A nurse is responsible for chest tube care and management. Which of the following actions should the nurse perform to maintain chest tube function? Select all that apply:

Choice A rationale:

The nurse should suspect tension pneumothorax in the patient with a chest tube who shows sudden decreased drainage, pink frothy sputum, and crackles on auscultation. Tension pneumothorax is a life-threatening condition where air accumulates in the pleural space, leading to increased pressure on the affected lung and heart. Immediate intervention, such as chest tube insertion on the affected side, is crucial to relieve the pressure and improve ventilation.

Choice B rationale:

Subcutaneous emphysema does not present with decreased drainage or pink frothy sputum. It is characterized by air trapped under the skin, causing a crackling sensation on palpation. Monitoring respiratory status and elevating the head of the bed are appropriate interventions for subcutaneous emphysema but not in this scenario.

Choice C rationale:

Re-expansion pulmonary edema is a rare complication that occurs after rapid lung re-expansion. It does not typically manifest with pink frothy sputum and crackles. Administering diuretics may be appropriate, but it is not the primary intervention in this situation.

Choice D rationale:

Infection does not explain the sudden decrease in drainage and pink frothy sputum. Although obtaining cultures from the chest tube site is important to assess for infection, it is not the most appropriate intervention at this moment. The priority is to address the potential tension pneumothorax.

Choice A rationale:

The nurse should instruct the patient and their family to keep the drainage system below the chest level at all times. This positioning helps ensure proper drainage of fluid or air from the chest, preventing any backflow or obstruction in the system. Gravity assists in maintaining the drainage flow, promoting the effectiveness of the chest tube.

Choice B rationale:

Deep breathing and coughing exercises are essential while the chest tube is in place. These exercises help prevent complications such as atelectasis and pneumonia by promoting lung expansion and clearing secretions. The patient should be encouraged to perform these exercises as directed by the healthcare provider.

Choice C rationale:

The nurse should educate the patient and their family to notify the physician immediately if they observe any subcutaneous emphysema around the chest tube site. Subcutaneous emphysema is a potential complication of chest tube placement, indicating air leakage into the tissues. Prompt notification allows for timely intervention to prevent further complications.

Choice D rationale:

The nurse should inform the patient that the drainage color may change from serosanguineous (pale, pink, or slightly bloody) to bright red during the recovery process. Initially, the drainage may be bloody, but as healing progresses, it should become clearer. However, if the drainage suddenly becomes bright red, it could indicate active bleeding, and the healthcare provider should be notified immediately.