6.9: Documentation
Documentation Tips:
Documentation should include all data described in the pre, during, and post-chest tube removal areas. Record the date/time of the chest tube removal, any drainage not recorded in the collection chamber, and the appearance of the dressing and wound if possible. Note the patient’s response to the procedure. Include vital signs and respiratory assessment. Document patient teaching and patient’s level of understanding.
Sample Documentation:
06/27/20xx 1430
Chest tube to right lateral lower chest wall intact. Water seal chest tube drainage system in upright position and below the level of the client’s chest. Tubing is free of kinks and patent. Suction is set at prescribed -20 mmHg. Tidaling present in water seal system. No air leak identified. 50 mL of serosanguineous drainage noted in collection chamber over 8 hours without clots present. Respiratory rate 18 and pulse oximetry reading 96% on room air. Respirations are symmetrical and unlabored. Breath sounds are diminished in the posterior right lower lobe. No adventitious breath sounds or subcutaneous emphysema noted. Trachea is midline. Dressing is dry and intact. Client rates pain at 2/10 and at a tolerable level. Denies sputum. Continue to encourage deep breathing and coughing hourly. Two clamps and a bottle of sterile water are at the bedside.
Hector Ramos, RN