Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic obstructive pulmonary disease (COPD). Which intervention should the nurse include in the plan of care?

A. If there is no fluctuation in the water seal compartment, the first action should be to check for kinks, obstructions, or other issues in the tubing that might block air or fluid movement. Fluctuation (tidaling) is expected during respiration, and its absence may indicate a problem with the system or that the lung has fully re-expanded.

B. Notifying the healthcare provider immediately is not the first step. The nurse should first assess the chest tube system to determine if there is an issue that can be resolved without medical intervention.

C. Increasing the suction pressure on the chest tube is not appropriate without first identifying the cause of the lack of fluctuation. Adjusting suction may not address the underlying problem.

D. Continuing to monitor and reassess in 1 hour delays addressing the potential issue. Immediate assessment of the chest tube system is necessary to ensure proper functioning.

Rationale

• Obtain intravenous access: Anticipated. IV access is crucial for administering fluids, medications (like pain management), and potentially blood products if needed.
• Computed tomography (CT) of the chest: Anticipated. A CT scan provides a detailed image of the chest cavity and can confirm the diagnosis of pneumothorax, as well as identify the size and location of the air accumulation.
• Thoracentesis: Non-essential. A thoracentesis is a procedure to remove fluid from the pleural space. In a pneumothorax, the issue is air accumulation, not fluid. While a hemothorax (blood in the pleural space) can sometimes accompany a pneumothorax, the provided information does not indicate this. A chest tube is the appropriate intervention for air.
• Obtain ABGs (Arterial Blood Gases): Anticipated. ABGs provide essential information about the client's oxygenation, ventilation, and acid-base balance. Given the client's low O2 saturation and respiratory distress, ABGs are necessary to assess the severity of respiratory compromise.
• Pulmonary Function Tests (PFTs): Contraindicated. Pulmonary function tests are not appropriate in the acute setting of a pneumothorax as they can exacerbate the condition and are not useful for immediate management.
• Prepare for insertion of a chest tube: Anticipated. A chest tube is the definitive treatment for a pneumothorax. It allows for the evacuation of air from the pleural space and re-expansion of the lung. Given the client's symptoms (dyspnea, low O2 saturation, absent lung sounds), a chest tube is highly likely to be required