Cover the site with sterile 4"x4" gauze sponges and tape occlusively.
Notify the professional nurse/physician immediately.
Monitor the patient for respiratory distress.
q. Record significant nursing observations in the patient's clinical record and
report the same to the professional nurse.
Amount, color, and consistency of chest drainage.
Presence or absence of air leaks or bubbling in the water-seal unit.
Presence or absence of fluctuation in the glass rod of the water-seal
(4) Time and results of chest tube milking. Specific observations about the
patient, such as vital signs, breathe sounds, and skin color.
Results of deep breathing and coughing.
Position changes or activity, including range of motion.
Condition of chest tube insertion site and dressing.
Section VI. DISORDERS INVOLVING THE UPPER RESPIRATORY SYSTEM
Nosebleed, called epistaxis, is caused by the rupture of the tiny blood vessels in
the nose. Most often, the vessels ruptured are those in the mucous membranes of the
a. Epistaxis may be caused by injury, such as a blow to the nose, "picking" the
nose, or forceful blowing of the nose. Nosebleed may also occur as the result of
disease or may occur as a symptom of conditions such as sinusitis, bleeding disorders,
b. Epistaxis can often be managed conservatively by compressing the nostril of
the affected side against the nasal septum for 5-10 minutes. A cold compress over the
nose is also effective in the reduction of both bleeding and swelling. Position the patient
with the head forward to allow blood to drain from the nose and not down the throat.
Swallowing the blood may lead to nausea and vomiting. Instruct the patient to breathe
through the mouth. If the source of the bleeding cannot be seen, the physician may
spray the interior of the nose with an epinephrine solution, which will constrict the blood
vessels, and pack the interior of the nose with gauze, which will act as a pressure