Running Head: PLANNING THE CARE
Planning the care of a patient with alteration in comfort related to chest tube removal and pain
Laura M. Varnier
Duke University School of Nursing
1
Planning the care
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Clinical Database
De-identified Patient
Information: E. G.
Patient's Age: 59
LOS: A&O X 4
Gender: F
Reason for Admission: Five days s/p mechanical fall with right axillary pain; per pt, she attempted to get out of
bed 5 days ago (6/24/2011) and “did not have her feet underneath her” and landed with a direct blow to her
right axilla. ED report states pain and ecchymosis over the right axilla area and mild SOB with deep
inspiration. Admitted 6/29/2011 with a hemopneumothorax approximately 40% with no airway compromise (I
cared for pt on 7/4/2011). A pleural chest tube was placed into the rt pleural space and checked with chest xray.
Past Medical History: Renal failure secondary to antineutrophilic cytoplasmic antibodies with positive
membranous glomerulonephritis, HTN, migraine, diverticulosis, hyperlipidemia, anemia, and irritable bowel
with colon polyps.
Unique Code:
Student Initials: L. V. Week: 5
Name of Agency: Duke 2300
Past/Recent Surgical Procedure: Chest tube placement (6/29/2011) checked with x-ray. Tonsillectomy at age
15 (February, 1967). Bone marrow transplant at 45 for sister with leukemia (November, 1997).
Treatments: Chest tube placed in rt pleural space; TEDs and SCDs; fall precaution plan implemented;
incentive spirometer.
Assistive Devices: Bedside commode while hospitalized, no mobility device assistance needed.
Advance Directives:
Living Will: Yes
Healthcare Power of Attorney:
Yes
Copy of AD in chart: Yes
DNR Status: Full Code
Source of Information: Patient
Pertinent Diagnostic Tests--- Chest x-ray for tube placement (6/29/2011) and removal (7/4/2011). Pertinent
labs (as of 7/4/2011): Calcium 8.2 (Normal 8.5-10.5 mg/dL), Hemoglobin 9.5 (Normal 12.0-15.5 g/dL for
females), Hematocrit 0.29 (Normal 0.35-0.45 for females), RBC 2.73 (Normal 4.7-6.1 million/cu mm ), MCH
34.8 (Normal 26-34 pg), MCV 105 (Normal 80-100 fL ), BUN 41 (Normal 8-20 mg/dL), Creatinine 3.0
(Normal 0.6-1.2 mg/dL), Platelets 149,000 (Normal 150,000-450,000/cu mm).
Pathology Report: negative for MRSA (6/30/2011), negative for VRE (6/30/2011).
Infection Control: Standard precautions
Allergies – food, environmental, mediations (indicate response for allergies): Erythromycin (stomach cramps), penicillin (swelling), shellfish
(blotches and anaphylaxis) and sulfa/sulfonamides (rash).
Medications: azathioprine (Imuran) (immunosuppressant for renal transplant candidates) 0.5mcg PO q DAY; calcitriol (calcium supplement for
hypocalcemia related to renal failure) 50mg PO Q day; calcium carbonate (Tums Antacid) (calcium supplement for hypocalcemia due to renal
failure) 1500 mg PO q DAY; clonazepam (Klonopin) (benzodiazepine for seizures prevention and anxiety management) 2 mg PO q HR;
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Lidocaine patch (topical analgesia for localized pain relief) 1 patch applied to site of pain (can be cut to fit), 12 hours on, 12 hours off;
oxycodone (OxyContin) (moderate to moderately severe pain relief) 30mg PO BID; paroxetine hydrochloride (Paxil) (reduce anxiety and
relieve depression) 30mg PO q DAY; temazepam (insomnia relief) 30mg PO q DAY; amlodipine/ hydrochlorothiazide/valsartan (hypertension)
40 mg PO q HR; docusate calcium (Senna) (stool softener for constipation with pain medication) 2 tabs PO BID; Lipitor (hyperlipidemia)
20mg PO q DAY; morphine (analgesia for moderate to severe pain during chest tube removal) PRN 4 mg IV.
