Be careful out there today

A "boo-boo?"

Well, okay, your post is kind of hard to respond to since it contains no details.

Hope your day goes better tomorrow.

I don't want to divulge much, because another someone could be frequenting this site. But here are the basics: I clamped a chest tube, so the pt. could go get an XRAY. I feel like absolute crap!! Seriously, I don't even know how to go forward, I am questioning everything. I have been an RN on the floor for 6 months, LPN for 1 year prior to that, and CNA for 3+ years before that. I don't understand where this asinine decision came from. Talk about a reality check!! I feel in danger, as if in a short time I have forgotten the seriousness of what we do. Oh I am a very conscientious nurse, patient advocate, quick to jump up and answer call lights, keep my people safe etc...I just hope I use this situation to make me a better nurse. Are the growing pains this ugly for every nurse out there?

Everybody makes mistakes, as long as you learn from them, at least there was a little bit of a positive. Its definitely good advice to slow down and ask before you do things. Weve all had that uh-oh moment, just make sure you dont ever do it again. I know a nurse who during her first year of nursing made tons of mistakes, and Im really surprised she was never fired. To this day though, this nurse is one of the smartest and most cautious nurses I know.

so, did the patient have a bad outcome because of this? Or is the mistake magnified because the parent was a nurse? Not saying the tube should have been clamped which it should not have been but I have seen some huge mistakes made with chest tubes all of which should not have happened but DID.

This too will pass. I am sure you will study chest tube care and will never clamp one again. In time it will only make you a better nurse.

Learn and grow. You only have 6 months in. Take this opportunity to remind yourself of how important it is to know what you are doing and take your time. I bet you will never do that again. :)

Thanks for the support. There was not a poor outcome because of this. I intend on talking to the surgeon and apologizing for this bad move, I haven't seen him since this occasion.

You are handling this perfect. Address the surgeon, and tell him/her what happened as I am sure the RN family member will. Tell the surgeon you have reviewed the policy and understand the severity of what "could have happened" and will NEVER make that mistake again.

Talk to your manager and see how to proceed with the family. Knowing this person is an RN, Honest confronting the issue with the manager, "yes it was clamped, it was a judgement that has been reviewed with me and the current practice and policy have been reviewed with me as well. Thankfully no harm has come to your family member and I appreciate your concern and feedback and steps are now in place to insure this will not reoccur." Mind you risk management will probably be involved as well for everyones protection, not in a punitive way.

The best thing to be done, and some will disagree, is to face this head on with the truth, as well as the action plan to avoid future potential of it happening. AN RN family member that does not respond to this, has other issues that need to be addressed with the care if no harm was done, and a conference with the doc, manager is a potential solution.

We all make boo boo's, you are very blessed that no harm came. Unfortunately it sometimes takes these moments for us to stop "tasking" and get out of the hurry up moment and review the policy or ask the question.

Deep breath, unfortunately you'll have more of these as it's inevitable. You handled this great.

it totally depends on what the chest tube was in for-- sometimes it is perfectly appropriate to clamp one, for transport or for other things, and may even be facility policy. and that rn parent might not understand that -- a dismayingly large number of rns don't. but you must know whether it's ok for this chest. was there an active air leak or bleed? see if the following helps you figure it out. if not, ask again.

chest tubes, pneumothorax, and tension pneumos made clear

this little tutorial started out with a few sample nclex questions someone posted. i answered this one....

confused and pulls the chest tube out. the nurse's immediate action should be to:

1. place the client in trendelenburg position.

2. hold the insertion site open with a kelly clamp.

3. obtain sterile vaseline gauze to cover the opening.

4. cover the opening with the cleanest material available.>>

as always in nclex-land (and in real life), you're looking for the answer that keeps the patient safest. i know you'd rather cover that hole with something sterile, but what is a greater immediate danger to this unfortunate fellow, an infection (which may not even develop) or a great honking pneumothorax, (which certainly will)?

and while we're at it, let's talk about how you know whether to clamp or not to clamp a chest tube that has been disconnected from its drainage device (but is still in the pleural space). to understand this, let's look at the differences between a tension pneumo and a pneumo that isn't a tension pneumo .

respiratory mechanics first ! when you breathe in, you're not actually pulling air into your lungs with your muscles. you're actually making a suction inside your chest with them (i know this may seem like a distinction without a difference, but stay with me), and the air enters the lungs thru the route provided for it to do so-- your trachea, via your nose or mouth (or trach tube, if you aren’t so lucky).

your lungs are covered with a slippery membrane called the visceral pleura. the inside of your chest wall has one too, the parietal pleura. they allow the lungs to slip around with chest wall motion, like you can slip two wet glass plates around that are stuck together. like the two glass plates, they're hard to pry apart due to the surface tension of the wet between them, and that's why the lungs fill the chest cavity and stay there. but just as you can easily pop those glass plates apart if you get a teeny bit of air between them, you can pop the bond between the two pleural layers with air, and if you do, the natural elasticity of the lung will cause it to collapse down to about the size of a goodish grapefruit.

