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Nursing dx - chest tube

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I feel a bit stuck on my dx. I have a pt with an interesting situation. She came in a few weeks ago after a fall, she broke her rib causing a pneumothorax. She had an emergency chest tube placed. They have tried twice to remove her chest tube and get her to rehab, but her lung keeps collapsing. She smoked x 50 years, recently quit this year. She has emphysema. She is anemic r/t bladder cancer and sever hematuria. She has a-fib with a pacemaker placed a few months ago. When I saw her this week, she was on her 3rd chest tube. They had it clamped to see how she tolerates it, and planned to remove it. They day I cared for her, they still had not removed the tube. Her vitals were wnl, her bp was a bit low, but she had just received HTN medication. I was thinking of going with Ineffective breathing patter r/t pain in left lower lobe from chest tube AEB shallow breathing and pt c/o pain. My teacher asked me to look for problems that could be serious, cause death with her. I just feel a bit lost on this one, she has been released for a week now, they have just been trying to make sure she can tolerate her chest tube being removed. An outside perspective would be appreciated! =]

I feel a bit stuck on my dx. I have a pt with an interesting situation. She came in a few weeks ago after a fall, she broke her rib causing a pneumothorax. She had an emergency chest tube placed. They have tried twice to remove her chest tube and get her to rehab, but her lung keeps collapsing. She smoked x 50 years, recently quit this year. She has emphysema. She is anemic r/t bladder cancer and sever hematuria. She has a-fib with a pacemaker placed a few months ago. When I saw her this week, she was on her 3rd chest tube. They had it clamped to see how she tolerates it, and planned to remove it. They day I cared for her, they still had not removed the tube. Her vitals were wnl, her bp was a bit low, but she had just received HTN medication. I was thinking of going with Ineffective breathing patter r/t pain in left lower lobe from chest tube AEB shallow breathing and pt c/o pain. My teacher asked me to look for problems that could be serious, cause death with her. I just feel a bit lost on this one, she has been released for a week now, they have just been trying to make sure she can tolerate her chest tube being removed. An outside perspective would be appreciated! =]

BostonFNP, APRN

Specializes in Adult Internal Medicine. Has 10 years experience.

Tell us what you saw, felt, heard; we need your assessment.

Sent from my iPhone.

akulahawkRN, ADN, RN, EMT-P

Specializes in Emergency Department. Has 6 years experience.

I'm not going to answer the question directly... You indicated that she's on her 3rd chest tube because her lung keeps on collapsing. Chest tubes are usually indicated for 2 things: pneumothorax and hemothorax. What complications might arise that could cause her lung to recollapse after a CT has been removed? What are the signs and symptoms of a pneumothorax? Did this patient exhibit any of those signs? What would happen if the lung collapses and a chest tube isn't placed? Might that lead to a life-threatening situation?

"Ineffective Breathing Pattern" is but one of the nursing diagnoses that are possible for this patient, all centered around the pneumothorax/Chest Tube issue. Look at her history, her recent troubles regarding multiple CT placements, your own findings from the respiratory assessment, then look at the defining characteristics of some nursing diagnoses that may have something to do with respiration/breathing.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Hi!

How is school going? Were you able to purchase the Nursing Diagnoses: Definitions and Classification 2012-14? It really is the best resource out there for you.

broke her rib causing a pneumothorax. She had an emergency chest tube placed. They have tried twice to remove her chest tube and get her to rehab, but her lung keeps collapsing. She smoked x 50 years, recently quit this year. She has emphysema. She is anemic r/t bladder cancer and sever hematuria. She has a-fib with a pacemaker placed a few months ago. her bp was a bit low
You are still picking your diagnosis first. This is completely backwards. You are missing the point altogether. You have it set in your head what YOU want and not what the PATIENT actually NEEDS. What ACTUAL problems does your patient have?

As I have said before....You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

What else does she have going on that affects her health? What was your assessment? We can go from there.

School is... going! I did my mental health rotation which was great! Now I'm back on the med/surge floor and my confidence level has already plummeted. Oye.

My assessment - her vitals are all wnl. She c/o pain in her chest, makes sense, a chest tube doesn't feel good! Her O2 was 99%, reps 20 and she did not c/o SOB. She has a stooped posture and she is weak, needing a walker to ambulate. She has a-fib, and has a pace maker. When I listened to her heart, I could hear her rhythm was different, the extra gallop in the lube-dub. She had very slight crackles when she exhaled, but she also made a humming/growling noise a lot too, even when asked to take a normal breath. She has not had a bowel movement since 8/28. She had red urine, she has a hx of bladder cancer. Her recent lab showed an elevated WBC, low h&h, high platelets. She is on aspirin, xarelto, iron, protonix, coreg, Celera, buspar.

So, With what is going on with her, my initial thought is a breathing problem, but at the time I took care of her, her chest tube was still placed, although clamped, which makes her at risk for another collapse, even with the tube in, right? That is my understanding when I was looking all this up! =] Another thought was bleeding risk, since she is on aspirin and xarelto, but then the anemia comes into play there too in a way I just haven't grasped yet I'm sure!