Activities of Daily Living/Level of independence: Prior to admission, pt denies any mobility restrictions or need for assistive devices; Pt states
prior to admission that she completed ADLs independently; pt states that with her glasses she is able to see clearly; pt is able to hear and
respond to verbal communication adequately. Pt reports a balanced vegetarian diet with a daily multivitamin, Calcium and Vitamin D
supplementation.
Psychosocial/ Cultural/ Spiritual Assessment: Prior to admission, pt was a very active veterinarian; Pt states she swims a mile each day and
walks a mile every morning and night. Pt reports a strict vegetarian diet. Pt lives alone in a one story house with three dogs and five cats. Pt
states that all other family members live in Texas, but that she has a “close knit group of friends and colleagues at work”. States that she
adequately handles stressors and that her primary concern now is receiving new kidneys due to current renal failure. Pt denies dialysis for renal
failure and stresses that her kidneys are not “in that bad of shape yet”. Pt enjoys reading, crossword puzzles, playing the piano and taking walks
at night. Pt states that she is largely involved in her Methodist church community and arranges summer vacation Bible school activities. Pt
states she spends about 20 hours a week involved with church activities.
Risk Assessment: Low pressure ulcer risk with Braden score 22 and currently absent of pressures ulcers; High falls risk according to the Morse
falls risk scale (score 75). Low risk for elopement according to Elopement Risk Assessment Scale. Low risk for nutritional deficiencies due to
pt eating full meal, consuming nutritious snacks, active lifestyle, vegetarian diet and BMI of 18.9.
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Physical Assessment Findings
Pt: E. G.
Chief Complaints (subjective data): “I am in a lot of pain and I do not
know why I need a chest tube.”
Current Level of Independence: Full independence; pt states that with
glasses she sees clearly; able to hear and respond to verbal commands;
pt self turns Q 2 hours.
Activity Order: OOB to walking; remove chest tube and get a follow
up in 6 hours to monitor for spontaneous pneumothorax chest x-ray.
Cardiovascular System
Cap refill < 3 sec bilaterally in all extremities, nail bed color pink; S1,
S2 audible, no audible S3 or S4 or murmurs; no edema; all pulses
intact bilaterally in all extremities 2+. No audible bruits; No JVD at 45
degrees. Apical pulse RRR; no pulsations, lifts, or thrills.
Gastrointestinal System
No N/V. Flat contour; soft, nontender abdomen, active bowel sounds
in all 4 quadrants; no guarding upon palpation; active flatus; last BM
7/4/2011; Vegetarian diet, feeds by mouth.
Genitourinary System
Frequently voids clear, yellow urine; output 200 mL at 0800 in
bedside commode (at 0400 nurse stated she emptied 450mL from
bedside commode). I=1400 mL, O=950 mL over 12 hour shift.
Integumentary System
Skin color appropriate for race, Braden score of 22 (low risk for
pressure ulcers); Skin dry, intact, warm, no tenting or tenderness. No
clubbing in nail beds. 20cm X 14 cm ecchymosis on right axilla noted;
pain and guarding upon light palpation.
IV Therapy (type/size, site/assessment, infusion)
#1 18G Antecubital, saline-locked; patent.
Student Nurse: Laura Varnier
Height:_5’11’’ Weight: adm 135
Vital Signs: B/P 118/57
T 36.6
current 135
P 82
BMI: 18.9
R 20
Time: 0800
Respiratory System
SpO2= 94% RA; Lt lobes CTA, Rt upper and middle lobes clear,
diminished at right base; no cough, natural airway, relaxed depth,
symmetric chest movement, breathing RRR; chest tube in rt pleural
lateral space covered by a transparent dressing producing scant amount
of pink thin watery serosangunious drainage, dressing CDI with no air
leak, continuous wall suction and water sealed; Inspiration to expiration
ratio 1:1; AP: Transverse 2:1.
Neurological System
A&OX4; awake, alert, calm, cooperative, follows tiered commands; CN
2-12 motor and sensory intact in all extremities; speech/voice clear.
PERRL.
Musculoskeletal System
Active ROM in all extremities with no discomfort noted; L=R medium
handgrips (2+), L=R strong dorsiflexion (3+); active movement, steady
gait.