how does the air get in the pleural space where it doesn’t belong? well, you can do it two ways. one is to play rough with the bad boys (or have surgery, which is, after all, only expensive trauma) and have a sharp object puncture your chest wall and admit air into the pleural space. how does it get in there? well, you make suction in your chest when you breathe in, and now air has two routes to get inside your chest-- down the trachea into the lungs, and thru the hole in the chest wall into the pleural space. this is called a pneumothorax, air in the chest that is outside of the lung. the lung will tend to collapse because the surface tension between the wet layers is now interrupted (remember how the pieces of wet glass can be separated by introducing air between them?) and the lungs are naturally elastic.

the other way to get air into your pleural space is from having blebs/bullae on your lung surfaces, and pop one (or more). then air gets out of your lungs thru the hole(s) and disrupts that pleural side-to-side thing, and there you go again, a pneumothorax. this, however, is called a tension pneumothorax, because that air increases with every exhalation (the lung now having two routes to exhale air out of, the trachea and the hole in the lung itself). this allows the lung to collapse on that side, and soon enough pressure (tension) will develop in that half of the chest to push the chest contents over to the other side, compromising blood flow and air exchange in the other lung & heart when it does so. (this is when you see the "tracheal shift.") this is also a bad thing.

so: now both of these fine folks have bought themselves chest tubes. the guy with the chest wall trauma has had his trauma hole sewed up, so when he takes a deep breath air enters his trachea only. he has a water seal on his chest tube so he can't pull air into his chest thru the tube-- the water seal acts like the bend in your sink drain and prevents continuity of the inside and outside places. the suction on the chest tube setup has done its job of removing the air from the pleural space where it didn't belong--it was seen bubbling out thru the water seal and then couldn't get back in. (when all the air is gone from his pleural space, there will be no more airleak in the water seal compartment.) now, if he disconnects his pleurevac (or other copyrighted device), he can again take a deep breath and pull air thru the open tube into his pleural space, where it doesn't belong, collapse his lung, and start all over again. therefore, when this guy disconnects his tube, you clamp it immediately, to prevent air from entering the pleural space. he should always have those two big old chest tube clamps taped to his pleurevac (so they go with him to xray and all), just in case he does this.

however, the other guy, with the ruptured blebs and the intact chest wall? well, his chest tube is pulling air out of the pleural space, but more is still getting in there since he still has a hole in his lung. the idea of the ct is to pull it out faster than he can put it in, and allow the hole to heal up, at which point he will no longer collect air in his pleural space and be all better. meanwhile, though, you see air bubbling in the waterseal chamber, showing you that there is still air being pulled out of his pleural space. he has “an air leak.” what happens to him if his chest tube gets disconnected?

well, remember, he still puts air into his pleural space, because there's still a hole in his lung. you put a tube in there to take it out, remember? ok, so what happens if you clamp his tube? bingo, air reaccumulates in the pleural space all over again, his lung collapses, and things go to hell in a handbasket. this guy never should have clamps at his bedside, because some fool may be tempted to clamp his tube before his airleak seals, and he'll get in trouble all over again. if he pulls his tubing setup apart, have him breathe slowly and shallowly (to minimize the air leaving the hole in his lung and getting trapped in his pleural space) while you quick-like-a-bunny hook him up again to a shiny new sterile setup. but do not clamp his tube while your assistant gets it set up for you.

now you should have an idea as to whether an intact chest tube set-up can be safely clamped or not. is something actively trying to separate the lung from its chest wall- an active air leak or bleed? or not?

I was helping a RN out yesterday in the ICU because she had 3 patients, we normally we have 1-2. She left the clamp on the chest tube for 3 hours. Pt. b/p dropped a little, thank God not harm was done.

It happens. Thank God pt. is okay and learn from your mistake.

Awesome post grntea. Chest tubes are one of those things that I know just enough to make it through the day, but I don't truly understand a lot of what I know. So your post has made things MUCH clearer for me!

OP, I really think that God lets us make a few mistakes that end up with no harm to the patient because it really is the BEST way to learn. You might take away lessons from others' mistakes, but you NEVER forget your own!

As a general rule it is NEVER a good idea to clamp a chest tube that is attached to the water seal device. I'm not blaming- I had 1 CT in school, and no one ever went over basic principals during my orientation-(assuming I covered it in school). Most nurses who don't see CTs often aren't good with even basic CT management- you aren't alone. If you are workng a floor that has CTs regularly there should been a review of the principals before they took you off orientation- it is a common knowledge deficit. Never clamp a chest tube when it is connected to the water seal device, never secure a chest tube to anything but the patient and the drainage device. The only reason there is a clamp on the tubing is so you can clamp it to change a full pleurevac or when discontinuing the tube. GrnTea gives a great overview of CTs but when in doubt- don't clamp even if for some reason the waterseal is broken- once it goes back to suction/seal any air that may have gotten into the pleural space will be evacuated.