The nurse notes that the patient's chest tube pulled out by 5.1 cm (2 inches) during turning and repositioning. Which should be the initial action by the nurse?
a. Instruct the nursing assistive personnel (NAP) to apply pressure for 5 minutes.
b. Replace the water-seal drainage system with a sterile waterless unit quickly.
c. Hold a towel firmly over the site and send for petrolatum gauze.
d. Push the tube into place and apply an oc-clusive sterile dressing.
C
The nurse secures the tube in place with a clean towel (or closest handy clean material) and sends the NAP for sterile petroleum gauze. The nurse securely wraps the gauze around the base of the chest tube insertion to re-create an airtight seal so negative intrapleural pressure can be restored. The nurse should collaborate with the healthcare provider for a chest x-ray film to evaluate the status of the lung after the accident. The nurse applies pressure to the site to prevent the wound from drawing in room air because this intervention requires clinical judgment and critical thinking to seal the wound completely. A standard or a waterless system is suitable for the patient's water-seal drainage; however, neither system is effective therapy until the airtight insertion site is reestablished. The portion of the tubing pulled out is now contaminated and should not be pushed into place.
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