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Assessment Nurses' Notes Vital Signs Nurses' Notes 1100: The nurse should Target 1 to prevent Target 2 Client returns to unit from interventional radiology following chest tube placement for pneumothorax. Client is alert and oriented x4. Client reports pain as 3 on a scale of 0 to 10 and mainly located at the insertion site. Vital signs obtained. Chest tube drainage system has 100 mL of blood in drainage chamber. Intermittent tidaling noted in the water seal chamber. Chest tube insertion site is dressed, dry, and intact. All chest drainage system connections secured. Client assisted to a comfortable position. Target 1 apply a nonocclusive dressing contact the provider place the drainage tube in sterile water Target 2 tension pneumothorax infection * hemothorax raise the drainage hemorrhage system above the chest 1700: Client reports shortness of breath and states, "I feel like the chest tube may have moved." Vigorous bubbling noted in the chest drainage systems water seal chamber. All connections are secure. Chest tube insertion site dressing removed. Air leaking heard from insertion site. O Search lay the client supine + subcutaneous emphysema - - 5 - ם cn L CONTINUE 2/10/20

Assessment Nurses' Notes Vital Signs Nurses' Notes 1100: The nurse should Target 1 to prevent Target 2 Client returns to unit from interventional radiology following chest tube placement for pneumothorax. Client is alert and oriented x4. Client reports pain as 3 on a scale of 0 to 10 and mainly located at the insertion site. Vital signs obtained. Chest tube drainage system has 100 mL of blood in drainage chamber. Intermittent tidaling noted in the water seal chamber. Chest tube insertion site is dressed, dry, and intact. All chest drainage system connections secured. Client assisted to a comfortable position. Target 1 apply a nonocclusive dressing contact the provider place the drainage tube in sterile water Target 2 tension pneumothorax infection * hemothorax raise the drainage hemorrhage system above the chest 1700: Client reports shortness of breath and states, "I feel like the chest tube may have moved." Vigorous bubbling noted in the chest drainage systems water seal chamber. All connections are secure. Chest tube insertion site dressing removed. Air leaking heard from insertion site. O Search lay the client supine + subcutaneous emphysema - - 5 - ם cn L CONTINUE 2/10/20

3-2-1 Code It
3-2-1 Code It
6th Edition
ISBN:9781337660549
Author:GREEN
Publisher:GREEN
Chapter14: Cpt Surgery Iv
Section: Chapter Questions
Problem 16MC
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Assessment Nurses' Notes Vital Signs Nurses' Notes 1100: The nurse should Target 1 to prevent Target 2 Client returns to unit from interventional radiology following chest tube placement for pneumothorax. Client is alert and oriented x4. Client reports pain as 3 on a scale of 0 to 10 and mainly located at the insertion site. Vital signs obtained. Chest tube drainage system has 100 mL of blood in drainage chamber. Intermittent tidaling noted in the water seal chamber. Chest tube insertion site is dressed, dry, and intact. All chest drainage system connections secured. Client assisted to a comfortable position. Target 1 apply a nonocclusive dressing contact the provider place the drainage tube in sterile water Target 2 tension pneumothorax infection * hemothorax raise the drainage hemorrhage system above the chest 1700: Client reports shortness of breath and states, "I feel like the chest tube may have moved." Vigorous bubbling noted in the chest drainage systems water seal chamber. All connections are secure. Chest tube insertion site dressing removed. Air leaking heard from insertion site. O Search lay the client supine + subcutaneous emphysema - - 5 - ם cn L CONTINUE 2/10/20
Transcribed Image Text:Assessment Nurses' Notes Vital Signs Nurses' Notes 1100: The nurse should Target 1 to prevent Target 2 Client returns to unit from interventional radiology following chest tube placement for pneumothorax. Client is alert and oriented x4. Client reports pain as 3 on a scale of 0 to 10 and mainly located at the insertion site. Vital signs obtained. Chest tube drainage system has 100 mL of blood in drainage chamber. Intermittent tidaling noted in the water seal chamber. Chest tube insertion site is dressed, dry, and intact. All chest drainage system connections secured. Client assisted to a comfortable position. Target 1 apply a nonocclusive dressing contact the provider place the drainage tube in sterile water Target 2 tension pneumothorax infection * hemothorax raise the drainage hemorrhage system above the chest 1700: Client reports shortness of breath and states, "I feel like the chest tube may have moved." Vigorous bubbling noted in the chest drainage systems water seal chamber. All connections are secure. Chest tube insertion site dressing removed. Air leaking heard from insertion site. O Search lay the client supine + subcutaneous emphysema - - 5 - ם cn L CONTINUE 2/10/20
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