M.S. is a 28-year-old male admitted to the ICU following a stab wound to the chest and diagnosis of tension pneumothorax requiring a chest tube. Over the nursing shift, the patient's vital signs, lung sounds, chest tube drainage, pain levels, and incision site were closely monitored and found to be stable and within normal limits. The chest tube drainage ceased and the plan is to monitor for 24 hours before removal. Patient teaching was provided on deep breathing exercises, coughing, pain management, and signs of infection or respiratory distress to watch for after discharge.

1. Narrative Documentation
Chelsey Benoy, SN
Background
I am a Intensive Care Unit nurse caring for M.S. 28-year-old Caucasian male who had
come to the emergency room by EMS from a stabbing chest wound from a local bar
after getting into a fight with another patron. He had a penetrating injury on the left
lateral chest and was diagnosed with tension pneumothorax. His vitals in EMS were
heart rate 120, respiratory rate is 40, and blood pressure is 90/60. He showed
symptoms of dyspnea, and cool clammy skin. His breath sounds were diminished on
the left side and heart sounds were distant. A chest x-ray was completed to have a
definitive diagnosis. He had a 24 FR chest tube inserted for an open pneumothorax
and is post op from surgery 2 days to close the chest wall defect. For this case, I will
be focusing on the patient’s lung sounds, heart sounds, and chest drainage system
and his penetrating wound as well as pain assessment.
Narrative Documentation
0700: Alert and oriented x 4. PERRLA. Patient is able to respond to verbal
commands. Patient is asleep. Chest tube drainage device is below the level of the
patient and is draining adequately. All connections are taped and secure. Suction is
at 20 cm H20 negative pressure. Chest drainage is documented as 50 mL and Chest
tube insertion site is clean and dry and no signs of infection. Patient has an IV 20
gauge running with 0.9% NaCl at 125 ml/hr in the right forearm. IV site is patent
and shows no signs of phlebitis or infiltration or infection. Skin is dry and pink.
Patients mother is at bedside.
0800: Alert and oriented x 4. PERRLA. Patient responds to verbal commands and
has strong hand grips. Patient is awake and alert. Pain noted at 6 on the number
scale. Pain medication morphine was administered and pain was noted again at a 3
on a scale reassessed 30 minutes later. Lung sound clear to auscultation. Bowel
sounds are active in all four quadrants and firm and round. Patient has 2 L oxygen
therapy per nasal cannula. Crackles are auscultated on the left bilateral lung base
and the right lung has clear breath sounds. Suction control chamber is -20cm H20.
Patient has equal expansion of the chest. Heart sounds are within normal limits.
Patient’s mother is at bedside.
0900: Alert and oriented x4. PERRLA. Patient is awake and alert and responds to
verbal stimuli. Reported voiding x 2 this morning 20 ml clear, yellow urine.
No pain, urgency, frequency or tenderness with voiding reported. No bladder
distention reported. Patient is stable and minimal air is accumulated. Suction
control chamber is at appropriate water level and added sterile water to replace

2. water. Wall suction has bubbling seen in the suction control chamber at 80 mmHg.
Chest tube dressing is clean and intact with no signs of infection. Patients mother is
at bedside. Patient report no pain on pain scale at this time. Incision dressing is
clean and intact.
1000: Alert and oriented x4. Lungs clear to ausculatation. Chest tubes are secure
and loose below the level of patient. Chest tube is draining adequately. Skin is clean
and intact. Heart sounds are within normal limits. Vital signs are heart rate 78,
blood pressure is 126/78, respiratory rate is 18 and O2 is 97% and temperature is
97.8. IV is infusing 0.9% NaCl at 125 ml/hr. Iv has no signs of infection or
infiltration. Patient stated no pain at IV site. Incision site has no signs of infection.
Patient stated a 2 on pain scale and requested no pain medication at this time.
Patient has good skin turgor and <3 seconds for capillary refill. Peripheral pulses are
strong. Bowel sounds are active x 4 quadrants. Patients mother at bedside.
1100: Alert and oriented x 4. Lungs clear to ausculatation. PERRLA. Skin clear and
intact. Chest tube is below level of patient and draining adequately. Chest tubes are
taped and secure. Patient incision site dressing is clean and dry and shows no signs
of infection. Vital signs within normal limits. Patient showed no signs of respiratory
distress. Patient reported pain at a 4 and at incision site. IV clean and intact and
infusing at 125 mL/hr. Patient is stable. Chest tube suction control chamber is at -20
mmHg pressure. Chest tube dressing shows no signs of infection. Patient showed no
signs of distress. Patients mother is at bedside.
1200: Alert and oriented x 4. Lungs clear to ausculatation. PERRLA. Skin clear and
intact. Heart sounds within normal limits. Vital signs within normal limits. Chest
tube is taped and secured and draining adequately. Suction control chamber is at -
20 mmHg. Bowel sounds active x 4 quadrants. Patient stated 7 on pain scale and
morphine was administered IVP and reassessed 30 minutes and patient reported a
3. Patient ate 70% of lunch. Patient turned every 2 hours. Patients fluid drainage has
ceased and has been scheduled for the chest drainage to be discontinued and set to
gravity for 24 hours before can be removed.
1300: Alert and oriented x 4. Lungs clear to ausculatation. PERRLA. Patient is
asleep. Skin clear and intact. Heart sounds within normal limits. Vital signs within
normal limits. Chest tube insertion site is clean and intact. Incision site shows no
signs of infection. Bowel sounds active x 4 quadrants. IV site is clean and intact and
infusing 125 mL/hr. Chest tube is below level of patient and is taped and secure.
Drainage has ceased. Patients mother at bedside. Patients chest expansion is equal
bilaterally. No signs of respiratory distress and patient is stable.
1400: Alert and oriented x 4. Lungs clear to ausculatation. PERRLA. Patient
responds to verbal commands. Chest tube is taped and secure and tubes are loosely
coiled. Chest tube drainage has ceased minimally and below level of patient. Bowel
sounds active x 4 quadrants. IV site shows no signs of infection and is infusing at
125 mL/hr. Skin is clean and intact. Passive ROM performed. Vital signs within

