The nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. What intervention should the nurse implement?

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Question

This question was previously asked in

SGPGI Staff Nurse Official Paper (Held On: 28 Feb, 2024 Shift 1)

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Answer 1

Correct Answer: Documenting that the lung has re-expanded

Rationale:

Fluctuations (also known as "tidaling") in the water seal chamber of a closed chest drainage system occur as the patient breathes. This is a normal finding, indicating that the chest tube is functioning properly, and the lung has not fully re-expanded yet.
Once the lung re-expands fully, the fluctuations in the water seal chamber will stop. This is because there is no longer a significant pressure difference between the pleural space and the lung, indicating that the lung has regained its normal position and function.
In this scenario, the nurse notes fluctuations, which suggests that the lung has not yet fully re-expanded. However, the cessation of fluctuations would be a key indicator of lung re-expansion.
The correct documentation is essential for tracking the patient’s progress and ensuring appropriate interventions are in place.

Explanation of Other Options:

Unkinking for an air leak

Rationale: Fluctuations in the water seal chamber are not caused by an air leak or a kink in the tubing. An air leak would present as continuous bubbling in the water seal chamber, not fluctuations. Therefore, this intervention is not appropriate in this context.

Assessing for an air leak

Rationale: While it is important to regularly assess for air leaks in patients with chest drainage systems, fluctuations in the water seal chamber are not indicative of an air leak. Continuous bubbling, not fluctuations, would warrant an assessment for an air leak.

Documenting that the lung has not yet re-expanded

Rationale: This option is incorrect because fluctuations in the water seal chamber do not directly indicate that the lung has not re-expanded. While fluctuations suggest ongoing pleural pressure changes, the cessation of fluctuations is the definitive sign that the lung has re-expanded.

Additional Information:

The nurse should monitor for other indicators of lung re-expansion, such as improved breath sounds, symmetrical chest rise, and updated imaging studies (e.g., chest X-rays).
It is critical to ensure the chest drainage system remains functional and free of obstructions to facilitate proper lung re-expansion.
Proper documentation of findings, such as tidaling or absence of fluctuations, is crucial for ongoing patient care and communication among healthcare providers.