EENT System
Pt. wears glasses; PERRL, peripheral vision intact; no tearing; no vision
lesions. Ears contained intact outer structures, no lesions or excess
cerumen; conversational hearing intact. Nose mucosa pink and clear, no
lesions or excess mucus, both nostrils patent. Lips pink and dry with no
cracking. Mouth moist and pink, no lesions, good tonsillary pillar
movement, no erythema. Teeth intact without dental caries, gums pink
and moist, no tongue lesions; uvula midline; no dentures or hearing aids.
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Plan of Care- Physical
COLLABORATIVE PROBLEM LIST
Renal failure secondary to antineutrophilic cytoplasmic antibodies with positive membranous glomerulonephritis; HTN; migraine; diverticulosis;
hyperlipidemia; anemia; irritable bowel with colon polyps; alteration in comfort related to chest tube removal and pain; ineffective pain
management related to opioid use prior to admission; risk for falls related to previous hx of falls, opioid use and polypharmacology; impaired gas
exchange related to decreased function of lung tissue; risk for injury related to chest tube movement limitations; alteration in nutrition related to
ineffective pain management; risk for impaired skin integrity related to immobility and presence of chest tube; risk for osteoporosis related to postmenopause loss of estrogen; anxiety related to discharge.
PRIORITY OF CARE
Key Problem / Nursing Diagnosis (from Nursing Problem List): Alteration in comfort related to chest tube removal and pain.
Supporting Subjective and Objective Data: “It hurts when I breathe. This tube is so annoying.” BP 118/57, pulse 87, RR 20, O2 sat 94% and
pt reports an 8/10 pain rating. Patient is 10 days status post mechanical fall, 5 days status post chest tube placement; history of
hemopneumothorax with chest tube placement. Pt respirations elevated above baseline data and patient appears in acute distress.
GOALS
General Goal to achieve through Nursing Interventions: E. G.’s pain will be effectively managed based on a patient-determined tolerance level; Pt
pain will be adequately managed pre, intra, and post chest tube removal without respiratory compromise.
Patient Behavioral Outcome Objective(s): The patient will report pain as tolerable on a 0-10 rating scale post chest tube removal; Pt will express
satisfaction with pain management techniques; Pt will be able to participate in activities of daily living pre-intra-and-post-chest tube removal. The
patient will remain free of signs of respiratory distress pre, intra, and, post chest tube removal, by observing respiration >12 per minute and O2
saturation level >90%.
Patient Educational Needs: Pt. needs to be educated on the rational for a chest tube and the importance of the tube draining her pleural space posthemopneumothorax; pt education on importance of alerting medical staff at the onset of pain, not when the pain is unbearable; pt education on
medication purpose, intended effects and side effects; pt education on chest tube removal procedure.
Nursing Interventions
(include frequency and specificity)
Question the patient at beginning of the shift
to establish a tolerable pain level goal
according to the patient.
PLAN AND INTERVENTIONS
Scientific Rationale
“The pain rating that allows the client to have
comfort and appropriate function should be
determined because this allows a tangible way
to measure outcomes of pain management”
(Griffie, 2003).
Patient Response/Evaluation
Patient established a tolerable pain level of
4/10. Pt reported pain fluctuated throughout the
day from 2-10 out of 10. The highest pain
reported occurred immediately after chest tube
removal (reported at 10/10).
Planning the care
Assess and interpret vital signs Q 4 and PRN
indicating an increase in pain, including
increased heart rate, increased respirations,
increased blood pressure, and physical signs of
acute distress.
Assess pain pre, intra, and post chest tube
removal. Administer 30mg PO oxycodone
PRN, according to MAR, for pain greater than
6/10 throughout chest tube placement and
post-removal.
Utilize a variety of complementary pain
management techniques, such as repositioning.
Administer PRN 4mg IV morphine, according
to MAR, for analgesia prior to chest tube
removal. Assess pt respiratory rate and O2
saturation 30 minutes and one hour post
medication administration.
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“The client’s report of the pain is considered
the single most reliable indicator of pain”
(JCAHO, 2010).