3. normal limits. Patient stated no pain at this time. Bed in low position. Call bell within
reach. Patients mother at bedside.
1500: Alert and oriented x 4. Patient responds to verbal commands. Patient shows
no signs of respiratory distress. Lungs clear to ausculatation. Bowel sounds active x
4 quadrants. Heart sounds are within normal limits. Vital signs within normal limits.
Skin clean and intact. IV site is clean and intact and infusing 125 mL/hr. Chest tube
drainage is taped and secure and below the level of patient. Drainage is ceased
minimally. Chest tube site is clear with no signs of infection. Incision site dressing is
clean and dry with no signs of infection. Patient is currently sleeping and denies any
pain at this time. Skin shows no signs of impaired integrity. Patient is turned every 2
hours. Patient’s mother is at bedside.
1600: Alert and oriented x 4. Patient responds to verbal commands. Patient shows
no signs of respiratory distress. Lungs clear to ausculatation. Bowel sounds active x
4 quadrants. Skin clean and intact and shows no signs of impaired integrity.
Incentive spirometry was taught and patient demonstrated successful. Patient states
6 on pain scale and hydrocodone was administered orally. Heart sounds within
normal limits. Incision clean and intact dressing and showed no signs of infection.
Vital signs within normal limits. IV site clean and intact and infusing at 125 mL/hr.
Chest tube drainage is ceased and monitored with no infection noted. Patients
mother is at bedside.
1700: Alert and oriented x 4. Patient responds to verbal commands. Patient shows
no signs of respiratory distress. Lungs clear to ausculatation. Heart sounds within
normal limits. Vital signs within normal limits. Skin clean and intact with no signs of
impaired skin integrity. Bowel sounds active x 4 quadrants. IV site clean and intact
with no signs of infection and infusing 0.9% NaCl at 125mL/hr. Patient being turned
every 2 hours. Patient reports 2 on pain scale at this time. Incision shows no signs of
infection. Chest tube drainage is taped and secured and below level of patient. Bed is
in low position. Call bell within reach. Chest tube drainage is ceased and being
monitored for 24 hours. Patient is stable and mother is at bedside.
1800: Alert and oriented x 4. Patient responds to verbal commands. PERRLA.
Patient shows no signs of respiratory distress. Lungs clear to ausculatation. Vital
signs within normal limits. Heart sounds within normal limits. Bowel sounds active
x 4 quadrants. IV site is clean and intact with no signs of infection and infusing 0.9%
NaCl at rate of 125ml/hr. Chest tube drainage has ceased and being monitored for
24 hours. Chest tube is taped and secure and below level of patient. Patient is turned
every 2 hours. Patient is using incentive spirometer every 2 hours. Patient reports 5
on pain scale and hydrocodone is administered orally. Patient is reassessed in 30
minutes and pain is a 1 on pain scale. Incision shows no signs of infection. Patient is
stable and mother is at bedside. Patient teaching is done with mother and patient.
SBAR

4. 1900: M.S. is a 28 year old male on the intensive care unit following a stab wound
and diagnosis of tension pneumothorax. Patient currently has a chest tube on
gravity for 24 hours because drainage has ceased and will have to be removed in 24
hours. Patient has no medical or surgical history. Patients mother is at bedside. At
this time patients lungs sounds are clear bilaterally and no respiratory distress is
noted. Patient has an IV 20 gauge in right forearm infusing 0.9%NaCl at a rate of 125
mL/hr. IV site is clean and intact and shows no signs of infection. Patient responds
to verbal commands. Patient is a full code. All vital signs are normal. Patient has no
abnormal labs or other diagnosis. Incision site has a 4x4 gauze dressing and shows
no signs of infection. Chest tube is taped and secured on lateral left side below level
of patient. Chest tube drainage is connected by gravity for 24 hours before removal.
Patients pain assessment has been assessed through out shift and is now on
hydrocodone tablets orally and is tolerating well. Patient has been using incentive
spirometer throughout shift and has been given teaching education. Patient is
currently on 2 L O2 via nasal cannula. My recommendation is to maintain clear
breath sounds bilaterally and no signs of respiratory distress. Also show no signs of
infection at IV site, Chest tube site or incision site. The goal is for the chest tube
drainage will cease and lungs will re-expand. When chest tube is removed the
patient and family need to be taught what to look for at incision site. Make sure to
report any signs of infection (redness, warmth, pain, burning, pus, yellow drainage)
or a temperature above 100.4 degrees Fahrenheit. Also saturating dressing with
bright red blood should be reported. Any signs of respiratory distress or trouble
breathing should call EMS or go to the emergency department.
Patient teaching
 Teach turn, cough, deep breathing and incentive spirometry
 If the patient splints with coughing or has decreased breath sounds, more
pain medications may be needed so that the patient can be pain free while
taking a deep breath. Assess patient’s need for pain medications to prevent
hypoventilation, compliance, and pneumonia. Monitor vital signs and pain
assessment.

5.  Getting the patient out of bed and encourage ambulation with physicians
order. With movement, administer pain medications before so patient can
tolerate activities.
Handout at discharge
https://patienteduc.fraserhealth.ca/search/results?f_language_facet=English&f_lan
guageGroup_facet=Pneumothorax&q=