preload and after-load so as not to overload or under-load the patient in line with the Frank Sterling curve. In this case, fluid loading helps in maintaining useful stroke volume and the cardiac output which in turn assists in maintaining an optimal blood pressure and oxygen delivery. Fluid imbalance of the chest drain patient might result in inadequate perfusion and potential oxygenation of the critical tissues including those of the lungs and heart as argued by Remerand et al (2007). When changing the chest drainage unit, always observe strict hand hygiene requirements before handling the chest drain setup. Make sure the new UWSD is ready and take proper care to maintain sterile condition when unpacking the new unit in readiness for replacement. With the help of another nurse if possible, momentarily clump the old drain before disconnecting the old drain from the suction chamber and then connect the tube to the new chamber until it clicks. Whereas clamping helps put off air from rushing into the pleural space, it should not last more that 10 second to prevent potential onset of tension pneumothorax (Henry et al, 2011). Upon recovery when the patient’s clinical condition shows no signs of respiratory compromise, then it is time to remove the chest drain. Nevertheless, the nurse should always ascertain that there is no more air leak and that the lung has completely re-expanded. Otherwise, it may not be safe to remove the chest drainage as this may potentially lead to pneumothorax complications. That notwithstanding, before removing the chest drain the nurse ought to prepare the patient prior to removal. Make sure the patient is fasted and given pain killers in line with the anaesthetic guidelines (Yarmus & Kopman 2012, p.1099). Once the patient has been prepared for drain removal, follow the post chest drain procedures to remove the dressing and the tubing. When removing the tube, explain to the patient, and ask them to cooperate (Taylor 2006, p.73). In addition, make the patient understand that the process is not painful and will not make them feel unusually comfortable. See to it that purse string suture remains uncut till the whole process is completed. Ask the patient to take deep breath and hold, and then pull out the drainage tube. Then pulling the suture string close, make two knots and cut the tail then seal the hole with occlusive gauze. This should take less than a minute. In post-removal nursing care, it is important to explain to the patient how to take care of the tubing site. The patient should keep the gauze in place for at least 48 hours and let it remain dry at all time. If the patient needs to take a bath, they should cover the place with plastic material to keep off water from wetting the dressing. After 48 hour, the patient may remove the dressing and replace it with normal bandaging. If they notice any bleeding, pus or odour, the patient should the dressing site checked by a nurse or the physician. Analysis Effective care for chest drain patients should be systematic and medically organized. The process has no room for guess work. Thus, chest drain nursing care must be carried out on the basis of evidence collected from clinical examination and accurate diagnosis. Hemodynamic data can also improve the integrity of effective nursing care for the chest drain patient. According to Monaghan and Swan (2008, p.2019), any diagnostic mistakes and procedural oversights could turn lethal within minutes or the damage might result in permanent disability. To that end, the mechanism of intervention matters a lot thereby making the issues of diagnostic accuracy and practical diligence essential factors in chest drain emergency care (Harrison & Roberts 2005; Tidy & Rull 2009, p.4). Secondly, effective chest drain and pneumothorax nursing care is taking a new approach with respect to the use of modern technology and strong medicine. For one, the practice has evolved from the conventional use of chest radiography to contemporary application of ultrasonography techniques deployed to increase the specificity of pneumothoraces imaging (Kelly 2009, p.377; Luh 2010, p.741). In the case management of chest drain patients, the application of focused abdominal sonography for trauma examination proved effective in improving pleural space imaging for trapped air in the pleural space. Normally, pneumothorax may be managed by simple aspiration through the second intercostals space within the mid-clavicular line on the placement site. This intervention allows simultaneous outflow of air from the pleural space. In open chest drains however, there is always the need to control potential laceration of the peripheral lung (Sharma & Jindal 2008, p.38). Such cases may require tubal thoracostomy manoeuvres also inserted through the second intercostals space within the site triangle on the affected side of the chest. The procedure is quite sensitive to infection hence the need to observe exemplary sterile condition. First-generation antibiotics can be used to prefect infection through the surgical site (Akram & Hartung 2009, p.118). Accurate placement of the chest drain thoracostomy tube is ordinarily followed by steady re-expansion of the lung and bubbling rise in the under seal water setting. Nonetheless, studies indicate that pulmonary oedema is a common complication of tube thoracostomy in emergency situations where the lung re-expansion occurred rapidly (National Patient Safety Agency 2008; Galbois et al. 2012, p.509). In that light, it is imperative to always keep an eye on the chest drain patient condition and control rapid thoracostomy re-expansion of the chest to circumvent potential pulmonary oedema (Ellis 2007, p.45; Fox & McLean 2010). To reduce the risk of empyema or pneumonia in chest drain patients, the nursing team should be keen to administer a dose of cephalosporin as advised by the doctor. Lehwaldt and Timmins (2007, p.144), ascertained that cephalosporin dosing should be parenteral and nurses should check for any contradistinctions in the use of antibiotics in critical chest drain care. In some cases of spontaneous pneumothorax, antibiotics might not be necessary particularly where sterile and pre-packaged thoracostomy tube is used (Olgac et al. 2006; Tidy & Rull 2009, p.5). Considering that the causal factors of chest drain pneumothoraces are varied, the use of antibiotics becomes a matter of situational need in keeping with opinion of the medical team. Reflective Conclusion Generally, any pneumothoraces should be highly suspected in any emergency case of traumatic injuries of the chest presenting with cardinal symptoms such as hyper resonance of the chest wall, tachycardia, chest pain and dyspnoea (Zhang et al. 2006, p.114). Consequently, the use of ultrasonography and chest CT scanning are sufficient pneumothorax case confirmation procedures. The two processes can be deployed to rule out tension pneumothorax. While tube thoracostomy and oxygen therapy are adequate to stabilize the patient with regular medication to promote healing of the stub wound, hemodynamic monitoring as well as fluid balance and pain control are essential in practical nursing care for chest drain patients. Action Plan My approach would include initial first aid to ascertain the patency of the patients’ airway and circulation. This would then be followed by quick clinical examination using CT scan and ultrasonography to verify the details of the chest drain case in the utmost bid to confirm pneumothorax and to rule out any mimics such as myocardial rapture. This approach is in line with the guidelines of thoracic chest drain nursing care (Smith & Johnson 2010). At every stage of patient care, my desire would be to foster constant hemodynamic monitoring of the patient while taking into account other physiological needs that might hinder recovery as advised by Indra and Alinier (2006, p.108). Furthermore, chest drain patients are at high risk of developing pulmonary oedema which makes it important to always put mechanism such as the use of under water seal technique to suppress the possibility of rapid lung re-expansion. High sterile conditions will also be ideal in managing future incidences of chest drain patients. At all times, it is important to uphold the principles of ethical nursing while taking into consideration the financial and social repercussions that may come up in the event of complication. Conclusion Practical management of chest drain patients remains a sensitive undertaking of emergency importance. The procedure demands methodical approach and professionalism at every step to ensure that high fidelity has prevailed throughout the medical procedure. Besides, it is imperative to constantly monitor the patient’s hemodynamic, fluid loading balance and pain control. On the other hand, the nursing team should observe a great deal of care to check for and control any bleeding or infection at the insertion site and at the stub wound site. It is also important to enlighten patient on how to identify and report any complications related chest drain procedures after the removal of the chest tube. 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