“Pain measurements are determined by closely
monitoring the patient’s other vital signs (heart
rate, respiration, pulse, and temperature) as
well as behaviors such as their level of
agitation, irritation, and restlessness”
(JCAHO, 2010).
“Pain assessment is as important as taking
vital signs, and the APS suggest applying the
concept of pain assessment as the ‘fifth vital
sign’” (APS, 2004).
“Pharmacologic interventions are the
cornerstone of management of moderate to
severe pain” (APS, 2004).
“Opioid analgesics are indicated for the
treatment of moderate to severe pain” (APS,
2004).
“Physical medicine approaches, such as the
application of heat or cold, massage, exercise,
and repositioning, may also be helpful in pain
management” (Yates, Edwards & Nash, 2002).
“Provide adequate analgesia prior to removal
of chest tube” (Duke Nursing Process
Standards, 2007).
“If used correctly, either an opioid (morphine)
or a nonsteroidal anti-inflammatory
(ketorolac) can substantially reduce pain
during chest tube removal without causing
adverse sedative effects. Thus, clinicians may
choose among several safe and effective
analgesic interventions during chest tube
removal” (Puntillo & Ley, 2004).
At 0800, RR 20, BP 118/57, pulse 87 were all
elevated above pt baseline. Pt reported highest
pain of the day 8/10 (other than immediately
post chest tube removal0.
At 1200, RR 16, BP 110/60, pulse 62.
At 1600, RR 16, BP 109/59, pulse 66
(immediately pre-chest tube removal).
At 1800, RR 14, BP 115/72, pulse 62.
Pt reports 8/10 pain at 0800, related to chest
tube. Pt reports pain decline to 3/10 pain one
hour after receiving 30mg oxycodone PO. Pt
satisfied with pain management.
Patient reported of pain of 6/10 1400; After
repositioning patient to a side-lying position
with the bed elevated to 30 degrees, patient
reported pain at a reduced level of 4/10 at 1500.
Pt provided with 4 mg IV morphine prior to
chest tube removal. Pt reported pain 10/10 with
chest tube removal (at 1600) but expressed
approval of pre-medication regimen.
At 1630, RR16, O2 saturation 95%.
At 1700, RR 16, O2 saturation 96%.
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“… administering opioids or nonsteroidal antiinflammatory drugs based on the time of the
peak effect of the analgesic medication has
been a factor in reducing pain ratings
immediately after and 20 minutes after CTR”
(Friesner, Curry, & Moddeman, 2006).
“An oxygen saturation level of less than 90%
or a PaO2 of less than 80mm Hg indicates
significant oxygenation problems” (Clark,
Giuliano, & Chen, 2006).
Instruct patient on the importance of notifying Return demonstration is one way to evaluate
Patient return demonstrated use of call bell
nurse of pain during onset of pain: Provided
learning related to a psychomotor skill
appropriately. Pt reported pain during first
verbal instruction and demonstrated use call
(Bastable, 2008).
onset of symptoms and expressed approval at
bell and asked for return demonstration.
“It is easier to control pain when you prevent
prompt nurse response time.
it from gaining a foothold in the first place”
(Stanik-Hutt, 2003).
SUMMARY OF PATIENT PROGRESS/OVERALL EVALUATION OF GOALS
What is your impression of your patient's progress toward goal from your nursing care? How might you change the plan of care to improve
patient outcomes?
E. G. mostly maintained effective pain management throughout pre, intra and post chest tube removal assessments. Pt expressed satisfaction with
pain management throughout different employed techniques Patient positively progressed through each nursing goal and complied with
suggestions, initiating her steps towards a successful recovery.
To improve my plan of care, I would like to incorporate deep breathing techniques when appropriate into the chest tube removal process, to ease
pain and anxiety experienced by my patient. Furthermore, a wider range of pain management strategies, throughout my shift, would have been
beneficial to incorporate in my patient care, such as listening to music and incorporating distractions. Furthermore, if my patient’s pain remained
inadequately managed throughout the day, I could have collaborated with the team and requested a pain consult, as well.