So with all this being said, I feel like she needs the most attention to her breathing and her risk of bleeding... am I totally off base?

And, also, I haven't gotten that book, but I have a little school money left and I just ordered it! =]

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

And, also, I haven't gotten that book, but I have a little school money left and I just ordered it! =]

The light of the heavens will open for you...trust me....((HUGS))

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

School is... going! I did my mental health rotation which was great! Now I'm back on the med/surge floor and my confidence level has already plummeted. Oye.

My assessment - her vitals are all wnl. She c/o pain in her chest, makes sense, a chest tube doesn't feel good! Her O2 was 99%, reps 20 and she did not c/o SOB. She has a stooped posture and she is weak, needing a walker to ambulate. She has a-fib, and has a pace maker. When I listened to her heart, I could hear her rhythm was different, the extra gallop in the lube-dub. She had very slight crackles when she exhaled, but she also made a humming/growling noise a lot too, even when asked to take a normal breath. She has not had a bowel movement since 8/28. She had red urine, she has a hx of bladder cancer. Her recent lab showed an elevated WBC, low h&h, high platelets. She is on aspirin, xarelto, iron, protonix, coreg, Celera, buspar.

So, With what is going on with her, my initial thought is a breathing problem, but at the time I took care of her, her chest tube was still placed, although clamped, which makes her at risk for another collapse, even with the tube in, right? That is my understanding when I was looking all this up! =] Another thought was bleeding risk, since she is on aspirin and xarelto, but then the anemia comes into play there too in a way I just haven't grasped yet I'm sure!

So with all this being said, I feel like she needs the most attention to her breathing and her risk of bleeding... am I totally off base?

Ok lets start....she is bleeding from her bladder would that be the cause of the low H&H and B/P which contributed to her fall? She is at risk for bleeding MORE from the med....absolutely. NO BM since 8/28...constipation. Bun Cr OK? Lytes oK? What does the emphysema have to do with high platelets and what complications can this cause her? The chest tube is a risk for infection....right?

Her here the potentials I see in no particular order

  1. Activity Intolerance
  2. Risk for Bleeding
  3. Ineffective Breathing Pattern
  4. Decreased Cardiac Output
  5. Constipation
  6. Risk for Falls
  7. Deficient Fluid Volume
  8. Risk for Infection
  9. Risk for Injury
  10. Acute Pain

Edited by Esme12

Esme, you are an angel. My list has a couple from your list so maybe I am on the right track this time. Lol.

So does this sound goofy:

Risk for bleeding r/t bladder cancer, medications (Xarelto, aspirin) AEB voiding 400cc bloody urine, low H&H.

Patient will maintain stable vital signs with minimal blood loss by end of shift aeb:

- No bloody urine noted

- BP will be >90 systolic and >60 diastolic

- H&H will be WNL.

SeattleJess

Specializes in None yet..

Hi!

How is school going? Were you able to purchase the Nursing Diagnoses: Definitions and Classification 2012-14? It really is the best resource out there for you...

Thanks, Esme12! I checked the link and saw that there is a more recent edition, 2012-17, coming out on Oct.6th that can be pre-ordered... so I did. (Trusting that two weeks into school will not be too long to wait.)

Thanks for your comments about nursing diagnosis. It's challenging to unwrap my brain from ideas about medical diagnosis and retrain it to think about "nursing diagnosis." Identifying the response to a condition, not the condition itself. I've been working on this for several months now and hopefully won't start school too far behind everyone else.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

that should be fine....I was not sure when the newer edition wold be out...thx

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Esme, you are an angel. My list has a couple from your list so maybe I am on the right track this time. Lol.

So does this sound goofy:

Risk for bleeding r/t bladder cancer, medications (Xarelto, aspirin) AEB voiding 400cc bloody urine, low H&H.

Patient will maintain stable vital signs with minimal blood loss by end of shift aeb:

- No bloody urine noted

- BP will be >90 systolic and >60 diastolic

- H&H will be WNL.

Then the question becomes...how will you stop the bladder from bleeding...when probably can't because of the cancer.

Risk for bleeding r/t medications (Xarelto, aspirin) and bladder cancer. An ask risk diagnosis has no as evidenced by.

Actual diagnosis includes the following components:

(Name of Diagnosis)_______ related to _______ as evidenced by_________

Risk diagnosis:

Risk for (diagnosis)_________ related to (risk factors)________

Doh. Well that makes sense. Sheesh. No wonder I felt like I was repeating myself!!

SeattleJess

Specializes in None yet..

Doh. Well that makes sense. Sheesh. No wonder I felt like I was repeating myself!!

takingcare19, thanks for posting this question and working through it online. It's very helpful to work through it with you and to follow along.

Broken record: I love AllNurses! The help we get here is just awesome. I've been helped with everything from first healthcare job to texts and supplies for school. I couldn't have made it through my CNA job this summer without AN and I plan on sticking close to it through nursing school. Thank you to all the staff and members who make AN great.