Damian Wallace, age 19, was admitted to the emergency department approximately 4 hours ago with a stab wound to the chest that he received in a knife fight while intoxicated. You are asked to care for Damian while his nurse attends to a new emergency. She gives you the following report: He was admitted in respiratory distress and bleeding from the stab wound. His wound is on the right side at the sixth intercostal space and is approximately 1 inch in length, sutured, and intact. The chest x-ray confirmed a right hemothorax and, as a result, the emergency department physician inserted a chest tube. The chest tube is connected to a disposable drainage system and placed to suction at 20 cm H2O. The chest tube is draining a small amount of dark-red blood. There has not been any new drainage for the past 2 hours.Damian's most recent vital signs were as follows: temperature, 98.4°F; pulse, 88 beats/min; respirations, 24 breaths/min; blood pressure, 112/74 mm Hg. He is receiving oxygen via face mask at 30% and is on continuous pulse oximetry. The oxygen saturation level is currently 96%. He says he feels short of breath. He does not have labored breathing and is not using accessory muscles. He reports pain at the chest tube insertion site and stab wound site. He has a patent IV infusing in his left forearm. His laboratory work reported a blood alcohol level of 0.12. The nurse giving report says, “Good luckHe says he's in pain, but I think he already drank his pain medication from a bottle.”Damian turns on his call light. When you approach him, you notice his breathing is labored with subclavicular retractions. The pulse oximeter reads 95%. Damian says, “This thing in my side really hurts.”You take another set of vital signs: temperature, 98.6°F; pulse, 90 beats/min; respirations, 37 breaths/min; blood pressure, 118/78 mm Hg. You find the breath sounds are diminished on the right. The chest drainage tubing is in the bed without a dependent loop, and Damian has been lying on a segment of the tubing. You ask him to describe his pain and rate it on a scale of 1 to 10 (10 = worst), and he says, “Really bad, sharp, about a 5, like I'm being stabbed again!” You ask if the medicine he got earlier helped with the pain, and he replies, “it didn't help one bit!” When you review the eMAR, you find that Damian has been prescribed ketorolac 30 mg IV, which was given 3 hours ago, and hydrocodone 5 mg and acetaminophen 325 mg po for pain unrelieved by ketorolac, which has not been administered. You find his nurse and ask if pain medication was administered. The nurse responds, “Are you kidding? If he's tough enough to drink and fight, he's tough enough for a little chest tube. If the anti-inflammatory doesn't help, he doesn't deserve anything stronger.”
Prescribed Interventions
- Chest tube with drainage system to suction at −20 cm H2O
- Intravenous fluids: NSS at 100 mL/hr
- Oxygen at 30% via face mask
- Ketorolac 30 mg IV q6h prn pain
- Hydrocodone 5 mg and acetaminophen 325 mg po q4-6h prn pain unrelieved by ketorolac
- Continuous pulse oximetry
Developing Clinical Reasoning and Clinical Judgment
- Which of Damian's needs is your first priority? Describe your assessments related to your first priority.
- How would you troubleshoot his chest tube drainage system? What could be the source of his respiratory distress?
- Describe the purpose of a chest tube drainage system for a hemothorax.
- Discuss valid reasons a nurse might not give a pain medication when there is a prn order.
- Discuss prejudices nurses may have that may prohibit adequate pain management.
Suggested Responses for Integrated Nursing Care
- Your first priority is Damian's increased respiratory distress (refer to Chapters 2 and 3). Although the change in oxygen saturation levels is very small, this is only because Damian's body is compensating for it now. Damian's work of breathing has dramatically changed, signaling a change in his respiratory status. Your preliminary assessment showed a respiratory rate of 37 breaths/min, up significantly from his earlier respiratory rate of 24. When you inspected the chest, you found subclavicular retractions; this indicates that Damian is using his intercostal muscles to breathe. When you auscultated breath sounds, you found decreased air movement on the right, indicating a hemothorax.
- In a hemothorax, blood collects in the pleural space and compresses a lung. The purpose of the chest tube is to evacuate the blood and allow the lung to expand fully (Chapter 14). In Damian's case, the stab wound created a puncture in the pleura, allowing blood to accumulate within the pleural space. It is important to evaluate the right lung on a routine basis to make sure the blood in the pleural space has been removed so that the lung can reexpand (refer to Chapter 3). Any change in respiratory status may indicate a problem with the chest tube drainage system.
- As you noted in this case, Damian has had a change in his respiratory status. Since you have completed his assessment, now begin inspecting the equipment. As with any equipment check, begin inspection at the patient and move to the equipment. Start your inspection at the insertion site of the chest tube (refer to Chapter 14). Observe the dressing to ensure it is occlusive and inspect the tubing for leaks, kinks, and dependent loops. Compare the amount of recent drainage in the drainage system, with the volume of old drainage, and check the amount of suction (see Chapter 14). In this case, Damian has been lying on his tubing, which would prevent it from draining properly. When you reposition Damian's tubing, approximately 60 mL of dark old blood flows into the drainage set. His respiratory status improves quickly. Thus, this accumulated blood in the pleural space was the source of his respiratory distress.
- There are several situations in which giving an opioid analgesic may be contraindicated. During a life-saving procedure, pain is not always a priority. In this case, Damian did not receive pain medication before the insertion of his chest tube, because he was at risk for respiratory arrest. Opioids may also be contraindicated when it is critical to assess mental status, because the opioid might mask neurologic changes. Opioid analgesics also are associated with the adverse effects of respiratory depression and vital sign changes. Patients sometimes do not receive the prescribed pain medication because the nurse is worried about these adverse effects (refer to Chapter 10). Because of this, controversy exists as to whether the benefit of pain control outweighs the risk of adverse drug reactions. Many hospitals have committees that can assist with these ethical decisions. Collaboration among nurses, doctors, and pharmacists can result in optimal pain control with minimal adverse effects. Speak with the health care provider before independently deciding to withhold pain medication to prevent adverse drug reactions.
- Another reason nurses may withhold medication is their own preconception of the patient's pain and their own prejudices. Some nurses are not even aware that they have these feelings. As a nursing student, you need to understand how you will respond to patients, and you need to explore your own beliefs and prejudices. The accepted standard in nursing is that a patient defines their own pain and that it is the nurse's responsibility to manage it properly. Guidelines for pain management have been written by State Boards of Nursing, the U.S. Department of Health and Human Services, the World Health Organization, as well as other professional organizations.