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Psychosocial
COLLABORATIVE PROBLEM LIST
Renal failure secondary to antineutrophilic cytoplasmic antibodies with positive membranous glomerulonephritis; HTN; migraine; diverticulosis;
hyperlipidemia; anemia; irritable bowel with colon polyps; alteration in comfort related to chest tube removal and pain; ineffective pain
management related to opioid use prior to admission; risk for falls related to previous hx of falls, opioid use and polypharmacology; impaired gas
exchange related to decreased function of lung tissue; risk for injury related to chest tube movement limitations; alteration in nutrition related to
ineffective pain management; risk for impaired skin integrity related to immobility and presence of chest tube; risk for osteoporosis related to postmenopause loss of estrogen; anxiety related to discharge.
PRIORITY OF CARE
Key Problem / Nursing Diagnosis (from Nursing Problem List): Anxiety related to discharge planning.
Supporting Subjective and Objective Data: “I am nervous about going home. I am do not know who will take care of me when I go home.” Patient
is 10 days status post mechanical fall, 5 days status post chest tube placement; history of hemopneumothorax with chest tube placement. Pt
appears anxious and pre-occupied prior to discharge teaching.
GOALS
General Goal to achieve through Nursing Interventions: Demonstrate significant decrease in physiologic, cognitive, behavioral and emotional
symptoms of anxiety. Patient will report that anxiety is reduced to a manageable level.
Patient Behavioral Outcome Objective(s): The patient will verbalize specific fears and apprehensions about going home by herself in order for
these areas to be addressed. The patient will demonstrate an understanding of discharge instructions. Pt will identify methods of anxiety
management specific to her. Pt will identify support system for care throughout beginning days of discharge.
Patient Educational Needs: Education on support groups in the area for other transplant candidates; education on who needs to be contacted in case
she has questions, including the chain of command to follow in the event of an emergency; Educate patient on role and function of social worker
in discharge planning.
PLAN AND INTERVENTIONS
Nursing Interventions
Scientific Rationale
Patient Response/Evaluation
(include frequency and specificity)
Assess client’s worries and apprehensions
“Specific labeling helps the client to isolate
Pt states prior to discharge that she is worried
surrounding discharge by questioning, preanxiety as a feeling that the client can begin to about going home by herself, although she will
and-post discharge teaching.
understand and manage” (Fortinash &
be having friends check on her throughout her
Holoday-Worret, 1999).
discharge. Pt states she is concerned about
caring for her animals at home and returning to
her job. Pt states she is worried about how
much her hospital stay will cost and expresses
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Collaborate with the social worker to address
specific needs regarding parking tickets and
paying for other hospital services, upon
request from the patient.
“Findings show that the involvement of a
discharge planning case manager is related to
a significant reduction in unmet treatment
needs…” (Mamon, Steinwachs & Fahey,
1992).
Assess client’s verbal and non-verbal anxiety
cues surrounding anxiety, both pre-and-post
discharge teaching.
“Early recognition of anxiety is critical to
prevent escalation of symptoms and loss of
control” (Fortinash & Holoday-Worret, 1999).
“The client’s knowledge of his or her typical
responses to anxiety-producing stimuli assists
the client to begin to manage them” (Fortinash
& Holoday-Worret, 1999).
Assess patient’s support system outside of the
hospital by questioning, as well as assistance
for follow up care, prior to discharge.
“Three main barriers to discharge were found:
having an unstable or complex medical
condition, lacking family or social support,
and being unable to obtain suitable housing.
Intervention staff advocated on the behalf of
clients, encouraged clients to build skills
toward independent living and contributed
extensive knowledge of local resources to
advance client goals. Cases of successful
transition suggest that a person-centered
approach from intervention staff combined
with a flexible organizational structure is a
promising model for future interventions”
(Meador, Chen, & Schultz, 2011).
concern regarding the payment of 6 parking
tickets for the last 6 days she has been in the
hospital.
Post-discharge, patient states that she is “less
worried about being at home by herself and
taking care of herself.”
Pt expressed satisfaction in meeting with the
social worker and getting her parking and
payment questions answered. Pt also requested
follow up contact information in order to
remain in touch with the social worker after she
is discharged.
Client seemed consistently distracted,
preoccupied and avoidant until receiving clear
answers to her question.
