Bautista - 3 Way Bottle System

Katherine Ashley R.
Bautista NCMB418
BSN 4-Y1-8 9/21/2023
CARE PLAN FOR CLIENT WITH A 3-WAY BOTTLE SYSTEM
A 56-year-old man is admitted to a cardiopulmonary unit following a transbronchial lung biopsy for lung cancer. Shortly after arrival to the unit,
the patient complained of excruciating pain in his upper right back, shortness of breath, and feeling anxious. Physical examination reveals
tachycardia at 112 bpm, tachypnea at 28 breaths/min, and hypotension at 90/46 mm Hg. Auscultation reveals the absence of breath sounds in
the right mid and lower lobes. The patient is diaphoretic with a SpO2 on room air of 88%. The physician prescribes emergent chest tube
insertion with dry suction water seal chest drainage set up.
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Ineffective Short term: Determine etiology and Understanding the cause Short term:
- The patient breathing pattern After 1-2 hours of precipitating factors is necessary for proper After 1-2 hours of
verbalized related to pain as nursing chest tube placement nursing
excruciating pain evidenced by intervention, the and choice of other intervention, the
in his upper right objective data patient will: therapeutic measures patient was able
back, shortness of tachycardia at to:
breath, and 112 bpm, Establish a normal
feeling anxious tachypnea at 28 and effective Monitor and record vital Monitoring the vital signs Established a
breaths per breathing pattern signs is necessary to evaluate normal and
Objective Data: minute, a SpO2 within the client’s the degree of effective
- HR: 112 bpm on room air of normal range compromise breathing pattern
(tachycardia) 88%, and within the
- RR: 28 breaths absence of Report pain as Maintain a calm attitude To limit the level of client’s normal
per min breath sounds in relieved or while dealing with patient anxiety range
(Tachypnea) the right and controlled and significant others
- SpO2 on room lower lobes. Reported pain as
air of 88% Participate in the Direct client in breathing To assist client in “taking relieved or
- Auscultation: treatment regimen efforts as needed. control” of the situation, controlled
absence of breath (e.g. breathing Encourage slower and especially when the
sounds in the right exercises, use of deeper respirations and condition is associated Participated in
and lower lobes oxygen) within the use of the purse-lip with anxiety or air hunger the treatment
level of technique regimen (e.g.
ability/situation Promotes maximal breathing
Maintain position of inspiration; enhances exercises, use of
Long term: comfort, usually with head lung expansion and oxygen) within
After 1-2 days of of bed elevated. ventilation in unaffected the level of
nursing side ability/situation
intervention the
patient would be Supporting chest and Long term:
able to: Assist patient with splinting abdominal muscles After 1-2 days of
painful area when makes coughing more nursing
Apply techniques coughing, deep breathing. effective and less intervention the
that would improve traumatic. patient would be
breathing pattern able to:
and be free from Once chest tube is
signs and inserted: Water in a sealed Applied
symptoms of chamber serves as a techniques that
respiratory distress Check suction control barrier that prevents would improve
chamber for correct atmospheric air from breathing pattern
amount of suction entering the pleural and be free from
(determined by water level, space should the suction signs and
wall or table regulator) source be disconnected symptoms of
and aids in evaluating respiratory
whether the chest distress
drainage system is
functioning appropriately
To prompt detection of
After chest tube insertion, respiratory distress for
assess the client every 15 timely intervention,
minutes until stable including tachypnea,
diminished or absent
movement of the chest
wall on the affected side,
increased work of
breathing, use of
accessory muscles of
respiration, cyanosis
Chest tube should be

Assess the chest tube regularly asses to check
drainage system for dislodgment, leaks, or
kinks in the tubing,
With suction applied, this

Observe for abnormal and indicates a persistent air
continuous water-seal leak that may be from a
chamber bubbling lager pneumothorax at
chest insertion site or
chest drainage
Prevents and corrects air

Seal drainage tubing leaks at connector sites.
connection sites securely
with lengthwise tape or
bands according to
established policy;
Useful in evaluating
Assess amount of chest resolution of
tube drainage, noting pneumothorax and
whether tube is warm and development of
full of blood and bloody hemorrhage requiring
fluid level in water-seal prompt intervention
bottle is rising;
If disconnected or
dislodged:
Pneumothorax may recur,
Observe for signs of requiring prompt
respiratory distress. If intervention to prevent
possible, reconnect fatal pulmonary and
thoracic catheter to tubing circulatory impairment.
or suction, using clean
technique. If the catheter is
dislodged from the chest,
cover insertion site
immediately with
petrolatum dressing and
apply firm pressure. Notify
physician at once.
Dependent:
Dependent: To monitor and evaluate
Perform physical the progression or
examination regression of baseline
data of the patient.
To promote deeper
Medicate with analgesics, respiration and cough
as appropriate (as ordered)
Collaborative:
Collaborative: A doctor who diagnoses
Refer the patient to a and treats diseases of the
Pulmonologist for any respiratory system.
further complications

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Katherine Ashley R.

BSN 4-Y1-8 9/21/2023

CARE PLAN FOR CLIENT WITH A 3-WAY BOTTLE SYSTEM

Assessment Diagnosis Planning Intervention Rationale Evaluation

Chest tube should be

With suction applied, this

Prevents and corrects air

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