Mr. Jones is a 19 year old male who was in a motor vehicle collision yesterday. He sustained a fractured left radius and fractures to ribs 4-7 on the left side. He was admitted to the trauma med-surg floor last night. This morning, he suddenly develops shortness of breath and ‘chest tightness’. He says “I feel like I can’t get a deep breath” and appears very anxious.
Critical Thinking Check
Bloom's Taxonomy: Application
What nursing assessments should be performed at this time for Mr. Jones?
Determine further details of symptoms if needed (OLDCARTS)
You assess Mr. Jones to find his SpO2 is 90%, his RR is 32, HR 108, and BP 117/72. You auscultate his lungs but find that lung sounds are diminished and almost absent over the left upper lobe.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What might be occurring physiologically? How would this be diagnosed?
Because of his rib fractures, he may have developed a pneumothorax – this would cause air to begin filling the space around his lung and cause it to collapse
The quickest way to diagnose this is with a chest x-ray, though it can also be diagnosed with a CT, ultrasound, or MRI – though that would be too time consuming.
You notify the provider who orders a STAT Chest x-ray. The chest X-ray confirms the patient has a moderate sized pneumothorax on the left side, with no shifting of the mediastinum or trachea. The provider determines the patient needs a chest tube placed. You gather supplies, set up the drainage system and assist with placement of the chest tube on the left side.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What output would you expect to see on initial placement of Mr. Jones’s chest tube?
Because this is a pneumothorax, we shouldn’t see any drainage or blood. It’s possible there may be a very small amount of pleural fluid, but mostly it is just draining air.
You secure the chest tube with an occlusive dressing and place the drainage system at the foot of the bed. The provider orders the chest tube to be placed to water seal, without suction.
Should have no dependent loops – loop the tubing on the bed to prevent dependent loops from forming – this could lead to clots in the tubing and occlusions.
Drainage system should be kept upright at all times .
Never clamp the tubing of a chest tube unless searching for an air leak or unless specifically instructed to do so by a provider.
Ensure that the tubing is covered with an occlusive dressing and taped securely to the patient’s chest.
Ensure that all connections are tightly secured.
Critical Thinking Check
Bloom's Taxonomy: Application
What assessments would you perform to monitor the effectiveness of the chest tube?
Tidaling – should see tidaling of any fluid in the tubing with reservations
Water seal – verify that the level of fluid in the water seal is appropriate (2 cm)
Output – assess the character, quality, and volume of output from the chest tube
Air leak – assess for air leak – continuous bubbling in the water seal chamber
Ability to breathe – assess the patient’s symptoms, ensure they aren’t SOB
SpO2 – assess oxygenation to ensure the lung is inflating well
You note intermittent bubbling in the air leak chamber and no output in the drainage chamber. The patient’s lungs sound clear, though still slightly diminished in the left upper lobe. SpO2 is has risen to 96% on 2L nasal cannula. Four hours later, you are checking the chest tube system again and notice continuous bubbling in the air leak chamber.
The entire drainage system and tubing (not the chest tube) should be changed. This can be done by a nurse without a provider order. Prepare the new system, clamp the chest tube, remove the old tubing, connect the new tubing. This should be done with sterile technique. Document the amount of drainage in the old system before discarding.
You notice the connections had come loose, so you tighten them, which fixes the air leak. Later that evening when turning the patient, the chest tube becomes accidentally dislodged from the patient’s chest.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What should your first nursing action be? Explain.
This creates a one-way valve to prevent the patient from developing a tension pneumothorax while we wait for the provider to arrive
Cover the site with an occlusive dressing taped on 3-sides.
Then, notify the provider immediately – stay with the patient and monitor their respiratory and hemodynamic status.
Mr. Jones remained stable even without the chest tube, therefore the provider decided that his pneumothorax had resolved and there was no need to replace it. You continue to monitor for any possible complications or redevelopment of a new pneumothorax.
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 