Deviation from the Standard of Care:

The nurse should have reassessed this patient during the insertion of the chest tube and documented all the assessment parameters listed previously.  In addition, it is also important to document the patient’s response to any procedure.  For example, after placement of the chest tube:

•    Did vital signs, level of consciousness, etc. improve or worsen?
•    Did the EKG monitor change?
•    Did the patient respond appropriately to the painful stimuli or not at
     all?
•    What was the initial amount of drainage from the chest tube? (Did
     amounts charted by other team members conflict with this
     documentation)?

Source of Standard of Care:  From ENA, Sheehy’s Emergency Nursing Principles and Practice, Fourth Edition. 2005, page 301.

Deviation from the Standard of Care:

This nurse documents chest drainage of 1800cc of blood, a massive blood loss indicating the need for aggressive fluid resuscitation and surgical repair of the bleeding vessels.  The physician ordered the nurse to get a second collection unit ready, indicating that he knew an excessive amount of hemorrhage was occurring in this patient’s chest.  He should have begun the process of transferring this patient to a surgery. If the hospital is equipped with an available thoracic surgeon, the patient should have been transferred immediately to surgery.  If the hospital is not equipped to adequately care for this patient, preparations should have been immediately made to ship the patient to a trauma center.  Since the physician didn’t, start making arrangements, the nurse should have suggested this plan of action.

“If blood return with chest tube insertion is >1000 to 1500 ml, or blood loss is > 200 to 300 ml/hr, surgical intervention may be indicated.” 

Source of Standard of Care:  From ENA, Sheehy’s Emergency Nursing Principles and Practice, Fourth Edition. 2005, page 301.