Student nurse identified these non-verbal
anxiety cues to the patient and the patient
recognized the cues. Student nurse and patient
collaborated ideas to verbally request
information and answers to allow for less
distraction and avoidance and enable focus on
discharge planning and teaching.
Pt states that that she has a group of colleagues
from work, friends in her neighborhood and
members of her church which can check on her
throughout her first days after discharge.
Pt colleague from work also attends discharge
teaching and expresses interest in helping her
friend after discharge. Pt states that her friend
will be with her at all follow up doctor
appointments.
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“Different types of activities including
Pt expressed stress relief with physical activity
domestic (housework and gardening), walking including swimming and walking. Pt states that
and sports were all independently associated
she will incorporate these activities into her
with lower odds of psychological distress”
discharge to help relieve anxiety.
(Hamer, Stamatakis & Steptoe, 2009).
SUMMARY OF PATIENT PROGRESS/OVERALL EVALUATION OF GOALS
What is your impression of your patient's progress toward goal from your nursing care? How might you change the plan of care to improve
patient outcomes?
Discuss activities the patient may incorporate
post-discharge, as needed, to help ease patient
tension and anxiety.
When I began working with my patient, I could not effectively implement my care due to her preoccupation with discharge planning. I feel that by
addressing her anxiety/fears and allow for verbalization and acknowledgement of these concerns, together, we were able to begin effective
discharge planning. I feel that my patient did progress to meet the goals that we collaboratively set.
To change this plan of care, I would hope to be involved in the discharge process earlier. My patient’s initial concerns were not brought up until
the doctor had placed the discharge orders and her departure was set to occur within the hour. I would like to have spoken more comprehensively
about her concerns, but I feel that we did address a majority of anxieties she had and put a plan in place to manage each concern effectively.
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Chest Tube Removal: Can anything other than opioids effectively manage pain?
One of the most reported stressors when a patient undergoes placement of a chest tube is
how painful the experience will be when the tube must be removed (Puntillo & Ley, 2004).
Within the Duke Protocol it is recommended that nurses “provide adequate analgesia to the
patient prior to removal of the chest tube” (Duke Nursing Process Standards, 2007). The Duke
University protocol does not specify the type, amount or form in which the analgesia should be
prescribed; this is determined by the health care practioners licensed to prescribe medical therapy
(2007). Regarding my patient, a standing order for 4 mg IV morphine with chest tube removal
(CTR) was prescribed. However, as highlighted by Friesner, Curry and Moddeman, “although
opioids are traditionally used to treat acute pain, they are not associated with optimal pain control
during CTR” (2006).
In a randomized control study of 40 hospitalized patients conducted by Friesner, Curry,
and Moddeman, effectiveness of opioid-only management in 21 participants versus an opioid
paired with focused breathing exercises in 19 participants was evaluated to determine the
differences in pain levels throughout chest tube removal (2006). The focused breathing exercises
directly preceding chest tube removal involved five minutes of inhaling through the nose and
pursed-lip exhalation. Pain levels were assessed in the treatment and control groups pre-CTR,
immediately following CTR and 15 minutes following CTR using the vertical Visual Analog
Scale (VAS). Before CTR, the mean VAS pain rating, on a 0-10 scale for the treatment group
was 5.05 (SD 2.86) and 5.04 for the control group (SD 2.44). Immediately after CTR, the mean
rating was 6.57 (SD 2.61) for the treatment group and 8.61 (SD 2.96) for the control group.
Fifteen minutes post-CTR, the mean rating for the treatment group was 3.07 (SD 2.45) and 5.57
for the control group (SD 2.96) (Friesner, Curry & Moddeman, 2006). The researchers
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determined that pain intensity ratings were consistently lower for patients receiving focused
breathing exercises and opioids compared to the control group receiving opioids only.
As an active member watching the chest tube removal procedure and as an advocate for
my patient, I would like to encourage prescribers and hospital authorities to investigate the
evidence regarding focused breathing techniques to assist in managing pain levels throughout the
chest tube removal process. To provide the best care for our patients, we need to investigate the
most appropriate, evidenced-based information for pain management during CTR and begin
implementing comprehensive pain management techniques into hospital-wide policy.
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