A nurse is assisting in the care of a client. Admission Assessment. 1500: Client transferred from postanesthesia care unit, following a left lung lobectomy. Client alert and oriented to person, place, time,. and situation. Reports pain as 3 on a scale of 0 to 10. Dressing dry and intact to left chest. Water seal chest tube drainage system has 100 mL sanguineous drainage. Right lung sounds clear. Left lung sounds diminished. For each potential nursing action, click to specify if the potential action is. indicated or contraindicated for the client who has a chest tube.

Clamp chest tube when client ambulates. Contraindicated. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition. The chest tube should be kept open and patent at all times, unless ordered by the provider for a specific reason. Report burning pain in chest to provider. Indicated. Burning pain in the chest may indicate an infection, inflammation, or injury to the pleura or lung tissue. The provider should be notified of any changes in the client’s pain or discomfort. Reinforce dressing around the tube as needed if it loosens. Indicated. The dressing around the chest tube should be kept dry and intact to prevent air leaks and infection. If the dressing becomes loose, wet, or soiled, it should be reinforced with sterile gauze and tape. Strip the tubing twice daily to ensure patency. Contraindicated. Stripping or milking the tubing can cause increased negative pressure in the chest cavity, which can damage the lung tissue and impair gas exchange. The tubing should be assessed for kinks, clots, or obstructions, and gently tapped or repositioned if needed. Maintain chest tube below the chest. Indicated. The chest tube should be kept below the level of the chest to facilitate drainage by gravity and prevent backflow of fluid into the pleural space.